EMERGENCY PAEDIATRIC REFRESHER COURSE 2013
TRAUMA & ORTHOPEDIC EMERGENCIES
Sebastian van As
TRAUMA UNIT
RED CROSS CHILDREN’S HOSPITAL UNIVERSITY OF CAPE TOWN
Not all is what it seems!
South Africa
• Approximately 52 million people
• Approximately 20 million children
Childhood Deaths
WHO TRAUMA NUMBER 1 KILLER IN 2020
Child Injuries
Trauma a leading cause childhood deaths Approximately 1 million deaths annually
1. Road traffic accidents
-Pedestrian (80%)
-Passengers (20%)
2. Drowning
3. Burns
Ratio Adults/Children
Age
18
Statistics
• Annually 8000 children die as a result of unintentional injuries
• Mainly motor vehicle accidents, burns and drowning
• Child in SA 25 times more chance to end up in hospital as compared to the UK
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Polytrauma • Very common in children & adolescents
• Represent often clinical decision problems Some of the reasons:
• Relative large head • Many organ systems densely packed together • Exploring the world • Risk behaviour • Dangerous sports
Trauma Team Approach
Doctors
Nurses
Support Staff
Polytrauma very common in young people
Polytrauma •Require a fine balance of numerous specialists:
• Trauma surgeons • Radiologists
• Neurosurgeons • Thoracic surgeons
• Orthopaedic surgeons • Paediatric surgeons • Plastic Surgeons • Hand surgeons • ENT surgeons
• Maxillo-facial surgeons • Urologists • ICU doctors
Polytrauma
Require often also numerous paramedics:
• Social workers
• Physiotherapist
• Dieticians
• Occupational therapist
• Counseller
Polytrauma
Resuscitation room = Flight Control Room
Leading Trauma Doctor = Flight Commander
Initial Phase
Resuscitation:
Airway & Cervical spine stabilization
Breathing
Circulation
– CGS 13-14/15
– Bp 80/40
– Pulse Rate 140, feeble
– Resp Rate 54
– Hb 10 Gram%
– Cyanotic, distressed
– No scalp wounds
– Left Chest > Right Chest
– Decreased Air Entry Left
– Abdomen soft, scaphoid
– Pelvis clinically fractured
– Near total amputation left leg
Second Phase
“Management frenzy”
All (sub) specialist want to be first on the list!
Often various interventions/investigations still on the go
Delay in diagnostic procedures due to specialist interfering
If patients needs to have imaging outside the resusc room this is even more complicated
Not always easy to find all pathology; often camouflaged!
Which teams to call?
Guiding principle: ABC
Airway & Breathing compromise
Thoracic Surgeons
Circulation compromise
Pediatric Surgeons
– CGS 13-14/15
– Bp 80/40
– Pulse Rate 140, feeble
– Resp Rate 54
– Hb 10 Gram%
– Cyanotic, distressed
– No scalp wounds
– Left Chest > Right Chest
– Decreased Air Entry Left
– Abdomen soft, scaphoid
– Pelvis clinically fractured
– Near total amputation left leg
Triad of Death
Bloody Vicious Cycle of Polytrauma:
Acidosis
Hypothermia
Coagulopathy
Damage Control
First Phase (Operating theatre)
Control hemorrhage
Alleviate contamination
Packing
Fracture immobilization
Second phase (ICU)
Rewarming
Correction coagulopathy
Reversing Acidosis
Team Management
We all know what to do; ABCDE
Main problem, nearly ALL hospitals:
Trauma Doctor the MOST junior one around
They don’t have experience
They often call the wrong specialist
They lack authority
Solutions to this problem:
Senior Specialist on close stand-by!
Always have experienced nursing staff on duty with junior doctors!
Change of staff gradually:
New teams / change over:
Make a sure there is a “critical mass”
of experience
Don’t change more than 2 members of the team at one time
(doctors/nurses/support staff)
Family management
Trauma surgeon often little time
Make sure the family is not left alone:
Family friends
Experienced nursing staff
Social worker
Pastor support
Conclusive remarks
•Each case represents a new challenge
•All cases are different
•Highly complex management
•Require experience and compassion
•Often an evolving management plan is the best (The situation is RARELY static)
•Open communication with all stake holders is crucial
Thank you!
Not all what it seems…