PEDIATRIC PEDIATRIC EMERGENCIESEMERGENCIES

Myrna D.C. San Pedro, MD, FPPSMyrna D.C. San Pedro, MD, FPPS

ScopeScope

Injury risk factors, assessment, Injury risk factors, assessment, emergency treatment and preventionemergency treatment and prevention

Foreign body accidents clinical features Foreign body accidents clinical features and managementand management

Burn types, assessment and managementBurn types, assessment and management

Near-drowning accidents assessment and Near-drowning accidents assessment and managementmanagement

Poisoning common causes, diagnosis and Poisoning common causes, diagnosis and managementmanagement

Injury versus AccidentInjury versus AccidentAccidentAccident (WHO): an event independent of human (WHO): an event independent of human willpower, caused by an external force, acts willpower, caused by an external force, acts rapidly and results in bodily or mental damagerapidly and results in bodily or mental damage

InjuryInjury: refers to the damage resulting from acute : refers to the damage resulting from acute exposure to physical and chemical agentsexposure to physical and chemical agents

Accident is the event while injuries the Accident is the event while injuries the consequencesconsequences

Accidents are random, chance, uncontrollable Accidents are random, chance, uncontrollable events but injuries are describable, epidemiologic events but injuries are describable, epidemiologic conditions that can be controlled and preventedconditions that can be controlled and prevented

The term “accident” has been abandoned in favor The term “accident” has been abandoned in favor of the more accurate term “injuryof the more accurate term “injury

Interactive Model of InjuriesInteractive Model of Injuries

VICTIM(HOST)

AGENT

HUMAN ENVIRONMENT

PHYSICAL ENVIRONMENT

Child Development and InjuriesChild Development and Injuries

TemperamentTemperament: a child’s behavioral style: a child’s behavioral style

1.1. Difficult childDifficult child: irregular rhythm, high energy, : irregular rhythm, high energy, negative mood, low adaptabilitynegative mood, low adaptability

2.2. Easy childEasy child: opposite: opposite

3.3. Slow to warm up childSlow to warm up child: low activity, positive : low activity, positive approach, highly adaptable, mild energyapproach, highly adaptable, mild energy

MotivationMotivation: interest in accomplishing a task: interest in accomplishing a task

1.1. Normal drive for Normal drive for autonomyautonomy

2.2. Interest in Interest in imitatingimitating behavior behavior

3.3. Risk-takingRisk-taking or self-destructive behaviors or self-destructive behaviors

Child Development and InjuriesChild Development and InjuriesCompetenciesCompetencies: level of functioning: level of functioning

1.1. InfantsInfants’ drive to explore and become ’ drive to explore and become autonomous but still underdevelopedautonomous but still underdeveloped

2.2. Preschool childrenPreschool children have cognitive and motor have cognitive and motor limitationslimitations

3.3. School childrenSchool children tend to be daring, impulsive tend to be daring, impulsive and adventurous; inclined to disregard rules; and adventurous; inclined to disregard rules; still unable to appreciate speed and danger; still unable to appreciate speed and danger; have reduced ability to localize sounds and have reduced ability to localize sounds and impaired perception of movementimpaired perception of movement

4.4. AdolescentsAdolescents become overly involved in abstract become overly involved in abstract matters and sometimes lose touch with reality matters and sometimes lose touch with reality combined with innate need for experimentation combined with innate need for experimentation and the tendency to imitate older adolescents and the tendency to imitate older adolescents and adultsand adults

Primary Factors in Pediatric AccidentsPrimary Factors in Pediatric Accidents

Increased vulnerability and/or risk situation

Psychosocial (endogenous)

Predisposing Factors

Environmental (exogenous)

Predisposing Factors

Accident

Precipitating Factors

Precipitating Factors

Psychosocial (endogenous) Psychosocial (endogenous) Predisposing FactorsPredisposing Factors

Unawareness of risksUnawareness of risks

Lack of experienceLack of experience

Need to explore and innovateNeed to explore and innovate

Role models (motorcyclist as hero)Role models (motorcyclist as hero)

Risk-taking behaviorRisk-taking behavior

Use of a motor vehicle to build up self-esteemUse of a motor vehicle to build up self-esteem

Psychological maladjustments (extreme Psychological maladjustments (extreme personality traits, unbalanced personality)personality traits, unbalanced personality)

Sociopathic behavior (aggressiveness, deviance)Sociopathic behavior (aggressiveness, deviance)

Family dysfunctions (chronic family syndrome)Family dysfunctions (chronic family syndrome)

Environmental (exogenous) Environmental (exogenous) Predisposing FactorsPredisposing Factors

Habitual use of a two-wheeled vehicle without Habitual use of a two-wheeled vehicle without due protectiondue protection

Lack of body protection (helmet, gloves, etc.)Lack of body protection (helmet, gloves, etc.)

Increased commercial advertising promoting Increased commercial advertising promoting vehicles that are dangerousvehicles that are dangerous

Inadequate age-specific driving regulationsInadequate age-specific driving regulations

Inadequate enforcement of existing lawsInadequate enforcement of existing laws

Increasing need to make long trips to and from Increasing need to make long trips to and from work, school, etc.work, school, etc.

Inadequately or excessively expensive public Inadequately or excessively expensive public transporttransport

Precipitating FactorsPrecipitating Factors

Heightened emotional Heightened emotional tension tension (endocrinological and (endocrinological and psychological)psychological)

Alcoholic conditionAlcoholic condition

Driving under Driving under influence of medicines influence of medicines or drugs (especially or drugs (especially hallucinogenic)hallucinogenic)

Special traffic Special traffic conditionsconditions

Social pressure to Social pressure to “perform” in a certain “perform” in a certain way (traveling in way (traveling in groups)groups)

Use of poorly Use of poorly maintained vehiclesmaintained vehicles

Use of stolen vehiclesUse of stolen vehicles

Classification of InjuriesClassification of Injuries

UnintentionalUnintentional InjuriesInjuries::

Road traffic Road traffic injuriesinjuries

PoisoningPoisoning

FallsFalls

Fire and burn Fire and burn injuriesinjuries

DrowningDrowning

IntentionalIntentional InjuriesInjuries::

HomicidesHomicides

Sexual assaultsSexual assaults

Neglect and Neglect and abandonmentabandonment

MaltreatmentMaltreatment

SuicidesSuicides

Collective violence Collective violence (war)(war)

Unintentional InjuriesUnintentional Injuries

Unintentional Unintentional InjuriesInjuries: :

400,000 400,000 deaths/year deaths/year globally – globally – the majority the majority in childrenin children

Survivors Survivors may suffer may suffer lifelong lifelong disabilitydisability Non-intentional injuries in children under

15 years (WHO, 2001)

U.S. Injury MortalityU.S. Injury MortalityInjuries almost 40% of deaths among 1-4 yearsInjuries almost 40% of deaths among 1-4 yearsMotor vehicle injuries leading cause of deaths Motor vehicle injuries leading cause of deaths due to injury at all agesdue to injury at all agesDrowning ranks 2Drowning ranks 2ndnd with peaks in the preschool with peaks in the preschool and later teenage yearsand later teenage yearsFire and burn deaths account for nearly 10% of Fire and burn deaths account for nearly 10% of all trauma deaths and more than 20% in <5 yrall trauma deaths and more than 20% in <5 yrAsphyxiation and choking account for about 40% Asphyxiation and choking account for about 40% of all unintentional deaths in <1 yrof all unintentional deaths in <1 yrHomicide leading cause of injury death in <1 yr, Homicide leading cause of injury death in <1 yr, 44thth leading cause for ages 1-14 years and 2 leading cause for ages 1-14 years and 2ndnd leading cause in 15-19 yearsleading cause in 15-19 yearsSuicide is only 1% in <15 yr but is the 3Suicide is only 1% in <15 yr but is the 3rdrd leading leading cause of death for 15-19-yr-oldscause of death for 15-19-yr-olds

U. S. Injury MorbidityU. S. Injury Morbidity

Twenty to 25% of children receive Twenty to 25% of children receive medical care for injury every year in medical care for injury every year in hospital ERs and at least an equal hospital ERs and at least an equal number in physician officesnumber in physician offices

Falls leading cause of both ER visits Falls leading cause of both ER visits and hospitalizationsand hospitalizations

Bicycle-related trauma most common Bicycle-related trauma most common type of sports and recreational injurytype of sports and recreational injury

DOH 2003 Study DOH 2003 Study By the Department of Health: 1 out of every 5 By the Department of Health: 1 out of every 5 Filipino children die from injuriesFilipino children die from injuries2003 DOH study done with help from the United 2003 DOH study done with help from the United Nations Children’s Fund and the Alliance for Nations Children’s Fund and the Alliance for Safe Children revealed that the top causes of Safe Children revealed that the top causes of death among children ages 1-17 years are: death among children ages 1-17 years are: 1.1. Drowning (8:100,000)Drowning (8:100,000)2.2. Road accidents (5.85:100,000)Road accidents (5.85:100,000)3.3. Violence (2.52:100,000)Violence (2.52:100,000)4.4. Falls (2.11:100,000)Falls (2.11:100,000)5.5. Suicide (1.93:100,000)Suicide (1.93:100,000)The study was made on 99,446 households or The study was made on 99,446 households or 418,552 people 418,552 people

Safe Kids Philippines StudySafe Kids Philippines StudyThe study was conducted in the ERs of 3 hospitals The study was conducted in the ERs of 3 hospitals in Parañaque, Pasay, and Olongapoin Parañaque, Pasay, and Olongapo

At least 20 million Filipino children are at risk of At least 20 million Filipino children are at risk of dying or being injured in road accidents every yrdying or being injured in road accidents every yr

At least one in four children brought to hospital At least one in four children brought to hospital for treatment were between 12-14 yearsfor treatment were between 12-14 years

Most of the injuries happen after 1 p.m. and their Most of the injuries happen after 1 p.m. and their peak incidence between 9 p.m. and 12 a.m.peak incidence between 9 p.m. and 12 a.m.

Accidental injuries are the third leading cause of Accidental injuries are the third leading cause of death for children 1-14 years in the Philippines death for children 1-14 years in the Philippines

Safe Kids Philippines StudySafe Kids Philippines Study

Road Accidents

30%

Assault28%

Falls20% Cuts

14%

Intentionally Inflicted, 28%

Road accidents50%

Home accidents

38%Bicycles 29%

Tricycles 23%

Motorcycles18%

Boys67%

Girls33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Anticipating Cardiopulmonary ArrestAnticipating Cardiopulmonary Arrest

Cardiopulmonary Failure

Many Causes

Respiratory Failure

Cardiovascular RecoveryDeath

Shock

Neurological Impairment Neurological Recovery

Path of various disease states leading to cardiopulmonary failure in infants and children

Rapid Cardiopulmonary AssessmentRapid Cardiopulmonary Assessment(requires 20-30 seconds to complete)(requires 20-30 seconds to complete)AirwayAirway patency patency

1)1) PatentPatent and clear and clear2)2) MaintainableMaintainable with suctioning, head positioning or with suctioning, head positioning or

adjunctsadjuncts3)3) UnmaintainableUnmaintainable, requiring interventions such as , requiring interventions such as

intubation, foreign body removal or cricothyrotomyintubation, foreign body removal or cricothyrotomyBreathingBreathing

1)1) Respiratory RateRespiratory Rate: normal in neonate is 40-60/min; : normal in neonate is 40-60/min; 1-year-old is 24/min; 18-year-old is 12/min1-year-old is 24/min; 18-year-old is 12/min

2)2) MechanicsMechanics: nasal flaring, grunting, retractions, use : nasal flaring, grunting, retractions, use of accessory musclesof accessory muscles

3)3) Air EntryAir Entry: stridor, wheezing, breath sounds, chest : stridor, wheezing, breath sounds, chest expansion, paradoxical chest movementexpansion, paradoxical chest movement

4)4) ColorColor of the skin and mucous membranes of the skin and mucous membranesCentral cyanosis – presence of 5 g desaturated Central cyanosis – presence of 5 g desaturated hemoglobin/dl of bloodhemoglobin/dl of blood

Rapid Cardiopulmonary AssessmentRapid Cardiopulmonary AssessmentCirculation Circulation

1)1) Heart RateHeart Rate::Newborn-3 moNewborn-3 mo 85-200/min85-200/min3 mo-2 yr3 mo-2 yr 100-190/min100-190/min>2 yr>2 yr 80-140/min80-140/minAll agesAll ages <<60/min bradycardia60/min bradycardia

2)2) Blood PressureBlood Pressure: lower limit (5: lower limit (5thth%) systolic%) systolic0-1 mo0-1 mo 6060>1 mo-1 yr>1 mo-1 yr 7070>1 yr>1 yr 70 + (2 x age in years)70 + (2 x age in years)Hypotension – 25% circulating blood volume lossHypotension – 25% circulating blood volume loss

3)3) Peripheral pulsesPeripheral pulses: whether present or absent, : whether present or absent, volume/strengthvolume/strength

4)4) Capillary Refill TimeCapillary Refill Time: normal <2 seconds: normal <2 seconds

Rapid Cardiopulmonary AssessmentRapid Cardiopulmonary Assessment

Circulation Circulation

5)5) Skin colorSkin color: mottling, ashen, pale or cyanotic: mottling, ashen, pale or cyanotic

6)6) Skin temperatureSkin temperature: whether warm or cold: whether warm or cold

7)7) Level of consciousnessLevel of consciousness (brain perfusion): (brain perfusion):

A – AwakeA – Awake

V – responsive to VoiceV – responsive to Voice

P – responsive to PainP – responsive to Pain

U – UnresponsiveU – Unresponsive

8)8) Urine OutputUrine Output: normal averages 1-2 ml/kg/hr, : normal averages 1-2 ml/kg/hr, reflects renal blood flow and end-organ perfusion reflects renal blood flow and end-organ perfusion

Classification of Physiologic StatusClassification of Physiologic StatusStableStable – adequate ventilation (elimination of CO – adequate ventilation (elimination of CO22), ), oxygenation (Ooxygenation (O22 exchange) and perfusion exchange) and perfusion

In respiratory failureIn respiratory failure – inadequate ventilation or – inadequate ventilation or oxygenationoxygenation Potential RFPotential RF – improves after initial therapy such – improves after initial therapy such

as oxygen administrationas oxygen administration Probable RFProbable RF – deteriorates, more aggressive – deteriorates, more aggressive

therapy neededtherapy neededIn shock – inadequate perfusion of vital organsIn shock – inadequate perfusion of vital organs CompensatedCompensated shock – blood pressure is normal shock – blood pressure is normal DecompensatedDecompensated shock – hypotension develops shock – hypotension develops

In cardiopulmonary failure – insufficient ventilation, In cardiopulmonary failure – insufficient ventilation, oxygenation and perfusionoxygenation and perfusion

Pediatric Cardiopulmonary ArrestPediatric Cardiopulmonary Arrest

Sudden Cardiac ArrestSudden Cardiac ArrestUncommon in young Uncommon in young childrenchildrenVentricular fibrillation Ventricular fibrillation only 10-15% of <10 only 10-15% of <10 years with pulseless years with pulseless arrest outside the arrest outside the hospitalhospitalPrehospital Prehospital normothermic asystolic normothermic asystolic or pulseless cardiac or pulseless cardiac arrest in infants and arrest in infants and children with 10% children with 10% survival ratesurvival rateMany suffer permanent Many suffer permanent neurological damageneurological damage

Respiratory or Circulatory Respiratory or Circulatory Failure Failure More commonMore commonInjury or disease Injury or disease causes respiratory or causes respiratory or circulatory failure with circulatory failure with hypoxemia and hypoxemia and acidosis ending in acidosis ending in asystolic or pulseless asystolic or pulseless cardiac arrestcardiac arrestRespiratory arrest Respiratory arrest alone >50% survival alone >50% survival rate with prompt rate with prompt resuscitationresuscitationMost patients survive Most patients survive neurologically intactneurologically intact

Basic Life Support ManeuversBasic Life Support ManeuversPALS 2006-2007PALS 2006-2007

MANEUVERADULT

> 8 YearsCHILD

1-8 YearsINFANT< 1 Year

Activate EMS (lone rescuer)

When victim FOUND unresponsive, activate EMS.If asphyxial arrest likely, activate AFTER 5 cycles 2 min CPR.

When victim FOUND unresponsive, activate AFTER 5 cycles CPR.For SUDDEN, WITNESSED COLLAPSE, activate after verifying victim unresponsive.

Airway Head tilt-chin lift maneuver.If trauma suspected, use jaw thrust maneuver.

Breaths Initial

2 effective breaths at 1 sec per breath

MANEUVERADULT

> 8 YearsCHILD

1-8 YearsINFANT< 1 Year

Rescue Breaths Without chest compression

10-12 breaths/min (about 1 breath every 5-6 seconds)

12-20 breaths/min (about 1 breath every 3-5 seconds)

Rescue Breaths for CPR With advanced airway

8-10 breaths/min (about 1 breath every 6-8 seconds)

Foreign-body airway obstruction

Abdominal thrusts Back slaps and chest thrusts (5)

CirculationPulse check (<10 sec)

Carotid (can use Femoral in the child)

Brachial or Femoral

MANEUVERADULT

> 8 YearsCHILD

1-8 YearsINFANT< 1 Year

Compression landmark

Center of chest between nipples

Just below the nipple line

Compression method:Push hard and fast allowing complete recoil

Heel of 1 hand on top of other hand

2 Hands: Heel of 1 hand on top of second hand1 Hand: Heel of 1 hand only

1 rescuer: 2 fingers2 rescuers: 2 thumbs with encircling hands

Compression depth

1 ½-2 inches Approximately 1/3-1/2 the depth of the chest

Compression rate

Approximately 100/min

Compression-ventilation ratio

1 or 2 rescuers 30:2

1 rescuer 30:22 rescuers 15:2

Basic Life Support CoreBasic Life Support Core

1.1. Push hard and fast at a Push hard and fast at a compression rate of 100/mincompression rate of 100/min

2.2. Allow full chest recoil between Allow full chest recoil between chest compressionchest compression

3.3. Minimize interruptionsMinimize interruptions

4.4. Avoid hyperventilation Avoid hyperventilation

AirwayAirway

Rescue BreathsRescue Breaths

The correct volume for each The correct volume for each breath is the volume that breath is the volume that causes the chest to rise.causes the chest to rise.

Foreign-body Airway ObstructionForeign-body Airway Obstruction

Pulse CheckPulse Check

Chest CompressionChest Compression

Airway AdjunctsAirway AdjunctsOxygen (OOxygen (O22)): highest concentration for all seriously : highest concentration for all seriously ill with respiratory insufficiency, shock, or traumaill with respiratory insufficiency, shock, or trauma Room air: 21% ORoom air: 21% O22

Mouth-to-mouth: 16-17% OMouth-to-mouth: 16-17% O22

SuctioningSuctioning: 80-120 mm Hg suction force usually: 80-120 mm Hg suction force usuallyHead positioningHead positioning: position of comfort if alert, head : position of comfort if alert, head tilt-chin lift or jaw thrust if unconscioustilt-chin lift or jaw thrust if unconsciousOropharyngeal airwayOropharyngeal airway: for the unconscious infant or : for the unconscious infant or child if procedures to maintain airway fails child if procedures to maintain airway fails Bag-valve–mask assisted ventilationBag-valve–mask assisted ventilation Self-inflating bag-valve device: 21% OSelf-inflating bag-valve device: 21% O22

If hooked to OIf hooked to O22 10 L/min: 30-80% O 10 L/min: 30-80% O22

If hooked to OIf hooked to O2 2 10-15 L/min and with reservoir: 10-15 L/min and with reservoir: 60-95% O60-95% O22

Airway AdjunctsAirway AdjunctsEndotracheal intubation Endotracheal intubation indications:indications: Respiratory failure or arrestRespiratory failure or arrest Airway obstruction (actual or expected)Airway obstruction (actual or expected) GCS GCS << 8, comatose or significant alteration of 8, comatose or significant alteration of

mental statusmental status Suspected increase in intracranial pressureSuspected increase in intracranial pressure Need for mechanical ventilatory supportNeed for mechanical ventilatory support

Cricothyrotomy Cricothyrotomy indications:indications: Foreign body complete upper airway obstructionForeign body complete upper airway obstruction Severe orofacial injuriesSevere orofacial injuries InfectionInfection Laryngeal fractureLaryngeal fracture

Respiratory monitoringRespiratory monitoring Pulse oximetry – noninvasivePulse oximetry – noninvasive Arterial Blood Gas analysis – most accurateArterial Blood Gas analysis – most accurate

DELIVERY SYSTEMS OXYGEN (%)FLOW RATE

(L/min)

Low Flow System

Nasal cannula 22-60 2-4

Oxygen mask 35-60 6-10

High Flow System

Face tent < 40 10-15

Oxygen hood 80-90 10-15

Oxygen tent > 50 > 10

Partial rebreathing mask with reservoir

50-60 10-12

Nonrebreathing mask with reservoir

95 10-15

Venturi mask 25-60 (mask specific)

variable

Oxygen Delivery SystemsOxygen Delivery Systems

Airway AdjunctsAirway Adjuncts

Endotracheal IntubationEndotracheal Intubation

CricothyrotomyCricothyrotomy

Pediatric Trauma ResuscitationPediatric Trauma ResuscitationTrauma is the leading cause of death and Trauma is the leading cause of death and disability in the pediatric age groupdisability in the pediatric age groupIn the average multiple trauma victim: head In the average multiple trauma victim: head injuries 59% while extremities 26%injuries 59% while extremities 26%Two major causes of death:Two major causes of death:

1)1) Airway compromiseAirway compromise2)2) Unrecognized hemorrhageUnrecognized hemorrhageTraumatic injuries that may affect successful Traumatic injuries that may affect successful resuscitation:resuscitation:

1)1) Cervical spine injuryCervical spine injury2)2) HemorrhageHemorrhage3)3) Chest traumaChest traumaPriority is to assess and stabilize first before Priority is to assess and stabilize first before surgerysurgery

Pediatric Trauma Score of Pediatric Trauma Score of >> 8 indicates 8 indicates multisystem trauma or significant mortality riskmultisystem trauma or significant mortality risk

Cervical Spine InjuryCervical Spine InjuryCervical spine injury less common in pediatric than Cervical spine injury less common in pediatric than in adult trauma becausein adult trauma because Child’s spine more elastic and mobileChild’s spine more elastic and mobile Pediatric vertebrae softer, less likely to fracture Pediatric vertebrae softer, less likely to fracture

But risk of cervical spine injury increased whenever But risk of cervical spine injury increased whenever child is subjected to inertial forces applied to neck child is subjected to inertial forces applied to neck during acceleration-deceleration e.g., motor vehicle during acceleration-deceleration e.g., motor vehicle injuries or falls from a heightinjuries or falls from a heightSpinal cord injury without radiographic abnormality Spinal cord injury without radiographic abnormality (SCIWORA) is now recognized as important cause of (SCIWORA) is now recognized as important cause of pediatric spinal cord injury because ofpediatric spinal cord injury because of Relative laxity of cervical spine ligamentsRelative laxity of cervical spine ligaments Incomplete development of cervical musculatureIncomplete development of cervical musculature Shallow orientation of facet jointsShallow orientation of facet joints

Cervical Spine ImmobilizationCervical Spine Immobilization

Hemorrhage in Pediatric TraumaHemorrhage in Pediatric TraumaControl external hemorrhage immediately by direct Control external hemorrhage immediately by direct pressure over the woundpressure over the woundHypotension will not be present until 25-30% or Hypotension will not be present until 25-30% or more of the child’s blood volume is lost acutelymore of the child’s blood volume is lost acutelyReliable vascular access must be obtained quicklyReliable vascular access must be obtained quicklyIf shock persists despite control of external If shock persists despite control of external hemorrhage and volume resuscitation, internal hemorrhage and volume resuscitation, internal bleeding is likelybleeding is likelyIsolated head injury rarely causes sufficient blood Isolated head injury rarely causes sufficient blood loss to cause shock but scalp lacerations may loss to cause shock but scalp lacerations may produce significant blood lossproduce significant blood lossIntra-abdominal bleeding signs due to organ Intra-abdominal bleeding signs due to organ rupture: abdominal tenderness, distention that does rupture: abdominal tenderness, distention that does not improve with NGT decompression and shock – a not improve with NGT decompression and shock – a life-threatening surgical emergencylife-threatening surgical emergency

Fluid Resuscitation in Hemorrhagic ShockFluid Resuscitation in Hemorrhagic Shock

20 ml/kg Isotonic crystalloid solution OR10 ml/kg PRBC or 20 ml/kg FWB

20 ml/kg Isotonic crystalloid solution

20 ml/kg Isotonic crystalloid solution

Reassess

Reassess

Reassess ---Urgent transfusion should be considered if child fails to respond

to 2-3 boluses of crystalloid solution (about 40-60 ml/kg)

Life-Threatening Chest InjuriesLife-Threatening Chest InjuriesChest injuries uncommon in pediatric trauma Chest injuries uncommon in pediatric trauma because chest wall extremely compliantbecause chest wall extremely compliant

When there is history of blunt trauma, intrathoracic When there is history of blunt trauma, intrathoracic injuries must be ruled outinjuries must be ruled out

Tension pneumothorax: ABCs, needle Tension pneumothorax: ABCs, needle decompression followed by chest tubedecompression followed by chest tube

Open pneumothorax (sucking chest wound) – rare Open pneumothorax (sucking chest wound) – rare but lethal: ABCs, occlusive dressing followed by but lethal: ABCs, occlusive dressing followed by chest tube, positive-pressure ventilationchest tube, positive-pressure ventilation

Flail chest: ABCs, prolonged positive-pressure Flail chest: ABCs, prolonged positive-pressure ventilationventilation

Massive hemothorax: ABCs, urgent placement of a Massive hemothorax: ABCs, urgent placement of a chest tubechest tube

/ Drugs

Principles of Injury ControlPrinciples of Injury Control

Education or persuasionEducation or persuasion

Changes in product designChanges in product design

Modification of the social or Modification of the social or physical environmentphysical environment

Haddon’s 10 StrategiesHaddon’s 10 Strategies1.1. Prevent the creation of hazardPrevent the creation of hazard2.2. Reduce amount of hazard brought into Reduce amount of hazard brought into

being (being (decrease number of cars decrease number of cars manufactured; use fuel that permits manufactured; use fuel that permits only low speedonly low speed))

3.3. Prevent the release of hazard (Prevent the release of hazard (drive only drive only in daylightin daylight))

4.4. Modify the rate of release of the hazard Modify the rate of release of the hazard from its source (from its source (use seat belts, child use seat belts, child safety seatsafety seat))

5.5. Separate the hazard by time and space Separate the hazard by time and space ((separate bicyclists from cars; use separate bicyclists from cars; use pedestrian lanespedestrian lanes))

Haddon’s 10 StrategiesHaddon’s 10 Strategies6.6. Separate the hazard by a physical barrier Separate the hazard by a physical barrier

((install air bagsinstall air bags))7.7. Modify relevant basic qualities of the Modify relevant basic qualities of the

hazard (hazard (eliminate hard surfaces in cars; eliminate hard surfaces in cars; use energy absorbing materials to use energy absorbing materials to increase space withinincrease space within))

8.8. Make what is to be protected resistant Make what is to be protected resistant ((wear helmetswear helmets))

9.9. Begin to counter the damage done by the Begin to counter the damage done by the hazard (hazard (maintain airway, stop maintain airway, stop hemorrhage, immobilize neckhemorrhage, immobilize neck))

10.10. Stabilize, repair, rehabilitate the object of Stabilize, repair, rehabilitate the object of the damage (the damage (develop a regional trauma develop a regional trauma system, trauma and rehabilitation centersystem, trauma and rehabilitation center))

Gustafsson Safety EquationGustafsson Safety Equation

H. P.H. P. S. E. S. E.

HH = environmental Hazard = environmental HazardPP = Proneness/“Personality factors”/Psychosocial = Proneness/“Personality factors”/PsychosocialSS = Supervision = SupervisionEE = Education = Education

When, in any context, the 1When, in any context, the 1stst term of the term of the equation balances the 2equation balances the 2ndnd one, there is no one, there is no chance of accident chance of accident When it is not the case, the risk of accidents When it is not the case, the risk of accidents arisesarisesThe equation is useful for preventive programsThe equation is useful for preventive programs

Three DELAYS that KILLThree DELAYS that KILL

1.1. DELAY in decision-makingDELAY in decision-making

2.2. DELAY in transporting patientDELAY in transporting patient

3.3. DELAY in managing patientDELAY in managing patient