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I'm going to run through uh some brief details about pediatric resuscitation in the context of battle trauma. So the first thing I'd like to say is that everything in this talk um in terms of how to deal with Children is available in this manual, which we produced for another conflict zone in Syria a few years ago. And you'll be able to find this through the link, the QR code that's on the screen now which will display at the end, this manual takes you from the child's point of injury through the care pathway to discharge will help you apply your trauma skills to Children as well as you do. Two adults. You can look at the characteristics of P electric trauma and why it's important. But we know we know from our data in military conflict in Afghanistan that it has uh an all cause mortality of 8% when they come into treatment facilities compared to the adult civilian counterparts. They are more severely, severely and more multiple e injured and they have a higher mortality in any care system. It's perhaps perhaps for this reason that there are lots of barriers or perceived barriers to success when it comes to treating pediatric trauma. And I think however, most of these barriers are not usually your knowledge or your skills, but predominantly psychological and function and a fear of failure. It's very important for me to emphasise that the adult trauma skills that you have and are gaining now are very transferable to Children. And if you use those, you will be very successful in treating Children. I'll give you an example. If you look at the surgical procedures carried out in Children in Afghanistan, in the British military facilities, there were no specific pediatric uh procedures, maneuvers or equipment requirements that were needed for those Children. We often look for differences where there are none. So it's very important to remember that we are treating the same species and that the secret may be that there is no secret to this. So the enablers of success for treating Children are using our adult skills and certainly teamwork where resources allow. But we should be applying the same structure of assessment and the same structure of a treatment to battlefield trauma that we would apply to the adult. So applying our principles of damage control resuscitation, they largely have the same injuries and they largely require the same interventions for those injuries. However, preparation for receiving a child is very important if you do get enough time or alert to do this and it's absolutely vital that you don't have the mental burden of calculating drugs, fluids, etcetera. At the time, the child requires treatment. And I would strongly recommend that you use a, an aide memoire or a resource such as one shown here, which is an age per page card and prepare some basic information before you start treating the child. And again, this, these cards and the checklist are available via the QR code uh and you can download them for free and use them. So the structure we're going to use for Children is C A B C D E. So starting with catastrophic hemorrhage and to do this successfully, it is important that we are familiar with the normal physiological ranges for Children, which you can get using cards or other resources. And as an adult, we identify life threatening injuries and and deal with those immediately before moving on to the next part of our assessment and treatment. So when dealing with a catastrophic hemorrhage, never ignore abnormal physiology. One of the communists or one of the more severe mistakes that I have witnessed in dealing with Children is ignoring abnormal pulse or a spiritual rate, which in the context of trauma and certainly battlefield trauma always indicates hypervolemia or severe injury unless you're absolutely certain it is otherwise. So Tuna Kaysen splints should be used on Children and will be successful tuna case, the combat applied to in a case, for example, will fit nearly any size of child's limb, but you may need to improvise with pelvic splints. Whilst pelvic injury is less common or blood pelvic injury is less common in Children. If you have a significant pelvic injury, the mortality is just as high as in adults. And one extremely important tip for Children is is just use interosseous access. You can resuscitate any size of human being through an intraosseous access and the time taken to try and get intravenous access in a shock. Child is pretty much wasted, just go straight for intraosseous access. And very importantly, there's no such thing as a hypertensive phase and resuscitation in Children, Children will decompensate late catastrophically. And once you've got measured hypertension, you're dealing with an extremely sick child. So when we're resuscitating Children who are hypovolemic in trauma, we should preferably use blood or blood products in a balanced fashion. Using 5 mg per kilo bolus is to trend them towards normal physiology, but not necessarily immediately give them their whole volume back. Necessitate a child to an easily palpable radial pulse and improving physiology. Tronics, atomics, acid should be used in Children at 15 mg per kilogram as as a bowl is followed by an infusion and the whole transfusion should be trapped on a massive transfusion record sheet such as one I have on the screen there, which again is available via that QR code. This will help you track the transfusion in terms of number of units and perform important stages like checking uh potassium and gas and clotting if available and very, very importantly, if blood products aren't available, never ever use hypertonic or high Opana tronic fluids. Only ever use isotonic uh fluids such as Hartman's or normal Salem in terms of airway and breathing early intubation is important in Children because of the size of their airways and the high likelihood of obstruction. Remember that chest wall signs are often if not always absent in blunt trauma in Children, uh particularly in blast. But the intro thoracic injuries still may be very significant. And respiratory tachypnea is a very good and early sign of significant injury. The life threatening chest injury seen in Children are the same as adults and the interventions are the same moving on to the uh D and E. Uh the only key points I'd like to point out that the Children are much higher risk of hypoglycemia and the stress of trauma will cause them to be hypoglycemic. This must be actively checked for an all Children that come in with trauma, checking a whole blood or serum glucose correcting to a normal glucose level, keep Children warm. So uncover, examine and then cover again and you always use warm fluids if possible in a warm resource room and a warm theater. Try to liberal only once for minimal handling and clocked preservation uh to look at the posterior of the child and cervical collars are almost no value in a child unless they are reduced consciousness. And you suspect a blunt c spine injury, a brief word on traumatic arrest. Again, this is this can be a survivable event in Children and should be treated along the same protocol as an adult traumatic arrest. But it does require uh consideration of the resources you have at hand to do it and not to detract from treatment of other Children in a multiple casualty situation. But imaging, uh if CT is available, have an extremely low threshold for a for a whole body trauma scan, uh particularly in the context of blast trauma where there is evidence of injury to the child or any abnormal physiology. So the pickup rate of hidden injury is is very high on CT in this, in this context, ultrasound is useful in terms of identifying where blood, which compartment blood maybe in and plain imaging should still be performed if no CT is available, Benzo uh very common. Uh one of the commoner injuries in blast and one of the most uh highest causes of mortality. Uh and again, simply in the recess uh phase, just clean, assess and cover and early fluids in any burns over 20% try and aim for fluids in the first hour along you know, on a calculated base. So calculated to the size of the burn assessed on on surface area, using a pediatric specific chart, like the one shown remember of the child is shocked within the first hour, certainly, then it's not likely to be the burn and they probably have other trauma causing their hypervolemia. So pain is very important to managing Children. It's a basic humanitarian, humanitarian standard in the management of Children. So aim to control control pain as soon as possible. In all circumstances, it's very often under recognized in Children. So actively uh score it either using uh you know, the child's uh subjective scoring or objectively using a tool such as the one shown good pain control, reduce tachycardia bleeding and will reduce the psychological stress for the child. So it's essential that we anticipate and recognized pain and the multiple routes of administration in the child of pharmacological and non pharmacological, uh excellent route of immediate pain relief for the child before you have access is the intranasal route and you can use either fentaNYL or diamorphine. Both of those are described in the manual in the pain section. Lastly, I just want to mention psychological first aid. Okay. Um Last injury and treatment will be extremely stressful to the child and the caregiver and physical injury and intense fear will lead to psychosocial impact and alter the outcome for the child. But we can mitigate this as we go through the care pathway and some key points are trying never to separate the child and carer or until it's necessary or absolutely necessary. Always try to involve the child in the discussion and what's happening and keep them informed. Always stay calm and be reassuring and speak normally and more and most importantly, be nice. So in summary, I'd just like to um reiterate, apply your skills and knowledge around the structure used for adults and you will be successful, prepare yourself and use resources to help you to do this. Be aware of the very few important differences in dealing with acute trauma. Children become reassure and be nice and scan and download this manual where all of this information will be available to help you deal with Children in acute trauma. So I want to talk about preparing for pediatric casualties and in many ways for the organization required to deal with them. I assume a level of anesthetic or medical knowledge that you all have. So I'm gonna look at the larger picture on dealing with these situations. So the aims are to talk about some practical suggestions on how we, how we prepare and treat Children in a treatment facility, how you treat them and also how you manage your colleagues and then to present some clinical cases for your thoughts as to what you and promote some thoughts and discussion as to what we did and what your views are on it as well. So pediatric casualties not only bring the clinical challenge but socially emotional challenge and you've got to be prepared to deal with all the cases that come through. Here is a polyp fragment case coming through one of our facilities a few years ago. Uh one of the most challenging cases you will face is burns. I think burns in any facility are difficult. But when you're faced with the pediatric burn is particularly difficult. And also something I want to talk about later on is dealing with the cases presenting late and some sometimes you have to deal with a terminal care situation in a child. Here's late burns. We, we get presented with uh uh blast injuries. That blast brings everything it brings burns, it, kinetic injury in planes crush collapsed. And then on top of that, we as doctors perform the escharotomy causing more certain political and finally conventional high velocity gunshot wound presenting here with an evisceration to a small child. Now, I don't present these pictures just to shock you. I present them to, to get across to you that if these cases came into any facility in the United Kingdom, any trauma center, they would cause a lot of distress, a lot of trouble, a lot of emotion and they would be very, very challenging cases. You will have to deal with them wherever you are. So it's actually dealing with the emotions and the surrounding command and control that goes with it. I want to discuss today, we will discuss that last case later in the talk as a background. When we deployed to Afghanistan and Iraq, we weren't prepared for Children, but they actually comprise a large proportion of the casualties. We got up to 10% of the trauma. And once you receive the kids, we had them for about 30% of the time in our intensive care unit. So why do sick Children cause anxiety? And to me, it's the anxiety they bring with them, which I think is the biggest problem we can teach you the medical stuff how to incubate, put drugs input lines in its managing the anxiety. So what happens with Children? Well, they're different, they have different physiology. Uh they communicate differently. Some can't communicate at all. Uh There's the physiological signs are different. Uh the drugs and the fluid doses are different. The anatomy is different. The equipment we uses different, the thermal regulations, different, everything's different about them in many ways and we scare ourselves into not being able to treat Children. Uh When actual fact, if you trained in it, you've done it before, you should be able to crack on with it. The one thing I want to stress is it's the emotional hinterland that comes with them. The emotions huge. The emotional temple kicks up in any facility where Children are brought home, especially for those with Children. And often they're accompanied by parents and family. So it's distressing for everyone. But compared to adults, compared to most of the adults, I think pediatric patient's, they are, they're healthier with better cardiovascular respiratory systems. They don't smoke, they don't take drugs. Most of them, they're very rarely are they fat, they're easier to manage and the areas are easier to handle. But you've got to be careful when handling a pediatric airway. You can turn an easy airway into a difficult one by being over anxious and ventilating too much. They're quicker to respond to resuscitation. Uh, they do fall off the perch quite quickly but they get back on if you treat them appropriately and they're easier to handle. So, preparations, it's all about preparation. You've got the medical knowledge you can prepare for that in a day. You have to prepare your facility. So nominate identify wherever you work. Pediatric, lead doctor and a pediatric, lead nurse to take charge of whatever situation comes. In order the equipment you need, check it, prepare it and have uh and then generate wherever you work, generate a pediatric area, whether it's in resource and in the emergency department or somewhere in the certain in the theater capability where you can deal with the pediatric cases and you have all your equipment and ensure whatever training you do while preparing it, you include pediatrics as part of your collective training across any facility. When I describe a nominating a pediatric lead, both nurse and doctor, what we do is that doctor is a nurse or there to make sure the pediatric care happens. It's not for them to do the pediatric care, that person is there to ensure standards and ensure everyone feels they can actually do the care. So it should be two people who have got regular pediatric clinical exposure or have done some training. It can be from any specialty. It doesn't have to be anesthesia or surgery or emergency medicine. Just someone who understands Children and can, can manage the overall medical treatment facility, pediatric care and they are vital to the distressing and the, the crowd control and team management when you get pediatric casualties. So crowd control is really important when the pediatric casualties arrive in emergency medicine department or into the theater where they come, it's crowd control is vital. Everybody wants to get stuck in and get do the best thing, but you have got to take charge. This is a schematic of our crowd control. When we deploy to a military operation, everyone is kept away behind the yellow line. It's important that you manage the crowd and don't let too many people try to get stuck in the child is anxious, the mother and father are anxious, there's anxiety everywhere. So crowd control is vital and uh the the same components for damage control surgery that you do for adults applies exactly the same for Children and at the risk of straying into a talks you've had before. I want to reiterate for the pediatric casualty. We do the same thing, the command huddle the snap brief and the reps and I think it's a great way of managing the injured child, injured adult in theater. Now, from the anesthesia perspective for the trauma call and leading into surgery to support the surgeons, there's the trauma call that you have the command huddle. When the lead surgeon lead in East, this will actually decide what the plan is. If there's multiple patient's, you have a team right to stand by uh snap brief when you're in surgery. Anesthesia is when the surgical team come back from X ray or CT and sailors plan is this allows the anesthesia team to carry on with resuscitation, often with the emergency medicine doctors, then the surgeon will give a snap brief as to what the plan is. But really importantly, uh for during the surgery dealing with pediatrics, particularly because things go wrong quickly. They get better quickly is what we call the stack every 10 minutes. You look at the systolic BP, the temperature and times and starting blood gas status clotting and blood products and how much stuff you've got left over to use, how much blood products it's called the stack. And you give it every 10 minutes to the surgical team. So they don't have to think they know they're going to get feedback as to what's going on. And I put at the bottom here, never let a patient die from embarrassment. If you think there's something you need to say, you should stand up and say it and let everyone and let and let everyone hear you. So for the anesthesia, keep it simple. You anesthetist, the child early, this distresses to the child. It, there's lots of panic to put the child to sleep early. It distresses the staff and it allows for insertion of invasive lines that as for better examination better wouldn't expression inspection and CT scan. I would stress though, for everyone involved be kind be can soft hands when you're dealing with Children, calm heads and quiet Axion. The reality is you do what you normally do but just do it quicker and if necessary use lower does and the simplicity of vital signs. The observations in a child, if the child is hypotensive and tachycardic, they don't have a complex cardiac dysrhythmia there, hypovolemic. They do what they say on the tin. So rely on your monitors and your clinical skills consider alternatives such as Quetta Fall, which is propofol and ketamine mixed together if you need to sedate the child briefly, nasal ketamine med as Lamix cetera. But for anesthesia, they get the same as an adult anesthetic. Just smaller closes heavy opioid based that are badly shocked and beware of the flat child. A child that's letting you put lines in and examine them and not responding is a very, very sick child. Have you pre pre printed drug calculations summer in your facility, the pediatric lead should have access to somewhere where all the drug charts, all the drug doses are readily available, make sure it's warm, it's warm, it's kids lose temperatures quickly. If you have a warm hot facility, you can expose the child, you can examine and resuscitate and assess at the same time. And I know burns can be a large, a lot of major cause of death in Children in trauma, but also massive transfusion causes a lot of stress. But with pediatric transfusion, first thing is do no harm. So have a plan for doing a massive transfusion in a child where bearing where that child's 5 kg or that child's 50 kg. But make a plan for it to be warm blood transfusion and no your equipment, the equipment we use can give 750 mils blood in a minute. You can rapidly fill a kid up with blood and over transfuse. So make sure you're trained and understand the equipment you're using. We use the Belmont, we connected to Children over 30 kg. Below that, we don't use a syringe and inject directly. Uh the principles for massive transfusion, major hemorrhage in child or the same as an adult. Just you have to understand the figures. Concern. Here is the reflection, but it's all about knowing when to start a major hemorrhage policy. Uh So you've got to know your equipment, you know what to use. You don't use sternal IOS and Children. You've got to know the right size of needle for intraosseous IOS and um in Children. And as Paul alluded to it, don't waste time getting IV access. If intraosseous access gets you some time use intraosseous access. And if you do put an intraosseous in one leg in a small child and it comes out, do not put it back in the same leg and cause it move it to a different leg. I'll get onto a simple transfusion rather than in the adult transfusion. You get one bag of blood, one bag of plasma, one bag of blood by the plasma, we distill it down to for the Children. It's five mils per kilo of blood, five mils per kilo of plasma repeated and giving tranexamic acid at the beginning. And calcium chloride, if you can't test at the bedside, give calcium chloride every 3 to 4 cycles of the site of the the plasma and the blood. Here's a simple uh color diagram with the numbers and figures, but please ignore the factor seven but importantly, a lot. Look at the top two boxes be wearing mind the risks of hypothermia, hyperkalemia, hypocalcaemia, and hypo magnesium magnesium eah. But importantly, do not keep transfusing the child continuously. Uh You stop if the hemorrhage stops and the heart rate and BP return to normal the computer, the refill is improved and the blood gasses and lactate look good in the hemoglobin. So you've got to have some clear endpoint for when you stop transfusing, don't continue doing it until the surgeon tells you to stop. You look at the gas is, look at the vital signs, you just have a sheet to record what you've given. So you know where you're at also at the top of the weight that the weight of the child is very important. There's a, there's three ways of doing the weight of a child age plus four times to you can guess or you can weigh the child. Most people who do pediatrics will recognize the weight of a child but age plus four times two is a good guide. Um, I just mentioned that were mass casualties. You do get pediatric mass casualties as well. All that stress is the principles are the same soft hands, cam heads quite Axion and crowd control. So POSTOP for pain relief for those who are not used to doing with pediatric pain, as Paul alluded to pain relief is very important. The Children bounce back quickly, they get well, better, so simple, analgesia, paracetamol proofing naproxen, you're vulture roll, uh nurse controlled opioid infusions or on the wards can help regional blocks work very well in Children, just do them asleep and you can consider things like inter operative, magnesium, cloNIDine and and ketamine. And finally, I just want to talk about one last case to prepare your team. Occasionally, you will have to deal with Children who are dying and you have to find somewhere to place the child who's dying and have identify your staff who can look after that child. That's a really, really important thing to do to be able to manage the dying child with the staff who can do that. We have these cases in the past. It's all about how you manage these cases and it's having an ethical framework to work by. It's having a clear plan to make these difficult decisions. And if you do make these difficult decisions to let a child die, uh be aware that you have to have a medical plan to, to look after the child till they die, identify the staff who are strong enough to do that and it's to plan for the patient and staff to look to do this job. So finally, I haven't talked much about the nitty gritty of anesthesia. I presume you can all do anesthesia. It's just applying the simple principles of sticking to the, the the policies and the guidelines and it works. Uh don't but don't underestimate the emotional impact on your team. I think anesthesia quite good at taking the lead. So my summaries give blood products early. Stick to the transfusion protocol. Stop surgery. Allow the, allow the beast is to catch up with a major hemorrhage. It's hard work. It's hard work emotionally and it's hard work physically, especially with the Children and in theater with these cases, it's at least a three person technique that simple stuff done early for Children, saves lives there not complex when they come in. And if you intervene early, you can make a huge difference.