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So I'm a pediatric surgeon working at Birmingham Children's Hospital. I've also had experience in the military doing both adult and pediatric trauma. A lot of the work that were that that I'll cover in this is actually in the save the Children, pediatric blast injury field manual. This is the QR code for it. So, um it's well worth getting a copy of that and the work we did out in Iraq and Afghanistan, what we realized is that you do not need to be a specialist pediatric surgeon to operate on Children. The most important thing when you see a child is that you keep all of your skills that you have learned on the management of adult trauma and apply that to the Children, uh to use exactly the same principles that we do for managing major adult trauma. First, we're going to control major catastrophic hemorrhage and then follow the A B C D E approach. Uh It's important to use whatever resources you've got in the most innovative way you can and we're going to use damage control principles the same as we weren't in adults. There are a few important differences with babies and Children, but essentially the principles are the same. But Children are scared to be calm, be reassuring and be nice. One of the important things that we have learned is the how essential communication is between um surgeons but also between all other members of the team, the anesthetist, the E D consultants, the nurses. We wrote a lot about communication and the and human factors from our work in camp bastion. The important things when a child is, is traumatized are exactly the same as adults. These Children are going to come to you with four uh serious problems, acidosis, coagulopathy, hypothermia, and hypercalcemia. We call this the Lethal Diamond and what's essential about your surgery and your resuscitation is that you interrupt, stopped this process from getting any worse. And so the surgeons need to remember that surgery itself is a major trauma and therefore we shouldn't prolong the surgery any longer than absolutely necessary. And these principles are just as important, if not more so in Children than adults. The other principle which is the same as adults is that we're going to use a ratio of 1 to 1 to one for resuscitation. The other thing that we have learned about surgeons is that they need to be able to stand back and make a plan rather than getting dragged into the resuscitation. You already have excellent doctors in the emergency room and excellent nurses. The surgeons don't need to be there. Stay behind the line So one of the things I think is most important is for the surgeons to have a plan. So in this example, the injured child has got a good BP. And so we've made a plan to go to CT scan and then to the operating room, but the same child has suddenly collapsed with bleeding. And so you, the surgeon needs to have already made a plan B and we know that damage control surgery works really well in Children. Uh been in this sort of situation many times before where the BP has collapsed. We've done a laparotomy, we've packed the patient and then um, resuscitated them after the surgery. It's physiological surgery. So, you know, most injuries can be left to a later point. If you control bleeding, remove obviously dead tissue and remove contamination, then you can come back when the child is fizz ideologically well. And do you know your, your clever surgery, whether that's on the abdomen, on the bones, neurosurgery plastic surgery? You know, we can do all of that when the child is in a better physiological state member. Keep talking with your anesthetist because they will tell you when the BP uh improves and you can continue with your surgery. So the general principles, we know the damage control surgery works well in Children. The principles are very simple. Okay. Once you've done the C A B C D approach, we go to, to surgery for damage control and the principles then of surgery are to stop the bleeding limit the contamination. So if it's bowel injury, you're going to take out the dead bowel and wash out the the contamination, the bowel contents and you're going to leave the abdomen open to avoid compartment syndrome. And then you go to the intensive care unit to correct the physiology before doing any more surgery. Now remember that in blast injury, more than one region can be injured and you must be aware of distracting injuries. So for instance, a traumatic blast amputation in the child is a very distressing thing for the staff to see. But actually the most dangerous part, maybe a small bit of shrapnel in the chest or in the abdomen and beware of late injuries, particularly in blast, sometimes problems with the bowel or the lung can only develop a few days after the original injury. So if the child deteriorates then think, have we missed something? So wherever possible, this child should eventually have a CT scan and it's perfectly okay to do this, you know, 22 days after the original injury, if the child is too unstable. So, so don't feel that you have to do it immediately in every situation. So I'm going to talk about thoracic injuries now. So the majority of injuries in the chest in a child can be managed by oxygen, chest drain and good analgesia. The dirty dozen injuries are exactly the same as you find in Children, imaging is vital. There are a lot of problems that you cannot pick up with clinical signs alone. If you look at the chest X ray, you'll see the tiny little fragment of shrapnel that was uh inside the heart causing a cardiac tamponade. It took us a long time to notice it. But once we had and we treated the child, they did very well. The other thing to remember is if you need to intervene, the only incision that's important is a clamshell for economy. And just in adults, you started about the fifth rib just below the nipples or the breast tissue. And you go from posterior axillary line, too, posterior auxiliary line and the sternum can be cut either with heavy shears or the jiggly saw just to, to go through that in more detail. So remember in a child, the diaphragm is much flatter. Um and they've got a really big liver just as we would do in the abdomen. The first thing to do is to stop the bleeding. And the easiest way to do that is with packing. If it is caused by uh tamponade, then you must open the pericardium. Uh If the bleeding is coming from the lung, then non anatomical resections of the lung work well, either with a stapling device or just with some clamps. But we always say in Children try to avoid taking out the whole lung and pneumonectomy at all costs. Even if you can only preserve a single lobe that will expand and keep the balance in the chest. So we'll move on to abdominal pelvic injuries. Again, the principles are the same as for adults with penetrating abdominal trauma or bowel perforation. Blast injury can cause delayed bowel perforation. The one thing that we do much more of the in Children is for blunt trauma, we are conservative with bleeding from solid organs. So just to go through that in more detail, in blunt injury. So injuries that cause rupture of the spleen, the liver or the kidney. Um these Children need resuscitation uh and they don't need to be rushed to theater immediately. So if you see blood on a fast scan or ct scan in blunt injury, it doesn't mean you have to rush to an operation, you need to resuscitate them with, with blood. But then after that, you need to continue to actively observe them. This can also be useful in blast injury because Children have got a thin abdominal wall. Um and that can cause major trauma to, to the solid organs. Plus the fact that in blast injury, the child will be thrown against um other structures and therefore can get the blunt injury. So when it comes to operative techniques, there's some things for you to remember in Children below a year, a horizontal side to side incision just above the umbilicus works much better. Uh As you can see from the diagram, the liver takes up a large part of the abdomen. So if you use a vertical incision, much of your incision is just over the liver. The first thing you do in massive bleeding is is open the abdomen and just press honestly, just press and wait until the anesthetist has got a good, got a reasonable BP, then start your your visceral rotation. So if it's on the on the left side, then you mobilize the left colon. Um And then you can, you can bring the colon forward, you can see the spleen um and the kidney and the aorta. And if it's on the right right side, you do the same again. I normally start at the cecum and I divide the lateral attachments. I bring it forward and you can then see the kidney, the duodenum and the inferior vena cava. Um So these are good techniques. But remember before you do it, you need to have proximal control and often in a small child that means opening the chest and pressing on the descending aorta. And I'd like to add just one thing too that, that the surgeon should not be frightened of starting their laparotomy just within Torossian. This access, if you've got no BP, then the emergency team and the anesthetist will not be able to get the BP up until you pack the abdomen and stop the bleeding. But the good thing is because the abdomen is relatively small packing works very well for controlling bleeding, however, vessels get easily damaged. So try to avoid using clamps. If you see that bowel has been damaged, you're much better off resecting it and leaving it disconnected to start with. Do not attempt a anastomosis when a child is unstable and it's much quicker to just leave the bowel, uh tied off and dropped back than it is to create a stoma. The Children tolerates sepsis very poorly. And so, um, uh, it's better, it's really important to aggressively clean any bowel contamination or, or dead, um, dead tissue within the abdomen. In this picture, I'm doing damage control surgery in a baby. I've respected the damaged bowel. I've tied it off with a silk suture and I'll wash out any contamination and you can often do this operation in less than half an hour. Most bleeding from solid organs will settle without an operation. If you are forced to operate on them, then try and preserve the organs where possible, either with packing or using a mental patch. It's much better to come back and do a second look a few days later and then you can either leave it behind, partially receptive or only remove it if it's absolutely necessary. Uh, with kidneys and liver particularly, um, it's best to try and pack drain and then transfer to a specialist to do a reconstruction. Um, so temporary, temporary abdominal closure, we use exactly the same technique that we did in camp bastion. And so this is now known in the UK as the mini bastion sandwich technique. And if you need to evacuate the child, then doing it with an open abdomen is a, is a good way to transfer them out. Um So let me just describe in detail how we will do this uh in babies. So, first of all, I take a bag of sterile saline and drain the water, the saline out. Um And then I'll cut uh and the lips of that plastic, which is just two centimeters wider than the incision. And then I'll put some small cruise ships. So cross like incisions with a 15 blade. So um here you can see the size of the incision. So it's not much bigger than the width of a 15 blade. And if you look at the little picture at the bottom, the green one, you can see I've made multiple uh incisions in the plastic to allow the fluid out. You then tuck that piece of plastic into the abdomen so that it's sitting between the abdominal wall and the bowel. And then you're going to cut some layers of gauze to just be slightly wider than your incision. And then into that, you, you place a nasogastric tube that's your sandwich and you need to get the skin really nice and dry and then play some plastic over the top of it. So sticky plastic, we use something called to God. Um I'm sure you've got something similar and then that needs to be attached to the suction. It's low pressure suction. So 3 to 5 millimeters of mercury if you can do it. But, but certainly no more than 15 to 20 millimeters if that's as low as your pressure goes. And it's important to keep that on continuous suction. Otherwise, the fluid from the abdomen will start to fill up and cause pressure problems. Um And it can also cause the dressings to come off. It also, if you don't keep the suction, the fluid will, will make the dressing come off. So, if you're transferring the child out with an open abdomen, you need to be able to continually suction on the dressing on the tube. We've written up the the use of damage control surgery even in the tiniest baby's below 1 kg in size. So, so after your first part of your damage control surgery, the abdomen has been left open, you're going to come back when they're off the iron, a tropes off BP support and the blood gases are normal. And usually this will happen at about 48 to 72 hours at this stage. A bowel anastomosis is well tolerated or if you need to, a stoma does much better at this point as well. And also if there are injuries to follow organs, this is the best time to do the partial resection. Uh, feeding is really important in Children because they need good nutrition to heal. And so we find that if you've got a, if you place a nasal jejunal tube, when you do the second look operation, then you can, um, feed them early and then for their POSTOP care. Uh, it's important that the same doctor or nurse sees the child everyday. We found in cam bastion that we could always find one doctor or nurse that had some experience of, of looking after Children and they would become the designated doctor. And if they see the child every day, they'll build up a relationship and the child will trust you and then speak to you. The other things that are really important post operatively are pain relief, looking out for sepsis and good nutrition. The other thing with Children is if your, if the pain relief is good, they will get mobilizing quickly. And you can see this child who's had a clamshell thoracotomy is playing football just a week after the surgery. As I said, I like to put an N J tube in early for feeding. Children develop an alias earlier signs of sepsis or major trauma, but that shouldn't stop you with continuous feeding with an N J tube. You can see from the picture is a trick that some that a surgeon in Syria showed me that if you tie some silk to the end of the nasogastric tube and push it in, then the bowel Paracelsus will, will move it into the jejunum. So it's a very easy way of um passing an N J tube if they're not having an operation. And I'm just going to show you a case that I was involved in many years ago. She had been shot an hour before there was an entry and exit wound on the abdomen and signs of a mentum coming out when the child arrived, she was still conscious, but she had no pulses and you couldn't get any capillary refill. The emergency doctors, um uh got venous access with an interest CS needle. Once I'd controlled the bleeding, then they got the BP up, then they put their federal lines in. Uh, and then we continued with the surgery. We decided that she needed to go immediately to, to the theater. As soon as the anesthetist had put her to sleep, I started the laparotomy incision and this was even before we had proper venous access, we just had interosseous access. As soon as I opened the abdomen, I found lots of blood and all I did at that stage was to pack the abdomen and press while the anesthetist transfused the patient. And for 20 minutes, I just pressed on this child's abdomen when the anesthetist told me that the child now had a better BP. We removed the packs, we found several bowel perforations. So we tied those off with silk. The uh stomach was badly injured as well. So we had to resect and repair that. And that was the only way to stop the bleeding from the stomach. The liver injury was just packed. We quickly debrided the edges of the wound. We washed out the abdomen of the the contamination. And we used a bastion sandwich for abdominal closure. And then after 36 hours, I brought her back to theater, I was able to remove the packs and re an estimate. The small bell, I inserted an N J tube, washed out the wounds and closed the abdomen. And you know, this little girl went home on on day seven. I hope it shows that the principles are the same as doing damage control surgery in an adult. It shows that nutrition is very important and Children keel well and want to get moving. And so my, my message on for this uh for Children is beware a child who's to cooperative. If they, if they behave themselves, then often they are more shocked than you realize. So always be careful if a child is behaving too well in the emergency room, it may mean that they are bleeding more than you think it's important to work as a team, particularly with Children and to be prepared before they arrive. Remember that damage control, resuscitation and surgery works well in Children treat sepsis aggressively and start feeding as early as possible. So I'll give you the final um slide that damage control is good at saving lives. So keep Compaq and then pause while you're anesthetist catches up. And again, I will tell you, remind you about the pediatric blast injury Feel Manual.