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I'm going to talk through the basic pediatric assessment and management in a trauma setting. And then I'm going to focus in on a limb fracture and amputation management from a pain perspective. Then look at the general immediate perioperative management and some of the longer term considerations. So why is pain management important? This I've taken from the pediatric blast injury field manual. This summarizes it really nicely. So excellent pain control is a basic humanitarian standard and in the management of injured Children and not only does good analgesia, reduce tachycardia and bleeding, but it will keep the child calm with the family calm and also all the healthcare workers around the child. And it will let you do your work much more easily and with less distress to the child. And so looking at how to assess a trauma patient. So if it's an older child, you can I asked them a pain score between zero and three, looking at zero being no pain, one being mild to moderate and three severe pain. And if they're much older, you can use sort of adult visual analog uh score where zero's no pain and 10 is the worst pain imaginable for a much younger child. The on the right hand side of the screen, the older, hey, triage pain score has been validated for trauma and in pediatric patient's and with this, if they score anyone, then you want to at least give them mild to moderate analgesia if they score to for anything and you want to give them strong analgesia. So that would be if they're inconsolable if they're crying in pain, if they look like they're in pain. So this is written as a long grimace of more than 50% of the time. And if they're tense defensive, if they're a mobile or thrashing or if they look very pale or green in color, looking at general assessment of these patient's. So, the European Society of Pediatric Anesthesia has written a Pain Management Ladder initiative and some of the, the some of the recommendations from this and are to make sure that you regularly assess pain that you do pain scores at least three times a day that you look at pain as being a vital sign. And so you don't forget to, to check on it and aiming that Children should have pain scores of under four. This is again straight from the blast injury field manual and but just to not forget the non pharmacological management and there are lots of, lots of simple things that can be done that really do help and manager child's pain. In addition to the pharmacological management and keeping a child, you're keeping the parents or the carer with the child. And is probably the most important aspect and where possible and involving the patient in the, in the child's pain. And it will really, really help and, and listening, listening to the family because they probably will know their child the best. So looking at the pharmacological management, the reverse who ladders to the reverse world health organization ladder. So treating severe pain going in with strong, strong opioids in, in some root whatever route you can, which, which we'll talk about shortly and but not forgetting simple analgesics as well. So regular paracetamol even giving that orally and oral couple, most Children love couple. And so it's not forgetting that and and then as their, their pain improves, you can step down. So step down to a mild opioid. So codeine or traMADol codeine is sort of has is out of favor really in the under 12 year olds and any child that might have obstructive sleep apnea. And I must say we don't use it very often now in the UK. So if you have traMADol, fantastic, if you don't consider using or or more more morphine instead, rather than rather than codeine and then stepping down to just simple painkillers. So regular passy two more regular ibuprofen or other anti inflammatories if them appropriate, why do you want to give the the simple stuff regularly? So if you give, for example, paracetamol four times a day, you maintain a therapeutic window which is shown on the graph at the top. And if you just give it as required, it drops down to being sub therapeutic and then you have to start all over again. So you just simply don't treat the pain as well. And, and also by doing this, you don't need to give as much as of the, of the strong pain killers. So of the morphine or other opioids that, that all have side effects. Um so, so the more of the simple stuff, the better really and what more on this, why combined the different painkillers? So you can see at the bottom right hand side of the screen, they all act in different places. And so from, you know, local anesthetics, anti inflammatories like ibuprofen peripherally, then you know, local anesthetics depending where you block. So if you, if you did a critical nerve block, they're slightly higher up this pathway. If you did a central block, the higher again, and then opioids, you know, work at the dorsal horn within the spinal cord and then also up in the brain and then other medications also act more centrally such as alpha two agonists like cloNIDine. And so, and then again, the opioids fearing effects are really important. And, and then if you, if you give multiple energy six together, you actually not only and improve the pain relief, but it actually lasts longer and which is shown, shown down on the bottom left. So Ibuprofen and paracetamol at a sort of full add out dose is the yellow at the top. Then a half a dose of both as a red. And then you can see I be proofing in green and, and paracetamol and blue and then, and then placebo at the bottom. So I'm now going to move on to present a case study um of of a six year old boy who um was involved in a road traffic accident last month at the beginning of April. So he was a back seat passenger in a people carrier and he was involved in a high speed collision on the motorway in the fast lane and the car collided with an abandoned stationary car and the car flipped and the child's left arm was trapped outside of the vehicle. Uh He was brought in by ambulance and his um injuries have been drawn on the screen. So his, his main injury was a left degloving and open humerus fracture. And he also had some distal fractures of that left arm. He had a deep scalp lacerations and a hand abrasion on the right and a small new lacerations that the following images I have consent from his family and to to show these. So this was taken at the scene. So the child's initial pain management was in a pre hospital setting. They attempted some enter knocks and then they gave him some intranasal ketamine, um 10 mg and then 15 mg which will see on subsequent slides is quite a small dose. And he then went on to have intravenous ketamine and then some intravenous morphine. Before coming in to hospital on arrival into the recess department. He had some further morphine um in in small Allah quilts and then he had a quite a big dose of ketamine sedation to allow it prolonged what was described in the looks as a prolonged examination and of his left arm, he was then moved to the high dependency unit, started on some regular paracetamol and a morphine and nurse controlled analgesia pump and which had a 20 microgram per kilo per hour infusion with a 20 microgram per kilo Bullis every 20 minutes uh as needed every 20 minutes. And then I'm going to go through his first three surgical operations because they interestingly show there's sort of probably three levels of, of approaches to pain relief for, for this type of limb trauma. So his, his first surgery, his initial operation, he had a washout and debridement of his wounds and an external fixator applied. He had paracetamol morphine and on down strong dexamethasone given. And then he was continued on his, his N C A POSTOP for the subsequent and operation, which was a second luke and further debridement of his injury. And he, and, and also the closure of his large scout lacerations and he had a super clavicular nerve block known as the spinal of the arm, so known as a block that will block the whole arm from the shoulder down and which he had 20 meals of um local anesthetic of 0.25%. Um 2.25% leave it with lidocaine and some cloNIDine 25 micrograms of cloNIDine and he then had the remaining dose of his, he could have 25 mills and in total of 250.25%. So the remaining five mils was diluted down and to make a 50.125% solution with some adrenaline for the plastic surgeon and scootering the scalp lacerations. He also had some paracetamol. He had one Mike kilo fentaNYL and he had some IV dexamethasone and IV dexamethasone is really useful and it's an anti emetic. It's crew synergistic with paracetamol. So it enhances paracetamol defect. And in its own right, there's good evidence that it improves and peri operative pain management and it also prolongs nerve blocks and in adults and work's going on to, to look at that in Children. But, but the likelihood is that, that it does than for his uh sort of definitive operation. So for his um left arm reconstruction and where he had a free flap from his scapula's the donor sites of left upper arm, he also had a split skin graft to the underneath of his left arm. The donor site was his right thigh. He had a sural nerve graft to his radio, your nerve, which had been damaged. And for this, he had a super clavicular nerve capita which was bullous for 20 miles a 200.25% legal bupivacaine. And then he had an infusion running of 0.2% mepivacaine. He had 0.1 meals, tequila per hour. So running at 2.5 miles an hour, which is sort of half of your maximum hourly infusion rate. Um He um, as you can see, the, the plastic surgeons did, did a fantastic job and reconstructing his arm. He has unfortunately had to come back to surgery because his flap has been infected, but they has managed to be washed out and, and so far is still intact and just a note on antibiotics. So he, so, so these sort of injuries and I understand that in some ways similar to ballistic injuries in terms of being very dirty and straightforward antibiotics. Again, my understanding and we will treat this very well that they're dirty with normal bugs and there can be a lot of resistance down the line with, with osteomyelitis and antimicrobial organism resistant bugs suits that. We're starting with simple anti antimicrobials. But then if, if things aren't responding and thinking about fungal infections as something else to think about, which is, which is what's happened in this little boy's case and which is being treated with anti fungals. So, more on the general immediate management of limb trauma. So the simple energies, it's very important. And then some sort of um opioid and or ketamine tend to be very commonly used and then regional nerve blocks if, if you have the resources to do them. So this again is from from the field manual and or um office at the top and then morphine and fentaNYL. So in their intravenous doses given in small and Eliquis and really giving until you have a good response from the patient and just being cautious of the side effects and which you know, you'll be all be familiar of respiratory depression and and CNS depression and then nausea and vomiting. Then I'm going to talk about the intranasal routes because these may be the best option before IV access is secured or IV access is very difficult or extremely distressing and then ketamine in terms of its its flexibility availability and it's cost that's got lots of positives for for immediate management of these sorts of injuries. So looking at the intranasal route, so diamorphine is a fantastic drug for intranasal and administration because it comes in a powder, you can make it very concentrated because of that and an intranasal absorption, each nostril about 0.2 meals and is sort of optimum any more than that. And it just drips down the back of the throat and isn't absorbed as well. And we have a shortage in the UK of diamorphine. So we're currently using fentaNYL and you know, also works very well it's just that you in a bigger kid, you end up with a bigger volumes that just being aware that, you know, some of it probably will be absorbed as well. And so intranasal fentaNYL can also be used in Children over, over one year of age and similar dose is two intravenous dosing and and it comes in. So it's 100 micrograms in two meals. So 50 micrograms in a meal. So if they're, for example, 20 kg and, and you want one microgram per kilo, that's 20 micrograms which then works out as 200.4 of a meal. And, and then these can be given, either drug can be given um intron easily with an atomizer device. So ketamine, so ketamine is an NMDA receptor antagonist is very cheap and it has a lot of benefits. It's in terms of if you're in a um if you are somewhere where you really can't access decent monitoring or you don't have um the resources to, to monitor fully monitor a patient, then it's probably the drug of choice and it can cause dysphoria and it can cause s salivation. It can cause funny movement. Um It's referred to as disassociative anesthesia and bigger doses. So the patient's looks and sort of out of it, but they're a week that they look sort of semi conscious and often with their eyes open steering and they, but benefits wise, it doesn't tend to reduce your respiratory rate. You tend to maintain your airwave reflexes and, and there's lots of different routes of administration. So, intravenous, intravascularly similar and, and similar speed of onset takes about five minutes to kick in and intranasal takes a bit longer sort of 15 minutes or so. And you need to give a bigger dose and then intra muscular usually say, you know, don't give any, any agents, anything thing intramascular because it's painful. But for example, a childhood, you know, extensive burns, if you just can't get intravenous access and then then intramuscular ketamine, you it's just weighing up the risk benefits. But you, you know, you'll quickly be able to give them some decent analgesia by, by that route. And now I'm moving on to peripheral nerve blocks and I'm going to run through the benefits of them. Some of the risks, hopefully reassure you regarding the risks and look at some of the common limb blocks for fractures and amputations and then go over some of the local anesthetics and the doses and some of the things that you can add, add to the local or give alongside it. So in terms of benefits, so there anesthetic and sedation spearing and that might be of great benefit if you really can't, you know, if you don't have the manpower to, to monitor a sedated patient. So if you can block an arm and make them make that arm pain free, you know, you're going to be able to easily move them to another center and without causing them a lot of distress. This way, it makes it a very efficient use of resources. It, as you can see on the right hand side and from is part of multimodal analgesia. And with the addition of and the addition of a block which you can see is in the orange at the top here. And patient's tend to need less of the rescue medication. So less of the opioid side effects and it in itself reduces the stress response, it reduces the side effects, more opioids as as mentioned, and there is reduced incidence of chronic pain with the use of these particular particularly phantom limb pain. So in terms of the risks and safety of pediatric, regional anesthesia. So nerve blocks and in the UK you know, a lot of is very much widespread in an adult practice but probably still lesser in in pediatrics. And I think patient uh so clinicians are perhaps slightly nervous of performing blocks in in Children, particularly asleep Children. Um These two very large databases and one from France and one from the US shows that the the nerve injuries and and adverse events are extremely rare in in these Children. And for example, in the American study, out of 10,000 nerve blocks, there were only 25 cases with and where there was a neurological deficit and all of these were transients, there was no no permanent nerve damage in in the 10 10,000. And then the European Society of Regional Anesthesia and the American Society of Regional Anesthesia um concluded from this, that there's that there's sound evidence and to recommend that these regional blocks can be performed under anesthesia or deep sedation in Children of all ages. Then looking at how, how we perform these. So, um this Cochrane review from 2017 and looked at the use of ultrasound in regional anus ease in pediatrics And it showed, you know, really a very improved success rate, improved postoperative pain scores, prolonged blocks, they were quicker to perform the blocks than those that had those using out sound. And compared to nerve stimulator techniques, and they needed fewer needle passes and they ended up using far less in terms of local anesthetic doses, which particularly you have a child with multiple injuries, needing local into lots of other sites. And these are all really, really important and, and the conclusion from um the apricot study which also looked at the ultrasound compared to other techniques. And they felt that actually the argument in pediatrics and in terms of safety is so strong that it's, it's hard to justify not using ultrasound. And I appreciate, you know, there may be settings where it's extremely difficult to access ultrasound. Um I think the Fascial Yaka landmark technique can be performed safely if, if you don't have access to ultrasound and you need to block the femoral nerve to allow you to manipulate fractures I think it's probably one of the few that you're, you know, suitably far away from the nerves that, you know, the risk of damaging. It is very small. So this is showing you if you draw a sort of virtual line between the anterior superior x spine and the pubic tubercle and divide this into thirds. And then you would like, you want to put your needle beneath that between the middle third and the lateral third and you can feel a sort of to pop if you use a slightly blunt needle to pops as you go through the fascia in Latin and Fascitelli aka to deposit the local anesthetic and the child again should be supine. You can have to buy slightly abducted and externally rotated. Um And, and this will block the femoral nerve, variable in terms of lateral cutaneous, never the thigh and the operator nerves, but that's where it's also known as a three in one block. Uh um So just to um so some take home messages. So really getting the basics right and giving simple analgesia doing pain assessments and, and treating the pain, you know, from the outset really will make a difference and to the patient's recovery and remember the non intravenous route. So for and for ketamine for diamorphine, for fentaNYL and intron easily is a fantastic option and local anesthetic infiltration and I even better a nerve block and but but don't forget the local anesthetic and then just thinking about the different resources you have available to you and that will make it, you know, that's really important when, when you're thinking of all, all these things.