Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

So the today's aims is to provide some practical suggestions on how to prepare your facility and subsequently treat the Children in your facility. Being a large building, being a small tented facility no matter where you are, so how to treat the Children. But I think really importantly also how to manage your colleagues. I think that's a real big issue when it comes to dealing with pediatric casualties. And at the end, I want to present some clinical cases and promote some thoughts and discussion. You've all seen pediatric casualties from the battlefield. I have a few pictures here which I showed my civilian colleagues to show the nature of the injuries and to get across sometimes how emotionally impactful they can be. This is a classic, multiple small fragments probably from a mine or a small rocket device. This particular picture I show because it causes most of our pediatric, at least is to get concerned because the patient is lying there fully exposed. And as you know, pediatric patients get cold very, very quickly, but it's here for a reason. So I think it's really important when dealing with the badly injured child when they reach your facility. I'm a big proponent, a big fan of put the child to sleep as soon as you can for several reasons. It distresses the staff. It deals with emotional burden from the child, the parents and the staff. It allows you to fully exposed and examine the child. It allows you to get the lines in and do everything that's necessary prior to the definitive treatment. However, it's very important if they are exposed, it's got to be warm. If it's not warm, then keep them exposed for as little time as possible. Some other pictures and not so much to dwell on the previous case. But I think burns are very challenging. But the common theme with all the pictures are the emotional impact, particularly for parents and for doctors and nurses who have Children is huge. And I think it's very important that the experienced members of the team, manage the team, manage their emotional impact and keep on providing care for the child in general. They're very simple to treat, but it does require everyone to focus on the task in hand. I think burns are particularly difficult. Also, I don't know if this applies to you, but we have the, when we deploy, we also have the capability to provide end of life care. I won't dwell on that on this particular talk, but it's something you may want to consider end of life care for Children can be a very challenging situation for all the staff, a brief mention of the challenges, the particular challenges and this is really in the surgical territory of blast injury. The blast obviously has its several stages of blast, including the blast wave debris, shrapnel bodies being flown and the burns and then particularly for anesthetists, it's difficult because we've got a very, very badly injured child and then the surgeons come along and do the necessary escharotomy ease, therefore, compounding the problem with multiple blood loss requiring massive transfusion. So I think the blast compounds all the injuries into one and probably the overall most challenging situation, especially if it's burns and blast. And finally, this this slide I show because this is a particular case that came in which really upset the whole staff. I seem to be talking about the emotional aspect quite a lot because I think it's very important. It's a classic case got high velocity gunshot wound to the back, exit wound to the front. Again, this girl came in wide awake, very distressed, very upset. And as I said before, if you can and it's safe, put them to sleep straight away before you then go on to get more lines in, examine them, expose them, investigate them. So historically, during the British experience in the military on our recent deployments, we have found that 10% of our work load has been pediatric. And when we through the door for our surgery, and traditionally, once we have the child in the facility, we, they tend to represent up to 30% of our intensive care bed bedtime. So when we prepare to go away, we know that we will get Children. But also once you have the child in your facility, you may have to look after them for quite a long time until they're better and ready for discharge. Unlike adults, you can often discharge earlier. So why do you injured Children cause anxiety? What is the problem? Why can't it just be like adults and Children? Well, it's multifactorial because if you can understand these and manage these with your team, you're well on your way to dealing with the injured child, the different. And if I work my way around communication is different, the communication is different with the child, with your team and with the parents uh blood transfusion. I think that's been a big win. And well, there's a couple of slides on managing major hemorrhage in the small child drug and fluid doses. I'll talk about later on. There's, there's download sheets, little sheets you put on your app. So your computer, I put the weight in, you get all your drug and fluid doses, physiology and vital signs. You just have to learn them. But they're in the book, I refer to later on the anatomy of the Children are different as you know, more vulnerable to some injuries. If they have broken bones, that tends to indicate a greater degree of transmission of force. Uh The equipment can be different and I mentioned thermal regulation. I get cold very quickly, so keep them warm. But compared to most adults and I stress this, compared to most adults, pediatric patient's are, they're healthier better cardiovascular respiratory systems. They don't smoke or take drugs to anymore age. They are. I say they're rarely obese, but that's obviously becoming an increasing problem in western Europe. Uh They are easier to manage the airways and incubate if it's done carefully, but you can make it quite difficult. And I'll mention that later on, I've seen a pediatric cases brought in where the airways been over enthusiastically managed and you have a large stomach bubble creating an issue and they do respond quicker to resuscitation, they fall off their perch quicker, but they get back on quicker and they're easier to pick up and move. So preparation, it's all about preparation with your team. Um I'll be brief on this before you. I'm sure where you work, you have nominated a pediatric lead doctor and a pediatric lead nurse. It's very important when we deploy that there's someone who is going to be pediatric lead and this person doesn't necessarily do the pediatric work very often. These people will stand back and just keep an eye on everyone and make sure that everyone is able to get on with the job and they can make sure everything is working properly. They will check the equipment, prepare the equipment and order the equipment. But also where wherever you work in your resuscitation area, make sure you have a pediatric area. So when Children come in, you can take them to that small area where all the equipment is and it's separate and it's quieter. And if you get a chance ensure that pediatric training is part of your training in trauma, throw in one or two cases, every time you train just to put in the small child, make it challenging, make them small burns blast, etcetera. The one tip, little tips for your area. We've already mentioned having a dedicated pediatric area. If you can source a white board for your calculations for the drugs, the tube sizes, you're tranexamic acid, etcetera and plan early. Um That's and then the drug calculations. I don't know if you use online drug calculators for pediatrics, but I often don't know the does. So what I do is I put it on my laptop, my iphone, put in the weight or a rough weight, have it all there and we'll print it off and have it in the corner. If anyone needs any links to these online calculators contact me and I will send them. Although I'm sure you've all seen this book, Pediatric Blast Injury Field manual, which has lots of what I'm talking about in it already. And references as to where to go for these, these um these links when you get a pediatric trauma coming in, I think I talk about people control, managing your team. I think that's more important. I assume most doctors will know how to do the clinical work. Sometimes it helps to be refreshed. I think the most important thing you can do as senior clinicians is crowd control and manage your team. You get lots and lots of people turning up. But I think it's important you send those away who are not required, keep those who are required and keep it calm and keep it simple and keep it very controlled for the child. So when the child first comes through now, this is straying into the recess territory for the emergency doctors and emergency surgeons. But in the UK system, we also have the anesthesiologist there as well. I've chosen, chosen a few points here, I think are worth mentioning. There's multiple things to talk about in the initial resuscitation before anesthesia. But I think these are very important points, a child who lives there and allows you to examine them without complaint, is very, very sick and you need to get on with the job. Bear in mind, hypertension in Children is a very late sign, very late sign, skin temperature, better refill time are useful if you have a child brought in and you're struggling to bag mask, ventilate with a with a bag. It may be because there's been overenthusiastic hand ventilation out in the country and they've got diaphragmatic splinting in those circumstances. Slipping a nasogastric tube or a gastric tube and generally deflate the stomach, intravenous access and intraosseous access once it's achieved securit. Well, my, my recommendation is you get one access and if you can off to sleep safely and then do the rest of your access and expose the child fully, so you can examine them fully and line them up fully, but cover quickly if you can't keep them warm. Um When you start the anesthesia resuscitation, um there's the three phases as the command huddle, you get together as a team deciding what you're going to do, then the anesthetist, uh then you'll be the snap brief and the situation reports. So in the trauma coal, we have the command huddle and the command huddle will be the trauma team leader, the emergency medicine doctor, the surgeon who will get together with the anesthetist, the surgeon and the theater nurse and determine a plan of Axion and has multiple patient's. You get the team together. So that's the command huddle. So the snap brief occurs next. So after the command huddle, when's a plan made, the anesthesia team will take the patient to theater and they'll do the anesthesia, which I'll talk about later on, they put the patient to sleep, they position them, they prepare them and the surgeons have a chance to talk amongst themselves with the radiology and make a decision. They then come back to theater and they perform the snap brief to everyone. So then the surgeons will start their surgery and when working their magic, I think that's really important now for the anesthesiologists in the team, they then have to support the surgeon. Obviously, keep the patient safe. But I think it's very important what we call going, ongoing sit reps stack and you feed to the surgeon every 10 minutes while he's dealing with the various year. He's dealing with very difficult multiple trauma, the systolic BP, the temperature and times and start blood gas status clotting and the blood products you've used. And I talk about kitten resources. It means that things you may be running out of or things you may need. So every 10 minutes you get, tell the surgeon a stack update a sit rep I tell everyone I work with whether it's in National Health or in deployment. If you think there's a problem, speak up, never let a patient die from embarrassment. So for the anesthesia for the best bit, obviously, the anesthesia down the left hand side, I tell my niece to keep it simple anesthetist, the child early. So it distresses the child distresses the staff and it allows for invasive lines, examination and wound inspection. And one thing, the three things that soft hands for Children, small Children, soft hands, calm heads and quiet Axion. So in reality, I would tell my anesthetist colleagues do what you do normally, but just do it quicker with purpose and bear in mind, the physiological status of the child. I've got some drug doses down here on the left. That's our classic trauma induction doses, fentaNYL ketamine, rocuronium, you can use whatever drugs you normally use. But I would suggest you lower. The dose is the more shocked and injured the child is stick to the simplicity of vital signs, heart rate and capillary refill. Remember, BP is a very late sign, heart rate, capillary refill and the general consciousness of the child. There are alternatives of drugs you can use such as ketamine and propofol mix or nasal ketamine or mad as Lomb, etcetera, etcetera. But the purpose is to gain some form of access, be intraosseous or intravenous. Remember intro sis's just a holding procedure, get the child to sleep as soon as you can but as safely as you can. But beware the very, very flat child, they may require very, very tiny dose. This is an example of the pre printed drug calculations you can get online. This is kids. I think this one is from Bristol. I think they're all accessible and open source and I think they're very, very useful. Just a reminder, keep them warm, allows for exposure and concurrent assessment. I understand you may not have power the whole time. You can't keep the warm, cover them up as quickly as you can. Now, I want to talk about the anesthesia. I'm going to leave now because I'm assuming all the Iniesta's will know how to give an anesthetic. It's just getting on top of some of the pediatric aspects, which is just as I mentioned beforehand, tailoring your drug doses, putting him to sleep early. There's two aspects I want to talk about. Now. One is I think it's been a big win is pediatric massive transfusion, pediatric major hemorrhage management. I think that's, that's been a huge, plus a big learning lesson for us all over the last 10, 15 years. However, the one thing I would say about pediatric massive transfusion is first, do no harm and that includes all fluids, not just blood. So in the my advice for treating major hemorrhage massive transfusion in a child, obviously, you need your surgeon to stop the major hemorrhage. But when you're using a massive transfusion device such as the Belmont or whatever you use, I wouldn't connect that machine to a child. Less than 20 kg. I would happily connect it to a child over 30 kg in between. It's a judgment call between you and your team. But if you are using a major a major hemorrhage device, like the Belmont, you have to know how it works because it can be very dangerous and make sure the blood is warm. I think, I think cold blood is worse than no blood. So the what I would recommend is if you are not connecting your Belmont or your machine to the child, you use the system here where you have a syringe on the end of it and you fill the syringe up and inject it as required. Um Now how you get access for giving the blood intraosseous is very often the way to go very early on if you can, if the patient has no access at all. Obviously, you don't use sternal Ayoze. I don't think I've seen them used for a long time. You certainly don't use sternal Ayoze in a child. You choose your appropriate easy I oh And there's various places to go in humorous Alliot crest, um tibial to upper end of the tibia, distal end of the femur. All I would say is once you've got access intraosseous, there's only a temporary access to allow you to transfuse up and then gain intravenous access. If you've stuck in an intraosseous access into the upper tibia or any other bone and it comes out, don't put it back in the same place because as you syringe in, you might create a hydrostatic tourniquet which puts the limb at risk. So what I recommend when you're dealing with a major hemorrhage situation is in an adult, you give a bag of blood, you give a bag of plasma, a bag of blood, a bag of plasma with the child to do the equivalent. And it can be quite concerning when you start is you give five mills of blood, five mils per kilogram of blood, five mils per kilogram of plasma. And you keep repeating that maybe four or five cycles and then reassess through some bloods, through some clotting through some blood gases. And after that, you may wish to add platelets or crowd precipitate. And don't forget at the beginning of this whole process to give tranexamic acid, 15 migs per kilogram as a bolus. Now, this may seem a small dose, five mils per kilogram, but you just keep giving it all the time and you've got a little flow chart here which covers some of the aspects of it. The, the important points are, you may think that you're actually giving way too much. But as long as you stick to some basic principles and look at your endpoints at the top here when the bleeding stops or the heart rate and the computer refilled, return to normal or the blood gasses and lactate look okay or the hemoglobin looks okay, then you can slow down but have the confidence to keep doing the blood and plasma continuously with some platelets and cried precipitate if you have them every, every three or four cycles. And it, it sounds quite daunting and sometimes it seems like it's an awful lot of blood. But if you're sticking to those basic clinical signs and your point of care, testing, if you have it, you shouldn't go far wrong things to look out for are hypothermia from cold blood. Try not to give cold blood hyperkalemia, hypercalcemia and hypomagnesemia. Again, uh you give calcium as and when required. And if you're necessary, you can use a tranexamic acid bolus. This floor chart has factor seven. We don't use Factor seven anymore and have some promise system for just keeping a record of what you're doing. And the same principle applies whether you get one casualty or 12 casualties at once. I'll briefly mention pain relief after the operation that maybe comes later on with a different talk. Children. my impression Children are very tough. They do very well. So simple, analgesia paracetamol in nonsteroidals, if necessary, a nurse controlled morphine infusion. But if you've got ultrasound or inter operative lee perform some regional blocks and I would recommend often single shop blocks can be enough depending what facilities you have. But for the anesthetists amongst you don't forget interrupt interruptive magnesium, about 40 mics per kilogram, cloNIDine one to to mix B kilogram or a single bolus dose of ketamine. There's a, there's a link there for the sake of the Children, a book which dives into these much in a, in a more deeper way. But at the end, I was going to talk about two cases just to give you confidence with the massive transfusion, the major hemorrhage protocol. This first case is the one you saw earlier on young girl shot in the back with evisceration through the front. We put her to sleep very early on in resource when she came in and she went to theater for a laparotomy, colonic reception and liver packing over the procedure. She was a very small child, very small and slight. She had 50 mils per kilogram of blood and 50 mils per kilogram of FFP. That equates to about 10 to 12 bags of blood and 10 to 12 bags of plasma for an adult. And she was in theater for a short space of time. So lots of blood products in a short space of time. And I don't think by looking her figures at any point, we gave her too much blood or we over transfused her. And as you can see from the numbers here, her hemoglobin didn't go too high 13.9, her basic cess corrected itself very rapidly. Her ph got better very quickly and her clotting stayed the same throughout. So despite a lot of blood products, a lot of plasma, we stuck to the protocol and everything was fine. The only thing she didn't need was some platelets at the end which we missed. She got them. Last case, I want to talk about. This is the same as the previous case. But on a bigger scale, this young boy had terrible, terrible injuries to his thigh. As you can see, he has a very nasty wound, shrapnel wound to his thigh. And I I talk about this case because I have a have a plea as an anesthetist. I have a plea to the surgeons when he came in from the ground he was very, very, very well packed, there was no bleeding, they packed it beautifully in the resuscitation room. The surgeons wanted to take the pack out and have a look and they took it out to have a look and then all his blood just started pouring out and he nearly bled to death on the floor. So I would say if you want to have a look or do you need to have a look? And we now change our policy that before we take packing down there in theater with blood and surgeons ready to go this little chat. We took to theater and he was very small, very slight, very nasty wound. As you can see lots of bleeding that for him, very small, his estimated blood volume was two liters and we gave him almost 10 liters of blood. So we gave him his body volume five times over. So we were concerned that we were throwing too much blood and blood products at this little boy. We had 19 bags of blood, 10 F F F plea platelets and cryo. But we stuck to the protocol. We did point of care testing blood gas testing lazing with our surgeons. If the surgeons were losing too much blood, we'd ask them to stop and allow us to catch up and give more blood and FFP. So I think it's important to have the hemostatic pause for the surgeons you're dealing with very, very difficult case I think it's important you nieces support you and say, can you stop and let us catch up with the blood because it's a two way process here and when the more you work together, the better it works. So this chap lots of blood in a short space of time. But as you can see by sticking to the protocol, his blood, he went from minus 19 basic cess to minus two. If you look at his hemoglobin at no point, despite all that blood did we overshoot and over transfusion. And at no point, despite all that blood and all that bleeding was his clotting too badly deranged. So I think if you stick to those simple principles, the blood plasma platelets, the car precipitate tranexamic acid and your point of care testing, it's actually a very, very safe weight. It's like you're in your lane, you feel safe, you've got your support, you've got your guidelines, it works very well. And the final thing um is have a framework to talk your way through the very difficult cases and the ones when you should treat and shouldn't treat, that's a separate lecture in itself. But I would say is that Children tend not to be a big consumable resource issue. Children don't use much blood, they don't use many of your resources, but they do carry a large emotional impact and could be a large emotional resource. That's a separate lecture in itself. I mentioned end of life care. That's a separate talk. I won't go into that now. So in summary, don't, don't, don't, the big thing is, don't underestimate the emotional impact this can have, but I think this can be mitigated and handled by reassurance and expertise. I think anesthesia is good at that. We can stand back, have our hands in our pockets and help across the facility. If you're pediatric experienced, if you're going to give product, blood products in a major hemorrhage, give them early in a high ratio. And do you certainly do not give hypotonic solutions such as dextrose. If you're falling behind on the resuscitation, the clotting is getting worse. The figures are getting worse, ashes, surgeons to pack, stop hemostatic pause, allow you to catch up. And overall pediatric major trauma in theater is hard work from the anesthetic perspective and from the surgical perspective and nursing. From the anesthesia perspective, I'd say it's a three person technique. You cannot do this on your own and simple stuff done early saves lives. So from a major hemorrhage, if you're the anesthetist, I think you need to stand back. You have one. So you're standing back running the anesthetic. You have one person checking the blood, sending off the blood, making sure there's more blood coming and you have one person who's actually giving the blood through the transfusion system