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That, sadly, there are many Children being injured by a blast and conflict injury in the world. Today, there are probably nearly 200 million Children living in high intensity conflict zones where which is defined by more than 1000 casualties per year, not Children, but all casualties dealing with conflict, trauma and Children can be difficult, but it's not impossible. And my involvement in this area came about when we were asked to produce this manual originally for Syria. It is now available in six languages and is free as a free resource which can be downloaded via this link on the slide. Everything in my talk is within this book, but it also covers the child's injury from the point of injury through to its discharge from hospital. The thing that I'm very serious about is that we psychologically talk ourselves out of dealing with injured Children. Either we are adult trauma clinicians who are not used to Children or we are pediatricians who are not used to trauma. I think we've got a great skill set that we somehow don't apply. So psychologically, there's a huge barrier that we fail to recognize. Uh and I like to encourage people just to do it because I think you will do a lot of good in a major insistent management. There are pediatric triage systems that will help you prioritize who the sickest child is, but they don't directly tie in with adult ones in terms of their slightly different. Um but in a major insistent management to a mass casualty management system, there are systems that triage all your patient's and then that will give you category one category to category three patient's if it is and this is where it gets complicated. There are times where you choose which patient's will take too many resources and you decide that you won't treat them first, even though if they were the only patient, you would be able to treat them. I think I can only say that the starting point of your decision making is using a triage system that prioritizes all your patient's adult and pediatric together, but then try and direct them to the correct resources. So your pediatric patients are going to the pediatric hospital, your adult patients are going to the adult hospital. So they are not competing with each other for whip for for resources. But at some point, if you are overwhelmed, then a clinician, a nominated clinician needs to decide which of those patients' you are able to save with the resources. You have the danger being that any one of them adult or pediatric may divert more resources away from other patient's and result in more death than if you didn't treat them. I think the starting point is to use a recognized major major incident management system that triage is all your patient's. So it's important to think about the blast mechanism in trauma. Thinking about the mechanism at the point of injury is very important. And that includes in Children, we define blast in four areas, primary secondary, tertiary quarter, nerri, but really the only area of trauma we are not familiar with as trauma doctors is the primary element is the blast wave which produces this primary injury, typically dismemberment, but also on the lung classically on the lung and gut that we need to consider, especially in a child that's been exposed to blast. The other mechanisms of trauma and blast such as penetrating and blunt and in particular blunt, we uh the principles of management are exactly the same. I'd like to point out burns is an area of consideration to if we look at data from conflict in Afghanistan burns with the single biggest cause of death in Children that have been exposed to blast injury. And we need to include them in their include their management and uh approach the child. From the very beginning. The issue of recognition combined with a reluctance to intervene when required, there's a balance but recognizing the sick child and also being prepared to intervene acutely in that damage control way is very important. I would say from discussion with trauma surgeons in conflict in Afghanistan and so forth. The, the only other thing that comes to mind is is that the issue of tissue preservation and limb injury is very critical. I'm sure it's critical adults as well, but Children are better perfused and we can sometimes be a tad, more conservative. But again, there's a balance there in terms of general surgery. One of the key differences is that in isolated blunt trauma, the need for laparotomy in solid organ injury is tiny, you can have a completely fractured spleen, for example. And that does not require intervention. It requires bed rest, uh and conservative management. But that can only be done in the context of not having other injuries and being able to put them in an HD high dependency environment to observe them. And it may be that in order to get through to make sure the child is safe and to get your next patient and that then the organ has to come out. But that, that's a key difference. So certain characteristics of blast injury in Children. And importantly, we need to highlight that all cause in hospital mortality. And again, this is from conflict data in Afghanistan is 8% which is higher than civilian adults and significantly higher than combatants. Children are more multiple e injured in blast with nearly one in three severely injured and nearly one in five critically injured. And they also have a higher requirement for surgery compared to non blast trauma. We should be familiar with the damage control philosophy in adults, which is to intervene and prevent the deterioration of the patient by early resuscitation and early damage control surgery. We need to ask why is this important? And is it relevant in Children? So, one of the key objectives of damage control is to prevent and treat coagulopathy, which we know in adults cause is a very significant increase in death. There is far less research and data on Children, but we do know that a significant proportion of Children with major trauma uh do uh present with coagulopathy which also increases their mortality. We know from adult data that blast causes more coagulopathy than blunt or penetrating alone. And whilst there is not supporting data in Children, it is reasonable to assume that this is also the case in Children. So we should approach the child with the same components of damage control. We'll be doing the Adderalls and the key components of control of catastrophic Cambridge. Having a clock preservation strategy which is minimal handling and key targets for resuscitation and having a approach to hemostatic resuscitation, which involves balanced blood products and applying damage control surgery principles to the child as we do in the adult, my own individual philosophy on Children though is that we have been taught over the years to be scared of the child will rather than be encouraged to treat the child. And rather than being presented with an injured child. When we are presented with an injured child, we behave in a manner in which we presented with something which is entirely alien. We have to be encouraged to remember that a child is still a member of the human race and not a different species. The barriers to success in treating Children are the very few of us see severely injured Children. So we have unfamiliarity and psychological barriers to treating the child. We add to this the emotional and communication challenges and the technical difficulties of dealing with smaller patient's. So it is key that before we start treating Children, we think of some of the ways in which we can succeed and the very important messages, many of the skills we have from tooting adults very transferable to the child in the context of trauma. And whilst we have to consider some uh sorry, we have to consider a few important differences. It is very important to remember that largely speaking, they have the same injuries. We use the same assessment and we use almost the same interventions to treat those injuries. Preparation is vital when we're dealing with unfamiliar patient's, and I will encourage everyone to use a pre pre arrival preparation list and have access to aids for our memory on drugs and physiological parameters. And this is an example from the book and also an example of a age per page resource which is also freely available through the same link as the book, calculating doses and volumes before the patient arrives, will help us prevent mistakes. And in the context of trauma, we can use the very simple weight estimation formula on the card here. I don't think there are any drugs that I can think of right now that we wouldn't use in a child or that you couldn't use in a child if you needed to. So Tranexamic acid, we should definitely using Children. It's, it's approved. Um whilst there's less evidence, it's a very safe drug to give. So definitely giving Tranexamic acid in terms of resuscitation in transfusion, we should be giving calcium in the same way that we give adults obviously in a different dose 0.15 mils per kilo. Uh and we should be monitoring potassium in all trauma. We should try and avoid vase oppressors to adrenaline, uh or you know, nor adrenaline or metaraminol in adults and Children. We should avoid those and we should replace volume and resuscitate the fluids in terms of antibiotics then that they're all fine. Um pretty much and certainly the commonly used wide spectrum one's for uh we can use the same. So on arrival, the priorities are to identify the child in cardiac or peri arrest. And if this chart, if we identify this child, then we should consider going straight to theater to undertake traumatic cardiac arrest protocol. Children are capable of surviving traumatic cardiac arrest. So this is the assessment process which we should apply to the child. It is the same structure as we use in adults. It identifies life threatening injuries and introduces early critical care and intervention. What we do need to do in Children, however, is pay particular attention to the physiological signs of injury. We're all taught that Children decompensate quickly, which is true. However, there is a prolonged period where they display signs of hypovolemia and injury during which we can intervene. I'm not a fan of the myth that Children just suddenly die and they, and they don't, it's just that we don't very, we need to very actively look for the signs of, of injury. And the key ones are tachycardia Tocchet near, uh and the, and, you know, being very, uh not end of bed, but they've been very close hands on looking for the signs of, of, of hyperperfusion. And that's the one thing, the signs are there for a long time when they decompensate. It's quick. The timing is, you know, the trajectory is different, but the timelines are probably longer than in adults. And we'll certainly Children over the age of two, uh, don't present as much of a physiological problem as, as we think they do, they are different, but they're absolutely not aliens. If you have, you got adult skills and you apply them to the child, you will be successful. And if we look at the patient's that you're probably dealing with in conflict zones. Apart from Children, you've got a young combatant population and young soldiers have got very similar physiology there fit, they compensate and then they decompensate quickly. So maybe young adults are the same as Children. Basically soldiers definitely in critical trauma. We need to be very closely monitoring pulse and respiratory in Children. Um BP is of less use because it, it goes, it decompensates later and we want to treat them before we see hypertension. So in adults, we might wait for a lower BP before we treat. But in Children that is too late to treat. So it's pulse, respiratory rate and other indicators of of hypervolemia such as their skin color, they're capillary, refill time, uh you know, their mentation, they're conscious level. And of course, we need to be familiar with the range, the physiological range for the age of the child. So have have that in front of you on a on a card or on a board so that you know, when that age of child has abnormal pulse or abnormal respiration. So in terms of the management of catastrophic hemorrhage, it is very important that we uh never ignore abnormal physiology. And one of the key messages I can give you is that a child in the context of trauma with tachycardia has hypervolemia until you have proven otherwise, tachycardia is not fear or pain until you are sure that they don't have hypovolemia in terms of immediate management of catastrophic hemorrhage. We should use tourniquets and amputations, splint the pelvis in the presence of lower limb amputations. There is a high incidence of pelvic injury in blast amputations, use interosseous access rather than IV in the shocked child. It is very possible to fully resuscitate Children through intraosseous access. It is important that we have the documentation policy and equipment to deliver massive transfusion. Uh This uh image is a, is an example of massive uh sorry resuscitation protocol, which is also in the book. In terms of equipment, it's preferable to use a high volume transfusion device that also warms the fluids. But in Children under 20 kg, these devices can be dangerous. And I'd recommend that you resuscitate them using filled syringes rather than the device directly. It is important that the medical teams are well trained in the use of the device. If this is not available or the child is too small to connect, you can use a system that we term the Christmas tree. And this is the blood and plasma products which is pushed through a hotline using three way taps to select your bonus. And this allows us to give a balance to transfusion of warmed blood products. So the components of damage control, which we looked at before, one of the key ones to consider his club preservation, which volumes and to what targets do we give fluids. It is very important to remember that as opposed to adults there is no concept, no such concept as hypertensive resuscitation or permissive hypertension in Children. But we don't want to resuscitate the child aggressively early either which may disrupt clot formation. So that a min the 1st 60 minutes is to give repeated five mil per kilo bolus is to maintain a radial pulse in the child or break your pulse in the infant to improve perfusion over the first hour. And then after that first hour to resuscitate to normal physiology and to consider damage control surgery. In terms of transfusion, we give blood or balanced blood products at five mils per kilo pulis's. We don't use crystalloids and we never ever use hypotonic fluids. Five mils per kilo for a child of a blood product equates to about one unit. So we should track our transfusion carefully using appropriate paperwork. We need to use tranexamic acid at 15 mg per kilo and periodically calcium. And whilst checking for high potassium levels do too packed red cell transfusion. We should also transfuse platelets which are given at five mils per kilo every fourth unit. So, platelets are also part of the balanced transfusion and I've given it five mils per kilo. Um in terms of airway and breathing higher spiritual rate is a very early sign of injury in Children. And we need to be careful to accurately record respiratory rate. A key difference between adults and Children is that external chest wall signs or evidence of rib fractures are often absent even in high energy trauma to the chest. But the the key life threatening injuries and the treatment of them remains the same. We need to be very careful about blast lung, which will present hours after the initial injury rather than our presentation. And that the only signs of this may be a presentation to come near or tachycardia. So a child that has been exposed to blast and has primary injury only as in may not have any other injuries. We should consider observing to make sure they don't develop blast lung in terms of disability. We know that Children are much higher risk of hypoglycemia and we must measure a glue uh talk to a whole blood glucose and all Children who have been injured, there are higher risk of hypothermia which contributes to trauma mortality, most trauma, most severe trauma patient's present with hypothermia. So we must do everything we can to prevent it and to warm the child and expose the child only briefly to examine them, use active warming and warmed blood products and keep the room as warm as possible, especially in the presence of burns. Once we've completed our initial survey, we should undertake a brief review and decision making process with the team members. The key decisions are, do we need to go straight to surgery? Can we complete imaging or can the child go uh have imaging and then go to the ward. The team leader can confirm that we have completed the assessment and given key uh medications such as antibiotics, tranexamic acid and pain. Really, I just want to highlight uh we discussed this before that traumatic cardiac arrest can be a survivable event in Children. And we should be prepared to go through the traumatic cardio respiratory arrest protocol to treat it. Imaging uh in trauma, extremely important and often in Children, we are reluctant to uh scan them because of radiation. But I would encourage you to have a very low threshold to uh perform ct trauma, grams and Children. In the context of high energy blast, it will reveal hidden injury that we don't pick up clinically. Ultrasound will help us decide uh the surgical strategy in the resuscitation phase. And a brief mention of burns, early fluids and burns is very important and reduces mortality in Children. So early burns and that is sorry, early fluids in burns. And by that, I mean, in the first hour reduces mortality of burns in Children. So that's for isolated burns. However, in the first hour, hypertension is not the burn. It is hypovolemia from other trauma. We must not be distracted by the burn. So pain and Children is often under recognized. We should use a pain score ing tool to assess pain in Children and that we consider both drugs and non drug management of pain. Uh Well, so the simple things first that, that anyone can do which is splinting and covering wounds, in particular burns, it's keeping a child comfortable and keeping them with their carer or parents. But if pharmacological pain relief is required, then intranasal diamorphine is really good. It's slightly time petunia. But if you've got, particularly if you've got a device to deliver it, then it's very quick and very effective for, for severe pain. So we've been giving intranasal diamorphine in Bristol since 1998 I think was the first trial and we must have given it subsequently two, tens of thousands of Children across the country. Uh We're using fentaNYL now because we can't get diamorphine. Uh And that's actually easier because fentaNYL is just drawn up meat rather than diamorphine being mixed in volumes. But we have, there are to my knowledge, no recorded significant adverse effects of giving intranasal opiates in literature. You know, if it's given in the correct dose, obviously, it's very effective. And if you look, if you go to the manual, there's a table on how to give diamorphine. And there's also dozing in terms of fentaNYL. Uh and ketamine, I would perhaps avoid ketamine and trauma if you can not. I mean, it's an excellent anesthetic drug, but it's an analgesic, but it can have adverse effects in terms of dysphoria and things like that. It's important that we always consider psychological care and the child. Uh and from the from the start of their care pathway, we can prevent psychological harm. The key thing is where if at all possible, never separate a child in care. Er always involve the child in the discussion and care decisions. If possible, you must be calm around the child and explain what is happening. And very importantly, always be nice. So in summary, I'd like to encourage you to apply your see ABC skills and knowledge around the same structure as adults. But consider some key differences. Always be prepared and use resources to help you remember things but be calm, reassuring it nice and nice at all times to the child. And I put up the link to the pediatric blast injury field manual. Uh if you wish to use it.