Computer generated transcript

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

Thank you Kela and thank you Simone for your excellent presentation on the prevention of childhood injury. This is a very confronting scene for most people. For many, it will also be a scene that will create fear when a severely injured child arrives in their department or in their environment at the roadside, for example, for prehospital practitioners. And that fear is in many aspects based around unfamiliarity. There's the fear of the unknown, even though you perhaps you are a practitioner with experience in adult medicine and the delivery of care to injured adults. The arrival of an injured child throws all of all of your knowledge uh to one side and becomes very confronting in that setting. We it can become chaotic errors can arise. And in that madness and badness, the experience with the child, the parent and the team that are gathered around with sincere want to deliver good care can be one of a negativity, a sadness. We are aware of the high risk of death for some severely injured Children. We are aware that Squama is the number one killer of Children in many settings. And so we are worried about the prospect of severe uh injury leading to death or disability. But what is it that saves lives in this situation? It is not particularly clever or skillful individuals. In fact, it is a highly structured and systematic approach. It is a structured approach which calls upon strict priorities which we're familiar to many of you. It is a systematic approach which I en enforces and imbibes strictly pediatric approaches to this injured patient. There may be similarities with the way that you approach an adult or there may be important differences and we're going to highlight some of those similarities and differences in today's talk. It is a team sport and teams caring for injured Children as they are also caring for injured adults should be prepared and practiced. And one of the elements they should be practiced in is procedural competency. And at the end, I'm hoping to be able to unpack and demystify some of the procedures that might save a child's life. It is really important that we understand that whilst trauma may be our core business, the injured child insists upon us that we may not need, may not be able to simply go about our business as usual because every aspect of this care needs to be pediatric in the way in which it is delivered, the expertise that deliver at the skill sets and the philosophies that underpin it and the experience of the injured child which sits at the center of this uh trauma care moment. So as we think about the prioritization of the structures and the systems with which we respond to a a severely injured child. I wanna run through the ABCD E and then TT standing for tests and tubes in the care of these Children. I want to highlight ways in which Children are perhaps different or maybe similar to adults to enable you to deliver better care to the severely injured child when you next care for them. So if we think about a being for airway, it is under well understood that a child's airway is prone to obstruction. And sometimes we think about that because the airway is smaller and therefore, for example, more prone to the the the relative changes of edema. But I want to actually highlight something that is bigger about a child and that is that they have a relatively bigger occipet on their head and the consequence of that relatively bigger occi, but is it tips the flat, the flat line, the supine child, it tips their neck into relative flexion. It takes away the neutral position of the spine, something which we are trying to achieve a neutral position of the spine to care for the potential for survival, spine injury in this child. It also brings the airway into, into, into a kink and pre the obstruction of that airway. So for both of those reasons, we want to be able to take away the impact of the occiput take away the flexion that it imposes on the neck. And the way we achieve that is to elevate the thorax, a thoracic elevation device. Now, a thoracic elevation device does not need to be something complicated. In fact, as seen here, it is simply a towel folded several times and that elevates the thorax of this child. And up until the age of eight, it is typical that the thorax of a child will need to be elevated, to open their airway to maintain a neutral position of the spine. It's a very simple and effective way to start off this child's prioritized systematic care excellently going beyond that and thinking about other aspects of a, we think about the cervical spine and the c spine along all its length. And there are many ways in which cervical sp, cervical spinal injury or and spinal injury differ between Children and adults that relates to the anatomy of the spine in the child. And the mechanisms with which Children are are uh who do sustain a survival spinal injury do so. And we'll highlight that they are often very high uh levels of injury compared with the levels of lower, relatively lower levels of injury seen in adults and in and around the assessment of this child understanding, can they be formally assessed? Can that spine be cleared? Uh We may need to arrive at a decision as to whether we're going to use a collar and whilst we can't go soft on the potential for cervical spinal injury or other spinal injury. We should go soft on spinal collars. And what do I mean by that? I mean that in many, many um trauma systems worldwide, uh the the trauma system which ii work in being one example, we have now gone well away from the use of hard rigid collars towards soft collars. And examples of the appearance of a soft collar is given here, the emphasis is no longer on spine immobilization because there is a recognition that we were never really achieving spine immobilization. They were words we used, but they were never, it was never an outcome we particularly achieved. And not only that but the attempts to achieve spine immobilization through using a hard collar was exposing Children, particularly the youngest of Children uh to the potential for secondary injury, secondary injury in and around the spine and secondary injuries such as pressure um and venous injury or venous congestion. Now, all of this was a negative against the fact that we were failing to achieve the positive of spine immobilization. So our actions have changed towards using a soft collar and our language has changed towards talking about spine, re restriction of spinal movement. And that is where we need to be uh focusing. And for those reasons, we strongly recommend whether it's in the prehospital or hospital setting in this undifferentiated uncleared spine that we use a soft collar. Of course, the experts in spinal trauma management, be that a neurosurgeon or an orthopedic surgeon, they may wish to recommend some of the semi rid collars such as a Philadelphia or Aspirin collar. That's a specialist recommendation. I'm not in any way contradicting that I'm talking about the undifferentiated child whose spider is not yet to be cleared in that child. We can use a soft collar for maximal benefit overall moving now down the prioritization from A to B. What is there around the chest that we could highlight in the child? Well, firstly, chest trauma in Children who are severely injured is common and dangerous. It is a common cause of severe injury and is a common cause of death in those Children. And when we look at the experience of our hospital and the Children who have severe chest injuries that we receive, we find that about two and three have a lung bruising or lung contusion, even though rib fractures are often thought to be uncommon because of the compliant nature of the child's bones. We see in that subgroup, one in three have rib fractures and one in four have a pneumothorax of some kind. Thankfully, the more serious clinical scenarios of a significant hemothorax is less common. One in 10 and even less common again, is the uh um intervention, demanding situation of attention, pneumothorax. Three and 100. And the key question we need to be asking here is, does this child need lifesaving pleural decompression, either around a suspected or known chest chest injury or perhaps in the setting of traumatic cardiac arrest. And we're going to park that question. And later in the presentation, I'm looking forward to tell, talking to you about some tips on pleural decompression and, and, and explain to you why I say it's a kind of magic when we think about the circuit assessment. Um it is, it is often correctly highlighted that Children can maintain a normal BP, a BP within the normal range despite losing significant volumes of blood. And it's that compensation which helps to protect the child's physiology from the consequence of the injury that they've sustained even in the setting of significant blood loss. Now that BP compensation is excellent. But if it is to fail, because the body can no longer compensate, then that child with a low BP, they are on a precipitous decline. They are in peri cardiac arrest situation. So it is great when they compensate, but it is terrible when they can no longer compensate. Co that reflects a child who's physiology is very um embarrassed in the, in the, in the setting of hype, typically in the setting of hypovolemic shock, but there can be some other contributors in the setting of severe trauma. So to make sense of a child's heart rate of their BP, we have to recognize that at different ages, a child's BP or heart rate has different expected normal ranges. So we can't just take our business as usual adult idea and say, well, heart AAA BP, le le systolic less than 100 or less than 80 must be provided us with some information without first understanding where uh would we expect that child's heart rate, BP to be relative to their age? It's important just if we start to think about what we expect also to know that in, in the setting of even significant tranquil trauma, the majority of Children who come to our hospital, many of whom will have had blood loss actually have normal um hemodynamic parameters. They are hemodynamically normal despite the fact that they have had significant injury. So the the normality of a of a of a BP and a heart rate and the stability of the BP and the heart rate are reassuring as to the the current status of the child, but shouldn't discourage us from, from synthesizing or in in, in considering particular injuries in and around their trunk or else around in their body. When we think about how we're gonna resuscitate Children. If they are losing blood, we should be replacing blood with blood or blood products. There is a significant debate as to whether um blood transfusion should be in the form of a balanced transfusion uh with red cells, uh platelets and plasma given separately in various ratios or where the whole blood is the best. But what we've gone right away from because we understand that it can cause injury in the setting of severe trauma is crystalloid resuscitation. It has been very well put by Phil Spinella who said that salt water is for cooking pasta and blood is for saving lives. So if this child is bleeding, let's give blood or blood products and I'll leave it to you in your setting to know which is the better balanced transfusion or whole blood. Moving one step down. The prioritization of this systematic structured approach is the assessment of a child's conscious state. And because some of the aspects of the Glasgow coma score can be hard to marry up against the age of this child where perhaps incoherent speech is the norm. Perhaps the child is just so frightened, they're not going to do as we ask, they might be withdrawing away from us as if they are um showing or G CS. But that might just be a response of fear because of all of this, we need to have an accurate way of assessing a child's conscious state. And we understand that the assessment of a conscious state is absolutely important for the child because Children who have these much larger heads relative to the size of their body and therefore sustain many injuries in and around the the head, either as a consequence of its size or the ways in which the size of the head um can impact with the mechanism of injury such as a whiplash injury, uh which can be devastating in a child or a child being shaken or a child being struck on the head. All of these amount to significant threats to the life of the child. And it is a sad truth that head injury is the number one killer of injured Children. So bringing all of that back, we have to assess the conscious state. A Glasgow coma score is very important to the specialists such as neurosurgeons that can be quite challenging and doesn't necessarily impact the, the way in which uh people like myself providing primary trauma care. Look after this child for all of those reasons. I and others recommend that we use the scale A pu A for alert, V for voice, P for pain and U for unresponsive and scoring a child on that four point scale uh is both informative as to as to the to the trend of their conscious state and informative as to when they, when their conscious state drops in a way that were we measuring G CS, we would normally uh respond with an action. So for example, the, the important G CS of eight below which we perhaps might consider interactions such as sa safety of the airway, a child that has a, an F AP score or either A for alert or V for voice is 100% positive predictive value of having a G CS above eight according to reassuring um research in this area. And I've highlighted the um reference for you here and you can see some of those results depicted, right? What about the environment in which all this is happening in? Uh Maybe you're at the roadside, maybe you're in a hospital, maybe it's a hospital that's used to receiving trauma. Maybe it's a hospital that's not used to receiving trauma, but wherever you are, is your department or your environment, is it ready for Children or is it actually upsetting for Children? Is it rated R 18 plus typical ways in which we can improve our environment no matter where we are, is to improve the warmth. Yes, there is a discussion around hyperthermy in, in, in trauma. Let's part that to one side and say it's not relevant specifically to this discussion. If the, if the heaters in your environment aren't on, you need to turn them on, you need to turn them on as early as you can because keeping this child warm uh will be important for their good recovery. It's a very busy environment. There are many roles that need to be filled, to deliver a team approach to, to a um structured systematic um delivery of trauma care. Uh But that makes for a very busy place. So we need to ask ourselves, do we have everyone that we need, do we have all the roles and, and the participants in this team uh that we require to deliver the care that this child needs. One of the forgotten members of that team are the parents. There is a great body of evidence that affirms that it is best practice to include the parents within the experience of this child's resuscitation. It is not for all moments and it is not to be done without sensitivity and compassion. Uh but please bring parents in and include them in and, and help them to understand the great care that their child is receiving from very uh committed uh clinicians. But in that busy environment, there may be people that you don't need, there may be people who uh perhaps are looking on but not contributing through a role. Uh That is a crowd control that needs to be attended to, you need to ask those people respectfully uh to, to make way for those that do have something to, to provide. We think now about the tests that we do, perhaps we should be asking ourselves are our investigations are rated not just our department or our environment and a really good way to think about this is the our attitude towards CT scanning and trauma. Um The best evidence that I can bring to you. And I think the, the best way that we can think about the impact of CT radiation on Children comes from a study which was done within Australian young young adults and published in the British Medical Journal in 2014. Uh This longitudinal study identified that for every 1400 CTS performed in, in, in young adults under the age of 20 every 1400 of those CT S, one of those young adults will develop a cancer in the next twen in the next 10 years. And that risk increases incrementally by 16% for every additional CT scan performed. So it's really important that we understand that even though CT scanning has an important part in the assessment of the severely injured child, that it is qualitatively and quantitatively different from the part that it plays in the assessment of the severely injured adult. We strongly recommend that the idea of the pa scan be challenged in a child by all means you may make the active decision to, to scan each of the areas represented by APA scan, but it should not be a simple decision to just get all of the scanning done at once because it makes it logistically easier or it somehow improves your assessment, it may not improve your assessments. It may uh prolong this the the the the child deferring and getting to the definitive care that they need and it's exposing them to a level of radiation that could have significant consequences. And often clinicians as I talk about this, they say, OK, well, who am I going to do a CT scan on if I wanna flip that question around? And I wanna say, I think it is best to define who you're not going to do a CT scan on. And one of the reasons I flip it around in that way is because of the various tools and rules that I've come across that help me and my practice in pediatric trauma. The rules around not doing a CT abdomen and not doing a CT chest, which will come out of large Multicenter North American trials I think are the most useful. And I've given you the um example here of a CT scan um rule which helps you to say no to an abdominal CT in the setting of um severe injury. So, if your child has none of the features that are none of the seven features that are listed here, there is a negative predictive value of that child having a a intra intraabdominal injury requiring treatment that approaches 100%. These are negative predictive values and confidence intervals which are just excellent and reflect the rigor of this project uh from which these uh data have been taken. And there's a similar CT uh guidance rule for CT chest in the same setting. And this is enabling us to safely say no to imaging a child. And we've looked in our own institution and use of this tool would probably in, in reduce safely without missing injuries. Uh CT scanning rate by approximately 20%. Well, if CT radiation is an absolute no, no and it should be done where it is required but it should not be done where it can safely be avoided. What about ultrasound scanning that avoids the radiation that has greater traction? Unfortunately, ultrasound scanning as it relates to fast scanning, uh has failed to a to to stack up to the experience of adult trauma care in Children. In particular, fast scanning lacks sensitivity and this may be related back to what I said before about hemodynamic stability in this patient group. This is a patient group which does not usually present with hemodynamic compromise. And when fast scanning was delivered to adults who were injured, who were not hemody compromised, it also lacked sensitivity in that situation. But as many as one in three Children um in who have a solid organ injury will not have free fluid on ultrasound. And there are a variety of reasons for that relates to clots of blood being echogenic, the obscuring of bowel bowel gas. Uh but there are many uh false negatives. Uh in the assessment of the ab of the child with a solid organ injury, there are also some false positives because just because we find fluid in the belly does not mean there's an injury in the belly. And about one in eight young Children of both male and female genders or male and female sexes will have a physiological free fluid within the abdomen. And this is really important. Um It it has also been uh it's also true that if we find some blood, if we say there is an injury and there is also fluid and there it is actually blood and not just physiological that does not in the child because of the absolute success of non operative management in those Children, for whom that is appropriate, who are the vast majority, the presence of blood does not mandate uh a next step in many settings, it goes on to mandate a CT scan, which is perhaps one of the things we were going to be um uh trying to avoid. But in that protocolise setting, it isn't even avoiding that potential negative. So one of the things I say about this is I think we should be going slow with fasting kids. Um but I'm looking forward to being able to turn that sentence right around and embrace fast when the ultrasound, um technology can provide us with a sensitive and specific answer. Well, I've just outlined to you some of the confusions that can arise. And another confusion that can arise in Children is when they have um changes, deteriorations in their vital signs and development of their abdominal signs. Often, not always, but in many, too many times, these deteriorations of vital signs and abdominal signs are actually due to distention of either the stomach or the bladder. Kids are very prone to gastric distention to gastric dilatation in the setting of acute trauma. So we must decompress the stomach. You can see here, examples of uncompressed stomachs uh this places the child at risk of a vomit and in the setting of a vomit in, in trauma, the risk of aspiration and erogenic injury. Not only do we have to anticipate this and respond by the patches of it or of a um gastric decompression tube. We need to check that it's being effective. Uh The, the uh picture shown here on the FF far, uh left of your screen is showing um a an d grossly distended stomach with a nasogastric tube in, in, in place that is a nasogastric tube which has been spigot and that is only been recognized secondarily and that child will have benefited from having their stomach decompressed. I feel that the debate between nasogastric and orogastric has validity. Uh but it shouldn't be a validity that distracts or delays that child having their stomach decompressed in most situations. A, a safe uh decision can be made between nasogastric or orogastric. And the priority is to decompress the stomach as it is to decompress the bladder. In the same way, we can see ch deterioration in vital signs um with changes in abdominal features confusing as to whether we have a patient who has perhaps a deterioration in their abdominal status with maybe bleeding into the abdomen or are we dealing with someone in urinary retention? The the answer given at CT scanning is often that the child is in urinary retention, that child should have had their bladder decompressed already and if not, you should decompress it. Now, finally, let's think about chest strain insertion or thoracostomy in Children to decompress their um their pleural cavities in the setting of trauma. This is a very important um procedure. It can be life saving or life preserving. Uh but it is actually often very, very, often complicated by error and new injury. So we don't want that these Children are injured enough as it is. But let me ask you how confident are you as to where you're going to perform a thoracostomy and a chest drain insertion. And how are you going to do that rapidly and safely to protect this child from ongoing injury? Well, I think that we can make pleural decompression easier in Children for us as practitioners and I want to just spend the last few minutes, uh unpacking two tricks or tips that we've been able to establish in recent times uh to help you with this. Let's just be clear about what the problem is here. The problem is that we have air and blood outside the lung inside the chest cavity. It's creating pressure, that pressure is dangerous and we need to release it. So a number one priority is a thoracostomy to form a hole which lets that air and blood out and that is gonna save the life of this child. The number two priority is to put a chest strain in to keep that life to keep that blood that pressure from reestablishing. Uh but the first priority is to form that thoracostomy. And we're gonna hold those priorities through the discussion that follows. Now, we don't just in reality have blood, air, blood sweat. We also have air blood sweat and tears and fears because actually when we look at this child, it is often completely confusing as to what we're gonna do. Where are we gonna cut? What are those anatomical boundaries of the, the safe triangle? You can't quite work out where you're gonna be. You don't know what tube you're gonna use. People start handing you things. They say is this what you want? You think? I don't know, ah, let's dive into that moment of need and give you one magic number that you're going to use because without the magic number for chest drain and for thoracostomy and chest drain insertion, you're probably gonna end up in the wrong hole using the wrong tube and you're probably gonna put your tube in too far. And that magic number getting it right first time and getting it done quickly is the magic number four. And I wanna tell you about the rule of force which we teach here here at the Royal Children's Hospital and is becoming popular well beyond Australia uh into other parts of the world. So the first part of the rule of fourth is we're gonna use four step plans and we're gonna use those four step plans to first form a good hole which we're going to put in the fourth inter costal space. Why not the fifth? Because some people talk about the fifth, we're gonna say fourth because you have one number to remember the magic number, which is the number four. So we're gonna use our four step plans to first make a good hole in the fourth intercostal space and we're going to use that hole and put through it a good tube. Now, many of you are involved in critical care delivery and you'll be a aware of the way in which we size an uncuffed E TT tube in Children. And if you take that sizing the formula for which is age over four plus four, that'll be a familiar formula for many of you. If we take that four based formula and times it by four, that is going to give us the good tube size that you're gonna use in your injured child. So again, magic number number four, and we're going to do all of that and we're going to insert the tube and rather than just putting it in as far as we can, which can lead to complication and reduce the effectiveness of a drain through kinking, we're going to start pushing it in and then we're gonna make 1/4 part, which is our good stop. Where are we gonna make that good stop at the four centimeter mark on the tube, the four centimeter mark is not four centimeters from the, from the tip of the drain. It is four centimeters from the last sight hole shown here in the various pictures. So it'll be a variable distance in according to the tube that you've used, but it'll always be a safe distance in our experience. So that's the magic rule of force. That is the, the magic number uh for thoracostomy and chest drain insertion. And you can see that you have various QR codes which will lead you to papers and videos about how we do that. So four is the magic number. What is the magic trick for chest for thoracostomy and chest strain insertions? And the magic trick relates to the mid arm point. And this is something that other colleagues within Melbourne identified and popularized in adult trauma. It uses a point which is um halfway between the electron and the achromia along the arm, the arm which is held by the side to begin with. And we then use that mid arm point to mark the corresponding level on the chest. And we raise the arm into, into um A B duction and we have that abducted arm, they're uh bringing, exposing the area of the chest and saying right, this is where we make our mark wherever the mark on the skin is, that's where we make our entry. And when these colleagues from Melbourne looked at this in adults, they found that in 100 and 20 adults in whom they performed this technique, it showed a safe zone which bridges the fourth to sixth intercostal spaces. OK. We've talked about the fourth being optimal, but this is a zone of safety. The fourth to sixth intercostal spaces in 100 and tw in a, in, in 100% of those, those adults. And we asked ourselves, what about in Children now, in Children? Uh We wanted to be able to perform this and we did this through a prospective study. We use four sites both within Australia and Ireland. And we looked at Children between zero and 18 years of age, we used the chest X ray that the child was going to get. Anyway, these were uninjured Children. We recruited into this study and we also created a video that you're seeing on the side here um to help people understand the technique by which um the mid arm point is used. And you can see here we've gone to the mid arm point and we're now going to swing it around and place the mark not on the arm, but corresponding to the level of the mid arm point on the chest. And in a moment when I, when I raise this child's um uh arm away from their chest into a B duction, you will see uh that the mark will go up ever so slightly and then we will be ready to put um the ch the chest strain in. If this were an injured child. But it isn't. We did this in almost 400 Children. And we found that um eight out of 10 times this identified a uh a place within the safe zone. So it didn't perform as accurately as in the, in the adult series. But when we looked at the data, we found that as in older Children, there was a tendency uh for the mark created by the mid arm point to be a bit too ca or a bit too low. And we considered, if there was in fact, some growth changes which were playing a part here, the arm in a child grows in a linear fashion, whereas the chest in a child grows in a curvilinear fashion in a more of a logarithmic fashion. And for these reasons, we considered the fact that in older Children it might be necessary to go up one intercostal space. So we redid our analysis as if we were going to go up one intercostal space. And we looked at what would be the ultimate cut off. And very excitingly, we found the ultimate cut off, optimal cutoff um shown by statistical analysis was four years of age. So for a child, four years or more up until the, until the adult age of 18, we recommend that you go up one intercostal space and into the space above the mark. And when we adjusted in this way, we now found that nine out of 10 times the um midarm point was providing entry into a safe uh into the safe zone, the fourth to sixth intercostal spaces and we published this experience and you can see here um the reference and the QR code we termed this adjustment according to age, the mapped rule. And you can see it's shown there that in a child under the age of four, the mid arm point alone will get you to the safe zone. But in four or more years of age, go to the mid arm point and go up one intercostal space and that will bring you into the safe zone. Now, I hope that one day you're gonna be doing a chest, a thoracostomy or chest drain insertion on an in child. And both the magic number four and the mid arm point in Children will, will assist you to deliver that child safe and rapid care the way that they need. So remember if the midarm point was only accurate in nine out of 10 showing on target. So it's not foolproof. You do have to have your, your brain in gear as well. So thanks for your time and I hope that you've enjoyed uh a bit of a, a run through pediatric primary trauma care. It's a lot to cover, but I hope that in that time, uh you've been able to see things that will help you care for Children who are injured. If you would like to reach out to me. Uh I'm available on email and the details for which are provided in the slides which accompany this presentation. Thank you for your time.