It’s the second day of the PREMIER Wessex, Paediatric Emergency Medicine, Conference in Winchester and today’s focus is paediatric major trauma. Just in case you missed it, have a read of the blog post about yesterday’s paediatric medicine content. Hopefully, you have also subscribed to the St Emlyn’s podcast, where we will be releasing recordings of the talks over the next few weeks.
Introduction
PREMIER Wessex is part of the PIER Network (Paediatric Innovation Education and Research). For those of you not familiar with PIER it describes itself as ‘a collaboration of multidisciplinary health professionals working to improve the care of children and young people in the South of England through the development of regional guidance, delivery of educational initiatives and exciting paediatric research’. In short, it is run by a group of incredibly dedicated and passionate paediatric clinicians. They publish pragmatic and practical guidelines as well as organising lots of educational events.
The Venue
The conference is taking place at Hope Church, which I must admit is unlike any Church I have ever been to before. A converted Bingo Hall and Cinema in the middle of Winchester with conference facilities equivalent to any major venue. Special mention for ‘Andy the Sound Man’ who has helped us record all of the talks for podcast release. It is also the first conference I have been to with an ‘Artist in Residence’.
Day 2 – Paediatric Trauma
Keynote Lecture – Paediatric Trauma Surgery – David Nott
Professor David Nott will be known to many of you as the inspirational surgeon who has travelled to many of the world’s most horrifying war zones, leading teams and educating local clinicians in how to manage some of the most challenging traumatic injuries. He has very kindly said that we can publish his talk as a podcast which I am sure will be a fascinating listen
Session 1 – The Cranium
Talk 1 – Facial Injuries in Major Trauma – Roger Webb
These injuries are rare – the only real way for us to maintain our expertise is to share the cases we see and how they are managed.
We often worry about the airway in these cases, but actually that can be surprisingly easy and often are a Grade 1 intubation
Roger went on to describe a complex major trauma case managed at University Hospital Southampton (with full consent from the patient and his parents). He had fallen from a significant height and had ‘flattened’ the entire front of his face. In order to control the bleeding the patient had his airway secured, epistats inserted, bite blocks put in and a hard collar applied (to ‘splint’ the jaw).
Further management involved 3 separate theatre sessions over three weeks and a total of 12 hours of theatre time, to fix his multiple structural abnormalities. 2 years later the patient is doing well.
White eye blow out fracture – a direct blow to the front of the face/eye which causes vagal symptoms including periods of bradycardia. It is a fracture of the inferior orbital floor and can cause ischaemic of the rectus muscle if not caught and treated early. Of note, the only way to pick up this diagnosis is on CT scan.
Talk 2 – Neurosurgical Decision Making from ED – Ryan Waters
A lot of what we need to concentrate on is the prevention of secondary insults. To do this we need to focus on the ability of the brain to get oxygen. This may involve removing large (and obvious) clots and if not, the monitoring of intracranial pressure. All pretty easy right?
But perhaps the decision making (particularly in children) isn’t always that straightforward. We still don’t really have nationwide agreement about what a ‘child’ is. Where should a 15 year old, six foot tall, 79 kg ‘child’ be looked after? The local Major Trauma Centre or a ‘Paediatric Major Trauma Centre’, which may be some considerable distance away.
A CT scan is the most important investigation of the brain, and we do this usually without argument in children, but what about the c-spine? It may be suggested that an MRI would be appropriate, but this could be several days after the initial trauma and take time in an unwell patient.
Are there interventions that can be done in the local hospital? The use of video referral may well help us in this and Ryan mentioned a patient having drainage of an extradural in the Channel Islands.
Ryan went on to describe three different, but very similar cases, with significant skull fractures each of whom had slightly different operative approaches. Each of these has influenced his own decision making and goes some way to explain why the choices that the neurosurgeons make may differ. Each case is different and each surgeon may have their own experiences influencing the advice and treatment they give. Paediatric neurosurgery management in trauma is a relatively evidence-free area and so some of the decisions are made extrapolated from experience with adults.
Vomiting in head injury remains a controversial part of the NICE head injury guideline. From a neurosurgical perspective, Ryan suggested taking vomiting as part of the presentation as a whole. If the patient is otherwise well it is really unlikely that they will have a head injury requiring neurosurgical intervention.
Talk 3 – Stealth Trauma – Jillian Boden
This talk was about non-accidental injury an area that we all find difficult to talk about and is also somewhat lacking in evidence.
Abusive Head Injury
- Incidence in UK – 40/100,000 (more than new diagnoses of diabetes)
- Mortality rate – 10-20%
- Peak incidence at 6-8 weeks (which is also the peak for crying)
- Remember the fontanelles – can have significant bleeding without significant neurological signs
High Suspicion Fractures
- Posterior ribs
- Non-parietal skull
- Scapular
- Sternum
- Outer 1/3 clavicular
- Metaphysical
Session 2- The Thorax
Talk 4 – Traumatic Cardiac Arrest – Matt Edwards
Is managing traumatic cardiac arrest a futile exercise? Older evidence suggests that there are very few survivors, often with poor neurological outcomes. More modern figures are rather more optimistic but do emphasise that the key time is in the pre-hospital environment.
Think HOT
- Hypovolaemia – be mindful of IO placement
- Oxygenation
- Tension Pathology – it may be tempting to use needles to decompress small holes are now recommended.
The aetiology will change across ages – in younger children traumatic brain injury is more common, whereas in teenagers the patterns are more similar to adults.
There is lots more on this subject on St Emlyns:
Talk 5 – Penetrating Chest Injuries – John O’Neil
Three main mechanisms – violence, impalement and self harm.
Penetrating injuries are rare but have significant morbidity and mortality. The key is early and accurate diagnosis, and many can be managed conservatively. The distribution of penetrating injuries across the UK differs widely, with most in the London area, although as seen in the news recently can happen anywhere.
Remember how traumatic it is to be a trauma patient. We put you on a bed, cut off your clothes, stick needles in you and take your family away. Some will also just not engage with you (teenage boys particularly) making assessment difficult. Be kind. Don’t get frustrated.
Physiologically there may be a strong vagal response that can hide some of the signs we’d expect. Also, bear in mind the events prior to the injury – the child may have been running a considerable distance (before and after the incident) raising their lactate (but don’t assume this is the cause). Children tend to ‘fall off a cliff’ – they appear well, but can suddenly decompensate – keep the momentum to definitive management going and do not be falsely reassured.
John mentioned a great friend of St Emlyn’s Vic Brazil and we would heartily endorse you have a look at her work.
Talk 6 – Airway and Chest Burns – Anthony Bradley
- Recognise inhalation injury
- Instigate treatment
- Reduce sequelae
The decision to intubate is not straightforward – it may be difficult and induce cardiovascular instability, leading to increased fluid administration and even pressors, and ventilator-acquired pneumonia or ARDS further down the line.
Session 3 – The Abdomen
Talk 7 – Bleeding in trauma – Ross Fisher
“If there is bleeding in trauma stop it and give blood”
Bleeding may be obvious, but for the bleeding that you can’t see CT is the investigation of choice. Ultrasound is only useful as a rule in and does not give any idea of the volume lost. Don’t be distracted by normal physiology – concentrate on the mechanism and the injuries.
If bleeding is obvious press on it, or put your finger in it. Carry a tourniquet in your car just in case. Direct pressure can be your best friend, although be careful of bone fragments.
Non-operative management of splenic, liver and kidney injuries in children have better outcomes.
Don’t make the situation worse – think carefully about what fluids you give. “Salty water is for cooking pasta” (although perhaps the situation is rather more nuanced than this). Whole blood may well be the future and the SWIFT trial could help (although this is not including children).
Talk 8 – Blast Injuries – Chris Hillman
Chris brought us a reflection on some of his extensive experience in two wars. Blast injury could be blunt, penetrating, may involve major haemorrhage. It’s worldwide and it’s getting more common.
Blast injury affects every body cavity, but it is the CABC approach that matters, Doing the basics well is still the key. Bleeding points may not be obvious so apply tourniquets wherever stops the bleeding.
Talk 9 – Trauma in the pregnant adolescent – Rachel Atkins
Remember the physiological changes in late pregnancy
- Blood volume and cardiac output increase by 30-40% by 28/40
- 500mls of blood per minute enter the uterine circulation
- Remember compression of the IVC as a cause for hypotension
- The enlarged uterus causes elevation of the diaphragm and reduces the functional residual capacity
Important not to forget the less scary stuff: antenatal anti-D prophylaxis for women who are rhesus D negative (where the fetus is rhesus positive – which should be known after the patient is 12/40).
Perimortem C-section/ Resuscitative hysterotomy
For the obviously pregnant patient with a palpable uterus above the umbilicus. Preferably within 4 minutes, but some chance of survival if later. The procedure is primarily about saving the life of the mother, but you will (hopefully) have two patients and need to be ready for both.
Spotlight
Sarah Herbert discussed the rather awe-inspiring multi agency SimEX exercise that takes place annually in Portsmouth
Summary
The second day of the conference certainly picked up where day one left off with some fascinating talks.
I am really grateful to the PREMIER team for making St Emlyn’s so welcome and I’m looking forward to bringing you more podcasts and content from the conference.
