 

   

 ~~nai%PI%~n~'~lni%aapd
% l ~ % WPreoperative
l to postoperative care

388-531 ,388-532

"Pediatric trauma"
 s i u ~ ~ i n i . j ~ a i n $ d a u f ~ o u i ~ a : ~ a " d n(Preoperative
i s ~ i ~ m to postoperative care )
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Content Page

Objective

Section 1 ;Pediatric trauma

Introduction
Pediatric unique

General evaluation and management

Specific system injury

Abdominal trauma

Ambulatory pediatric trauma

Maternal fetal trauma

Child abuse
Prevention

Conclusion

Section 2: Pediatric trauma case study

Case I : boy 3 yr , laceration wound Rt leg 3 cm
Case 2 : girl 10 yr ,nail pit at Lt sole
Case 3 : girl 14 yr ,dog bite at leg
Case 4 : boy 15 yr ,MCA ,rt ankle deformity
Case 5 : Boy 14 yr ,{U MC
Case 6 : liVWL$1(11~~1~lfl$s4a'n3

Case 7 : Boy I0 yr I~w~~"UY~.IMIS~~~~UU~YW

2 9 9
Case 8 : Girl 8 yr , 3 4 m J ~ ~ 4 n 5 ~ i l ~ n u " u " l n

tanai%6i~i%
 Pediatric trauma (Lecture)

Upon completion of this topic, the participant will be able to demonstrate

an ability to apply the principles of trauma care for managing the acutely injured

pediatric patient. Specifically, the participant will be able to:

A. Identify the unique characteristics of the child as a trauma patient.

1. Types of injury

2. Patterns of injury
3. Anatomic and physiologic differences in children as compared with adults
4. Long-term effects of injury

B. Discuss the primary management of the following critical injuries in children based

on the anatomic and physiologic differences as compared with adults.

1. Airway management

2. Shock and maintenance of body heat

3. Fluid and electrolyte management

4. Medications and dosages

5. Central nervous system and cervical spine injuries

6. Psychologic support

C. ldentify the injury patterns associated with the abused child and the elements that

lead to the suspicion of child abuse.

Y
bU'aM1
I. Introduction

- size and shape

- skeleton

- surface area
- psychologic status

- long-term effects

- equipment
II. Airway : evaluation and management
- Anatomy
- Management

1. Oral airway

2. Orotracheal intubation

3. Cricothyroidotomy

Ill. Breathing : evaluation and management

- Breathing and ventilation

- Tube thoracostomy

IV. Circulation and shock : evaluation and management

- Recognition

- Fluid resuscitation
- Blood replacement
- Venous access

- Urinary output
- Thermoregulation

V. Chest trauma

VI. Abdominal trauma

A. Assessment

B. Diagnostic adjuncts

1. Computed tomography ( CT )

2. Diagnostic peritoneal lavage ( DPL )

3. Focused assessment sonography in trauma ( FAST )

C. Nonoperative management

D. Specific visceral injuries

VII. Head trauma
A. Assessment

B. Management

VIII. Spinal cord injury

A. Anatomic differences

B. Radiologic considerations

IX. Musculoskeletal trauma

A. History

B. Blood loss

C. Special considerations of the immature skeleton

D. Principles of immobilization

X. The battered, abused child

XI. Pitfalls in childhood injury

XII. Summary

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Section 1 ; Pediatric trauma
Introduction

Pediatric unique

General evaluation and management

Specific system injury

Abdominal injury

Ambulatory pediatric trauma

Maternal fetal trauma

Child abuse

Prevention

Conclusion

lntroduction
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Pediatric unique

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- skeleton
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d a i t i i u u u ~~~~erii~riufin~iwunsz~ni~rns~s~"n(rib
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 - equipment
=.A 9/ d
r u o i l ~ i n r l n ~ n i t l i r ~6d$uqdnr6dlfirtdaz4adaiqqzdid;u
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Agelweight ETtube suction NG tube urinary chest tube
catheter
0-6mos 3.0-3.5 8Fr 1OFr 5-8 12-18Fr
3.5kg feeding
6- 12mos 3.5-4 8- 1OFr 12Fr 8 Fr 14-20Fr
7kg
1 -3yrs 4-4.5 10Fr 12 Fr I OFr 14-24Fr
10-12kg
4-7yrs 5.0-5.5 14Fr 12Fr 10- 12Fr 20-32Fr
16-18kg
8- 1 Oyrs 5.5-6.5 14Fr 14Fr 12Fr 28-38Fr
24-30kg
General evaluation and

Airway : evaluation and management

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' Ah Iu ABCDES djuT~du~isa{ulu@vi
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vinWfiiui~~1iilBi9z~~m
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(ventilation) ~flufii~v~~fiGa%~vqm$idiu
~niaz~ua~uaaim~an~~qu~~nzni~rzuiuaini~
(Cardiac arrest)uiniqm rwrizaz6unirm~~adiKuL~oni;aGmniomidLAuviukaailL6n

(airway)

- Anatomy
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t i i u n i u n i w ~6ni;naiu~rmniidn'u$v~m~u

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9

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omega

shape

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i;"lliwlvClJ
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i ~ 0 r d ~ r a ~ ~ m i t 8 i i u v d(anterocaudal
indi angle)

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- trachea t?u' l u ~ ~ n m i m u i a d r z u i5mcm ~ ~ & a i a s ~ b q ? ~ ~ ~ u ~7 m
cmq Lu& ful i 4i a

d s z u i m 18 LZau ~ ~ a i ~ l d i a d a u v i uRight
I ~ ~mainstem
n ~ ~ i bronchus rzuiua?ni~rls.i

LfkNvla (inadequate ventilation) ~ i a d ? u v i u ~ (accidental

~ ~ ~ a u tube dislodgement) v?a

dambbmn (mechanical barotrauma)

Management
I u n t G ~ R n \ r l u k a aa i q i a w d u v ? u k q m K u u 7 a d a u nat<ml6adluvna sniffing

Position b u d cervical spine m a d l u ~ ~ u a o(neutral

iu airway 41
alignment) n ? ~ d w

6 a u ? ~ u n n i s $ u(chin lift) v%w&n&imntdnt (jaw thrust) fau~uiunr::qn$uv$~~lSR"

m&ueenuanLLuatiu (Bimanual inline spinal immobilization) niu6auLaidaLLdnndna~

av; afiuv:: LAWBi1119 a a n q i n d i n qunun::na vkqin&a16a~n$bqu ~mi~ingautri

P 8 n h (Unconcious) Ei~itmiI%~dntnid.lu
(mechanical method) n ' a u l i n n i s n i ~ ~ A u

wif!I?,Q;af!I mechanical method b z n m a % ~ ~ ? u a a n ~ b Q u

1. Oral airway
natld oral airway ~uLin?!c\ri?8nGadiu?uL~ndP$niauj~
Gag reflex a $ r i m ~ l d

'i'$~d~riLLu::iii;ald LL6avYu n ~ I
~daaqineiqaiiiuuqud7~n16 u80 aa HI LW ti:.
sr -4
oropharynx a i ~ u i m ~ ~ u ~ u ~'i;?!qnatdOunnml.n"b6nmfu(tongue
~ a m a m blade)d?unm
9

iiuna~~6ald
oral airway fmuns~adiaFiaqnuou

2. Orotracheal intubation
n i s ~ d v i a d a s u i u l sendotracheal
( intubation )k~a$luLinuimL+uiiasinvniu

ania:: 1611rinituim~GuAtw::~u~~o;~(
severe brain injury ) luntG~dnWfiiu~tnviulq
dsi 4
t 6 ~ l n ~ l ~ b ~ ~ \ r ntm~wnua1ni~nitt~u1ua1n1~6~~~~a(~enti1atory
l ~ % ~ ~ n ~ i a ~ failure)

\ r ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ a m u i n ( h ~ ~ o v o ~ e m i(operative
a ) P d aintervention)
~ a a ~ ~ i ~ m ~ n ~ t ~ i n ' n
ni~ldia"duv1ul~lu~Gndaulv~4id~G~aiu1tn~~fl"11~vi~ia~?uvi0l~
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4
dmaddLLuul~~nnPdd
Uncuffed
( tube) L d o v ~ n r ~ u a n i t u l m L 6 ~ ( s u b ~ ledema.
ottic
.
ulceration disruption ) (fragile airway) 98Pda~
m~il~?ua~uk.lirauauuia"~~aa~Gn
dt::ulm"119d1~~ada0v1u%q(tube
diameter) a; a u i m ~ a a i q y n(diameter of the child's
pl

external nares) v+a "uuiw~afiau(diameter of the child's little finger) v?afi1~174nq

%urosel low^^ Pediatric Emergency tape

~uplu~~u'n~vydau~~~~~~~~u~iidiv?unit~diad~uviu~~~ufinia::qnb~
"rapid sequence intubation" (RSI) gmudsdiaaLaltE~aai7aa~~qribbri
i~uu d a ~ n ~ a ~ g n

vital sign (pulse LLK blood pressure) ~m:.t::Kunir~8nGa

A i h r i e u l d endotracheal tube diahL~nLdadauniab~uviu1q16bb6

%fmn$Ll~

riau (preoxygenated) nitldviadauns::4u vagal ref~ex~u~dnu~wanismaufiuaauinn~i

lu$\rd o i ~ i f i i L v ~ u i ~ i n a n hypoxia
l?r nltno::~u~lnlarygoscopy LLn:.wnueaul
La
-mnisaw"atropine r / n u ~ i o ~ ~ t n n i s n n u f l uvagal i n 16 (atropine pretreatment
a ~ ~reflex
dose ; 0.02 mg/kg , minimal dose 0.1 mg , maximal initial dose 1.0 mg)Pmu16iauldvia
"d~vlu%"ladldPd"a 1-2 ul; ~ 6 n ! 6 ? u u i l v C u (sedated druq ; Normovolemic child-
etomidate 0.3 mg/kg or midazolam 0.3 mglkg , Hypotensive child- etomidate 0.3 mglkg

or midazolam 0.1 mglkg) Lbazn?sbm?au flurnazenileddbfh antidote d i v k midazolam

!ilh?aula"69u ~da~lnvgulfinmntz~nniadb3ud
(cricoid pressure) ~ & d ? u v ~ n ~ d u d
n i s d ~ C n n . a ~ ~ ~ i v i s v ~ a ~ i e i a u ~ ~ n n ~ z ~content)
~ i z a ~ vCims s~~avsutl rzidc~ n n ? s l i u l
a- *

n n i u n h u b t a q v ~ s u ~(short-acting
u paralysis agent ; succinylcholine) <ilaanl)m&%
t&.drmrdnom5u vinh~1fiaen~m~uiu8uei~1;a"
vecuroniurn ~dutunsE;r6adnirCT scan

do!d vfi.ulnldvied?uviulq~fi?q LL&?Y?~~

di~u'uiaui6edms??dszb~u~ikvrid$~n6ed
nniu~L?dnmnszqnniadb$ud(cricoid pressure) vlnujldfi1~~~nUYiadauwiul~!&v6~

~ 6 n ! ~ F u u ~ n n i u n & i u ~ d a 6 a ~ d a u ~ z u ~"bag-valve-mask
uaini~au device" .uuntzidl6
definitive airway
szps<ia%d Orotracheal intubation 6aab~usllaanauabazdiab~aa(vocal
cord)
b:
u a ~ spinal i m m o b i 1 i z a t i o n ) l d ~ a divru
w k u n a f l a a n ' u n s z ~ n ~ e ( ~ i m a ninline
Nasotracheal intubation ~ n ' l ~ i i ~ m u b ~ ~ i z ~ u b 6 n a9~d~bCb a
e :u~nl hi iin r d o m i n
~ ~ u n i s l d ~ ~ u ~ l b m i ~ u e j i u y u(acute
v ~ ~angle
C w ~inqthe
n nasopharynx) nsd'ldfidniad
~ ~ w d o ~ u i a u ~ m i ~ u u(anterosuperiorly
~iuvCi located glottis) uan'lin:aiw.mdmI$
2 A
nzbnnAswz ~?ao~1iflb6~.lladb~ab~9 nasopharygeal iii%b%ma~n

~dolilmndeadus(glottic opening) !&bb&a n ~ s l endotracheal

d tube 7 $ b a a d u
2-3 cm
b & ~ (vocal cord) ~ d d s z u i w abaz~sa~~ibbps~da~bwuiza~~~ni~~a
b:
(auscultation) r ~ a a w i a ~ ~ ~ u n s a t o n p ~ ~~aw
(axillae) ~ n b ~ ~n?oiiil09"6u~qi~
nanaai'ia

ldl.;m Right mainstem bronchial intubation 1 m u L ~ u d ~ r u i u ~ l n i ~ i d f l a d ~ i d 6 a d L v i l n i d

w c p
uunnszn'u~aiuBn~in~urlinli&amuau a z ~ n ~ n 7 $ $ u ~vak q i n h l ~ d n i
orogastric-tube ~ ~ n r ~ m s n u i u n u e m i n n s z b ~ i z~a~i v&~?s( i l u n i ~ ? d d d a m d ~ z b ~ u

d i r ~ v r i ~ v i e d i r l 6 ?nun l s ~ n ~ a u n ~ u a s ~ ~ s w z a ~ ~ i i l f i v i a ~ ~n?s6b;ud
au~de~~mi~~~vri~
v%aol.ui;nisszuluainifiimdnZ
(ventilatory dysfunction)
3. Cricothyroidotomy
bag-valve-mask v7f1orotracheal intubation 16
%.n"b~n~~~dfi1%11~61"d~si11~~4C~~

Needle cricothyroidotomy &au Needle jet insufflation bbmdej'lu cricothyroid

bbuz~1lps"b.a"

~b'uinisszuiualniR!da$u~wf~
membrane bflu?c$<dbvui"u bda~fiaan?aqubbuu.o"ansi?

L L R ~ ~ I I ~ I , ? Hypercarbia
~ L~ufiu
 div?ulu~in~dn~~nz'vli~nlilni~~u::Cilfi.j;i
surgical cricothyroidotomy h v ? ~

b8inCmaiqGi surgical cricothyroidotomy v i n ~ i u i s n n icricothyroid

i membrane 1641~

a2a3i ~
& P m s i a ~ n d i m " ~ ~I

Breathing : evaluation and management

- Breathing and ventilation
~ m s i n i s v i u ~ q ~ u ~ i n ~ m n dwwn
miua i ~ ) 40-60 breathstminute daurm"n1m
(infant

(older child) 20 breathstminute L ~ ~ I ~ I u ~ L ~ ~ (tidal

~ u volumes)
I ~ o ~ ~ ~ ~ ~ ~ I ~
d ~ z u i n 6-8
r mltkg I m r f i a q n i o l $ u & ~ ~ u d b i n ~ a u r d a f i a ~ ~ ~ b n i a q i a u7-10
v i u ~mltkg
qia
4 *Dl

b b r i i l bag-valve mask devices 6u brww~6adil!~ilb~a

~lanu~8in~naanbbu~1fi~in"m~b~d
I P,

~ ? ~ ~ ~ u ~ i u l ~ d a u u i C ~ l d(tracheobronchial
~ ~ ~ y ~ 5 ~tree)
~ ~ bbAr?daU
~ 9 T i (alveoli)
a~u
'j;i%363u~1imb;~vTa 2nwml6
niazaimaan~nu(hypoxia) r ~ u a i a q ~ a u ~ w ~ d . j ; ~ ~ f i b i i m f i a ~ ~ w q m b ~ u ( c a r d i a c
arrest) Ita~Kndqwurieur~mcardiac arrest i e nia:: hypoventilation i i l f i ~ i i mrespiratory

acidosis &Gnuimdu~daulwdacid-base iimdn? mj~unanlsiauviuk(ventilation) M::

n i ~ 1 w n i u u(perfusion) lfi~~uswafiiuisanqAi
p~ l$dn? &imasszTdwin6uimnis
.baawiah sbaznistwab?au bb$awaiaiubbn"b6uniaz acidosis Kaa sodium bicarbonate
d PX.
wawtnaa hypercarbia bbazw°iT$nia%acidosis t.~daaaasIelZn
- Tube thoracostomy
n ~ r u i m d u ~ d ~ l f i ~ E l a ~ u d a m ( ~ ~ e u oiqrzm
r a ~ ) ~ nhemothorax.
"u~m
pneumothorax, Gioa hemopneumothorax ~ ~ u b i n ~ i u l ~ u a n " u ~ P d ~ v ~ a i n i T ~ b i i m m i u u i

6aubiufk gbbnniruiml~un~u~mu~rfliu.d~dwsadan
(pleural decompression) lmub~an

v i a o z u i u d ~ n n i(i m l t i - 1 d 2) ~~arldluda;l~lnTdibw~aniib~ua
skin incision ~ d ~ n v d i e d

~~lnis$uu u
(superiorly) bbnr'vli.rak (posteriorly) miuw~qan6lulu ~iv?u~i!,bw~dd
3 a n l u ~ d n a i i a d u $ v d i a 5th intercostal space L M ~ ~ I L & anterior midaxillary line

biwbtinCau
Circulation and shock : evaluation and management
- Recognition
n i f ~ $ uphysiologic reserve di'LGE~ns
~gnuiunl"uaiqiiwaIes"~lu~dmml6
V W d
5yyidw (vital signs) dau'Lv~"bSR"a~lutz~~dniIm
nqaad'lunl?:: shock o i q ~ n

LG~.IE~&W w i o u ~ u ~ v uindq-fiufi;fzrdiuuLbdad~ub~n
nj Hypovolemic

shock sin19 tachycardia LLarLi;am1vaijou~iav.ld"9unwimd(poor skin perfusion)

hypovolemia LLaz
finrflurlryLndi~bw"ud~ub~uaduan'b6n'auaini?~u~ad
~ l L f l ~ 6 ~ d 1 crystalloid
~ ~ ~ 1 f 4au~vi;eaLiid~vu1zfiu
~i n~sdsrriiurAnumrGu
a6ms6ufwa8aarbww6r~u$s~~7b~u
fiuim4Lzamdamaqldaeiid~au30 % qz
Lumd~es"r~unir~d$uu~bdadqaq$yyidwTu~~n
l,

n i f m a u f i u a ~ b ~ a d 6 d u b ~ n ~ i nhypovolemia
niaz a; tachycardia adlslfn"
W d W
n l u % o n a 4 f ~ a ~ ~ n a 9 ~ i ~ d b ~ s b ~ i i h m i u ~ m(heart
f i n i frate)~w"udLi~?
b6u~a~~
~ a i u n t h~bazphysiological stress ~ d ~ u 6 a d
tachycardiaai~uiqinnaiub~udam

'vI?DA~~I~.~I~
(loss of peripheral pulses) 5mna~u6uCaGm~~~a
pulse pressure bbnu
(< 20 mmHg) ~av.ld"d~fluai8
(skin mottling) daL~iLLaeLauqiLiiu~dab~uun"uii~a

~a~d:qe;l.o~azd~nmniazqimLdom(inadequate organ perfusion) ~ 4 ilfifimzd

u
man na~Gmniuedi;ltnRm ainiodndia%is6uLLfimd3d hernodynamic i m d n i
(mimad 3:Systernic responses to blood loss in the pediatric patient.)

R I I I P ~3 : ~ I S R O U ~ U O I U U J ~ I J ~ I ~ ~ B ~ I S L ~ U L ~ O ~ ~ W ~ ~ ~ ~ L ~ ~

5:~u ( mild I moderate severe

i=+
hypotension,

narrowed pulsed
Dressure
1 r:nr~~lsrnmnd~unn~aI iuaiu 1 Qulriiounounua~cis I comatose
I
prolonged capillary prolonged capillary
refilb2sec refilled > 5 sec
d?uindnai13: osnd~uas douuin '1P'J O B ~ ~ L W O
 El 54
n?iuGuIaCm systolic blood pressure dim$mm~ddn~~uL~nbS/iin"u
70 mmHg
van a%sbviinaseiq @) iiv?umaiunid~a~m
diastolic pressure ~ ~ b S / i l f k f l a d

luaiuradn~iuKulaaolsystolic blood pressure lu~And$n?iuGula~mhi

(hypotension) bbflmdni9z uncompensated shock bbazejdiib~ub~mnuinn~
45% Yad

fiulm?~amd~rraiiauod
q i n tachycardia ~ d i u u ~ fbradycardia
lu ~ ~ ~ b ~ ~ l t a l s b ~ ~
a d i ~ ~ u w n i l u r d n m(infant)
m nirnl&tuL~dn.t$&adlfi~~
crystalloid imc. rBam mdw

r~mJ.nduiu
(mirwd 4 : ~ i t afunctions)
l

mind 4: normal limit of physiology values

Age groups weight (Kg) 1-Teart Systolic blood Respiratory Urine output
(in years) rate(1mi pressure(mmHg) rate(1min) (mllkglhr)
n)
Infant 3-10 <I60 >60 <GO 2.0
(0- 1)
Toddler 10-14 <I50 >70 <40 1.5
(1 -3)
Prescl~ool 14-18 440 >75 <35 1.O
(3-5)
School age 18-36 420 >80 <30 1 .O
(6-12)
Adolescent 36-70 <I00 >90 <30 0.5
( > 12)
calculated Agc(yr)x 2 + 10 Age(yr)x 2 + 70

- Fluid resuscitation
~ m v u i u ~ o ~ n i r l f i a i ~ ~ ~ ~ ~mm~ ~mum
t z ~u ~ l~" buvfai ~uu~u ~ a ~ m a d i d r a m ~ a
lmudrzuinru&~rl~uim~FaGm~od~~n~viin'u
80 mllkg bdaadbni?z shock
6aio.lnirair:ilu crystalloid solution bolus 20 mllkg vinfiimdnqrair;ign~p~"mFa

a: 20 mlikg ~muo?u"ba.iL%daiunid
v ~ m ~ u l r i i i60
i umlikg ddiUirnmmLnuL~ami
l, l , l

gt-g~RaW25% l G v h a i u n v l u v & r 4 u b ~ u a i u l u ~rda6ulfiairliink4aqu

v~ (20
l,

mlikg) ~ a r ~ q i ~ n r l \ f i b ~ a mPacked
~ m u ~red
$ blood cells (PRBCs) m?dac. 10 mlikg
a w & d l & u i u 6 i v ~ n b ~ niosn!dqneinr\uh;lonb?udrzb~u~iv~nLdn~m
vin'bai'b6msas?n81b~n.Idn~bbuzlii%fl$rose low^^ Pediatric Emergency ~ a ~ e b f l u
P C I ~I
? s ~ d i u b b a z d ? \ u n i r ~ i u a ~ ~ i v ~ n b ~ n ~ ~ s l f i f i u i l i ; l r a ~ r ~uanqindfid
i~baz"uuimui
H g G m r i n ~ r v i u l .f ~i u ~ m ~ a i r ~ i~dal z~a u i m u i ~ u i ~ ~ i q
 ~ ~ a l w " f i i s $ i i a u d n d u i m ~ ~ u ~ a s i m m i u ~ n i 9
Idtjoiclazoii.rl ~ m u d o z ~ i j u q i n n l r i i ~ i u d iHemodynamic
ilw" bfludnt? &d.r<~nu
~nn'?iipllnn'uuidnS
~m;nsinismiups"a7qnmns~ksidnSmiun~uoiq
rnsaql'u~wq;nsu'sra~dai~rr"~1~"~111~ du
l i i a d n l qmvmiiuauu~~u$u
d
systolic blood pressure r i u pulse pressure (> 20 mmHg) ili(liamnoan
dsmuind 1-2 mllkglhour (:u:un'oiu)
~uluka'bdrindszuiwvidlufiiu(113) d'bdTufiis$imaufiuat~unisTnwidau
"b~'b6?ub{ud crystalloid bbazlb9j6adlw"b~am(responders) uisdaumaufiua~wnnis
11% crystalloid L L ~ L (responders)
L ~ ~ ~ b ~ n ~ i d n ~ ~ ~ a ~ b b m g b ~ ~ ~ ~ ~ ~ ~ l f i ~ ~ 9

l w " crystalloid bbazbzam rridauioriad (transient responders) ~ n n ~ u ~ 9 j n a u f i u a d

q i n n i ~ l wcrystalloid
" bbazb~ambau(nonresponders) b&7~~nf$.I
transient bba:

nonresponders 6ad'b~b~omb~u~mufiabbaz~qiswi1d~dnisdi~m

- Blood replacement
Lda~Gfiis& crystalloid RhUsn (first bolus 20 rnllkg) bb&a Hemodynamic k
u I

~ m d n ~ ~ i i i ~ d ~ d i d u ~ h i n v i a b ~ a m f l . r a6adlfifiiriilnLgunk~fiaa
ana~dau
v'bfiiu ~~~zbj"ruMku~anciuiTmnisFmuw'ui
luszviid$lGfiisiiln!di~lu
(third bolus) bi;sm~afw?au%i 6 l f i n i a r b ~ n ~ ~h6hifonlfi
ad rzom~$~
(warmed
PRBCs) 10 mllkg miun~uJom(type-specific) rr?o 0-negative
- Venous access
luns6i severe hypovolemic shock ~nb~nqinniob~ub~sm~uwsadanbbnz~adw"a9
w
qinaTuazviavaam~zam$n"uimn i s v i v u ~ i s l w " f i i s G i ~ i ~ v a a m ~(Venous
~amii
access ) ~ a s ~ i ~ ~ d a d i d r ? m ~ a u ~ b a w d a i u b b " u u d ~(peripheral
~~nfz~nps'n
u
percutaneous route) vinwuiuiu~~&afias~s"J'bajdiJq
~asG~isw19W"~i~"uns~~n
(Intraosseous infusion) v~adi~nb~mvaanb~amil%dfiiufiau
(Direct venous cutdown)

luui~eo~ud~~w~~~idszfiuniT6166iiuiyfiiuis~ldfi~ufiaudiuvfiambdamii~"uiv~u
26 (Femoral venous line)
u
(venous access) I u G n 'b6b~r-ivfiam~~amdaudaiu
ii~~vPd~"~~nisl99"fiisGi
(Percutaneous peripheral 2 attempts) lanrzpn (Intraosseous) fiiufiauvnamildam
(Percutaneous placement- Femoral vein) ~i&admvaambzan(Venous cutdown -

Saphenous vein at the ankle) diufi?uvfianbzam (Percutaneous placement- External

jugular vein)
 4 A4
aubinbn"naiq6aunh 6 d mu hypovolemic shock n i ~ l intravenous
6 access bgu

i l r u v i ~ ; i i n i u d i v ? u ~ ~ a ~ l u b v ~ n i s ~ ndia~ul 6l va ~i r ~ i n i ~ . d a ~ l " ~ n s z q n ~ b " ~ u " u i d

\xi fin ~ i ~ u ~ n : h d d ~ u n i b~udiw?u
a z ~ n bin~+uv<ncioaI6Fuuim~iui;lii16ainria
dnamfiu idsz8m~niwbbnzb~an~iw7~mb~mvnambzam
(venous cutdown) afjid~s6miu

~daaiuisnlfia~s:imi~vnambZamdivui:au~~6anasvqmnis~fiais:iwiq~"unszqn
~ ~ l i a ~ d i v ? u n i s l f i ~ i s ~ i ~ i(intraosseous
~ ~ " ~ n ~ z qinfusion)
n !mY~rri~ini~
C

a i u i ~ n % 6 ~ i s i i n i ~ v n a m ~ ~ ~niaz
m!6q in
nis!vn~uu6ubvna (circulatory collapse)
C

vTa Cnuwuiuiulw"wi;lvnam~~amdaudniu
(peripheral venous cannulation) aadn?;l

~~6aCd'9'baidi~?q intraosseous infusion l&bbri ce11ulitiswul661d,

niaza~wsn$~u"uad
osteomyelitis, compartmental syndrome lln: nisii~fii;nsz$nfin (iatrogenic fracture)

iinbvlhdrru:~idiw?u intraosseous cannulation fla fwqn~6ibb$d(proximal tibia) IK

&a tibia1 tuberosity fiinszgnvdi~~5dfin
aisld~ludiunszqnfium(distal femur)
uanqini!lil$ intraosseous cannulation 1n"daiirrv~;lii;nszqnfin
- Urinary output
fiuimilaaiat.~aan$un"ua7qb4ub~uan"ufiuimsbZamf i u i m t i l a a i a z d i v h
odnziuldrrri ~ubbsnb~m$;laiqwdd~(newborn-infant)
Pmllkglhour Tu~FinbBn(toddler)

1.5 mllkgihour ?udnTm$dTufu (older child - adolescence) 1 mllkglhour div%@qj

mde, $
(adult) uiidnmiua~m~mffa
0.5 ml/kg/hour

fiuimsilaai?zdaaniaun"p~~aiu~$u$u
(urinary specific gravity) du5;duam

~duulunisl$dr:~2unislfiais~iadi~auizauvlin~Eiom1urzuubniiuun"uuidnR
fiuimilaaiaziaanfiasdn~6aunisdoz~Guilaaiaz~e;l~innas2da7uaauilaaiaz
1 C

~.du
div?u~Rn%Giv<n6aunii15 kg eiqqz~qaiuaaud~aii;~n~dqFeeding tube 5-7 Fr.

- Thermoregulation
2 A-
rdad8mdi?uaadwuwwa (BSA) 5uuanniu (body mass) e ~ l u ~ ~ n 4 ~ ~ ~ ~ n i s
8Qbi(un?lu!au~fin"uidLbam~auLLnz~Fini;$u1~fiu1fi~av~d6aui~ii1finaiu~au
I C

wnaadiidnludru"uv+a Hypothermia rill6

~lu!db~iui;uunzhnisw~;l~iubiu
iidniulaimausuasionirTnnw ~ l a m l i r ~ l ~ n i v ~ a a a n l x i ~~nzauec!airiidiu
vqm
C C

6~Culunir?nwi~da~fiufia~fla~n"uGl6i;
Hypothermia v;a%6nis?n~ Hypothermia

~ il u r z v i i r ~ d m d i o ~ m s ~ ~ i i ~ n i u ~ ~ 6 ~
'Kgn'il raicii$unaan ilmm~adiinaiu
f i a ~ u t i u $~3a~.a"&dudu
i ais~!ifiaddu b&mb.ibu"u
nqu~sw:~inw?asadldlfi~u
9,

sauw"9 inhaled gases 69u

Specific system i n j ~ r ~ ' ' ~ ' ~

Chest trauma
d a u l ~ ~ w e r i a u n " E l n i s u i n ~ ~ ulu
nisuiar~uu?~amwsa;lanwu'baainjau ~~~ius~u
bbaz mediastinum fliuionbn$eu1vacl?l6diuii
~dniinaiui;nrr~ura~ns:4nuinn41$~1~
1 ~ d n l z w u n r ~ n ~ T ~ ~ f i dqziibniatfin
n~66au dan;inn-iib~anbbazauka16njau
(tension pneumothorax, lung contusion)

nlsrnw~afhufinj rrdh~dnb;lldviarzuiuaratan (intercostal drainage) ~%ldvis

.dauuiullaeildsanta (endotracheal intubation) adidran~abwsizbdnwunis.rrineen~blu

l ~ a i u i u~ k ~ i n d s z ~ i r ~ ~ ~ 6 a ~ ? i i ~ i i ~ d a u i i n i a z ~ n ~ ~ u d f l ~ ~ ~ u 5 n ~ i ~
l6bbf-i
1. tension pneumothorax % $ n i s ~ n ~ ~ n u n i s ~ d a " b(needle
.ii~~b~ iz
decompression) wlu
6 a u n i s ~ d v i a ~ z u i u w(tube
~ m thoracotomy) ~ u i i ~ ~ i d l l d a d5i ~midaxillary
n~d line
P,

2. massive hemothorax %$nis~n~i~nunir~.aps"flis6i~$biudwa 61

~~6aldviaszuiuwsasan
fiulnarisnffoenulnnurasn uinnil 10-20 mllkg rr'so oanulnnil 2 mllkglhr
r ~ ~ ~ b ~ ? , ~(emergency
w i ~ ~thoracotomy)
~ ~ ~ ~?,u~oaw'l&n
n w i
3. opened chest wound liinlo~nwiL~aaflu~munif~mbbwa6au?~
sterile occlusive
Y

dressing ~nuiafi'dfliu6iu~~6aldvias~uiuwra;lenFmu~~wiuwi~~~wa
bb6aqnbbwa6iuG
bud8
4. flail chesVlung contusion ~ d ~ u ~ z i i i r ~ V l d B Q n l s V l O 1 l d l ' b ~ f l l ~ l ~ ~ V 7 ~ 1 l ~ 6 b i ~ d ~

T n u g q ~ n o i n i r w i ~ ~ ~mi: ~ 9 ~wuii
~ nABG a ~ >lfidviadauriuk
PO^ < ~ O , P C O 50
Y

5. cardiac temponade wul~ainjau~ 9 j i n i r ~ n w 1 ~ n u n i r ~ 9 j i f l i r 6bb6a?h

i%~w~
percardiocenthesis bb6a61f$auWd16fl
Abdominal trauma
A. Assessment
B. Diagnostic adjuncts
1. Computed tomography ( CT )
2. Diagnostic peritoneal lavage ( DPL )
3. Focused assessment sonography in trauma ( FAST )
C. Nonoperative management
D. Specific visceral injuries
nituim~<uu~~am4a~6a~lu~inw~ll6iau~~~nitdtz~~u~ziil6uin
~wtizbinnGaqin
n l f 1 6 ? u u i m d u ~ d i u n l ~ ~ n d t ~ ~ m t a ~ ~ 7 d n i u ~~ddiaiu~~6nudi~nr i f g n ~ a L L a z S n i t

uimdunniur:uulflfi~biliiunitu~mdu.do~via~6au~zlua
~ ~ a z @ a u d d ~mtaqi.wniu
zG
s~biliiulflntaq6uinijau(~]1audSnifuim~f
ul~.da~fiad~eua
nimsaq~d~~i?iu
1.Focused assessment sonography in trauma (FAST) ~ u n i r m ~ q 6 a u P l ~ u m a i u ~ ~ d d a u

~ndil~msdiuu~~~nddps"ad~nb~u
f i i u ~ ~ n m t a ~ a ~ ~ E ; a m s a n a~~ u~ ~
a ~i ~Wa" ua ~d I~~ r i
f ~ n o i ? n ~ a ~ a u d b i l i i Q ~ i m ~ w(unstable
~ r i m d d patient)
$44
2.computed tomography (CT) Lflunitnt?qnm~maiu~a~d
dlultnuanfldaiu?zduimb<u
~u:l4.daulunitimniunit?nwi L ~ o i $ a u ~ a ~ ~ i d w n ; l d L L a z l u L i n a i q k d l p s " u i u a u
W ~ (sedation
I drug)

procedure) bccluW
3.Diagnostic peritoneum lavage (DPL) ~flunlrolt?q$~u~Lfd(invasive

L5u~~d1riinir
Ltaniu 'Lu~in'L+warmed Ringer's lactate solution 1Omllkg ~nm6nituan
Ad a
w a u a n ~ ~ a z h ~ a ~ l u n i t c i i K m ~ nun~iu[daunu~aamaanlu.d~~W"a~aiq?nwiCmu
ijau~n~
nit'bdejiGm
nisFnwi
1.Id NG tube r ~ urethral
~ z catheter y n f i u ~ ~ ~ i z ~ u ~ ~ n n ~ ~ ~ w i z a i n i t ~ n ~ z ~ d
msaq'imwaimI6
2.[dau penetrating injury with shock i m d ~ n ~ ~ m u n i ~ c i i ~ m w ' u ~
3.nio?nwiFmu?friejiGmiilm"bu[daud solid organs injury LLd6addilufiniljudSmaiu
I,

w~~uLLB~~~~~LLwMCL~~UQ~~;T~M~~LY~ICU
4.nisuim~~uaa~ii~&~Andau6u~~nzGuiau
(duodenal and pancreatic injury) 1u~inq:wu

iaunii~n~~~a:aiui~n?nwiFmunitlriwiGm
u
~.ni~~~nnn~~aail~iuazlu.da~6a~6a~l~?uni~~n~Cm0n~~ei1~m~~1~u
Head trauma
A. Assessment
r n ~ s 5~ Pediatric
d~ verbal score
Verbal response V-score
Appropriate words or social smile,tixed and follows 5
Cries,but consolable 4
Persistently irritable 3
Restless,agitated 2
None 1

nituimduu'Eranai~wzd ? u ~ ~ ~ ~ ~ ~ m ~ i n ~ u ~ ~ a ~ ~ s i ~ ~ r d a ~ ~ i n ~ ~ w
Y
, w rl
uim~iuu?ranai%wzI&fiauI m c l n i ~ u i m ~ 4 u u ~ ~ a m i r w ~ l u ~ d n r ~ w n d i a ~ i n ~ v y m ~ u
I . e r a n i s ~ n w i n i ~ u i m r 4 u u ~ ~ a m A ~ w z l u r ~ ~nra"ur6naiy
n q z ~ n i i ~ vGaonii
~ 3
d
el wanisi4nwiqzIi~~iirgnFm
2. l u r 6 n r 8 n d n ~ z a r i ~ u ~ ~ l r i ~ m a i m i n i ~ r ~ ~ ~ ~ a m ~ i n n i t u i m ~ G u u 3 r a n a A s w z r ~ i

subgaleal U~@~UUI~LGU
epidural space qu~il$(d'il?u~?iuKu~aGwnn'b6
u~~ana~twzdnaiu~u~a~ndiyn~ub~aifii~~~~uiau~fiua
3. r6nb8nnszaiaufqr% (open fontanelle) a i ~ i i l f i a i n i s m ~ n " a u l u f i u a ~
(expanding intracranial lesion) 1 d ~ ~ ~ u ~ ~ d a i n i ~ ~ z r d ~ ~ u b b d a 9 a61
didfamb?a
~ i i w u n s z a i a u ~ ~ 6 a ~ ~ m i i i w u i " s n i w f i ~ ~ ~ ~ a ~ ~ a zA'a0~~ww6
6a~finwid~zfiiw

15 maswsas~anabs$~aufia~wa5fiuas
5. ~ 6 n ~ i ~ ~ ~ i n i ~ % n a k 1 6 ? u n i s u i m i u d ~ u l a ~ a ~ m ~ a r r d a i ~ 6 a i a a n r ~ s r ~ u
SlU

axonal injury) d?ulac&d

6. ni~uim~~u~ufiua;laa~b~nbfluni?uimbfu~a"bd(diffuse
i a 9 l ~Ki l nltm~fin91~~uildli;~
~ L L ~ ~ ~ ~ u ~ " J ~ ~ O ~ ~ I I L~ ~R U" R ~ I U ~ M~ Ia C
~i~ ~ ~ ~ ~ ~ ~ ~

a i l u r n na6elni
7. 6 a 9 f i n W d s z f i i w k u L L w w ~ y n s i u d d r z ~ n i T u i m r ~ f l i ~G
?wn z$ i d r t . G f i ~ u
b;Pa GCS ;in41 15 , notid GCS score iiniil~rarvii:u 8 , ~~~~~~~~~~~uu .
inaiuindn'lluran.nrs6~aufiarna5fiuo9
B. Management

9,

1. bbfiflyvibfl~96~&dniiabb6a~u
primary survey (rapid, early correct ABCDEs)

.
m51d 6 Management strategy for children less than 2 years old based on the risk of
TCI
High risk.for ICI: CT scan is recommended
1 .Depressed mental status
2.Focal neurologic findings
3.Signs of depressed or basilar SF
4.Acute SF by clinical examination or by skull radigraphs
5.Irritability (not easily consoled)
6.Bulging fontanel
7.Scizure(a)
8.Vomiting > or 5 times ,> or 6 per hour(a)
9. 1,OC > or 1 minute(a)

Inlermediate risk with any potenfial indicators ofbrain injury: recommend CT or

observation
1 .Vomiting, 3 to 4 episodes
2.Transient LOC < or 1 minute
3.History of lethargy or irritability, now resolved
4.Behavior not at baseline, reported by caretaker
5.Nonacute SF (> or 24 hours old)

Intermediate ri.rk with concerning or unknown mechanism or.jindings on clinicul

examinafion [hat may indicate underlying SF : reco~lunendan imaging procedure(
CT, skull radiography, or both) or observation
1 .Higher force mechanism (high speed motor vehicle crash or ejection, falls > or 3
feet )
2.Falls onto hard surfaces
3.Scalp hematoma (especially if large, bogby, or located in temporoparietal area )
4.Unwitnessed trauma
5.Vague or absent history of trauma in the setting of signs or symptoms of head
trauma ( should raise the suspicion of child abuse or neglect)

Low risk-fur ICI : recommend observation

1 .Low-energy mechanism ( fall < or 3 feet )
2.No signs or symptoms more than 2 hours since injury
3.Older age is more reassuring (especially age > or 12 tnonths

(a)Represents expert consensus.

Adapted from Schutzn~anet al. Evaluation and nianagement of children younger than two years old
with apparently minor head trauma: proposed guidelines. Pediatrics 2001 ;107:983-93.
m a l cord i n i u ~
A. Anatomic differences
B. Radiologic considerations
niruim~:uu?~am~awu'b~d~aubwsizbGnna~u
od$wuldiliauniloaz~umsiuuin~a
niruiminl'uaaanoz~nduv~du?bam~a
niruimrquaadnrz!n8uv&'lu~in~+a~q~smiiid
q i n 0 n . J i;a
1. 6nnamznianiuniwdirnir (anatomic difference) riu tdni;no:!n igu i%miuuin
niruiuniulu~Gnkimndirqin~vn.J
Y

2. n 1 w 6 i 1 u w i d ~ d d i u(radiographic difference) bddu pseudosubluxation ~ d 6 ~ %

6aioJiina~u~Ldua5unisiiuniw4d3lpdbGnL3uaeiid~
3. ~Gninisuim~~u~a~l"uKuvK~Fmfll~i~aiu~mdn~"ua~niwk8
(spinal cord injury
Yd

without radiographic abnorrnality:SCIWORA) KdGu 611,~n~ainis

drz%nlsulmL~u
fi~KulGfinwidrzfii~~au~~wnfiGui
v~awraq%i;lniu
niss;lln ~vijau?i'unio~nwiluQvn.J

Musculoskeletal trauma
--

A. History
B. Blood loss
C. Special considerations of the immature skeleton
D. Principles of immobilization

~ ~ a ~ ~ i n ~ n i a z n i ~ n i u n i w " u a ~ n ~ z ~ n u n z ~ a l u ~nrzolnrlni;
in~~mnii~~in~n.Jdu
n a i u ~ m ~ t / u u i nunz~~n6ad~nir~q?~b?uFm"uadnrz~ndeW
ii niruim~iuradnsz!n~~sz
+a~uLGnii+anao~qismi~dd
dd si
I .d~:%ni~nraqiirniul~%m~qu
iiiidozGCiamraqi1.lniufidKu 1mumwi:nrm);Lnnk
Y

uaurGuiulrauuihuriuk~fi~Kuiiiinisuimduua~nry
nuoz+a'ohu&au~fiua
0, 4-
2. n i r r i i u n i w r ~ ~ a n u i l u ~ G n ~ z u i n n i i ~ v ~ d i l ~ ~ ~ ~ l ~ n a ~ r i i u f i a ~ + i ~ ~ ~ u

finui~Auari~
3.nisiinao~nr:~nd;lnsiu~~a:6u"ui(pelvis and femur fracture) a l q h l ~ b 8 f l L ~ a m l u
11~uimuinm"~~inaovifiibv~aa~nirb8u~~amqinaa'ua:du&au
nisFnw7
I.~~KJ;'~11~i-~iauTjrnu(
primary survey)
Y

2.61ubgmlal~lalflnlTnm(direct or splint)61u~u
pressure)bbn~~s~mbbIua~(immobilization

3.fi1iin~su1lalduuo~~&u~~~m~~~~~dud~~~1~1iau~a~~a~finw1~~~~a~1;~
 ewneJ1 ~su!wopqv
S-E
 B. Diagnostic udjirncts

107 (9.8%) of 1.095

Blunt torso trauma had lAl

Abdominal tenderness

liad IAl

1 ALT 1.1 25 or A S T >200 IJ/L

Helnatocrit .r3UOJA
p-
28 ( 4 0 4 ~of
liad IAl
) 70
*tjclonlina CT scan

GCS score 513, Consicler

abcloniinal CT scan

Appropriate
Low likelihood for observation and
IA l
2 (0.4%) of 4 8 4 lnstrlrctlons

1. Computed tomography ( CT )
2.44
~91unioms?~nmum~iula~~
fiiui~n~on~~o~ua~duim~4u~~~zl.a"d~uluni0iu
nioFn:nm L b ~ @ ? ~ ~ ~ 9 8 q r y l d W A 9 w " b b ~ ~ ~ U b ~ n ~ 7(sedation
~ 6 ~ 9 ~ drug)
~ ~ i M ~ M W ~ Y

2. Diagnostic peritoneal lavage ( DPL )

'Lu~lnH
bguniomo?qdfubbo9(invasive procedure) ~iauu'La"riuui~~wi9b~mniu

warmed Ringer's lactate solution 10rnlikg bnor6ni~u~n~fiu~nbbfiz~~fid~1uniswi~m

dcl d 4
~ v i h u g v 4un~iu~da~nu~fiomaonlu.do~w"o~~iq~nwi~munio~iwi~m
 3. Focused assessment sonography in trauma ( FAST )
~ u n i r . m q & a u n ~ u m ? i u ~ n ? d d a u ~ u ~ ~ i ~ m u ~ a u b baiuion
ww~~~adPn~u
noasuir~amaanluiadw"ad\&Iu(daoi1if8nk$a(flaui8~~im$w1indi (unstable
patient) ~fln15'$1ultrasound Gbabld right paracolic gutter, left paracolic gutter, cul-de-
P, d c y
sac L L ~ Pericarciium
Z ~amnaazm9n ~ n ~ a u f i i u ~ d d i I ij'dauIaifia;lI&?u?9&~az
&~ni
n n i ~ n n i i n iCT
t dau$e&au \Lri $uriu?nniwua;lLnje9bLaz(ii noridaiuaz
w
uin~4u~~i~i;omfi~~~a~niuluaa'uazCuqzIiaan%~i~fluais~
$19
ut?nnimail FAST Aenit! intraperitoneal fluid ~d&uwir<~uniouimbiu~udadw"ad
sensitivity, specitivity, PPV bbaz NPV ~ i n n i i ~ n " u I d w i u i i ~ a z n i o~Aonl m
' ~e s ~ b b a z ~ n z I &
d l metaanalysis b&.lafh~ Ultrasound l u blunt pediatric trauma 19 Ad;
% D l 4

m l ~ l a 8.
d LL~W.I sensitivity, specitivity, PPV Lra: NPV una FAST'
Ultr~wundpmtrral I.AiT (imging solely for LPj FAST fimiiirng mlcly fm P) Imaging br hnth ih a d d i d myins
C h t c m c nf lntermi Hmwptritrj~um Any hl* Any I A l a

...
.. . .. .. .
94% Ch .we jmv;in.d in p m ~ l ~ . s i r . ......
.......... .. ,. . . ......
.
.. ". . ... .:..
IP iffdicavs intqxri~mhid. l : .. .
. .... .
..
. .
Aay L41 r2fdr.i k, r L s z L4h wiilt aid wifhnut I r a n ~ p t i l m a ~ . . .......
,...... ...
.

~ i ~ isensitivity,
uimbiu%u"ddw"adiau&auw u a i n i o n s a ~ i i d n i u f m u i u ? a FAST
Y

specitivity, PPV Lbaz NPV

~ 1 9 1 Q9.
d bbflma sensitivity, specitivity, PPV La: NPV uaa FAST"
S~nsitivityond spciticiw of PE andkc fast at detecting the nwd fcc
1qo~oton-y
N Smsitivity Spcificity PPV NPV
('I.) ('5) ['%I i:cx\.l

PE 513 1C P ~ 39 34 LOO
PE+PAST 71 IM -IT- 35 1CIO

PE = pbvsicol emrnincitlon: PPV = pxitive pmclictive velue: NPV =

nagotive p~cdictivevolue.
 ~ o u n d a ~ ~ abbaznmz
n" l6~nwii;daccuracy rod FAST diiCmsku~wnulra(flau~~n
Fmu%fifiaubbwwgFAST tioubb6~iiCT WIU wuiii sensitivity 81%, specitivity 100%, NPV
97% bba: PPV 100% Cmuz accuracy 97%

CT

&'iu$?ugu?La?~w"b~unit
~ilu~n~b~snlu$?udfld~unituimb<u~u.dodfiod
o m ~ i ( media ) ~ ~ B ~ ? U ~ ~ ~ ~ b b ~ Z f l ? CT
~ ~ f l i s ~ u ? d 8 ~ 1 d a a B m b ~contrast ~ f l i t ~ ~ 1 ? d 8
w d a
si?ulunir?iil.riu~~azGmrni~~oini~(flau
roolrdu nlwiij'i Aiswoiu~:16ynrdou iYuai
n i t u i n ~ 4 u r o ~ i i 1 f $unsz~nl6%m~~ulnu~awi:Kua~~~~~z~~d~nnu
ik d?uh~8u'lu
d ~ ? ~ u t i n i w~ d u ~ f i u r i l u u z ~ ~ ~ i n n i t l 6 ?~ud?ud. r8~ u n i r bcontrast
b~ media mn$od

lriiiluynkwuiuin rn~oufiiulail6u a : a i ~ r i ~ l i i d ~ ~ ~ a i l u n i t ~ w i P m u n i o l n ~ i u
41 b i l l 4
ultrasoundbbn: CT %ublunt abdominal
~ b u - z i d a n tb2b n ~ ~ m~6~nwib&uubiuu
z
CT I%~udild
trauma wuil ultrasound ~dndbauiziiak1%Lflunit~mntodL~md6u~mui

~?suim~:u~usisdriaar~wizntid
hemodynamic stable

C. Management
~IzF~wI'~
1.ad NG tube L L ~ : urethral catheter yntiu b w s i z ~ u b ~ n n t : b w i z a i ~ i ~ ~ n 9 : ~ d d ~ i ~ f i n i s
~saqi3wwainlk
2.ci139u penetrating injury bbne shock 6od?nwi~munitwifimw"u!
3 . n l ~ h M ~ o l ~ ? ~ ~ ~ l ~ m ~ solid
i ~ ~organs ? f l~du ~ n l ~ u ~ ~ n ? l U W f B U b b a z
9 d ( dinjury
V

&au~~wn~~fluQKm~ul~~iiCu
4 . n i s u i m ~ ~ u r o ~ i i l & ~ 5 n d a u 6 u ~(duodenal
~ a ~ 6 u dand
~ u pancreatic injury) dub6n9zwu
lieunii~a~unz~lirritn?nwiFmunitlriwi6m
V

5.niturnnn:rj~a;laiu~z%u.do~fio~6o~l~?uni~?nwiFmunit~i6mrvi1Cu
 D. Specific visceral injuries

Hepatic trauma
!hi3
nnlnnisuiaiiu%~rioliibiian1tu1~~4~l"uaa~3~
quTrvylinsnuuP1'(39%)

trauma(5%) CT abdomen ~ i u l f n l $
~~ldb~~a.l~adl~~1unif~~4~ubb~::uanPalu

AAST(American Association for the Surgery of Trauma) 1;~bE~

~'ldbbfa"uadnlf~l~b~3J i
w
*or rl
s:m'ernaiu;uusd"uad liver injury lamu
Ciradc 1 : Subcapsxllar hcttiato~nalcss than 1 ctn in maximal thickness, capsular
avulsion, superficial pnt-cnchytnal laceration lcss than I crn clccp, and iso-
lated pcripot-tal blood tmcking
Grade 2: Parcnchytnal lacuation 1 3 cm dccp and pan.nci~yrnnLsukcnpsular
hcrnatomas 1 3 cm thick
Grade 3: Patcnclty~~ial lacc~mtioilInon: tllati 3 cm dccp and paivnchynlal or
subcapsular hcrnatoma ttion: that1 3 em ill diacnctcr
Ciradu 4: Parcnchymal/subcapsular ticrnatorna Inore than 1 0 crn in tliarnci.cr;
lobar dcstriiction, or dcvascularization
Ciradc 5: Global dcstructiot~or dcvasc~~latization of thc livcr
C;~-adc6: 1 lepatic avulsion f2 I 1 (C'I' scan grade not AAS'I' grade)

1. Lmnd Grade 1 Liver injury

?dd 2.16Rn-I Grade 11 Liver injury

;'dd 3. 66flR-I Grade 111 Liver injury

;d1 4. LIRR-I Grade IV Liver injury

5. IIRR-I Grade V Liver injury

a
619bb6dl CT 9 z ~ d ~ z ~ ~ "liver
d I trauma
Jl bbd hemodynamic status figdbfl~
indicator d+ii-iJie!m~ranl?
management
 Management

liver injury)%ubGn
nis?nwi~munio~~~i~ml)l%uniouim~~n_laad~ua~id~~ua(lsolated
r i u d u n i r h w u i a o j i u ~ m o i n ~ i u d i J q a t j o z v i 185
9 - 90% Landau l4L L B ~
nnrz ~ 6 i i n i r f i n a i ~ u nliver
o i injury 1; hernodynamic stable ~munlrkrnnuu
non operative management ~;1qz~d~uuduniskwi~muniociiKmLda
Hemodynamic instability v k l 6 volume resuscitation i w u i m u iiainiousr
1mu~~mulni?zd4i~flu&a9~ji~maan!d
ainirrramdaed~~aneanl~vym ~ d hollow
u
viscus, diaphragm bbazuidno&aad renal vein injuries ~u~iaiuisn~nwi6au
nio~idiKm'b6i%93%l5.l6
A.4 w
~ t ~ ~ i a n uaznnrz
os" ~6blnwih$~u~Rnnua~lv3afiiuuim~4~~4u ~adi~Wu~
856

n u ~ a z l 6 a ~ d ~guideline
flu ICU, iiuquiud
Liu9~u4iuQu~ud&ad8+Lnmainiolu
Ad
n u injury gr v
,
~znGulddiii~imtdtz4ia"ul6
l m o n i o ~ n w i ~ l 6 ~ @ q ul~ver
aenld

ICU star (dl none none none 1

Hospital stay Id) 2 3 4 5
Psedisch~ r g imaging
e nome none none none
Bostdischar~eimaging nona nonle none none
Activity restric?ion fwk)* 3 4 5 6

"Return to full-contact* competitive sports lie, football, wrestling,

hockey. lacro3se. mountain climbing) shauld be a1 the discretion af
the individu~lpediatric trauma surgeon, The proposed guidelines fcrr
sarlr tn ta unrast r i c t ~ d
actlvlty include ''normal" age-appsbp rlatle ackivb
ties,
Splenic
a a
du solid organ dwunlrulmL~u'l6~au1ublunt abdominal trauma 6adfzenw
L d o Q ~ q u i i o i n i t ~ q n ~ q 6 i uu?a5 u lower rib fin u'~e~fluiaaoaunl~uimL1ud
~ n " ~left
P,u =4
m~1onunz4ed6ad'~ MST
~;~I~LL~-JR~IU~ULLN ~ I N bmd;

Ciraclc 1: Subcapsular licnlatorna of luss tllatl 10uCo of surfacc srca or capsular

tcas of lcss than I cnl in dcpth
Grade 2: Su brapr;ular hcmntoma of 1 Or!/h 5 0'3.8 of surface arca, intrapare~~cl~y-
tnal ticmatonla of lcss than 5 cln irz dirunctcr. or laccratinn r3f 1 3 CIII ill
dupth and not involving tmbecular vcsscls
Grade 3: Sul~capsularhcmatorr~aof rnorc than 513% of surface alca or cs-
panding and rupk~rud suhcapsulnr or parunchyrnal llct~~atotna, intropn-
rundlymal hcmatoma of moru than 5 ctn or expanding, or Iaccrntic,tl of n1ot.c
than 3 em in dcpth or involvit~gtrabccular cicsscls
Gmdc 4: Laceration invalving scgmcntnl 01-hilar vcsscls with dcvaseulslriza-
tian of r11on: than 2 5 ' h of ttlc splccn
Glade 5 : Sllattcrcd spleen or hilar vascular injuty

1rmit?naIiLru?16%]dqzbflunif'lidi~m~maLawlz~d.ir?ud
hemodynamic stable

Hct ~ d 12-24
'i~uidnoi~Uqz6@9T9Uddgdi d au h d I K u ~ ~ a m d a ~ nUnit
i 1 2LLazIin

CT b h u contrast blushing

Splenic angioembolization id0z~u"IIuin CT contrast blushing

A 4
Surgery {ILU~U hemodynamic instability n ~ i d ! t ~ ~ % u u i d ~ o i ~ ~ binjury
b6bflu
Grade V ndcjll7ui hemodynamic stable ~ 1 ? ~ i t n ~ ~ i 6 ~ u n i f ~ i w i ~ m ' l 6
Renal injury

n i ~ u i m ~ ~ u u . i l a h l u ~ f l arinwu't&.ieonii$mJ
u~Zn dmaqinrrnmaeabbZni
a u i n u i n n i i ~ v d ~ i e L ~ u u ~ u d i v ~ di m
v nzg~aa u i m n o ~ n ~ k ~ d d a ~ w 4 a o d ovi
nflms
dau"b~u~ani~uimb~u~~~i%6b~mniazbb'~l~n~au

;dd 6. IltYRd grading V ~ ~ ~ I ~ ~ U ~ R L ~ U U O ~ ~ R

Management

Grade I d k d ~
hematuria f i i u i ~ 0 l 6 n G u U I i ~ ' t ~ m u l ~ 4 i ~ i l u 6 ~ a R m n i ~ n i w d i u ~ i a
C
W = i 4
ss~s~sansa.r~fifiiaz41
di $4
Grade 11-11 MOBMU hematuria t i o t k t n q e i n i ~ l u l ~ ~ w u i u i n24
~~ ia~~u
&TW

lolulc bed rest w:kbnnadia~n~mbwTizi~anifi~b~emBBnb~u$u

~~ar~i.il~~"n~u~iufi
9,

% ~ 4 i < m i i . r n s s u ~ ~ q u nimaging
~iq:~ ii~~azwui?viufiCw~~&a
Grade IV-V & a s b ~ m n @ d i ~ o z ~ m ~ z a ' ~ ~ u n i r operative
b ~ m n ~ : bbaz
~ i s non
C

operative management lmu%dffI.l hemodynamic status bbazna'tnnis~1imb~u

;
I

hemodymamic stable qz&Ba admit observe ICU, strict bed rest, monitor vital sign bba:

CT aid 48 ?lu.
Angioembolization ~ ~ L I a d ~ m f l L Q w l z L dPrimary
~ ~ L f h treatment Tad isolated
grade IV injurydi; segmental artery bleedingm
;v delayed bleeding l u grade II I V

d l ~ ? ~ . l ~ d ?hemodynamic
ud unstable na~l65uni0CiiAw'u?~ m u O r a ~ l r s e n l t

wi~m~as't6?uniOiii
one-shot IVP[contrast 2cclkg iv bolus]
 6 i t z v d i a non operative management @ ? u ~ ~ n w m z " U ahemodynamic
a unstable
w dl9
[hypovolemia%
.i?
a
v\ response {u PRC 3 Unit] 68a!6?uniseji$mwuw

v
$ O ~ ~ % V ~ W I Trenal
W I ~exploration
@I

Absolute
Expanding renal heniatoma
Pulsatile hematoma
Relative
Urinary extravasation
Nonviable tissue
Arterial injury
Incomplete staging

v& conservative management l u ICU nsu 48 ~ ? T W

r r i n stable aiuion6i;luld

CTn i;i
va~suai~yl6~~ z i iqz1~nriu&u16Liioflaaiaz~ibflub~mm
Wd?m~~szAu163

Tmub~wizgrade IV bbnz V iibflu6Qa1fiiibbuz~ib8nbbnryi~b~ul6u

ni?=bbwsn48udaiqbAm[i;liuuil6

Pancreatic trauma

aaa solid organ 20 2 mortality

~nitwunisuimduaea$ud~u'b~daubflu~~d~ud4
rate 8-lo$' Jacornbs 20unmmz~biius?usau~8Ynb~ndi
pancreatic injury Iu

iflu~mi
~~wuiuinb~n~estm e a d 20 ?I wuiiairv~nismiudaulrr~bfluqinszuudu
I,
w w rl
~rnia~zKun~i~pur~ta"~~anisuim~4~"~~a~u~aula~au
- -

Grade Description
1 Minor contusion or
si~perficiallaceration
without duct injury
2 Major contc~sionor
laceration without
duct injury or tissue
loss
3 Distal transectFon or
parcnchylnal injury
with duct injury
4 Proximal transection or
parenchylnal injury
involving ampulla
w

~ o s b o o m ~ ~ b b n z n b l d ~ 6 ~ n w l ' l ublunt
{ d wabdominal trauma W"9rru~br~:wuk
initial US and CT Id sensitive % u n ?
i ~b < u pancreatic duct transaction n i s i 1 CT 6 4
 w
2
u i n w P d u n i s ~ n w i ~ b33~ %u
n 34 n u \ 6 ? u n i s ? n w ~ 6 a u n i t ~ i e j i ~ m ~ ~ u w ~ d i ~ q
~ o l l a n d "~mznru:: Anw?lu{dau~6nI4 tiodld?uni~~q~iiiGuieu~lim~4u
Irat.~6?unlt?nwi6aunio~~di~m
8 %u14 oiuz pancreatic pseudocyst mud 3 f l u
9- 4 G
viua;lIkmz3 oiub.rnio open drainage Lmafifddiu?quldauii8iuitn?nwi(daudi
Gudeuuim~4u"bmudaemKu

Duodenal injuries

w u l ~ i l i e u d o z r r i m k a e t3. fla 5 aoani~uim~4uludea$ed~dv%-]m~~

rdaulrrqjriin
24
~ l n ~ u ~ b w ~ ~ l n u CT
l u with
~ l e~
v; u without
z oral contrast bflu imaging i 1 6 n ~ l u n i ~
99

?~q<Elbb6<14zlibflucontrast extravasation bbdnifb9jiu focal mural thickening,

PI9
periduodenal fluid collection $e periduodenal soft tissue mass i i ~ f l u ~ n w m z d r i i ~ v n p l w
z<13.

Grade Injuy k r i p t i o n

I Hemstoma Inw:~kingsingle prti13nof duodenum

Laceration Partial thicknew, noperforation
II Hematoms Invc~bingmore than one portion
Laceration Diwuption *:. wad of circumferen~
Ill Laceration Disruption 60% to 7W! circumference sf D2
Disruption 60% to iCO?* circumferenm cif
Dl, D3, D4
PC Laceration Disruption :-%76?dcircumference of D2
Inw:*king ampulla or distal common bile
duct
Y Laceration Mae5ive disruption of duodanopancreatic

Vaqcular Dwascularimtian of duodenum

Management
%u{d:u; hemodynarnic stable q~hwidi?uniolrdNG decompression, bowel rest

rieu dau~mlid$uednior;l7\dejiGm iintraperitoneal e;r retroperitoneal air rr'%~{dau

A 90.
n ~ ~ \
~ e t a bbaz~mz 6 ~ n w i ~ u b ~ n ~ ~ m o ~ l n iduodenal
t ~ ~ ~ ~hematoma
u i i i bbnzl6

w = . 2
ui?unioeiiGm%uniuvS~~niaz~~'~~~n.a"eu~e
~~waejici.lmrnm~.ae
I nubm::i peripancreatic

abscess 1 n u bmz1u/iu?ud?nwi166aunit\ieji~m iini~zunsn.a"euniurrkffaBiloma

cd
l ~ l8fd Duodenal hematoma ~iuifn?nwi6?unit\~eji~lpl'bdaei1d
W l 6 ~ ~ uPCD
Ambulatory pediatric trauma
Laceration
Sport injury
Toxin

Lacerations
urjiiui~~~wn~u~ub~ni~finwi
uioluwe d?u~M~t~~unls~bbe~mUbbWWd~bbwun~nb~u

n151.r; 1 1. Lacerations that may require referral to a surgeon

Lacerations with any of the following:

Wound at high risk for infection
Lacerations of nerves, tendons, blood vessels, or glands
Devitalized tissue edges, requiring more than minimal debridement
Suspicion of retained foreign body
Cosmetically difficult wounds, including full-thickness wounds of the nose or ear or
lacerations to the vermilion border or the lip
Repairs that require sedation or immobilization beyond what can be done safely in
the ER

rnm.r$ 12 . Material needed for laceration repair

Local anesthesic
l%lidocaine solution ,with and without epinephrine
Small syringes[3-5ml] and needles[25-30 gauge for injection ]
Irrigation and wound cleaning meterials
Large syringes [30-60mll with Luer-Lock connector
Large-bore intravenous catheter or needles, or splash guards for pressure irrigation
Sterile saline solution
Sterile bowl
Povidone-iodine solution
Gauze pad[4x4]
Sterile drapes
Sterile gloves

Suturing equiment : scissors, toothed forceps, needle driver

Suturing material
Absorbable sutures [Vicryl], sizes 3-0 to 5-0
Nonabsorbable sutures, Ethilon or polypropylene, sizes 4-0 to 6-0
Steri-strips
Sports injuries

n i s ~ i ~ ~ s ~ ~ ~ i n n i sconcussion
~ ~ i I ~~K9 1n1 ~f i i6~ ~A id4 ~
i~m~aiu
m1~19?i13. Concussion grading schemes

Colorado medical society

Gmde I No LOC , transient confusion , No PTA

Grade 2 No LOC , Confusion with PTA

Grade 3 LOC of any duration

American academy of Neurology

Grade I No LOC , Transient confusion , Symptoms resolve < or 15 rnin

Grade 2 No LOC , Transient confusion, Symptoms last > or 15 min

Grczrle 3 Any LOC, brief or prolonged

m1s19?i 14. Return-to-play guildlines for concussion grading scales

System
Colorado medical society 1991
Grade 1
Remove athlete from contest and examine immediately and every 5 min; permit return to
contest if amnesia or symptoms do not appear for 20 min
Grade 2
Remove from contest and disallow return; examine athlete next day ; permit return to
practice after 1wk without symptoms
Grade 3
Transport athlete to hospital and performed neurologic exam; admit to hospital if sign of
pathology are detected , otherwise overnight observation ; permit return to practice if
asymptomatic for 2 wk

American academic of neurology

Grade 1
Examination athlete immediately for mental status changes; may return to contest if no
symptoms or mental status changes at 15 min
Grade 2
Remove athlete from contest and disallow return; examine athlete on site for symptoms or
mental status changes; athlete may return in 1wk if asymptomatic
Grade 3
Remove athlete from contest and transport to hospital ; perform neurologic exam and
observe overnight ; permit return to play if asymptomatic after 1wk (if LOC was brief) or 2
wk (if LOC was prolonged )
 1 Important points of history taking in a poisoning
~ 1 5 1 9 f 15.

Toxin identity
Exact toxins involved
Single toxin vs. Polydrug overdose
Dose
Drug/chemical /toxin's concentration
Amount of toxin involved in the incident [worse case scenario ]
Route
Ingestion, inhalation , dermal or eye exposure, parenteral
Events
Single episode [acute, one-time] of
poisoning or one of several
repetitive events [subacute]
Chronic overdose
Withdrawal [abstinence] syndrome
Duration
Time and duration of exposure
Span of time between exposure and presentation to medical facility
Victim
Age and weight
Symptoms and tempo
Symptoms*
Progression of symptoms[rapidly improving or getting worse [tempo of progression I]
Medical background
Underlying relevant medical conditions
Known allergies[either to the toxin or to a potential antidote]
Current and past medications available to the patient
Circumstances of incident
Location [e.g., home, grandparent's house, child care facility, school]
Unintentional vs. Intentional
Other potential victims
Suicide attempt vs. Drug misuse
Occupational or environmental exposure to the toxin
Child abuse or neglect involved
How many similar such injures in child's past

*note: Some toxin [e.g.,acetaminophen, Amanlta mushroom poisoning , oralhypoglycemics

such as glipizide or glyburide, Lomotil, monoamine oxidase inhibitors, paraquat ] are notable
for a symptom-free period after exposure ranging from 6 to 12 hours to as long as a day or
two before toxicity develops.
Maternal fetal trauma

gu~ay'lumtijat%nronizdr wai;t n u a a ~ n u i ~ u r i r r n z ~ ~ n ~ m ~ ~ ~ ~ u n i s ~ ~ ~ a i i m u i : a u

d i u ? u n i o , ~ ~ a ~ t a d 6ABCs
u ~ t r j d i d ~ u ( d a o g u ~ b mniono?q%%&
y~u m% niofim3ulq
dcrd
? n w ~ r j n a o k L a d a a $ iniolfini~?nwinmngmqzdilfiddwaiikrLrirLazLZn m k q i n

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i~i~uini~m
~ i n n i x o n a a n K a(Abruptio placentae) d~d~~rg1unio~na~~~~~noo6~do:au~u~
aPii~~doz3n~ni~6a~~diiilqa~o~ian~aa~noo6

n~~~dn"uuurln.rw~a~7~w~~w.s"~~a~~a~an~~i
v~ons&nssfi,-$a'h
rilu 50%
f i u i n o L ~ a m L i u i u i a u ~ o z m a i ~ n i o k d n o 25%aaddnfi%ud?daiub~aubbon
m~in
~detntinaam~ i r Z a m ~ ~ u f i u i m o u i n & d i ~ f i ~ r m ~ a u ~ ~ a m ~ i ~ a ~hematocrit
ri~ro$ur:uiu
L d i u u q i n 40% du 3 2 % ~ d s a i ~ n o o 6 3&'dmiddau
4 Cardiac o u t p u t ~ ~ u $ u q i30%
n flu
40% .[ualld:iCentral venous pressure amw ~~n:~nolnnio~6u~adfla%~o:~~idw"nq~
B 1
Liuiu I0-15 nidd a u i i u a n q i n d d a m i nnoz~jauLaapd"uu.j;i~fibLpda~a~qLniau~d
w i d ~ i u ~ d L ? iQ-waves
m %ulead II bbaz AVF

'M7a9on
no:ljdaug;liudilfi Functional residual capacity ama;1!d20%~dmln~ntu~imumnaam

d a w a l f i i i d n i u d ~ u tidal
~ ~ uv o ~ u r n e ~ ~ a z ~ m o i n(minute
i ~ m ~ uventilation)
l~ QihI~aniaz

compensated respiratory alkalosis d u ~ m y l f i a mbuffering capacity ~ d ~ l ~ r g ~ l n ~ u n l ~

d o : L ~ u ~ ~ d ~ d n T S 6 ~ f i l a " d ~ r g L ~ u Lshock
~amW~a

w~ssGuo~v7~un,-sTa~fi~a~
T : V ~ i d ~ d R ? ~ 6 q y L ~ U n i 9 A a E l gastroesophageal
q~ sphincter rLLaEAVI smooth muscle

toneidmum ~ l ' l f i n o z ~ w l ~ o l a l r ~ ~ d(delayed

" a " ~ a dgastric emptying) LLazfh~&rn&n.dl%
P,
2
b a a i u i u ~ u(prolonged intestinal transit times) uanq~nu~eritoneurnamnlommu~uadda
~14b~u~fifiiaz~6~u~aqinnisnmb~umaeiid~~n"m i u ~ n m s a q ~av;~ u
hydronephrosis
I
hydroureter ~ ~ a i ~ i n i i a f i i ~ z i ~ i ~ a ~ w u ~ i b d u ~ a n i f i ' i m b ~ a w i ~ b ~ u i i ~ f i i a z ~ u s z v ~
)r

$4 nssfi

?-6u hematocrit amad ! L L ~ ? T ~ u L ~

leukocytosis
u ~ I ? ~ ~ m u ~ ~ w i z l uthird
i ? dtrimester

.ld'u~a7m~i;amri?M 12000-15000/mm3 ~~emi;ni?:: hypercoagulable bdu factors VII. VIII.

IX, X LLazXll L d u s ~ 6 uFibrinogen Lil~218dbVilwu400-450 mgIdL L d ' l ~ ~ z 6 u

Plasminogen activator ~ z f i a u 7amadLLaz~iiPm~~alndnaam

iiM~3uns~u9unisazaiu

GubZom

ungnuwzsn
~ u i ? d l 82 d ~ l f i b b ~ n u ~ $ n ~ n d ~ ~ ~ ~ ~ dbdaaiqntsfi26
b ~ d n ? i ~ ( 8~ de ml ~i ~i u~ m) ~ n a d i
n&nid~zvii;lfiz~abbaznsz4nBud(xipoinisnd?ulvdl6?uuimb<uluiadthird
trimester A s ~ z a F j l u ~ e ~dvci s~ u i i $ ~ a F j u ? ~ ? ~~wm" s
~ iad ~ u u a ~ f i u i m s G i n ~ i ~ ~ a : J i v ~ n

d?utn
nionamnd h~~uw.ld'dum~nuidad~au~~i~ss"b~u~anifiuimb~ub~adszfiu~u~bvy
I dici
~ P m ~ u l u s z v i i ~ ~ ~ n t s f i ~ i n n i m ~ u o r u o n l ~!vnomrAamuuiuo~iiu~uuin~~6
;n?iuimv~u
)r

maufiuad6a Catecholamine stimulation !6aeiids'lm~? ~ ~ U V I $ ~ L L B ~ ? ~ U ? T ? ~ ? ~

a di
Tromboplastin ~ l u ? u u l~dLUav~dB~nulnfilUlT61bilufilbsilyu~d
n Disseminated

intravascular coagulation (DIG) umr?ni~m$u6iuDuvdiuqznmvaamb~am

vena cava
w=i
r d i a cuanqinG~jbiuLLs.t~i~Li;amii
0,

~ u ? ~ i l ~ ~ a m i ~ d u j i i ? k i i b u a u m s i u n " u c aoutput
PI

"bpe~vis~~azaiqii~'lunisnan$aua~sn

nalnn-werim,%
Blunt trauma

~ n a n a z q u ~ a y ~ d i d n ' u v ~ ~d i6va?~u da i s n ~ u n s o f i ~ m iblunt

u ~ i ntrauma ijnl6Fu

uim~iuui%amAswzi; fracture skull bbaz intracranail hemorrhage ~ m u a i n i ~ u i m ~ i u " ~ d b b a i

bflu pelvic fractures ~d~?ubbsdn?zLLwn~mumsdaiqii"1ss"b~nmiuqinshock

vT8 ~ n a a n m i

Abruptio placentae 8u~us"n"ubbuabbs9nsz~inszv~id

flexible U ~ ~ ~ U S L Cinflexible
~JZ
I * d
placenta snaan$~25%ni~noiqCdnu!6umnina50%n~snmiu~~pdu~u
raominaumgn
Penetrating trauma

d ~ d v ~ u i ~ i n n i t ~ z ~ a i z n " u ~ u (domestic
m t a u ~ ?violence)
a uimduw-qn?lu2;llu.dad

fiiu second trimesterLLaz third trimester akn9~t$w~ty

i l f l L L ) . i ~ ~ m ~~i fFl m l f i i L h - m i ~

54"
fetal monitoring niouiw~iuu'Er~nr~aadauuu'd~wz~ciiu
11uTiUainit~ad~ri~~azw~"11ad
peritoneum i;L~~C~nlfid~?~~:nlulpdl&?uuIm~~u
n~tciiKmdtz~iju4adW"aa

Burn

wisnmiulunsd major burn rf.!aminni?z stress , n i t v k d ccteecholamine.

maternal shock, uaz sepsis dquumrLwadliriiu 2 0 0 / . n i t n a i ~ w u l A u t a m ~ SdivFu

m

5iu
uiiilswadri;u 50%~timiuaaauitmlBdbLa:witnb~au6~vummiu'dd~nwuniutu

ak~inquT~a
i i iyl i n j w a m u ~ o i ~ d i o 3 vcesarean-section
ii

Minor trauma

m u i ; ~ i u ~ i u w i t n m i u l u n t t f i q i n ~ u T r v ~ ~ i u ~dqralv~rZmqinfnaanKq(p~acenta~
bAn~m
rl WDI
separation) ~ a k m m l u n i ~ ? n ~ i ~ i t n 6 l m t u ~ u m t i u 1 X ~ ~ ~ w u ~ l a m a a n w i ~ ~ a ~ n a a m

(vaginal bleeding) vIauagnduK~(uterinecontractions) v ~ a d t z G n z m i z m u ' i l u

nrounh(domestic violence) bbaznaomt?sqwionaiiddaL~ad(continuousfetal

monitoring)

8 d d vw
ms~~ua~ana~ssnn~ms~~~~T~u~
bd PIw
n i ~ q ~ ~ a b d d h d i a ~ u v ~ ~ ~ d ~ ~ t n 6 ~ m t u ~ u ~ b v y f i a t i i b ~ drwoiz
qn~~uinni~v$ai~
nitd?uoi?das shock ~ u r r i a ? q m t ? q l &lurnrziwitndiaddrzfiun"un7az
~i hypoxic

Prehospital care
 h l f iresuscitation ~ n a r ~ f i ~ a i u ~ u ~uaainr qoi n
~ ~ u z ~ Fluid l idi n a r ~ fHigh-flow
i oxygen

LdalfirrKuaan8LqunionLfludn2 i i i r ~ ashock
i f i i u i r n ~ i uoxygen saturation16 t:uii.r
iid~warlfium~nn~w7aRiu4~u
~ ~ d f i i ~ i n f i ~ 8 u u i m ~ < ~ 1 ~ a(spinal
d 1 ~ 8cord
u~G d
injury)
3
i n e 6iumim 15'
v ~ d q i n u a u u uspine board ~ ~ 6 a n a r u n s ~board

Emergency department

d r z l z u ABCDEs niudiKu n i r l d v i a i ? u v i u l q (intubation) tfiniu$add$did7iuflmd~d

~aluunwiaa~unloruddaan8bqu
(oxygen delivery) nlr~nr:Lwiziid%iadidnaT~dvi~~d

f i n ~ : ~ w i w i v i r ~ u : ~ m m ~ a i ~ ~Kraa~arn: ~ ~ n ~ r a i G u u v ~ a i i ~Ln ~a i~v ~

itP ~ u u L R & I ~ ~ ~
(suction) 1afiw;au rzaiid intubation n?ol$ "crash induction" w?au6unmnr:!n cricoid

r i a f i o d n i r n i t i i ~ nn i ~ i f i f i i o ~ i n ? rt~
crystalloids lm: packed cellsmiU$a~d$

u a n q i n 6 n a r v d n L i u w i n 4 u Vasopressors ~ w r i z i ~ a 6placental
u circulation

Radiographic studies
w

di~?~naiu~nit~~~~ib~m~~~~an
~ l a n W n i u a i n i m a a ~ i l av~adiiod9%WnarRj~a
u

Cesarean section

n i r d n i l a ~ v l i r n l u ~ r ~ n ' v G ~ ~ u ~ ~ ~ ~ i ~ ~ m ~ a ~ ~ ~ a ~ ~oxygenation
a i l f i d f iLL~:
s1iwdn'1~~
perfusion i 1 9 ~ ? u n a l ~ ~ i b ~ u "cesarean
uad section % f i ~ q i r m i q igestational
n age, fetal

monitoring. LLa:$a~rl4lunirciigmnanm 1.6ur-i placental

maiuLijua~umirniL~miaufiiwum
separation, uterine rupture, unstable pelvic fracture, u m ~ n ~ m ~ ? i d n i ~ d a u ~ ~ i d a a " u a z ~ u
9,

l u o : ~ i i ~ w i 6 m ~ 3 m i a ~ fLLazniaz
ia~, DIC d a ~ d n ~ s ~ w i s n ~ i u ~ u n r r f i ~ l ~ $ n d ~ ~ l u n i r . j ; i

cesarean section
A ,, '4
I . qa i ~ i ~ m q ~ ~ m ~ u ~ u a ~ ~ a i m i u ~ ~ 6 a ~ i r n q : ~
l u n r G perimortem cesarean section $ d ~ d ~ l %
4=4=,
i i f t o l a d o"iqzri7 cesarean section l u n o m ~ n m i i r r a i ~ z nlfiiauflw
iu (resuscitation) ~~ai
daLdaiqunrzidmlrnnaam ~mu~qb~ddilfimiTnibzmadram16bbi
fetal age>28 8dmiG.
5 ui$vkqin&aiwiu
mrn~iimniolu LLa: niriauav7amirn~~rn~"nmadi~w"uia~~
~ ~ ~ l ~ n l ~ ~ ~ ~ ~ d ~ ~ ~ ~ ~ n ddllwanirAnaiulhuniriu6u
l ~ ? ~ ~ i ~ d " lmu U ~ 9 ~ b ~ b b ~
A, a"
~niaram~maadaion~uo~6uiiwirnl6?uuimbiu6auvTald
ua:naiu~u~~od~~nm~un'u
,A0
uirmidf:b~u~iuInjury Severity Score ~9qu~a16y~a~w'us"n'unia:
shock "~89bba.i n i r
!: A 9
rm"larn~aoi~iimdnE
v T a f i u i o l r a ~ o u i n n a ; ~ ni;n~iuriiudafdl&Lri
io
1. Cardiotocographic monitoring 4-48 hours

2. Ultrasonography i ; d ~ : ~ ~ ~ u ~ u n i ~ d ~ : ~ ~ u a i ~ ~ s o f i v ~ a n i a : E n a a n ~ a

3. Tocolysis %?fhn0ti premature labor a e j i d ~ o ~ l i ; 1 i u n i ~ d a m ~ a d n a a m ~ i s b ~ u w a ~ i n

maanGa n i o d i l i i u m ~ n n ~ i u ~ ~ ~ : r ~ u ~ v ~ l $ r d a m a a n ~ i n r n ~ a l d
4. aininiulwson'naols~"aandiup1i~4a~Raom
rra:rlliEmmiu clotting b d ~ a i a i n

oanlfivun
9rlrl4
5. Resuscitation ~~d~vuaaoloamriau~fluBuKu~r~n
rflunir~~ulaniads:dil~wiona~
oamltiulndqm
Child abuse

The battered, abused child

~2;n~nviihudenisni~runssurln
b~ngndihsiivaiurruud?u~v~duiwubbww~b~uniodif~uw~d~idniu~nwu~ub~nb~nd
C
-d
as8a'sbnmqmJszZ r n s a ~ % i ~ n i u ~ ~ a z n ~ ~ m o a q K u
I . na7ufu~~Hratnlouimb:uuinniidozZd~
W I
69 w rl 90,
2. ~ s l l a u ~ 7 ~ u ~ ~ ~ ~ ~ ~ i m ~ w l m o u u i m ~ 4 u u i u 1 u ~ ~ ~ a

3. l b 6 T ~ ~ l m b 4 ~ ~ 9 f l b b f i z ~ u b b ~ ~ ~ n ~ a ~ b b V / d t ~

6. multiple subdural hematoma

7. retinal hemorrhage

8. perioral injury
9. uim~~ulu.da~fia~aeii~puuo~Fmu!~iidozZ~uT~vq

11. healed fracture ?ubl?wdiu?da

12. fracture long bone iurdnaiqCaun41 33

~.du
13. niruim~:u~~danl oouyvj <
14. uwalvlbu" $7 fausan diiaourun%mLqdmu!~pd.lqzb"nm

Abusive head trauma

~ l ~ d U ~ ~ W d ~ o d ~ ~ ~ f i l b v q ~ 7 n b b on1milnah"violent
dbl7uMan acceleration -
C

deceleration " nszbbwnnozbbiaub~afiuosbbazvaamb$amfiuadb ~ u v ~ n n i o m d

"shaken

baby syndrome "(SBS) k ~ n n i i @ a n~udiin7su7mbiuI11

s aad intracranial hemorrhage
2
bm: retinal hemorrhage v?a brain injury mnqlnuwunT:9n%~nN~n
metaphyses ~uilq~ljub~nuimdu~s~:d'bi"bd~u~bv~
7~~n?~u7dfiaukY~"~ips"nU?ba61d

abusive head trauma (AHT) 911%

uof01flbfl~d inflicted traumatic brain injury (iTBI)

n ~ u a ~ ~ d w u ~ ~ ~ r n f f a ~ l n w i s n1v9~ o a i ~ ~ a u n ~ ~
Prevention

n1~3~.yrYu
MW. ?f%u8M&fkld

~d~d~uuL~~aflmiinituimb<ubfluftA
1 r j l d ~ u 3 a ~ & l $ v t Y n~ o sagent
t LLaz

environment ~ m i a u ~ t p l k aLlmd: Haddon ~dbiu~uuadaodilq<ubflPd

pre-event, eventllar.
w
=i w
post event u i m m i t i l m ~ n i r a t Y n 6 l ~ n ~ u i u i u ~ ~ ~ 1 r j ~ a u d turi.mf it u
n i~t 4
a iE~ ~ i ~ ~ ~ a
Iklrieducation, enforcement , engineeringbbar. economic b ~ a d q i n ~ v [ ? v t Y n ~ l d ? ~ d ~ v ~ b f l ~
Ir

n i t u im ~ i u ~ Z mntn<ntuiuu~[i;lC~aa~a~m~~ur.~"sfla~n"uK~~
qi

I.i?iu~6naiqGauna?6 ~ T n u a i s t n < n ~ u i u d

2.~t;n~n~u~fmuairon~ntuiuu~6~n~u6m~fia~vuan~tfiu
n ~9
3 . ! ~ % i ? b ~ n a i ~ $ f 1 f l18 i~urfl<ntui~u~i

4.~i~m~aiua~~~a~~a~~n~uu6~~a::w"iuKm~~da~~n<ntui~u~~
5.G~hl.a"ngwuiuaii~~wi~n?m
Conclusion

b ~ n ~ $ n a r u - n i u ' i n i n b b a z f i ~ ~ " a ' v ~ u i~$ ~i m~ qui~~ ~ o n i f i d q z ~ u a i n w a i n

n?tb~an'ldv;aiauu1u~qib~nb"n~"bda1q.j;11fi~bfi~~u~~nK~!641
o~u~~via4auuiukaiq
d 1
mouslua~ciavpn~~urzui~~n~rau~?ad~ia[dau~~3n~~m~u'b6iauu~na~mn~rm
~ ~ ~ b bn ~~ stabilization
~ ? ~ ~ f i i i n ~ i u f i ~ ~ q ~resuscitation ~z f i i ~ ~ n ~ ~ ~ ~ f l ~

~u~zuz~maa~ni~~~ub~amiinaiufiiui~nG~~ara~~n~ad?uKa!~u~rv~
!vaiiuuIaBmdn? ~ f l ~ ~ a l ~ 6 ? u f i i ~ ~ i ' b r i ~ u ~ ~ a l u r z u i i ~ n i r i a e r 4 ' i m ~ ~ a z a i n i ~ ~ a a
adwtamJa ddioun!ddbiimnird?tauau u a n q i n d a i q ' i % ~ ~ i ~ f i u i m b ~ u ! ~ d lmubawiz
i.a"i
k l u l q k ~ K uu"iu M'a b ~~uu!riciiKm(nono~erative)k6uniolgu,a~dnntjui!
iir3uh~nimn~rru?a"iaduCi i u d r z ~ i i u ~ i ~ iLaLu~~I L ~ T U U W ~ U
~ k u m r a q / i . ~ nu?a
b.44 4
diKm!6maemraai ~nn~udnao!6?unir~bba~muXaerbbwwumubnrad~a
yJntoiifiznanlu
nir~mnir?nai~dnlunri~idAau
A, 2
niruim~4uquGnisvaiuadi~m~nmaulu~~n
~16aoainis!d5m~qunirmsaq
i i ~ n i u I r i w u n a i u i m ~ nnis a q ~ 1 u?a
6 mraquin dd$nar8dmm'~aw~inTTudim
4 4 P,
firsuai?aa;l~dnritarriuaudqza~u~bau
u% a i &'briuauad~iutin nrru~medldklunis
w
1 d Y

Imuwq?ntsu~~riidfin!kinnirk~nljil"ua~
drz~iiuvinr~!nGnu?a~fluqimuo~ua.aani1
a ~~iarii~Ln'miuu~wmGqz6a~rzdnZ~via~~8u
niriiw1~61dnsrubdnIa"6aubfiua
A P,P, ad a
lmunumaudrz~n'ynirmraqii~niuvl!nrainuva~d~dnn~a~~iilfifl~dalri
d
ni~?u~arraz~ua[dau~!nuim~4u6a~nir~nwzwiyaainduduan'uni~~~~a
t$u~uimdu ainlirzi~fiiuioniilfi~iimnaiuimwaim$~ubbrd
qunii~~wvlGqzii~d5d
h w m z i i r w i z a a ~ r l n u i m ~ ddlkri
4u niuininaa~wi~rfluuiuk~mznir~~~a
*
naiu6asnirfiisGi f l l ~ b $ l ~ ' 9 ~ ~ ~ ~Vl9~4'ilflbba~i~9w"~d
d~~fil'VI flI~'i~q<Clfl~z~~~~
n i r i i i ; ~ Z d ~ ~ n d g n i i f i u v ~ a w i P ml nur~r n~ ~ u i m d u v a i u o z u u d ~ i 1 6 ~ 6 a ~ ~ ~ ~ a
8 y y i d w l f i d n A o d i ~ ~ a m 3 a ~ ~ n z ~~~nuui~zaf iwui z n i P u i n r i u a a ~ ~ r w z 6 a d u ~ n b ~ u d
hypovolemia ha:: secondary brain injury ~dnuindunar~ps"~aubbwmu"~a!du~a~uir
p~nuuwm6ui!ti?u!&bbdbbsn ~IM?U non-operative management qinniruimdut/w"ad
d.4 a
nara~luniru?~~aaa~~~wm~$Gnaiufiiuirn~~a~a~lufiniu~u~nsa~Ga~u~vu~z
~ fiiuitnn~u~~~~a$fiiu!6uin~flunifuim~4u!~~u~bs~
e d i d b n ' m i u ~ d a u d a u l u85%
 Section 2: Pediatric trauma case study
Case 1 : boy 3 yr , laceration wound Rt leg 3 cm

Case 2 : girl 10 yr , nail pit at Lt sole

Case 3 : girl 14 yr ,dog bite at leg

Case 4 : boy 15 yr ,MCA ,rt ankle deformity

Case 5 : Boy 14 yr , GIl MC 6u

Case 6 : Lb"lluL%l~d~uLAimQ<nt

Case 7 : Boy 10 yr ~ ~ u m ~ ~ i d n ? d ~ n s n f l u 6 " d p d

.
Case 8 : Girl 8 yr ~d&u;~;imdntz~mnfipd~m

Case 1 : boy 3 yr , laceration wound Rt leg 3 cm

Case 2 : girl 10 yr , nail pit at Lt sole

Case 3 : girl 14 yr ,dog bite at leg

 Case 4 : boy 15 yr ,MCA ,rt ankle deformity

Case 5 : Boy 14 yr , MC &

6-1

iiniu
1. 4 i u ~ n ~ ~ n i s u i n a ~ u a z I z G i ~
dY
2. ~ i u P u u a n i s ~ u s $ a ~ o i u u a d i d s
3. azts~a$a~~baz$ms~a~unisw°i
DPL , FAST, CT
4. ~ ~ d a w a n iCT
w bbaz m z ' L s Z a G ~ G i ~ d i ~Non-operative
?u management

Case 6 : LL.~UI,&'~~P~ULA?!QQ~V~S

iin1a.l
I. miu6m~.a"nds~Gs~aznsaq41~nia~ii~IsGi~
2. naInImui~d+iilG~iimniaz
Compartmental syndrome
3. ~iPd~bbPda~id%Pdn~s?~~~abbaz~mdn"~dniaz
Compartmental syndrome 8fi19\7
v PI

bb"UPdbba5"Ul
4. ~ d ' 3 l t N l~lI ~~ ? A I A MPdlIP7~%Qd
 Case 7 : Boy 10 yr ~?usi~1~7il~1annsoau6~u
PI PI

Case 8: Girl 8 yr , %a'u$sanszuvln~u'bm

 i761185
Y

P/iiu~mE~ni~uim~~uv~~aTaazlm~i9
1. wusaadia~au~sam"~~iuOnz~vai
2. nisds~~iiurrsn9'ur~n~Gndzz8.11~
30 ~g S n E a A y m l n i a u a d n i ? u o n ~ i u G ' a l w n '
V a l RR 20lmin, PR 140lmin low amplitude , BP 80170 mmHg P/iiuibbuawid%uni=i
Fn3siaaazlGnis~nwia4i~IsGi~
24 w d %:
3. wgdnisFnwi~ueswuw~w~izar~
d s z ~ ~ U ~ n n s 4 ( ~ e - e v a l u aPR
t i o n1201rnin
) BP
120180 mmHg ~ l u ~ z ~ ~ n i s ~ n w i a ~ i d ~ ~ ~ ~ ~ d
4. 7 9 b b d a ~ l a n l w F d 1CT-abdomen bbazlGaid b b ~ ~ n i 5 ~ w~i n~~ lg ~dCT-abdomen
Q ~ d
bsgawu<i PR 140lmin low amplitude , BP 80140 mmHg
~anai&'Gh
1. American College of Surgeons Committee on Trauma. Extremes of age: a

pediatric trauma in Advanced trauma life support for doctors: student course

manual 7Ih edition: Chicago :first impression 2004:243-62.

2. 5. Cooper A. Early Assessment and management of trauma . in :Ashcraft KW,

Holcomb GW, Murphy JP. Editors.Pediatric Surgery.Philadelphia: Elsevier

Saunder; 2005:168-84.

3. Avarello JT, Cantor RM. Pediatric major trauma: an approach to evaluation and

management. Emerg Med Clin N Am 2007;25:803-36.

4. Eppich WJ, Zonfrillo MR. Emergency department evaluation and management

of blunt abdominal trauma in Children. Curr Opin Pediatr 2007;19:265-9.

5. lsenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin N Am

2007;25:713-33.

6. Wegner S, Colletti JE, Van Wie D. Pediatric Blunt Abdominal Trauma. Pediatr

Clin N Am 2006;53:243-56.

7. Holmes JF, Sokolove PE, Brant WE, Palchak MJ, Vance CW, Owings JT, et al.

Identification of children with Intra-abdominal injuries after blunt trauma. Ann

Emerg Med 2002;39:500-9.

8. Bixby SD, Callahan MJ, Taylor GA. Imaging in Pediatric Blunt Abdominal

trauma. Seminar in Roentgenology 2008:72-82.

9. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography

in pediatric blunt trauma patients : a meta-analysis. J Pediatr Surg

2007;42: 1588-94.

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