Leading trauma surgeon Dr Mary Langcake of St George Hospital in Sydney discusses management, diagnosis and outcomes of limb-threatening injuries in children from Australia to Afghanistan.
Mary is Director of Trauma at St George Hospital in Sydney. She trained as a general surgeon with specialty training in Upper Gastrointestinal Surgery. After a deployment to Afghanistan with the RAAFSR in 2008 she was offered the position as head of trauma. Mary has a particular interest in clinical education and training and is an Executive member of the Royal Australasian College of Surgeons NSW Stare Committee. In her spare time Mary loves reading, enjoys a good smoky single malt, and also plays drums. If this whole trauma thing becomes a bust look for her on upcoming episodes of Rage.
• Severe limb-threatening trauma is rare so very few people have much experience outside the military.
• The growing skeleton reacts differently to injury than that of an adult. Although bones may remodel to near perfect anatomical alignment the blood vessels are small and thin-walled and thus vulnerable to damage.
• The smaller circulating volume of a child means a severe limb injury can lead to early shock.
• These limb-threatening injuries might distract the trauma team from the basic ABC approach though management of catastrophic haemorrhage comes first.
• Whilst direct pressure might help reduce some blood loss, tourniquets can be life and limb saving.
• Damage control resuscitation in children involves restricted crystalloid use, early use of blood products and permissive hypotension (except in the setting of head injury).
• Tranexamic acid should be considered in serious trauma in children.
• Pulsed lavage may lead to worse outcomes and forced contamination of wounds so copious warm saline lavage is more appropriate.
• Children may develop compartment syndrome with minimal external evidence of injury.
• Consider compartment syndrome if the child appears anxious, agitated and requires far more analgesia than you would expect.
• Multidisciplinary care is required to assess the viability of the limb as well as plan staged, operative management and rehabilitation.
From the 2013 APLS Paediatric Acute Care Conference in Noosa, Australia.