PEDIATRIC TRAUMA STANDARDIZING CARE !/?

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PEDIATRIC TRAUMASTANDARDIZING CARE !/?

• DAVID A. LISTMAN, MD
• DIRECTOR
• PEDIATRIC EMERGENCY MEDICINE
• ST. BARNABAS HOSPITAL

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LEARNING OBJECTIVES

• EPIDEMIOLOGY/ HISTORY
• ATLS
• PRIMARY SURVEY/RESUSCITATION
• SECONDARY SURVEY
• PEDIATRIC SPECIFIC ISSUES
• REFERENCES

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EPIDEMIOLOGY/ HISTORY

• 5 million trauma related deaths worldwide in 2000
• Age lt20 in US visits for injuries
• 10 million ED visits and
• gt 10 million primary care office visits
• 300,000 pediatric hospitalizations annually
• 11,090 injury related pediatric deaths per year

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INTRODUCTION

• Trauma - 1 cause of death in children older
  than 1 year
• Effective initial resuscitation can reduce
  mortality by 25-30 (Stafford et al 2004)
• National Pediatric Trauma Databank 2008 ( 19
  yrs)
• 474 Trauma Centers (127 Level 1)
• 108,863 cases from 2007 record

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NATIONAL PEDIATRIC TRAUMA DATA BANK 2008
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NATIONAL PEDIATRIC TRAUMA DATA BANK 2008
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MECHANISM OF INJURY

• Motor vehicle/traffic 31.5 of injuries
• Increases at 14 years of age with a peak at
  19 years of age
• Associated with largest number of hospital/ICU
  days
• 47 of all mortalities
• Falls 26.6 of injuries
• Peak at 19 years
• 2nd highest hospital/ICU days
• 4.2 of all mortalities
• Firearms 5.7 of injuries
• Peak at 19 years
• 26 of all mortalities

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TRI- MODAL DISTRIBUTION OF DEATHS

• First peak- within seconds to minutes of injury
• Second Peak- within minutes to several hours of
  injury
• Third Peak- days to weeks after the injury

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TRI- MODAL DISTRIBUTION OF DEATHS

• First peak- within seconds to minutes of injury
• Apnea- brain or spinal cord injury
• Rupture of the heart or great vessels
• Treatment- prevention
• Second Peak- within minutes to several hours of
  injury
• Third Peak- days to weeks after the injury

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TRI- MODAL DISTRIBUTION OF DEATHS

• First peak- within seconds to minutes of injury
• Second Peak- within minutes to several hours of
  injury
• Subdural and epidural hematomas
• Hemopneumothorax
• Ruptured spleen/ liver
• Pelvis fxs and other sources of major blood loss
• Treatment- golden hour and ATLS
• Third Peak- days to weeks after the injury

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TRI- MODAL DISTRIBUTION OF DEATHS

• First peak- within seconds to minutes of injury
• Second Peak- within minutes to several hours of
  injury
• Third Peak- days to weeks after the injury
• Sepsis
• Multi organ system failure
• Treatment- maximize care during preceding stages,
  Hospital/ ICU care

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Friday Sept 30, 2005
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(No Transcript)
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HOW DO WE IMPROVE SURVIVAL DURING SECOND PEAK?

• Standardize evidence based best practices
• A 1976 crash of a private plane piloted by an
  Orthopedic surgeon. His wife and children were
  on board.
• Hospital care in rural Nebraska was substandard
• 1978- 1st ATLS course to standardize initial care
  of trauma patients by doctors who do not manage
  major trauma regularly.

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CASE

• 4 year old female in stroller
• Mother and stroller hit by car
• Child ejected from stroller
• No LOC
• C-spine immobilized at scene
• Minor contusions and abrasions of scalp

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CASE

• 4 year old female in stroller
• Does patient require trauma evaluation?
• What if any radiologic workup should be done?

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Who requires trauma evaluation?
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ACTIVATION OF TRAUMA TEAM

• Level of activation determined by
• Physiologic parameters
• Anatomic location/type of injury
• Mechanism of injury
• Options code, alert, consultation

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ACTIVATION OF TRAUMA TEAM

• Trauma Alert
• Anatomic
• Significant injuries above and below the
  diaphragm
• 2 or more proximal long bone fractures
• Burn of 15-30 BSA (second/third degree burn)
• Traumatic amputation of limb proximal to wrist or
  ankle
• Crush injury of torso
• Spinal injury with paralysis

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ACTIVATION OF TRAUMA TEAM

• Trauma Alert
• Mechanism
• Ejection from automobile
• Extrication gt 20 minutes
• Fatality of another passenger
• Intrusion of vehicle by collision
• Unrestrained passenger or vehicle traveling gt 20
  mph
• Fall ? 20 feet
• Pedestrian struck at significant rate of speed
• Lightning

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ACTIVATION OF TRAUMA TEAM

• Trauma Code
• Physiologic
• Cardiopulmonary arrest
• Hypotention (by age)
• Respiratory distress
• Neurologic failure (GCS?8)

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ACTIVATION OF TRAUMA TEAM

• Trauma Code
• Anatomic
• Penetrating wound to head, chest or abdomen (prox
  to knees/ elbows)
• Burn gt 30 BSA, inhalation airway burn
• Major electrical injury

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Who requires trauma evaluation?

• All patients with significant or potentially
  significant injury should have a systematic
  evaluation

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Standard Precautions

• Cap
• Gown
• Gloves
• Mask
• Shoe covers
• Goggles / face shield

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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary Survey
• Airway
• Breathing
• Circulation
• A,B,Cs with special trauma concerns

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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary Survey
• Airway maintenance, with cervical spine control
• Breathing, with special concern for pneumothorax
• Circulation- control bleeding
• Disability- neurologic deficits
• Exposure- expose (examine) all of patient
  prevent hypothermia
• Resuscitation
• Oxygenation, airway management, ventilation
• Shock management
• Intubations urinary tract, gastrointestinal
  tract

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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• As you perform the Primary Survey, stop and
  intervene as needed
• Airway maintenance, with cervical spine control
• Airway positioning
• Oxygen
• Airway adjuncts- nasopharyngeal airway, oral
  airway
• Endotracheal intubation
• Surgical Airway

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CHIN LIFT MANEUVER

• Airway obstruction by tongue and epiglottis

• Relief by head-tilt/chin-lift

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Airway Management
Basic Techniques
Chin-lift Maneuver
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Airway Management
Basic Techniques
Jaw-thrust Maneuver
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INDICATIONS FOR INTUBATION

• Shock
• Cardiac arrest
• Respiratory distress or failure
• Severe head injury
• GCS lt 8

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RAPID SEQUENCE INTUBATION I

• Preoxygenate with 100 O2, insert IV lines,
  attach cardiac/respiratory monitor
• Prepare equipment for possible emergency surgical
  airway
• Inline manual immobilization of cervical spine
• Lidocaine 1.5 mg/kg (for elevated ICP)
• Atropine 0.02 mg/kg (minimum of 0.1 mg, maximum
  0.5 mg) to prevent bradycardia
• Begin Sellick maneuver (cricothyroid pressure to
  prevent vomiting and aspiration)

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RAPID SEQUENCE INTUBATION II

• Paralyzing agent
• Rocuronium (0.6 1.0 mg/kg) or
• Vecuronium (0.1 mg/kg)
• Succinyl Choline (1mg/kg)
• Sedative agent problem specific
• Hypotension Etomidate (0.3 mg/kg)
• Head injury without hypotension Thiopental
  (3-5 mg/kg)
• Severe asthma Ketamine (1-2 mg/kg)
• Oral intubation
• Confirm location of ET tube with end-tidal CO2
  measurement

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SURGICAL AIRWAY

• RARELY needed in children
• AVOID in children lt 12 years due to small target
  size and risk of damage to surrounding structures
  (Reamy 2004)
• Indications failure to intubate, apneic with
  c-spine injury, facial trauma with c-spine
  injury, severe facial and neck trauma
• Needle cricothyroidotomy with needle jet
  insufflation is a short term solution

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SURGICAL AIRWAY
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SURGICAL AIRWAY
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COMPLICATIONS OF SURGICAL AIRWAY

• Hemorrhage
• Laceration of surrounding structures
• Subcutaneous emphysema
• Hypoxia after failed/prolonged attempts
• Aspiration
• Infection
• Tracheal stenosis or cricoid cartilage damage

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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary Survey
• Breathing, with special concern for pneumothorax
• If pneumothorax suspected and patient unstable-
  needle decompression
• If pneumothorax suspected and patient stable-
  x-ray and chest tube
• Pt may require intubation and mechanical
  ventilation
• Prevent hypoxemia

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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary Survey
• Circulation- control bleeding
• Control Bleeding
• External- direct pressure
• Bony- align and splint fractures
• Internal- surgery/ interventional radiology
• Establish 2 large bore IVs
• Crystalloid fluid
• O neg blood

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SHOCK I

• Early recognition of shock critical
• Tachycardia, pain, anxiety
• Decreased pulse pressure (lt20mm Hg)
• Mottled skin, warm/cool extremities
• Most common cause is hypovolemic shock due to
  hemorrhage
• BUT beware of
• Spinal cord injury can cause distributive shock
• Cardiac tamponade or tension pneumothorax can
  cause obstructive shock

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SHOCK II

• Minimum systolic BP 70 2 (age in years)
• Compensated shock
• Normal BP (may see orthostatic changes)
• Tachycardia
• Tachypnea
• Bounding pulses, widened pulse pressure
• Altered mental status
• Warm and dry extremities
• Delayed capillary refill (gt 2 seconds)
• Uncompensated shock
• Hypotension
• Severe tachypnea
• Cold extremities
• Capillary refill gt 4 seconds

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SHOCKMANAGEMENT I

• 20cc/kg infused rapidly
• 0.9 NaCl or Lactated Ringers solution
• 2 large bore IVs
• If severe shock ? 10cc/kg type specific or O-
  packed red blood cells
• Identify and treat source of bleeding

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SHOCKMANAGEMENT II

• Maintain urine output
  1-2cc/kg/hour
• Monitor urine output with catheter/feeding tube
  placed in urethra
• Contraindications to catheter placement
• Pelvic fracture
• Blood at urethral meatus
• Blood in the scrotum

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VENOUS ACCESS

• 2 attempts peripheral vein
• Intraosseous needle
• Central line
• Complications arrhythmias, thrombosis, and
  embolism
• Locations
• Subclavian vein
• Femoral vein
• Jugular vein
• Cutdown

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VENOUS ACCESS INTRAOSSEOUS NEEDLE PLACEMENT
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VENOUS ACCESS INTRAOSSEOUS NEEDLE PLACEMENT
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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary Survey
• Disability- neurologic deficits
• Level of consciousness- GCS

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Glasgow Coma Scale

• Eye Opening
• Spontaneous 4
• To speech 3
• To pain 2
• No Response 1
• Best Motor Response
• Obeys -6
• Localizes 5
• Withdraws 4
• Abnormal flexion 3
• Extension response 2
• No Response 1
• Verbal response
• Oriented 5
• Confused conversation 4
• Inappropriate words 3
• Incomprehensible sounds 2
• No response - 1

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GLASCOW COMA SCORE
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Glasgow Coma Scale

• A strong predictor of outcome
• 13 mild brain injury
• 9-12 Moderate brain injury
• lt 8 Severe brain injury (coma)

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INITIAL ASSESSMENT AND MANAGEMENT GUIDELINES

• Primary Survey
• Exposure- expose (examine) all of patient
  prevent hypothermia
• Remove all clothing
• Roll Patient
• Examine axillae, groin, rectum
• Cover patient with warm blankets etc

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INITIAL ASSESSMENT AND MANAGEMENT

• Primary Survey
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Adjuncts to primary survey
• Labs
• Cardiopulmonary Monitoring
• Urinary and Gastric Catheters
• X-rays- chest and pelvis
• FAST/ DPL

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SECONDARY SURVEY

• Begins after primary survey is completed
• Resuscitation in place
• Vital signs improving
• Head/toe complete evaluation of trauma patient
• Complete history/physical exam
• Reassessment of ALL vital signs

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SECONDARY SURVEY - HISTORY

• Obtain AMPLE history allergies, medications,
  past illnesses, last meal, events related to
  injury
• Mechanism of injury blunt vs penetrating
• Motor vehicle/pedestrian head injury, traumatic
  aortic disruption, abdominal visceral injuries,
  fractured lower extremities/pelvis
• Injury due to burns/cold

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INITIAL ASSESSMENT AND MANAGEMENT

• Secondary Survey- head to toe exam
• Head/ Face
• Neck/ C-spine
• Chest
• Abdomen
• Perineum
• Extremities/ Musculoskeletal
• Neurologic
• Adjuncts to secondary survey

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INITIAL ASSESSMENT AND MANAGEMENT

• Secondary Survey- head to toe exam
• Adjuncts to secondary survey
• Additional studies that may include
• X-rays of c-spine
• CT scans of head, c-spine, chest, abdomen/ pelvis
• Angiography
• Extremity x-rays

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UNIQUE PEDIATRIC CHARACTERISTICS

• Compared to adults, children have
• Smaller body mass to surface area ratio ?
  increased susceptibility to insensible fluid and
  heat loss
• More elastic connective tissue less rigid
  skeleton protecting tightly packed thoracic and
  abdominal structures
• Transmitted energy delivers greater force/volume
  ? multisystem injuries
• Thoracic and spinal injuries rare

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RESUSCITATION EQUIPMENT
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FACILITIES/EQUIPMENT REQUIREMENTS

• Designated Trauma Area with essential pediatric
  equipment always ready
• Full range of pediatric endotracheal tubes, chest
  tubes, blood drawing equipment angiocatheters,
  butterfly needles
• Heated air, warming blankets, heat lamps, room
  temperature 85F
• Ultrasound available for Focused Abdominal
  Thoracic Sonography for Trauma (FAST Scan)
• Broselow Tape

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UNIQUE PEDIATRIC CHARACTERISTICS THERMOREGULATION

• Critical in children
• High evaporative heat loss/caloric expenditure in
  children
• High body surface area/mass
• Little subcutaneous tissue
• Hypothermia can affect coagulation time, CNS
  recovery
• Management focus
• Overhead heat lamps
• Warm room
• Warm fluids, blood products

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PEDIATRIC AIRWAY
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AIRWAY I

• Larger occiput results in neck flexion with
  obstruction of the posterior pharynx
• Larynx more anterior orienting midface slightly
  superior and anterior for protection of airway
• Need to protect cervical spine
• Large tongue may obstruct airway

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AIRWAY II

• Cricoid cartilage at level of C6 in adults, but
  C4 in children
• Cricoid ring most narrow anatomic site until 8
  years of age
• Trachea is short increases risk of mainstem
  bronchial intubation

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SCIWORA

• Spinal Cord Injury WithOut Radiologic Abnormality
• Accounts for up to 2/3 of severe cervical spine
  injuries in children
• Elasticity in cervical spine allows severe spinal
  cord injury to occur
• Diagnosis of exclusion MRI useful
• Watch for pseudosubluxation anterior
  displacement may be up to 4mm

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Radiation Exposure

• Increasing concern in literature for malignancies
  secondary radiation exposure
• CNS lymphoma
• Thyroid cancers
• Unshielded radiation to genitals

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Radiation Exposure

• Use of Abdomino-pelvic CT scans is more common
• C-spine scanning done as a routine in adults if
  scanning the head to replace plain film

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Radiation Exposure

• Pediatricians have championed injury prevention
• Kids are not small adults

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Radiation Exposure

• Attempt to decrease plain pelvis films as routine
  part of trauma series
• Review of all blunt trauma 2002-2006 at SBH age
  lt/ 25
• 579 patients, 580 trauma evaluations
• 22 pelvis fractures (4)
• Can we identify low risk for pelvis fx?

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Radiation Exposure

• Can we identify low risk for pelvis fx?
• No lower extrem injury (NPV 98.3)
• Normal Exam of pelvis (NPV 99)
• No clinical need for abdomino-pelvic CT (NPV
  99.5)
• If all three are absent (NPV 100).
• Retrospectively applying criteria to study group
  would eliminate 45 of pelvis x-rays.
• Wong et al. Pediatric Emerg Care in Publication

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Radiation Exposure

• Trend in trauma care towards routine CT scan of
  c-spine if head CT is to be done (replacing plain
  films).
• CT c-spine exposes the thyroid to 90-200 times
  the radiation dose of plain films.
• (Jimenez et al Pediatr. Radiol)
• Rate of c-spine injuries is very low in children
  1-2, 0.8 in SBH
• Ligamentous injuries are more common
• NEXUS criteria are valid in children
• Absence of midline tenderness
• Not intoxicated
• Normal level of alertness
• Normal neurologic exam
• Absence of painful distracting injury
• Develop new protocols for Peds specific concerns

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SUMMARY

• Practice routines in Mock Code
• Primary survey (ABCs, emergency conditions),
  resuscitation
• Secondary survey
• Consider unique characteristics of children
  (temperature requirements, anatomy)
• Prepare protocols, dedicated area, equipment

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REFERENCES

• Yamamoto LG. Multiple trauma in a 2 year old.
  Radiology Cases in Pediatric Emergency Medicine
  Volume 7, Case 8. http//www.pediatriconcall.com/f
  ordoctor/ DiseasesandCondition/Multiple_Traumadia.
  asp
• DeRoss AL and Vane DW. Early evaluation and
  resuscitation of the pediatric trauma patient.
  Sem Pediatric Surgery. 13(2) May, 2004, 74-79.
• National Trauma Data Bank. Pediatric Section.
  http//www.facs.org/trauma/ntdbpediatric2004.pdf
• Stafford PW et al. Practical points in evaluation
  and resuscitation of the injured child. Surg Clin
  North Amer 82273-301, 2002.
• Prince JS et al. Unusual seat belt injuries in
  children. J Trauma 56(2)420-427, Feb 2004.

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REFERENCES

• Arensman RM and Madonna MB. Initial management
  and stabilization of pediatric trauma patients
  http//www.childsdoc.org/fall97/trauma/trauma.asp
• Reamy RR and Losek JD. Pediatric trauma and
  initial resuscitation. Jour South Carolina Med
  Assn 100(12) Dec 2004 317-321.
• Advanced Trauma Life Support 6th edition.
  American College of Surgeons, Chicago, Illinois,
  1997.
• Nguyen D et al. Considerations in pediatric
  trauma.http//www.emedicine.com/med/topic
  3223.htm
• Ruddy RM and Fleisher G. An approach to the
  injured child. In Textbook of Pediatric Emergency
  Medicine, Fleisher G et al., Ed. Lippincott,
  Philadelphia, 5th edition, 2006.
• Walzman M and Mooney DP. Major trauma. In
  Textbook of Pediatric Emergency Medicine,
  Fleisher G et al., Ed. Lippincott, Philadelphia,
  5th edition, 2006.