Apply ATLS/APLS protocol: primary survey to exclude life-threatening injuries, secondary survey, re-evaluation and definitive care.
- presentation: pedestrian, unrestrained passenger, HI, NAI, fall
- more abdominal injuries with multiple organs involved
- large head: increased chance of closed HI
- skeleton: pliable, internal organ damage with no fractures (pulmonary contusions, SCIWORA)
- surface area/volume ratio: at risk of hypothermia
- psychological: difficult historians, modified examination, investigations may require GA
- family: distressed parents and siblings
- consent issues
- equipment: adequate size/dose
- drugs: calculated to weight
- may require transfer to specialised paediatric center
- large occiput -> passive flexion of c-spine (may require padding under chest)
- large amount of soft tissue in oropharynx -> visualisation of larynx more difficult
- larynx is funnel-shaped, more cephalad, anterior -> difficult to see cords
- tracheal short -> RMB intubation and accidental extubation common
- narrowest at the cricoid ring -> uncuffed tubes commonly used
- small diameter -> susceptible to airway obstruction
- small FRC + high O2 consumption -> desaturates quickly
- Guedel airway insertion: don’t rotate
- higher RR
- smaller VT
- higher risk of barotrauma
- increased reserves: can tolerate large volumes of blood loss and maintain BP
- tachycardia and poor skin perfusion may be only signs of shock with 45% loss of blood volume
- fluids: 3 x 20mL/kg crystalloid -> RBC 10mL/kg
- IV access: have low threshold for IO
- modified GCS
- susceptible to hypothermia (high BSA:Wt ratio)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.