WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:46.869 fast. Welcome to the emergency room. Welcome 00:00:46.869 --> 00:00:50.109 to the Deep Dive. Today we're taking on a topic 00:00:50.109 --> 00:00:53.229 that is just profoundly high stakes, essential 00:00:53.229 --> 00:00:56.609 pediatric trauma care. And when you look at the 00:00:56.609 --> 00:00:59.560 data, I mean, the need for this couldn't be clearer. 00:01:00.179 --> 00:01:02.359 Injury is the single most common cause of death 00:01:02.359 --> 00:01:05.099 and disability in kids. It surpasses everything, 00:01:05.680 --> 00:01:08.739 all major diseases combined. Exactly. We're talking 00:01:08.739 --> 00:01:11.659 about more than 10 million children a year in 00:01:11.659 --> 00:01:14.530 the U .S. alone. needing emergency care for injuries. 00:01:15.150 --> 00:01:17.469 These are the critical moments. They are. And 00:01:17.469 --> 00:01:19.489 you know, our mission for this deep dive isn't 00:01:19.489 --> 00:01:21.870 to reread a textbook. It's to apply the Pareto 00:01:21.870 --> 00:01:24.209 Principle. The 80 -20 rule. Right. We're focusing 00:01:24.209 --> 00:01:26.689 on the 20 % of the information. The formulas, 00:01:26.909 --> 00:01:29.310 the pitfalls, the red flags that give you 80 00:01:29.310 --> 00:01:31.569 % of what you need for that critical life -saving 00:01:31.569 --> 00:01:33.890 management. It's the ultimate clinical shortcut. 00:01:33.950 --> 00:01:36.159 So we're really focusing on the why. why kids 00:01:36.159 --> 00:01:37.900 are different, the physiological traps, and those 00:01:37.900 --> 00:01:40.459 tiny details that you have to remember when everything's 00:01:40.459 --> 00:01:42.719 chaotic. And before we jump in, there's this 00:01:42.719 --> 00:01:44.920 one need -to -know stat that I think frames the 00:01:44.920 --> 00:01:47.819 whole discussion. Globally, for adolescents, 00:01:48.420 --> 00:01:50.500 road traffic accidents are the number one killer. 00:01:50.799 --> 00:01:52.620 Right, that's what we tend to think of. But for 00:01:52.620 --> 00:01:55.750 infants... So kids under 12 months, the story 00:01:55.750 --> 00:01:58.950 changes completely. For that group, child maltreatment 00:01:58.950 --> 00:02:00.790 accounts for the great majority of homicides. 00:02:00.930 --> 00:02:02.430 And that's a context you have to have in your 00:02:02.430 --> 00:02:04.170 mind from the second that child comes through 00:02:04.170 --> 00:02:06.650 the door. It sets the stage for everything. OK, 00:02:06.650 --> 00:02:09.490 so let's start there with that fundamental principle. 00:02:10.409 --> 00:02:13.370 A child is not just a small adult. Let's unpack 00:02:13.370 --> 00:02:16.669 the physics of that. Why is multi -system injury 00:02:16.669 --> 00:02:19.729 the rule? Well, it really just comes down to 00:02:19.729 --> 00:02:22.400 the transfer of kinetic energy. Children have 00:02:22.400 --> 00:02:24.639 a much smaller body mass, right? Right, so that 00:02:24.639 --> 00:02:28.520 means any energy from blunt trauma a car fender 00:02:28.520 --> 00:02:32.500 a follow It results in a much greater force being 00:02:32.500 --> 00:02:36.240 applied per unit of body area. It's concentrated 00:02:36.240 --> 00:02:39.539 and they have less padding less fat, less connective 00:02:39.539 --> 00:02:42.319 tissue to absorb that shock. Exactly. That lack 00:02:42.319 --> 00:02:44.439 of insulation means all the organs are packed 00:02:44.439 --> 00:02:46.800 much closer together. So if you get a significant 00:02:46.800 --> 00:02:48.580 impact to the torso, you're not just hitting 00:02:48.580 --> 00:02:50.379 one thing, you're hitting multiple things. So 00:02:50.379 --> 00:02:52.560 you have to assume it. Yeah. Multi -system entry 00:02:52.560 --> 00:02:55.599 is the rule until you prove otherwise. You absolutely 00:02:55.599 --> 00:02:57.960 have to. That has to be your default assumption. 00:02:58.330 --> 00:03:01.650 And this physics also defines some of the anatomical 00:03:01.650 --> 00:03:03.669 weak spots. Let's talk about those, like the 00:03:03.669 --> 00:03:06.069 head and the skeleton. Sure. So take the head 00:03:06.069 --> 00:03:09.409 first. It's proportionately much larger and heavier. 00:03:09.770 --> 00:03:12.069 Right, that classic toddler look. And that creates 00:03:12.069 --> 00:03:14.729 more momentum during any kind of deceleration. 00:03:15.110 --> 00:03:18.050 So you see a much higher frequency of blunt brain 00:03:18.050 --> 00:03:21.169 and cervical spine injuries, even in what seems 00:03:21.169 --> 00:03:23.900 like a minor event. OK, and the skeleton? The 00:03:23.900 --> 00:03:26.699 skeleton is more pliable. It's not fully calcified, 00:03:26.979 --> 00:03:30.080 so it acts more like a flexible shell than a 00:03:30.080 --> 00:03:32.460 rigid cage. So if the chest wall, for example, 00:03:32.520 --> 00:03:34.819 is pliable, what does that mean for the organs 00:03:34.819 --> 00:03:38.159 underneath? It means that the fractures we rely 00:03:38.159 --> 00:03:41.180 on in adults to signal a massive energy transfer, 00:03:41.780 --> 00:03:43.960 they're just less likely to happen in kids. A 00:03:43.960 --> 00:03:45.719 rib fracture is actually pretty uncommon. But 00:03:45.719 --> 00:03:47.460 you can still have a devastating injury underneath. 00:03:47.639 --> 00:03:50.479 Oh, absolutely. A massive pulmonary contusion 00:03:50.479 --> 00:03:52.840 can be hiding under a perfectly intact chest 00:03:52.840 --> 00:03:55.719 wall. So if you do see a rib fracture or a skull 00:03:55.719 --> 00:03:58.199 fracture, you have to assume the energy transfer 00:03:58.199 --> 00:04:00.659 was absolutely immense. And that combination 00:04:00.659 --> 00:04:03.860 of size and pliability also creates a huge problem 00:04:03.860 --> 00:04:06.800 with heat. A major one. The high body surface 00:04:06.800 --> 00:04:09.479 area to body mass ratio means they lose thermal 00:04:09.479 --> 00:04:12.860 energy incredibly fast. Hypothermia sets in quickly, 00:04:13.340 --> 00:04:15.520 and it complicates everything. Clotting, metabolism, 00:04:15.800 --> 00:04:18.459 everything. So fighting heat loss is just as 00:04:18.459 --> 00:04:20.160 important as stopping the bleeding. Yeah, yeah, 00:04:20.220 --> 00:04:23.100 it up there. OK, so this leads us to maybe the 00:04:23.100 --> 00:04:26.100 biggest prioritization shift in pediatric trauma. 00:04:27.100 --> 00:04:30.279 Compared to adults, things like apnea and hypoxia 00:04:30.279 --> 00:04:33.399 happen five times more often than hypovolemia 00:04:33.399 --> 00:04:35.829 with hypotension. And that just hammers home 00:04:35.829 --> 00:04:38.230 the point. You have to aggressively manage the 00:04:38.230 --> 00:04:41.470 airway and breathing first. A and B before C. 00:04:41.750 --> 00:04:43.730 Airway is number one. And you said positioning 00:04:43.730 --> 00:04:45.750 is one of the smallest details that makes the 00:04:45.750 --> 00:04:48.029 biggest difference here. It really is. We mentioned 00:04:48.029 --> 00:04:50.470 that large occiput, the back of the head. When 00:04:50.470 --> 00:04:52.910 a child is lying flat, it pushes the head forward, 00:04:53.310 --> 00:04:55.629 flexes the neck, and immediately compromises 00:04:55.629 --> 00:04:58.329 the airway. So how do you fix that while keeping 00:04:58.329 --> 00:05:01.009 the spine safe? It's so simple. To get a neutral 00:05:01.009 --> 00:05:03.689 position, you place a one -inch layer of padding 00:05:03.689 --> 00:05:06.300 under the the infant's entire torso, shoulders 00:05:06.300 --> 00:05:09.680 to hips. That's it. That one -inch lift compensates 00:05:09.680 --> 00:05:12.300 for the head and brings the whole body into alignment. 00:05:12.660 --> 00:05:15.579 It opens the airway. Missing that detail can 00:05:15.579 --> 00:05:18.220 derail your whole resuscitation. And the challenges 00:05:18.220 --> 00:05:21.399 don't stop there. Intubation is just... It's 00:05:21.399 --> 00:05:23.560 a different world. Completely. You have a relatively 00:05:23.560 --> 00:05:26.759 large tongue, large tonsils. The larynx itself 00:05:26.759 --> 00:05:28.779 is funnel -shaped, and it sits higher up and 00:05:28.779 --> 00:05:30.980 more anterior. It can feel like you're trying 00:05:30.980 --> 00:05:33.439 to intubate around a corner. But the really critical 00:05:33.439 --> 00:05:35.660 detail is the length of the trachea itself. Which 00:05:35.660 --> 00:05:38.939 is incredibly short. An infant's trachea is only 00:05:38.939 --> 00:05:42.660 about five centimeters long. Five. It only grows 00:05:42.660 --> 00:05:46.360 to seven centimeters by 18 months. Wow. So any 00:05:46.360 --> 00:05:48.360 little movement of the head or neck. And you 00:05:48.360 --> 00:05:51.399 risk dislodging the tube or, just as bad, pushing 00:05:51.399 --> 00:05:54.459 it into the right main stem bronchus. So getting 00:05:54.459 --> 00:05:57.339 that ETT placement right from the start is paramount. 00:05:57.480 --> 00:05:59.939 What are the rules for that, for sizing and depth? 00:06:00.199 --> 00:06:02.399 Well, for sizing, a good rule of thumb is to 00:06:02.399 --> 00:06:04.540 look at the size of the child's nostril or the 00:06:04.540 --> 00:06:06.879 tip of their pinky finger. Ideally, you're using 00:06:06.879 --> 00:06:09.339 a length -based tape, like a Braslo tape. But 00:06:09.339 --> 00:06:12.350 here's the critical detail for depth. The calculation. 00:06:13.089 --> 00:06:16.110 The optimal ETT depth in centimeters is three 00:06:16.110 --> 00:06:19.550 times the appropriate tube size. So a 4 .0 tube 00:06:19.550 --> 00:06:22.470 goes to 12 centimeters at the gum line. Exactly. 00:06:22.769 --> 00:06:25.810 Three times the tube size. That calculation gives 00:06:25.810 --> 00:06:28.730 you a reliable starting point and buys you critical 00:06:28.730 --> 00:06:31.029 time before you get a chest x -ray to confirm. 00:06:31.449 --> 00:06:33.910 That's so simple and so actionable. So once the 00:06:33.910 --> 00:06:36.410 tube's in and things still go wrong, what's the 00:06:36.410 --> 00:06:38.930 mental checklist for that? You need to know the 00:06:38.930 --> 00:06:41.410 DOPE mnemonic. It's your troubleshooting guide. 00:06:42.129 --> 00:06:44.850 D is for dislodgement, the biggest risk because 00:06:44.850 --> 00:06:47.769 that trachea is so short. O is for obstruction 00:06:47.769 --> 00:06:50.810 from secretions or a kink. P is for pneumothorax, 00:06:50.949 --> 00:06:53.670 especially attention pneumo. And E is for equipment 00:06:53.670 --> 00:06:56.370 failure. Always check your ventilator, your oxygen 00:06:56.370 --> 00:06:57.889 source. And you said dislodgement is the one 00:06:57.889 --> 00:07:00.110 that gets missed most often. In a chaotic room, 00:07:00.589 --> 00:07:02.089 absolutely. Before we even get to intubation 00:07:02.089 --> 00:07:04.250 though, there's a reflex in infants we have to 00:07:04.250 --> 00:07:07.050 manage. Yes, the vagal response. It's profound. 00:07:07.689 --> 00:07:09.910 Stimulating the larynx during intubation can 00:07:09.910 --> 00:07:12.670 cause a dramatic severe bradycardia. So what's 00:07:12.670 --> 00:07:14.970 the move? You have to consider pre -treating 00:07:14.970 --> 00:07:17.850 with atropine sulfate for any infant getting 00:07:17.850 --> 00:07:21.089 drug -assisted intubation. It counteracts that 00:07:21.089 --> 00:07:23.990 vagal response and prevents a dangerous drop 00:07:23.990 --> 00:07:28.029 in heart rate. Okay, so if we nail airway and 00:07:28.029 --> 00:07:30.470 breathing, we give ourselves a fighting chance. 00:07:31.329 --> 00:07:33.430 But now we move to circulation and this is where 00:07:33.430 --> 00:07:36.329 you said the biggest physiological trap is hiding. 00:07:36.560 --> 00:07:39.680 This is, without a doubt, the highest yield topic 00:07:39.680 --> 00:07:42.300 for understanding pediatric shock. It's all about 00:07:42.300 --> 00:07:45.060 the deceptive reserve. The deceptive reserve. 00:07:45.139 --> 00:07:47.459 Children have these incredible, healthy hearts 00:07:47.459 --> 00:07:49.939 that can maintain blood pressure by just jacking 00:07:49.939 --> 00:07:52.180 up the heart rate. They can look stable with 00:07:52.180 --> 00:07:53.980 a normal blood pressure, even when they've lost 00:07:53.980 --> 00:07:56.879 a huge amount of blood. How much? Up to a 30 00:07:56.879 --> 00:07:59.300 % decrease in their circulating blood volume. 00:07:59.819 --> 00:08:02.420 30%. So if you're waiting for hypotension to 00:08:02.420 --> 00:08:04.899 diagnose shock? You've already lost. You've missed 00:08:04.899 --> 00:08:06.920 the critical window. You're waiting for the crash. 00:08:07.240 --> 00:08:09.420 So what are the early signs then? If not blood 00:08:09.420 --> 00:08:11.579 pressure, what are you looking for? It's subtle. 00:08:12.019 --> 00:08:15.480 Tachycardia is often your only early key. That 00:08:15.480 --> 00:08:18.160 and poor skin perfusion. So you're looking for 00:08:18.160 --> 00:08:21.079 weakening peripheral pulses, cool arms and legs, 00:08:21.620 --> 00:08:23.699 skin modeling. Which is the infant version of 00:08:23.699 --> 00:08:26.319 clammy skin. Exactly. And the most measurable 00:08:26.319 --> 00:08:28.699 sign is the narrowing of the pulse pressure. 00:08:28.970 --> 00:08:31.870 If that gets to less than 20 millimeters of mercury, 00:08:32.269 --> 00:08:34.809 you're in trouble. So when hypotension finally 00:08:34.809 --> 00:08:39.070 does show up, it means decompensated shock. Massive 00:08:39.070 --> 00:08:41.669 blood loss. Greater than 45 % of their total 00:08:41.669 --> 00:08:44.220 volume. It's a crisis. And there's a formula 00:08:44.220 --> 00:08:46.279 for that threshold, right? The point of no return. 00:08:46.379 --> 00:08:48.840 Yes. And this is when you have to memorize. The 00:08:48.840 --> 00:08:51.019 lower limit of normal systolic blood pressure 00:08:51.019 --> 00:08:54.419 is 70 millimeters of mercury plus twice the child's 00:08:54.419 --> 00:08:57.159 age in years. So for a five -year -old, 70 plus 00:08:57.159 --> 00:08:59.500 10 is 80. Right. If they're below 80, they're 00:08:59.500 --> 00:09:02.159 in decompensated shock. And the most terrifying 00:09:02.159 --> 00:09:04.330 sign... If you see that heart rates suddenly 00:09:04.330 --> 00:09:06.929 go from tachycardia to bradycardia while they're 00:09:06.929 --> 00:09:09.370 hypotensive, that's impending cardiac arrest. 00:09:09.710 --> 00:09:11.250 So time is absolutely everything. What's the 00:09:11.250 --> 00:09:13.610 hierarchy for getting access? Peripheral IV is 00:09:13.610 --> 00:09:15.470 what you try first, but you don't waste time. 00:09:15.809 --> 00:09:17.789 If you can't get it after two attempts, you move 00:09:17.789 --> 00:09:21.320 immediately to an IO. Intraeus. Proximal Tibia. 00:09:21.720 --> 00:09:24.179 Proximal Tibia is the preferred site, and IO 00:09:24.179 --> 00:09:26.840 is a lifesaver. You can get it in under a minute, 00:09:26.960 --> 00:09:29.200 and it gets fluids into the system just as fast 00:09:29.200 --> 00:09:31.100 as a central line. And once you have that access, 00:09:31.419 --> 00:09:33.600 what's the initial fluid strategy? It's weight 00:09:33.600 --> 00:09:36.700 -based. A 20 milliland per kilogram bolus of 00:09:36.700 --> 00:09:39.159 warmed isotonic crystalloid. That's the standard. 00:09:39.500 --> 00:09:42.299 Warmed. Always warmed. Now, you know, big trauma 00:09:42.299 --> 00:09:44.360 centers are moving more toward damage control, 00:09:44.419 --> 00:09:46.840 resuscitationless, crystalloid, more blood products 00:09:46.840 --> 00:09:49.980 early. But that 20 per kilo bolus is still the 00:09:49.980 --> 00:09:52.580 standard first step everywhere else. OK. And 00:09:52.580 --> 00:09:54.820 what's the one clinical measure we can use to 00:09:54.820 --> 00:09:56.799 know if our resuscitation is actually working? 00:09:57.100 --> 00:10:00.379 The smallest detail, but so important, urinary 00:10:00.379 --> 00:10:02.840 output. For infants, the goal is high, one to 00:10:02.840 --> 00:10:05.360 two millimals per kilo per hour. For older kids, 00:10:05.399 --> 00:10:07.980 it's about 0 .5 to 1 .5. If you're not hitting 00:10:07.980 --> 00:10:10.059 those numbers, you're not caught up. Got it. 00:10:10.379 --> 00:10:12.240 Okay, let's shift to a couple of focused areas, 00:10:12.840 --> 00:10:16.200 head and abdominal trauma. For head trauma, there's 00:10:16.200 --> 00:10:18.559 a rule about hypotension that gets misunderstood. 00:10:19.019 --> 00:10:22.200 Yeah, and it's non -negotiable. Hypotension is 00:10:22.200 --> 00:10:24.559 almost never caused by a head injury alone. Unless 00:10:24.559 --> 00:10:26.379 the situation is catastrophic. Right, unless 00:10:26.379 --> 00:10:28.759 they're resting. If a child with a head injury 00:10:28.759 --> 00:10:30.679 is hypotensive, you have to look for another 00:10:30.679 --> 00:10:34.399 source of massive bleeding. Chest, abdomen, pelvis. 00:10:35.200 --> 00:10:38.019 The hypoxia and hypovolemia will kill the brain 00:10:38.019 --> 00:10:41.159 faster than the injury itself. What about imaging? 00:10:41.419 --> 00:10:43.179 We're always worried about radiating kids, so 00:10:43.179 --> 00:10:45.720 how do we decide who needs a CT? That's where 00:10:45.720 --> 00:10:48.399 the PCARN criteria come in. It's a validated 00:10:48.399 --> 00:10:50.639 screening tool that helps you identify the low 00:10:50.639 --> 00:10:54.100 -risk kids who do not need a CT scan. It's a 00:10:54.100 --> 00:10:56.279 crucial tool for balancing diagnosis against 00:10:56.279 --> 00:10:58.879 that long -term cancer risk from radiation. Okay, 00:10:58.879 --> 00:11:01.620 let's move to the abdomen. What's the one physical 00:11:01.620 --> 00:11:03.860 sign that should immediately make you suspect 00:11:03.860 --> 00:11:06.899 a major internal injury? This seatbelt sign. 00:11:07.120 --> 00:11:09.659 If you see bruising or abrasions from a shoulder 00:11:09.659 --> 00:11:12.299 or lap belt, your suspicion for an intra -abdominal 00:11:12.299 --> 00:11:14.159 injury has to go way, way up. Especially for 00:11:14.159 --> 00:11:16.419 things like bowel perforation or a lumbar fracture. 00:11:16.700 --> 00:11:19.639 Exactly. That sign is a major red flag. And this 00:11:19.639 --> 00:11:22.379 brings us to a huge paradigm shift in management, 00:11:22.840 --> 00:11:25.279 especially for solid organ injuries like the 00:11:25.279 --> 00:11:28.929 liver or spleen. It is a huge shift. The modern 00:11:28.929 --> 00:11:31.509 approach is selective non -operative management 00:11:31.509 --> 00:11:34.090 as long as the child is hemodynamically stable. 00:11:34.409 --> 00:11:37.769 So even if you see blood on a fast scan or the 00:11:37.769 --> 00:11:40.570 CT shows a high -grade spleen injury If the child 00:11:40.570 --> 00:11:42.950 is stable and responding to fluids, you do not 00:11:42.950 --> 00:11:45.389 automatically rush to the operating room. The 00:11:45.389 --> 00:11:47.549 presence of blood does not mandate surgery if 00:11:47.549 --> 00:11:49.929 the vital signs are normal. We want to save that 00:11:49.929 --> 00:11:52.870 spleen if we possibly can. What's the big pitfall 00:11:52.870 --> 00:11:55.669 with using fast scans in this situation? You 00:11:55.669 --> 00:11:57.769 can't rely on it to rule out an injury. It's 00:11:57.769 --> 00:12:00.070 great for finding free fluid, but it can't see 00:12:00.070 --> 00:12:03.070 injuries inside the organ itself. The ultimate 00:12:03.070 --> 00:12:05.929 pitfall is delaying surgery when you shouldn't. 00:12:05.929 --> 00:12:08.529 If that child becomes unstable despite resuscitation, 00:12:08.629 --> 00:12:11.120 they need to go to the OR immediately. Got it. 00:12:11.320 --> 00:12:13.480 Okay, finally, let's hit a few high -risk pitfalls. 00:12:13.860 --> 00:12:16.100 Let's say a child has an isolated closed femur 00:12:16.100 --> 00:12:18.240 fracture and they're hypotensive. What's that 00:12:18.240 --> 00:12:20.759 tell you? It tells you to look somewhere else. 00:12:21.019 --> 00:12:23.519 An isolated femur fracture just doesn't cause 00:12:23.519 --> 00:12:25.940 that much blood loss. It's not enough to cause 00:12:25.940 --> 00:12:28.960 decompensated shock. If they're unstable, the 00:12:28.960 --> 00:12:31.440 bleed is somewhere else. Probably the abdomen. 00:12:31.720 --> 00:12:34.110 And what about spinal injuries? Kids' spines 00:12:34.110 --> 00:12:36.950 are so flexible. That they can sustain a devastating 00:12:36.950 --> 00:12:39.210 spinal cord injury without any broken bones on 00:12:39.210 --> 00:12:42.669 an x -ray. It's called Cicora. Spinal cord injury 00:12:42.669 --> 00:12:45.889 without radiographic abnormality. Right. It's 00:12:45.889 --> 00:12:48.549 much more common in kids. So if the neurological 00:12:48.549 --> 00:12:51.409 exams suggest a cord injury, you have to assume 00:12:51.409 --> 00:12:54.070 the spine is unstable, even if the x -rays look 00:12:54.070 --> 00:12:56.129 perfect. Looking at the long term, the outcomes 00:12:56.129 --> 00:12:59.679 can be... Pretty sobering. They can be. Up to 00:12:59.679 --> 00:13:02.720 60 % of severely injured kids have residual personality 00:13:02.720 --> 00:13:05.620 changes a year later. 50 % have cognitive or 00:13:05.620 --> 00:13:08.120 physical handicaps. You're always thinking about 00:13:08.120 --> 00:13:10.440 the future growth plate injuries causing a leg 00:13:10.440 --> 00:13:13.320 length discrepancy, the lifelong risk of sepsis 00:13:13.320 --> 00:13:15.659 after a splenectomy. Which brings us back to 00:13:15.659 --> 00:13:17.720 the most critical pitfall we have to discuss. 00:13:18.779 --> 00:13:21.379 Child maltreatment. This is a vital area for 00:13:21.379 --> 00:13:23.919 every clinician. You have to know the red flags. 00:13:24.169 --> 00:13:26.649 The biggest one is a major discrepancy between 00:13:26.649 --> 00:13:29.529 the story and the injury. Like a major head injury 00:13:29.529 --> 00:13:32.049 from falling off a couch. Exactly. Or injuries 00:13:32.049 --> 00:13:34.289 that don't match the developmental stage, like 00:13:34.289 --> 00:13:36.450 leg fractures in an infant who can't walk yet. 00:13:36.649 --> 00:13:38.629 And what about the physical findings? You're 00:13:38.629 --> 00:13:40.929 looking for bruises of different colors, which 00:13:40.929 --> 00:13:43.730 suggest different stages of healing, injuries 00:13:43.730 --> 00:13:46.409 around the mouth, and skull or rib fractures 00:13:46.409 --> 00:13:49.529 in any child under two years old are huge red 00:13:49.529 --> 00:13:52.350 flags. And as a clinician, the mandate is clear. 00:13:52.429 --> 00:13:55.250 It's absolute. You are legally required in most 00:13:55.250 --> 00:13:57.649 places to report suspected maltreatment, and 00:13:57.649 --> 00:13:59.769 you have to, because a third of the kids who 00:13:59.769 --> 00:14:03.429 die from maltreatment were seen before for a 00:14:03.429 --> 00:14:06.870 prior unrecognized injury. Reporting is prevention. 00:14:07.210 --> 00:14:10.610 So to pull our 20 % guide together, airway and 00:14:10.610 --> 00:14:12.610 breathing first, using that one -inch padding 00:14:12.610 --> 00:14:16.250 under the torso, the 3X ETT depth rule and the 00:14:16.250 --> 00:14:19.690 DOPE mnemonic. For circulation, it's recognizing 00:14:19.690 --> 00:14:22.389 mass shock through tachycardia and a narrow pulse 00:14:22.389 --> 00:14:24.870 pressure, and knowing the hypotension formula, 00:14:25.190 --> 00:14:27.490 and then the red flags for things like the femur 00:14:27.490 --> 00:14:29.789 fracture rule, and most importantly, for maltreatment. 00:14:29.909 --> 00:14:32.210 That's a great summary. And despite all of that... 00:14:32.250 --> 00:14:34.409 Despite the challenges and the long -term effects, 00:14:34.549 --> 00:14:36.470 here's the final thought that I think justifies 00:14:36.470 --> 00:14:39.330 everything we do. The long -term quality of life 00:14:39.330 --> 00:14:41.970 for children who survive major trauma is surprisingly 00:14:41.970 --> 00:14:44.909 positive. Most of them report a good to excellent 00:14:44.909 --> 00:14:48.169 quality of life as adults. That incredible resiliency 00:14:48.169 --> 00:14:50.870 is why we fight so hard in those first chaotic 00:14:50.870 --> 00:14:53.629 minutes. That is a powerful final justification. 00:14:54.210 --> 00:14:56.289 And it leads us to our final provocative thought 00:14:56.289 --> 00:14:59.350 for you, the listener. The source material states 00:14:59.350 --> 00:15:02.549 that the greatest pitfall of all is our failure 00:15:02.549 --> 00:15:04.669 to prevent these injuries in the first place, 00:15:05.029 --> 00:15:07.450 noting that up to 80 % of them are preventable. 00:15:07.889 --> 00:15:10.470 And for every dollar spent on prevention, $4 00:15:10.470 --> 00:15:13.190 are saved in hospital care. So building on that, 00:15:13.470 --> 00:15:15.610 what are the most effective local coalitions 00:15:15.610 --> 00:15:18.110 needed in your community to actively turn these 00:15:18.110 --> 00:15:20.570 devastating statistics around? Something to think 00:15:20.570 --> 00:15:22.429 about. The work definitely doesn't stop when 00:15:22.429 --> 00:15:24.330 the child leaves the trauma day. Thank you for 00:15:24.330 --> 00:15:25.169 diving deep with us.