Pediatric emergencies

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  • CP arrest in infants and children is rarely a sudden event. Instead, it is often the end result of progressive deterioration in respiratory and circulatory function. No matter what the cause is, the end result in this deterioration is the development of cardiopulmonary failure and possible arrest. If pulseless cardiac arrest develops, there is very poor prognosis. If the clinician recognizes early the manifestations of respiratory failure or shock and quickly starts therapy then cardiopulmonary arrest can often be prevented.
  • Skilled physical examination is needed to recognize cardiopulmonary deterioration in the infant or child. Laboratory tests are useful adjuncts in determining the severity of physiologic derangements but they are not crucial to the initial evaluation. Every clinician who works with children should be able to recognize potential pulmonary and circulatory failure and impending cardiopulmonary arrest based on a rapid CP assessment. The rapid CP assessment is designed to evaluate pulmonary and cardiovascular functions and their effects on end-organ perfusion and function.
  • Since the conditions of these patients are often dynamic, repeated assessments are necessary to evaluate trends in their conditions or the responses to therapy.
  • Hypovolemic shock is the leading form of shock in children worldwide.
  • Since cardiac and cardiopulmonary arrest in children is most commonly associated with the development of hypoxemia rather than with ventricular arrhythmias, about 1 min of rescue support may restore oxygenation and effective ventilation or may prevent the child with respiratory arrest from developing cardiac arrest.
  • If the infant or child is unresponsive, has no evidence of trauma and obviously breathing effectively, the rescuer should place the victim in the recovery position and activate EMS.
  • Cardiac output = volume of blood ejected by the heart each minute. Stroke volume = volume of blood ejected by the ventricles with each contraction. Of the variables affecting and affected by cardiac output, only the heart rate and blood pressure can be easily measured. Stroke volume and systemic vascular resistance must be indirectly assessed by examining the quality of pulses and evaluating tissue perfusion. Blood pressure is the product of cardiac output (flow) and systemic vascular resistance. Normal BP can be maintained despite a fall in cardiac output only if compensatory vasoconstriction occurs. Hypotension is a late and often sudden sign of cardiovascular decompensation. Therefore, even mild hypotension must be treated quickly and vigorously because it signals decompensation and CP arrest may be imminent. An observed fall of 10 mm Hg in systolic BP should prompt careful serial evaluations for additional signs of shock.
  • Epinephrine: for cardiac arrest, symptomatic bradycardia unresponsive to ventilation and oxygenation and hypotension not related to volume depletion; severe acidosis may depress its action, thus, should be corrected first with oxygenation, hyperventilation and restoration of systemic perfusion. Atropine: symptomatic bradycardia associated with poor perfusion, intubation and AV block; not indicated for asystole or cardiac arrest. Isoproterenol: for heart block unresponsive to atropine, for bradycardia with poor perfusion. Dopamine: for hypotension or poor peripheral perfusion with adequate intravascular volume and stable rhythm; for cardiogenic, distributive (DSS) and hypovolemic shock conditions. Dobutamine: for hypoperfusion with high systemic vascular resistance; most effective in severe congestive failure or cardiogenic shock.
  • This is due to larger head of a child than adult, more likely to “lead” in the fall. Cervical spine injury may be anatomic or functional. SCIWORA cannot be ruled out by radiographic examination and must be assumed to be present in all children with multiple injuries especially those apneic; accounts for large number of prehospital deaths previously thought to be due to head trauma.
  • In hemorrhagic shock: 3 for 1 rule, 3ml blood loss to 1 ml fluid.
  • Pediatric emergencies

    1. 1. PEDIATRIC EMERGENCIES Myrna D.C. San Pedro, MD, FPPS
    2. 2. Scope <ul><li>Injury risk factors, assessment, emergency treatment and prevention </li></ul><ul><li>Foreign body accidents clinical features and management </li></ul><ul><li>Burn types, assessment and management </li></ul><ul><li>Near-drowning accidents assessment and management </li></ul><ul><li>Poisoning common causes, diagnosis and management </li></ul>
    3. 3. Injury versus Accident <ul><li>Accident (WHO): an event independent of human willpower, caused by an external force, acts rapidly and results in bodily or mental damage </li></ul><ul><li>Injury : refers to the damage resulting from acute exposure to physical and chemical agents </li></ul><ul><li>Accident is the event while injuries the consequences </li></ul><ul><li>Accidents are random, chance, uncontrollable events but injuries are describable, epidemiologic conditions that can be controlled and prevented </li></ul><ul><li>The term “accident” has been abandoned in favor of the more accurate term “injury </li></ul>
    4. 4. Interactive Model of Injuries VICTIM (HOST) AGENT HUMAN ENVIRONMENT PHYSICAL ENVIRONMENT
    5. 5. Child Development and Injuries <ul><li>Temperament : a child’s behavioral style </li></ul><ul><ul><li>Difficult child : irregular rhythm, high energy, negative mood, low adaptability </li></ul></ul><ul><ul><li>Easy child : opposite </li></ul></ul><ul><ul><li>Slow to warm up child : low activity, positive approach, highly adaptable, mild energy </li></ul></ul><ul><li>Motivation : interest in accomplishing a task </li></ul><ul><ul><li>Normal drive for autonomy </li></ul></ul><ul><ul><li>Interest in imitating behavior </li></ul></ul><ul><ul><li>Risk-taking or self-destructive behaviors </li></ul></ul>
    6. 6. Child Development and Injuries <ul><li>Competencies : level of functioning </li></ul><ul><ul><li>Infants ’ drive to explore and become autonomous but still underdeveloped </li></ul></ul><ul><ul><li>Preschool children have cognitive and motor limitations </li></ul></ul><ul><ul><li>School children tend to be daring, impulsive and adventurous; inclined to disregard rules; still unable to appreciate speed and danger; have reduced ability to localize sounds and impaired perception of movement </li></ul></ul><ul><ul><li>Adolescents become overly involved in abstract matters and sometimes lose touch with reality combined with innate need for experimentation and the tendency to imitate older adolescents and adults </li></ul></ul>
    7. 7. Primary Factors in Pediatric Accidents Increased vulnerability and/or risk situation Psychosocial (endogenous) Predisposing Factors Environmental (exogenous) Predisposing Factors Accident Precipitating Factors Precipitating Factors
    8. 8. Psychosocial (endogenous) Predisposing Factors <ul><li>Unawareness of risks </li></ul><ul><li>Lack of experience </li></ul><ul><li>Need to explore and innovate </li></ul><ul><li>Role models (motorcyclist as hero) </li></ul><ul><li>Risk-taking behavior </li></ul><ul><li>Use of a motor vehicle to build up self-esteem </li></ul><ul><li>Psychological maladjustments (extreme personality traits, unbalanced personality) </li></ul><ul><li>Sociopathic behavior (aggressiveness, deviance) </li></ul><ul><li>Family dysfunctions (chronic family syndrome) </li></ul>
    9. 9. Environmental (exogenous) Predisposing Factors <ul><li>Habitual use of a two-wheeled vehicle without due protection </li></ul><ul><li>Lack of body protection (helmet, gloves, etc.) </li></ul><ul><li>Increased commercial advertising promoting vehicles that are dangerous </li></ul><ul><li>Inadequate age-specific driving regulations </li></ul><ul><li>Inadequate enforcement of existing laws </li></ul><ul><li>Increasing need to make long trips to and from work, school, etc. </li></ul><ul><li>Inadequately or excessively expensive public transport </li></ul>
    10. 10. Precipitating Factors <ul><li>Heightened emotional tension (endocrinological and psychological) </li></ul><ul><li>Alcoholic condition </li></ul><ul><li>Driving under influence of medicines or drugs (especially hallucinogenic) </li></ul><ul><li>Special traffic conditions </li></ul><ul><li>Social pressure to “perform” in a certain way (traveling in groups) </li></ul><ul><li>Use of poorly maintained vehicles </li></ul><ul><li>Use of stolen vehicles </li></ul>
    11. 11. Classification of Injuries <ul><li>Unintentional Injuries : </li></ul><ul><li>Road traffic injuries </li></ul><ul><li>Poisoning </li></ul><ul><li>Falls </li></ul><ul><li>Fire and burn injuries </li></ul><ul><li>Drowning </li></ul><ul><li>Intentional Injuries : </li></ul><ul><li>Homicides </li></ul><ul><li>Sexual assaults </li></ul><ul><li>Neglect and abandonment </li></ul><ul><li>Maltreatment </li></ul><ul><li>Suicides </li></ul><ul><li>Collective violence (war) </li></ul>
    12. 12. Unintentional Injuries <ul><li>Unintentional Injuries : </li></ul><ul><li>400,000 deaths/year globally – the majority in children </li></ul><ul><li>Survivors may suffer lifelong disability </li></ul>Non-intentional injuries in children under 15 years ( WHO, 2001 )
    13. 13. U.S. Injury Mortality <ul><li>Injuries almost 40% of deaths among 1-4 years </li></ul><ul><li>Motor vehicle injuries leading cause of deaths due to injury at all ages </li></ul><ul><li>Drowning ranks 2 nd with peaks in the preschool and later teenage years </li></ul><ul><li>Fire and burn deaths account for nearly 10% of all trauma deaths and more than 20% in <5 yr </li></ul><ul><li>Asphyxiation and choking account for about 40% of all unintentional deaths in <1 yr </li></ul><ul><li>Homicide leading cause of injury death in <1 yr, 4 th leading cause for ages 1-14 years and 2 nd leading cause in 15-19 years </li></ul><ul><li>Suicide is only 1% in <15 yr but is the 3 rd leading cause of death for 15-19-yr-olds </li></ul>
    14. 14. U. S. Injury Morbidity <ul><li>Twenty to 25% of children receive medical care for injury every year in hospital ERs and at least an equal number in physician offices </li></ul><ul><li>Falls leading cause of both ER visits and hospitalizations </li></ul><ul><li>Bicycle-related trauma most common type of sports and recreational injury </li></ul>
    15. 15. DOH 2003 Study <ul><li>By the Department of Health: 1 out of every 5 Filipino children die from injuries </li></ul><ul><li>2003 DOH study done with help from the United Nations Children’s Fund and the Alliance for Safe Children revealed that the top causes of death among children ages 1-17 years are: </li></ul><ul><ul><li>Drowning (8:100,000) </li></ul></ul><ul><ul><li>Road accidents (5.85:100,000) </li></ul></ul><ul><ul><li>Violence (2.52:100,000) </li></ul></ul><ul><ul><li>Falls (2.11:100,000) </li></ul></ul><ul><ul><li>Suicide (1.93:100,000) </li></ul></ul><ul><li>The study was made on 99,446 households or 418,552 people </li></ul>
    16. 16. Safe Kids Philippines Study <ul><li>The study was conducted in the ERs of 3 hospitals in Parañaque, Pasay, and Olongapo </li></ul><ul><li>At least 20 million Filipino children are at risk of dying or being injured in road accidents every yr </li></ul><ul><li>At least one in four children brought to hospital for treatment were between 12-14 years </li></ul><ul><li>Most of the injuries happen after 1 p.m. and their peak incidence between 9 p.m. and 12 a.m. </li></ul><ul><li>Accidental injuries are the third leading cause of death for children 1-14 years in the Philippines </li></ul>
    17. 17. Safe Kids Philippines Study
    18. 18. Anticipating Cardiopulmonary Arrest Cardiopulmonary Failure Many Causes Respiratory Failure Cardiovascular Recovery Death Shock Neurological Impairment Neurological Recovery Path of various disease states leading to cardiopulmonary failure in infants and children
    19. 19. Rapid Cardiopulmonary Assessment (requires 20-30 seconds to complete) <ul><li>Airway patency </li></ul><ul><ul><li>Patent and clear </li></ul></ul><ul><ul><li>Maintainable with suctioning, head positioning or adjuncts </li></ul></ul><ul><ul><li>Unmaintainable , requiring interventions such as intubation, foreign body removal or cricothyrotomy </li></ul></ul><ul><li>Breathing </li></ul><ul><ul><li>Respiratory Rate : normal in neonate is 40-60/min; 1-year-old is 24/min; 18-year-old is 12/min </li></ul></ul><ul><ul><li>Mechanics : nasal flaring, grunting, retractions, use of accessory muscles </li></ul></ul><ul><ul><li>Air Entry : stridor, wheezing, breath sounds, chest expansion, paradoxical chest movement </li></ul></ul><ul><ul><li>Color of the skin and mucous membranes </li></ul></ul><ul><ul><li>Central cyanosis – presence of 5 g desaturated hemoglobin/dl of blood </li></ul></ul>
    20. 20. Rapid Cardiopulmonary Assessment <ul><li>Circulation </li></ul><ul><ul><li>Heart Rate : </li></ul></ul><ul><ul><li>Newborn-3 mo 85-200/min </li></ul></ul><ul><ul><li>3 mo-2 yr 100-190/min </li></ul></ul><ul><ul><li>>2 yr 80-140/min </li></ul></ul><ul><ul><li>All ages < 60/min bradycardia </li></ul></ul><ul><ul><li>Blood Pressure : lower limit (5 th %) systolic </li></ul></ul><ul><ul><li>0-1 mo 60 </li></ul></ul><ul><ul><li>>1 mo-1 yr 70 </li></ul></ul><ul><ul><li>>1 yr 70 + (2 x age in years) </li></ul></ul><ul><ul><li>Hypotension – 25% circulating blood volume loss </li></ul></ul><ul><ul><li>Peripheral pulses : whether present or absent, volume/strength </li></ul></ul><ul><ul><li>Capillary Refill Time : normal <2 seconds </li></ul></ul>
    21. 21. Rapid Cardiopulmonary Assessment <ul><li>Circulation </li></ul><ul><ul><li>Skin color : mottling, ashen, pale or cyanotic </li></ul></ul><ul><ul><li>Skin temperature : whether warm or cold </li></ul></ul><ul><ul><li>Level of consciousness (brain perfusion): </li></ul></ul><ul><ul><li>A – Awake </li></ul></ul><ul><ul><li>V – responsive to Voice </li></ul></ul><ul><ul><li>P – responsive to Pain </li></ul></ul><ul><ul><li>U – Unresponsive </li></ul></ul><ul><ul><li>Urine Output : normal averages 1-2 ml/kg/hr, reflects renal blood flow and end-organ perfusion </li></ul></ul>
    22. 22. Classification of Physiologic Status <ul><li>Stable – adequate ventilation (elimination of CO 2 ), oxygenation (O 2 exchange) and perfusion </li></ul><ul><li>In respiratory failure – inadequate ventilation or oxygenation </li></ul><ul><ul><li>Potential RF – improves after initial therapy such as oxygen administration </li></ul></ul><ul><ul><li>Probable RF – deteriorates, more aggressive therapy needed </li></ul></ul><ul><li>In shock – inadequate perfusion of vital organs </li></ul><ul><ul><li>Compensated shock – blood pressure is normal </li></ul></ul><ul><ul><li>Decompensated shock – hypotension develops </li></ul></ul><ul><li>In cardiopulmonary failure – insufficient ventilation, oxygenation and perfusion </li></ul>
    23. 30. Pediatric Cardiopulmonary Arrest <ul><li>Sudden Cardiac Arrest </li></ul><ul><li>Uncommon in young children </li></ul><ul><li>Ventricular fibrillation only 10-15% of <10 years with pulseless arrest outside the hospital </li></ul><ul><li>Prehospital normothermic asystolic or pulseless cardiac arrest in infants and children with 10% survival rate </li></ul><ul><li>Many suffer permanent neurological damage </li></ul><ul><li>Respiratory or Circulatory Failure </li></ul><ul><li>More common </li></ul><ul><li>Injury or disease causes respiratory or circulatory failure with hypoxemia and acidosis ending in asystolic or pulseless cardiac arrest </li></ul><ul><li>Respiratory arrest alone >50% survival rate with prompt resuscitation </li></ul><ul><li>Most patients survive neurologically intact </li></ul>
    24. 31. Basic Life Support Maneuvers PALS 2006-2007 MANEUVER ADULT > 8 Years CHILD 1-8 Years INFANT < 1 Year Activate EMS (lone rescuer) When victim FOUND unresponsive, activate EMS. If asphyxial arrest likely, activate AFTER 5 cycles 2 min CPR. When victim FOUND unresponsive, activate AFTER 5 cycles CPR. For SUDDEN, WITNESSED COLLAPSE, activate after verifying victim unresponsive. Airway Head tilt-chin lift maneuver. If trauma suspected, use jaw thrust maneuver. Breaths Initial 2 effective breaths at 1 sec per breath
    25. 32. MANEUVER ADULT > 8 Years CHILD 1-8 Years INFANT < 1 Year Rescue Breaths Without chest compression 10-12 breaths/min (about 1 breath every 5-6 seconds) 12-20 breaths/min (about 1 breath every 3-5 seconds) Rescue Breaths for CPR With advanced airway 8-10 breaths/min (about 1 breath every 6-8 seconds) Foreign-body airway obstruction Abdominal thrusts Back slaps and chest thrusts (5) Circulation Pulse check ( < 10 sec) Carotid (can use Femoral in the child) Brachial or Femoral
    26. 33. MANEUVER ADULT > 8 Years CHILD 1-8 Years INFANT < 1 Year Compression landmark Center of chest between nipples Just below the nipple line Compression method: Push hard and fast allowing complete recoil Heel of 1 hand on top of other hand 2 Hands: Heel of 1 hand on top of second hand 1 Hand: Heel of 1 hand only 1 rescuer: 2 fingers 2 rescuers: 2 thumbs with encircling hands Compression depth 1 ½-2 inches Approximately 1/3-1/2 the depth of the chest Compression rate Approximately 100/min Compression-ventilation ratio 1 or 2 rescuers 30:2 1 rescuer 30:2 2 rescuers 15:2
    27. 34. Basic Life Support Core <ul><li>Push hard and fast at a compression rate of 100/min </li></ul><ul><li>Allow full chest recoil between chest compression </li></ul><ul><li>Minimize interruptions </li></ul><ul><li>Avoid hyperventilation </li></ul>
    28. 35. Airway
    29. 36. Rescue Breaths The correct volume for each breath is the volume that causes the chest to rise.
    30. 37. Foreign-body Airway Obstruction
    31. 38. Pulse Check
    32. 39. Chest Compression
    33. 40. Airway Adjuncts <ul><li>Oxygen (O 2 ) : highest concentration for all seriously ill with respiratory insufficiency, shock, or trauma </li></ul><ul><ul><li>Room air: 21% O 2 </li></ul></ul><ul><ul><li>Mouth-to-mouth: 16-17% O 2 </li></ul></ul><ul><li>Suctioning : 80-120 mm Hg suction force usually </li></ul><ul><li>Head positioning : position of comfort if alert, head tilt-chin lift or jaw thrust if unconscious </li></ul><ul><li>Oropharyngeal airway : for the unconscious infant or child if procedures to maintain airway fails </li></ul><ul><li>Bag-valve–mask assisted ventilation </li></ul><ul><ul><li>Self-inflating bag-valve device: 21% O 2 </li></ul></ul><ul><ul><li>If hooked to O 2 10 L/min: 30-80% O 2 </li></ul></ul><ul><ul><li>If hooked to O 2 10-15 L/min and with reservoir: 60-95% O 2 </li></ul></ul>
    34. 41. Airway Adjuncts <ul><li>Endotracheal intubation indications: </li></ul><ul><ul><li>Respiratory failure or arrest </li></ul></ul><ul><ul><li>Airway obstruction (actual or expected) </li></ul></ul><ul><ul><li>GCS < 8, comatose or significant alteration of mental status </li></ul></ul><ul><ul><li>Suspected increase in intracranial pressure </li></ul></ul><ul><ul><li>Need for mechanical ventilatory support </li></ul></ul><ul><li>Cricothyrotomy indications: </li></ul><ul><ul><li>Foreign body complete upper airway obstruction </li></ul></ul><ul><ul><li>Severe orofacial injuries </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Laryngeal fracture </li></ul></ul><ul><li>Respiratory monitoring </li></ul><ul><ul><li>Pulse oximetry – noninvasive </li></ul></ul><ul><ul><li>Arterial Blood Gas analysis – most accurate </li></ul></ul>
    35. 42. DELIVERY SYSTEMS OXYGEN (%) FLOW RATE (L/min) Low Flow System Nasal cannula 22-60 2-4 Oxygen mask 35-60 6-10 High Flow System Face tent < 40 10-15 Oxygen hood 80-90 10-15 Oxygen tent > 50 > 10 Partial rebreathing mask with reservoir 50-60 10-12 Nonrebreathing mask with reservoir 95 10-15 Venturi mask 25-60 (mask specific) variable
    36. 43. Oxygen Delivery Systems
    37. 44. Airway Adjuncts
    38. 45. Endotracheal Intubation
    39. 46. Cricothyrotomy
    40. 51. Pediatric Trauma Resuscitation <ul><li>Trauma is the leading cause of death and disability in the pediatric age group </li></ul><ul><li>In the average multiple trauma victim: head injuries 59% while extremities 26% </li></ul><ul><li>Two major causes of death: </li></ul><ul><ul><li>Airway compromise </li></ul></ul><ul><ul><li>Unrecognized hemorrhage </li></ul></ul><ul><li>Traumatic injuries that may affect successful resuscitation: </li></ul><ul><ul><li>Cervical spine injury </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Chest trauma </li></ul></ul><ul><li>Priority is to assess and stabilize first before surgery </li></ul>
    41. 52. <ul><li>Pediatric Trauma Score of > 8 indicates multisystem trauma or significant mortality risk </li></ul>
    42. 53. Cervical Spine Injury <ul><li>Cervical spine injury less common in pediatric than in adult trauma because </li></ul><ul><ul><li>Child’s spine more elastic and mobile </li></ul></ul><ul><ul><li>Pediatric vertebrae softer, less likely to fracture </li></ul></ul><ul><li>But risk of cervical spine injury increased whenever child is subjected to inertial forces applied to neck during acceleration-deceleration e.g., motor vehicle injuries or falls from a height </li></ul><ul><li>Spinal cord injury without radiographic abnormality (SCIWORA) is now recognized as important cause of pediatric spinal cord injury because of </li></ul><ul><ul><li>Relative laxity of cervical spine ligaments </li></ul></ul><ul><ul><li>Incomplete development of cervical musculature </li></ul></ul><ul><ul><li>Shallow orientation of facet joints </li></ul></ul>
    43. 54. Cervical Spine Immobilization
    44. 55. Hemorrhage in Pediatric Trauma <ul><li>Control external hemorrhage immediately by direct pressure over the wound </li></ul><ul><li>Hypotension will not be present until 25-30% or more of the child’s blood volume is lost acutely </li></ul><ul><li>Reliable vascular access must be obtained quickly </li></ul><ul><li>If shock persists despite control of external hemorrhage and volume resuscitation, internal bleeding is likely </li></ul><ul><li>Isolated head injury rarely causes sufficient blood loss to cause shock but scalp lacerations may produce significant blood loss </li></ul><ul><li>Intra-abdominal bleeding signs due to organ rupture: abdominal tenderness, distention that does not improve with NGT decompression and shock – a life-threatening surgical emergency </li></ul>
    45. 57. Fluid Resuscitation in Hemorrhagic Shock 20 ml/kg Isotonic crystalloid solution OR 10 ml/kg PRBC or 20 ml/kg FWB 20 ml/kg Isotonic crystalloid solution 20 ml/kg Isotonic crystalloid solution Reassess Reassess Reassess --- Urgent transfusion should be considered if child fails to respond to 2-3 boluses of crystalloid solution (about 40-60 ml/kg)
    46. 58. Life-Threatening Chest Injuries <ul><li>Chest injuries uncommon in pediatric trauma because chest wall extremely compliant </li></ul><ul><li>When there is history of blunt trauma, intrathoracic injuries must be ruled out </li></ul><ul><li>Tension pneumothorax: ABCs, needle decompression followed by chest tube </li></ul><ul><li>Open pneumothorax (sucking chest wound) – rare but lethal: ABCs, occlusive dressing followed by chest tube, positive-pressure ventilation </li></ul><ul><li>Flail chest: ABCs, prolonged positive-pressure ventilation </li></ul><ul><li>Massive hemothorax: ABCs, urgent placement of a chest tube </li></ul>
    47. 61. / Drugs
    48. 63. Principles of Injury Control <ul><li>Education or persuasion </li></ul><ul><li>Changes in product design </li></ul><ul><li>Modification of the social or physical environment </li></ul>
    49. 64. Haddon’s 10 Strategies <ul><li>Prevent the creation of hazard </li></ul><ul><li>Reduce amount of hazard brought into being ( decrease number of cars manufactured; use fuel that permits only low speed ) </li></ul><ul><li>Prevent the release of hazard ( drive only in daylight ) </li></ul><ul><li>Modify the rate of release of the hazard from its source ( use seat belts, child safety seat ) </li></ul><ul><li>Separate the hazard by time and space ( separate bicyclists from cars; use pedestrian lanes ) </li></ul>
    50. 65. Haddon’s 10 Strategies <ul><li>Separate the hazard by a physical barrier ( install air bags ) </li></ul><ul><li>Modify relevant basic qualities of the hazard ( eliminate hard surfaces in cars; use energy absorbing materials to increase space within ) </li></ul><ul><li>Make what is to be protected resistant ( wear helmets ) </li></ul><ul><li>Begin to counter the damage done by the hazard ( maintain airway, stop hemorrhage, immobilize neck ) </li></ul><ul><li>Stabilize, repair, rehabilitate the object of the damage ( develop a regional trauma system, trauma and rehabilitation center ) </li></ul>
    51. 66. Gustafsson Safety Equation <ul><li>H. P. S. E. </li></ul><ul><li>H = environmental Hazard </li></ul><ul><li>P = Proneness/“Personality factors”/Psychosocial </li></ul><ul><li>S = Supervision </li></ul><ul><li>E = Education </li></ul><ul><li>When, in any context, the 1 st term of the equation balances the 2 nd one, there is no chance of accident </li></ul><ul><li>When it is not the case, the risk of accidents arises </li></ul><ul><li>The equation is useful for preventive programs </li></ul>
    52. 67. Three DELAYS that KILL <ul><li>DELAY in decision-making </li></ul><ul><li>DELAY in transporting patient </li></ul><ul><li>DELAY in managing patient </li></ul>

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