paediatric trauma ppt

1. PAEDIATRIC TRAUMA
PRESENTER:DR JITESH YADAV
Senior resident trauma anaesthesia
MODERATOR:DR KAVITA MEENA
Associate professor department of
anaesthesiology IMS BHU varanasi

2. OBJECTIVES
 Types and patterns of injuries,
 anatomic and physiologic changes
 Different equipment needs when compared
with adult trauma patients.
 ABCDEs of injury prevention.

3. EPIDEMIOLOGY
 Most common cause of death and disability in
childhood.
 Each year, > 10 million children—Approx. 1/ 6
children—in the United States require emergency
care for the treatment.
 Each year,10,000 children in the United States die
from serious injury.
 Causes of unsuccessful resuscitation
 Failure to secure a compromised airway,
 Support breathing,
 Recognize and respond to intra-abdominal and intracranial
hemorrhage are the leading in pediatric patients.

4. TYPES AND PATTERNS OF INJURY

6. UNIQUE CHARACTERISTICS
 most serious pediatric trauma is blunt trauma that
involves the brain.
 As a results
 apnea,
 hypoventilation
 hypoxia-- 5 times more often than hypovolemia with
hypotension in children who have sustained trauma.
 Therefore, treatment protocols for pediatric trauma
patients emphasize aggressive management of the
airway and breathing.

7. SKELETON
 Incompletely calcified
 Multiple active growth center
 More pliable#less in child even they have sustained organ
damage
 E.g.significant damage of soft tissue of thorax and
mediastinum without bony injury or external truama.
 Presence of skull and ribs # suggest underlying injury like TBI,
Pulmonary contusion

8. TRAUMA TRIAGE SCORES
 Two of the most commonly used:-
 Pediatric Trauma Score
 Revised Trauma Score
 help identify a child with more severe injuries.
 Revised Trauma Score of <12 or a Pediatric
Trauma Score of <8 should prompt transfer to
a pediatric trauma center

9.  Maximum PT Score:12
 Minimum PT Score: -6
 PTS>8 0% Mortality
 PTS<8Should be triaged to an appropriate pediatric trauma
center

10. Revised trauma score
 Revised Trauma Score of <12 should prompt transfer to a pediatric trauma
center

11. SIZE ,SHAPE AND SURFACE AREA
 smaller body mass than adults,
greater force being applied per unit of body area This
concentrated energy is transmitted to a body  has less fat,
less connective tissue, and a closer proximity of multiple
organs than in adults high frequency of multiple injuries
seen in the pediatric population.
 Child’s head is proportionately larger than an
adult’sblunt brain injuries .
 Higher ratio of body surface area to body
volume increases risk of hypothermia

12. PSYCHOLOGICAL STATUS
 Potential for significant psychological ramifications
should be considered in children who sustain
trauma.
 Presence of parents or other caregivers during
evaluation and treatment, including resuscitation
may assist clinicians by minimizing child fears and
anxieties.

13. LONG TERM EFFECTS
 Effect of the injury on their subsequent growth and
development.
 May have prolonged disability in cerebral function,
psychological adjustment, or organ system function
 Bony and solid visceral injuries
Fracture of femur - Leg length discrepancy
Fracture through growth centers of vertebra - scoliosis,
kyphosis, or even gibbus deformity
Massive disruption of a child’s spleen- lifelong risk of
overwhelming postsplenectomy sepsis and death.

14. Ionizing radiation
 Increase the risk of certain malignancies
 Should be used if the information needed cannot
obtained by other means
 Use the lowest possible radiation doses.

15. EQUIPMENT
• Broselow Pediatric Emergency Tape to help rapid
determination of weight based on length
Provides appropriate fluid volumes, drug doses, and equipment size

20. AIRWAY
 Due to inability to maintain a patent airway lack of oxygenation
and ventilation is the most common cause of cardiac arrest in
children.
Child’s airway can obstruct easily:-
Younger children (< 3 yrs) have a larger cranium and occiput, so
natural flexion of cervical spine causes pharynx to buckle and
obstruct
 Ensure that the plane of the mid face is maintained parallel to the
spine board in a neutral position, rather than in the “sniffing
position”
 Put 1 inch thick padding under infant or toddler’s entire torso vs.
under the head in adults

22. Pediatric vs Adult Airway
 Small oral cavity with relatively large tongue and tonsils
 Predisposed to airway obstruction
 Makes visualization difficult
 If child is unconscious, insert an oral airway to help hold
back the tissue
 Larynx more superior and anterior so more difficult to
visualize
 May need to apply posterior-inferior cricoid pressure to help
visualize
 Floppy and larger epiglottis
 Often, the Miller (straight) rather than the Macintosh
(curved) blade is better for intubation

24.  Narrowest at cricoid rather than vocal cords
 Used to recommend uncuffed tube, but now cuffed more
common for better ventilation
 Ideally, cuff pressure should be measured as soon as is feasible,
and <30 mm Hg is considered safe.
 Larynx is funnel-shaped, so secretions accumulate in
retropharyngeal space
 Infant’s trachea is approximately 5 cm long and grows to 7 cm
by about 18 months.

25. Management
 Spontaneously breathing child with a partially
obstructed airway : -
 keeping the plane of the face parallel to the plane of
the stretcher.
 Use the jaw-thrust maneuver.
 Clearing of secretions and debris, administer
supplemental oxygen.

26.  Unconscious child : - Mechanical methods of maintaining
the airway may be necessary.
 Oropharyngeal airway
 Orotracheal intubation under direct vision with restriction
of cervical motion is the preferred method
 Do not perform nasotracheal intubation in children
 Difficult due to relatively acute angle in the
nasopharynx toward the anterosuperiorly
located glottis
 Potential for penetrating the child’s cranial vault
or damaging the more prominent
nasopharyngeal (adenoidal) soft tissues and
causing hemorrhage
 Rescue airway with either laryngeal mask airway (LMA),
intubating LMA, or needle cricothyroidotomy
 Before attempting to mechanically establish an airway, fully
preoxygenate

27. OROPHARYNGEAL AIRWAY
 Should be inserted only in unconscious child
 Vomiting may occur
 Inserting the airway backward and rotating it 180 degrees
not recommended
 Trauma and hemorrhage into soft-tissue structures of the
oropharynx

28. Orotracheal Intubation Indications
 Airway trauma
 Inhalation injury (burns)
 Prolonged seizures
 Severe head injury (GCS ≤ 8)
 Significant hypovolemia that leads to depressed
sensorium
 Other signs of ventilatory failure

29. Intubation Equipment
Prepare all equipment as in adults
Endotracheal tube size
 Approximately the diameter of child’s external nares or
tip of the small finger
 If ≥ 2 yrs, 4+(age in years/4), decrease by 0.5 if cuffed
 Length based pediatric resuscitation tapes also list
appropriate tube sizes

30.  Availability of tubes that are one size larger and one
size smaller than the predicted size.
 Ensure that the stylet tip does not extend beyond the
end of the tube.
 Depth of tube
 3 x tube diameter size
 If ≥ 2 yo, (age in years/2)+12 cm

32.  Endotracheal tube should be positioned 2-3 cm below
level of vocal cords
 Check for tube position:-
 Bilateral breath sounds
 Capnography , colorimetric device or esophageal detector
 Chest x-ray

33.  Trachea is about 5 cm long in infants and 7 cm in
toddlers
 Right mainstem intubation is common
 Small movements may dislodge the tube
 Evaluate breath sounds periodically to ensure that the
tube remains in the appropriate position and identify the
possibility of evolving ventilatory dysfunction

35. CRICOTHYROIDOTOMY
 More difficult to feel in younger
children due to
 softer cartilage
 Surgical cricothyroidotomy rarely indicated
for infants
 Indicated usually by the age of 12 years
 Could use needle cricothyroidomy
using 16 or
 18 gauge angiocath and attach 3.0
or 3.5 ETT
 cap to end
 Allows for oxygenation but not ventilation

36. BREATHING
 Key factor - recognition of impaired gas
exchange
 Pneumothorax/contusion/aspiration
 Be familiar with normal respiratory rate
based on ages :-
 Infants - 30 to 40 times per minute
 Older child - 15 to 20 times per minute

37.  If available, use bag-mask devices designed for
children to avoid the risk of iatrogenic
barotrauma – recommended for < 30 kg
 Spontaneous tidal volume for infants and children :-
4 to 6 ml/kg
 Assisted ventilation :- 6-8ml/kg till 10ml/kg
 Immature tracheobronchial tree and alveoli
increases risk of barotrauma, especially with adult
devices
 Goal is gentle chest rise

38. Hypoventilation Respiratory acidosis Hypoxia Cardiac arrest
 Goal - maintain relatively normal pH with adequate
ventilation and perfusion
 In the absence of adequate ventilation and perfusion,
attempting to correct an acidosis with sodium
bicarbonate
 further hypercarbia
 worsened acidosis

39. Pneumothorax
 Similar in children and adults
 Needle decompression over top of 3rd rib in mid-clavicular line
 Chest tube insertion 5th intercostal space, just anterior to midaxillary line
 Due to thinner chest wall, the needle itself can cause a tension
pneumothorax
 When inserting chest tube : -
 Tunnelling over rib above the skin incision site
 Directing superiorly and posteriorly along the inside of chest wall

40. CIRCULATION AND SHOCK
Key factors in evaluating and managing circulation:-
 Recognizing circulatory compromise
 Determining the patient’s weight and circulatory volume
 Obtaining venous access
 Administering resuscitation fluids and/or blood
replacement
 Assessing the adequacy of resuscitation
 Achieving thermoregulation

41. Recognition of circulatory compromise
 Multisystem injuries in children may lead to significant blood loss
 Children have higher physiologic reserve and can maintain systolic
blood pressure while in hypovolemic shock (compensated)
 Tachycardia and poor skin perfusion are usually the only keys to early
recognition of hypovolemia
 Systolic blood pressure may be maintained with a blood loss of up to
45%
 Early assessment by a surgeon is essential to the appropriate
treatment of injured children.

44. Pitfall prevention
Failure to recognize
and
treat shock in a child
• Recognize that tachycardia
may be
the only physiologic
abnormality.
• Recognize that children
have
increased physiologic
reserve.
• Recognize that normal vital
signs vary
with the age of the child.
• Carefully reassess the
patient for
mottled skin and a subtle
decrease in
mentation.

45. PATIENT’S WEIGHT AND CIRCULATORY
VOLUME
Ask caregiver
Length based resuscitation
tapes
Wt in kg=(2 × age in years)
+ 10

46. venous access
(18 G –Infants, 15 G –
above 1 year)
 C/I - known or
suspected fracture
 Complications –
cellulitis
osteomyelitis
compartment
syndrome
iatrogenic fracture
venous
Saphenous veins at the ankle
Percutaneous central access
1. Femoral veins
2. External or internal
jugular or subclavian veins
Intraosseous
1. Anteromedial tibia 2. Distal femur
Percutaneous peripheral(two attempts)
1. Antecubital fossa 2. Saphenous veins

48. FLUID RESUSCITATION AND BLOOD
REPLACEMENT
 Evidence of hemorrhage may be evident with
the loss of 25% of a child’s circulating blood
volume.
 Previous editions of ATLS
 20 mL/kg bolus one or two additional 20 mL/kg
isotonic crystalloid boluses pending the child’s
physiologic response.
 If evidence of ongoing bleeding after the second or
third crystalloid bolus, 10 mL/kg of PRBC may be
given.

49.  Recent “damage control resuscitation,” consisting of the
restrictive use of crystalloid fluids and early
administration of balanced ratios of packed red blood
cells, fresh frozen plasma, and platelets
Adequacy of resuscitation
 Slowing of the heart rate (age appropriate with
improvement of other signs)
 Improving of the sensorium
 Return of peripheral pulses
 Return of normal skin color

50.  Increased warmth of extremities
 Increased systolic blood pressure with return to
age-appropriate normal
 Increased pulse pressure (>20 mm Hg)
 Urinary output of 1 to 2 mL/kg/hour (age
dependent)

51. RESPONSES
 Responses to fluid resuscitation:
 Most children will be stabilized by using crystalloid fluid only,
and blood is not required;
“responders.”
 Initial response to crystalloid fluid and blood, but then
deterioration occurs; this group is termed
“transient responders.”
 Do not respond at all to crystalloid fluid and blood infusion;
“nonresponders.”

53. The urine output goal:
 Infants is 1-2 mL/kg/hr;
 Children-- adolescence 1-1.5 mL/kg/hr;
 Teenagers 0.5mL/kg/hr.

54. THERMOREGULATION
 Due to high ratio of body surface area to body mass,
have increased heat exchange
 Increased evaporative heat loss with thin skin and less
subcutaneous tissue
 Children with burns particularly susceptible
 Hypothermia can worsen coagulopathy and adversely
affect neurologic function
 Use :- Overhead lamps , Thermal blankets , Heaters
 Warm :- Room , iv fluids and blood products , inhaled gases

55. CPR
SECENRIO RESULT
CPR in the field with ROSC before
arriving in the trauma center
approx. 50% chance of
neurologically intact survival.
Still ongoing CPR at trauma center uniformly dismal prognosis
CPR > 15 mins before arrival to
ED/fixed pupils
nonsurvivors

56. THORACIC TRAUMA
8% of injuries in children involve the chest
2/3 of children with chest injuries have multisystem
injuries
Mostly due to blunt mechanisms
 RTA
 Falls
Penetrating thoracic injury increases after 10 years
Tension pneumothorax – m/c immediate life threating
injury

57. PHYSIOLOGIC DIFFERENCES
 Less ossified bones in child make the chest wall more
compliant
 More force is transmitted to intrathoracic organs
 Can have serious intrathoracic trauma without much visible
damage to chest wall
 Increased mobility of mediastinum increases the risk of tension
physiology from pneumothorax or hemothorax

58. Types of Thoracic Injuries
 Injury to esophagus and great vessels - Posterior displacement
or dislocation of clavicle
 Pulmonary contusion - blunt trauma
 Rarely see diaphragmatic rupture, aortic transection,
tracheobronchial tears, flail chest, sternal fractures
 Life-threatening injuries are uncommon in children due to
fewer penetrating mechanisms

59. IMAGING
 Most chest injuries in children can be seen on chest x-
ray
 Chest CT:
 Not routinely used in children
 Lower incidence of cardiac and great vessel injury
 Obtain if have widened mediastinum or findings on plain
film are inconclusive
 Bedside ultrasound to evaluate for pericardial fluid

60. Management…..
 Supportive care or a chest tube if pneumothorax or hemothorax
present
 Thoracotomy not generally needed
 Indications for emergency department thoracotomy in children
similar to adults:
 Penetrating thoracic trauma that is hemodynamically unstable
 Signs of cardiac tamponade
 Thoracic or trauma surgeon available within 45 minutes

61. ABDOMINAL TRAUMA
 Most pediatric abdominal injuries result from bluntTrauma
 hypotensive children who sustain blunt or penetrating abdominal
trauma require prompt operative intervention
 Do not apply deep,painful palpation when beginning the
examination;this may cause voluntary guarding that can confuse
 Upper abdomen is distended on examination:-
 insert a gastric tube to decompress the stomach as part of
the resuscitation phase.

62.  shoulder- and/or lap-belt marks increases the likelihood that
intra-abdominal injuries are present.
 Decompression of the urinary bladder facilitates abdominal
evaluation.
 Since gastric dilation and a distended urinary bladder can both
cause abdominal tenderness.

63. DIAGNOSIS
CT scanning…..
 Rapid and precise identification of injuries.
 Used to evaluate the abdomens of children who have sustained
blunt trauma and have no hemodynamic abnormalities.
Fatal cancers are predicted to occur 1 in 1000
 Radiation must be kept As Low As Reasonably Achievable
(ALARA).
 Perform CT scans only when medically necessary, scan only
when the results will change management.
 scan only the area of interest, and use the lowest radiation
dose possible.

64.  FAST…..
 should not be relied upon as the sole diagnostic test
to rule out the presence of intra-abdominal injury.
 If a small amount of intra-abdominal fluid is found
hemodynamically normal, obtain a CT scan.
 Poor study for identifying intra-parenchymal injuries

65. DPL
Detect intra-abdominal bleeding in children
 Hemodynamic abnormalities
 Cannot be safely transported to the CT scan
 CT and FAST are not readily available
 Presence of blood will lead to immediate operative
intervention.
 10 ml/kg warmed crystalloid solution for the lavage.
 Diagnosing injuries to intra-abdominal viscera only,
retroperitoneal organs cannot be evaluated

66. NONOPERATIVE MANAGEMENT
 Selective, nonoperative management of solid organ
injuries done:-
 CT or FAST that is positive for blood alone who are
hemodynamically normal or stabilize rapidly with fluid
resuscitation.
 Facility with pediatric intensive care capabilities
 Supervision of a qualified surgeon
 Hemodynamically normal
 Angioembolization of solid organ injuries

67.  Emergency laparotomy to control hemorrhage : -
 Hemodynamic condition cannot be normalized
 Diagnostic procedure performed is positive for blood
 In resource-limited environments

68. HEAD TRAUMA
Mechanism:-
Motor vehicle crashes
Child abuse
Falls
Physiologic Differences of the Head :-
Brain size doubles in first 6 months of life, and by 2
years of age, brain is 80% of adult size
Smaller subarachnoid space results in less protection
With larger head and less protection lead to
parenchymal structural damage

69.  Cerebral blood flow is twice the amount of an adult by
5 years of age , susceptible to cerebral hypoxia and
hypercarbia
 In infants with open sutures and fontanelles, signs of
brain swelling may occur late, right before rapid
decompensation
 Outcome in children
 Better than that in adults.
 < 3 years of age is worse than that following a similar
injury in an older child.

70. ASSESSMENT
 Particularly susceptible to the effects of the secondary brain injury :-
 Hypotension from hypovolemia is the most serious single risk
factor
 Ensure adequate and rapid restoration of an appropriate
circulating blood volume
 Avoid hypoxia
 Infrequent hypotension can occur in infants following significant
blood loss into the subgaleal, intraventricular, or epidural spaces
 Treatment focuses on appropriate volume restoration.

71. An infant who is not in a coma but who has bulging fontanelles or
suture diastases should be assumed to have a more severe injury,
and early neurosurgical consultation is essential.
 More tolerance to mass lesion
 Vomiting and amnesia
 Common
 Persistent vomiting that becomes more frequent mandates CT of the
head.

72.  Impact seizures, or seizures that occur shortly after brain injury
 Common
 All seizure activity requires CT of the head.
 Elevated intracranial pressure due to brain swelling is more
common.
 Look for raised ICP
 Emergency CT is vital to identify children who require imminent
surgery.

73. GCS
 Useful in
evaluating
pediatric
patients
 Verbal score
component
must be
modified for
children
younger
than 4 years

74. MANAGEMENT
 Neurosurgical consultation to consider intracranial
pressure monitoring should be obtained early in the
course of resuscitation for children with
GCS score of 8 or less, or motor scores of 1 or 2
Multiple injuries associated with brain injury that require
major volume resuscitation, immediate lifesaving
thoracic or abdominal surgery, or for which stabilization
and assessment is prolonged;
CT scan of the brain that demonstrates evidence of brain
hemorrhage, cerebral swelling, or transtentorial or
cerebellar herniation.

75.  Medication dosages are determined by the child’s size and
in consultation with a neurosurgeon.
 Drugs often used:-
 3% hypertonic saline and mannitol to reduce intracranial
pressure
 Levetiracetam and Phenytoin for seizures.

79. SPINAL CORD INJURY
 Uncommon
 Only 5% of spinal cord injuries occur in the pediatric age group.
 Children younger than 10 years of age - motor vehicle crashes
10 to 14 years - motor vehicles and sporting
activities
 Anatomic differences :-
 Interspinous ligaments and joint capsules more flexible
 Vertebral bodies wedged anteriorly
 Large head of child means fulcrum is higher in the cervical
spine and higher injuries
 The facet joints are flat.
 Growth plates are not closed, and growth centers are not
completely formed.
 Forces applied to the upper neck are relatively greater than
in the adult.

80. RADIOLOGICAL
 Pseudosubluxation
40% of children < 7 years of age show anterior
displacement of C2 on C3
20% of children up to 16 years exhibit this phenomenon.
 When subluxation is seen on a lateral cervical spine x-ray
:-
Ensure the child’s head is in a neutral position by placing a
1-inch layer of padding beneath the entire body from
shoulders to hips and repeat the x-ray
True subluxation will not disappear with this maneuver and
mandates further evaluation.

81.  Cervical spine injury identified from :-
 Neurological examination findings
 Detection of an area of soft-tissue swelling
 Muscle spasm
 Step-off deformity on careful palpation of the posterior cervical spine
 Approximately 20% of young children:-
 Increased distance between the dens and the anterior arch of C1
 Basilar odontoid synchondrosis appears
 radiolucent area at the base of the dens
 younger than 5 years.

82.  . Apical odontoid epiphyses appear
 Separations on the odontoid x-ray
 5 and 11 years.
 Growth center of the spinous process can resemble fractures of the
tip of the spinous process.

83. C-spine Management
 Spinal cord injury without radiographic abnormalities
(SCIWORA) more common
 When in doubt about the integrity of the cervical spine or
spinal cord, assume that an unstable injury exists, limit spinal
motion and obtain appropriate consultation.
 Start with plain films of c-spine, unless patient unresponsive
and head CT will be done, then can obtain C-spine CT

84. Indications for the use of CT or MRI scans
 Inability to completely evaluate the cervical spine with plain films
Delineating abnormalities seen on plain films,
Neurologic findings on physical exam
Assessment of the spine in children with traumatic brain injuries
CT scan may not detect the ligamentous injuries that are
more common in children.

85. EXTREMITY TRAUMA
Can be difficult to diagnose in children :-
 Growth plates may be mistaken for fractures
 Fractures in growth plates may be difficult to see
 Different growth plates close at different times
 Typically growth stops 2 years after pubertal growth spurt completed
 History
 Magnitude, mechanism, and time of the injury facilitates better
correlation of the physical and x-ray findings
 Radiographic evidence of fractures of differing ages should alert
clinicians to possible child maltreatment
 Blood loss
 Blood loss associated with long bone and pelvic fractures is
proportionately less in children than in adults.
 Hemodynamic instability in the presence of an isolated femur
fracture should prompt evaluation for other sources of blood loss

86. Age and X-rays
 Upper humeral physis fuses around 20-22 years
 Distal femoral physis fuses at 14-16 years in girls and 16-18 years in
boys
 Proximal fibula epiphysis unites with diaphysis around 17 years
 Proximal tibia physis fuses around 13-15 years in girls and 15-19 years
in boys
 Injury to or around physis can lead to problems with growth
 Crush injuries to the growth plate have the worst prognosis
 Supracondylar fractures at elbow or knee are at high risk for vascular and
growth plate injury
 Immature bones are pliable
 Greenstick fracture: One side of the cortex still intact
 Torus (or Buckle) fracture

87. Management
 Fracture splinting
 Simple splinting of fractured extremities in children usually is
sufficient until definitive orthopedic evaluation can be performed.
 Injured extremities with evidence of vascular compromise require
emergency evaluation
 A single attempt to reduce the fracture to restore blood flow is
appropriate, followed by simple splinting or traction splinting of
the extremity.
PITFALL PREVENTION
Difficulty identifying fractures • Recognize the limitations of radiographs in
identifying injuries
especially at growth plates.
• Use the patient’s history, behavior, mechanism
of injury and physical
examination findings to develop an index of
suspicion.
Missed child maltreatment • Be suspicious when the mechanism and injury
are not aligned.

88. Non-Accidental Trauma: Special
Circumstances
 Non-accidental trauma, or child maltreatment accounts for
largest proportion of homicides in infants
 nonaccidental trauma have:-
 significantly higher injury severity
 sixfold higher mortality rate than children who sustain accidental
injuries.
 Recognizing Maltreatment :-
 Understand mechanisms of injury – discrepancy between history and
degree of injury or injury pattern
 Delayed seeking of care
 History of repeated trauma, multiple ED visits
 history of hospital or doctor “shopping.”

89. Concerning Physical Findings
Bruises in different stages of healing or of certain patterns
Fractures of different ages on x-ray
Injuries to genital or perianal area
Fractures of long bones in children < 3 yo
Classic metaphyseal lesions or bucket handle fractures
Multiple subdural hematomas
Retinal hemorrhages
Sharply demarcated 2nd or 3rd degree burns
Skull or rib fractures in children less than 2 years old
Intra-abdominal injury without history of trauma

90. PREVENTION
Mandatory
reporting to agencies
of maltreated children
The greatest pitfall
related to pediatric
trauma is failure to
have prevented the
child’s injuries in the
first place.

91. SUMMARY
o Unique characteristics of children , normal vital signs vary
significantly with age Initial assessment and management guided by
the ABCDE approach. Early involvement of a general surgeon or
pediatric surgeon
o Nonoperative management of abdominal visceral injuries should
be performed only by surgeons in facilities available
o Child maltreatment should be suspected if suggested by suspicious
findings on history or physical examination.
o Most childhood injuries are preventable . Doctors caring for injured
children have a special responsibility to promote the adoption of
effective injury prevention programs and practices within their
hospitals and communities.

92. THANK YOU