The War Injured Child

Description:

Around 1 in 6 of the world’s children live in a conflict zone, and of these 357 million children, 165 million are affected by high intensity conflicts. Pediatric war injuries pose a huge challenge to health professionals treating such patients. The evidence base on the quality and scale of this challenge is scarce, and the majority of clinicians treating these patients are either not sufficiently experienced in the treatment of war injuries, are not pediatric surgeons, or both. The majority of the evidence in the literature comes from a small subset of children who were managed in well-resourced military facilities that differ drastically from the conditions in which the majority of war wounded children are treated.
This book – the first of its kind – is a comprehensive and state-of-the art guide for both local and humanitarian non-pediatric specialists who are often forced to operate on and treat children with war injuries with little or no previous experience or training. It provides healthcare workers in conflict settings with knowledge and practical advice on the entire continuum of care, from point of injury, to treatment and reconstruction, to rehabilitation and mental health support. It is comprised of concise yet comprehensive overviews of the current status of the pediatric war casualty patient treatment and will help guide patient management based on evidence from the literature, clinical and surgical experience and ongoing research and will stimulate investigative efforts in this dynamic and active field of war medicine.
The book draws on the knowledge and long experience of clinicians at the American University of Beirut Medical Center, one of the largest tertiary care and referral centers in the Middle East, which has been the foremost civilian academic hospital treating war injuries, both adult and pediatric, initially from the Lebanese war and then the Iraqi and Syrian wars.

Acknowledgments

This book represents an attempt to capture the wealth of expertise that has developed over the years within the American University of Beirut Medical Center in the treatment of children with war related and weapons inflicted injuries. My thanks go to everyone within that institution, which is the Middle East’s primary academic medical institution and the world’s leading civilian academic institution with such unique experience and expertise.

I would like to acknowledge the support given to this project by the Global Health Institute at the American University of Beirut, which is leading the way in undertaking and disseminating research on the clinical burden of war injuries. My gratitude also goes to the Center for Blast Injury Studies at Imperial College which supports collaborative research on war injuries through the ProTect project consortium and to the National Institute for Health Research (UK) which has been funding these international research partnerships looking at the complex relationship between protracted conflict and health. I am grateful to the UK charity Save The Children which was the first to highlight the need for more clinical data on pediatric war injuries and launched the Pediatric Blast Injury Network that continues to work on improving outcome in pediatric war injuries.

The partnership forged between the Department of Surgery at the AUBMC and the charity the International Network for Aid Relief and Assistance (INARA) and the United Nations Children’s Fund (UNICEF) to set up the Pediatric War Injuries Program at the Division of Plastic and Reconstructive Surgery was a critical step towards developing a multidisciplinary approach to the treatment of these injuries.

My personal gratitude goes to Dean Mohammed Sayegh (Raja N. Khuri Dean of the Faculty of Medicine and Executive Vice President of Medicine and Global Strategy at the American University of Beirut (AUB) from 2009 to 2020) for his support and encouragement in developing the field of Conflict Medicine at the AUBMC and to my friend and colleague Dr. Imad Kaddoura who was my strongest supporter and ally in developing these projects and partnerships. Most of all my heartfelt thanks and enduring gratitude to Professor Jamal Hoballah, Head of the Department of Surgery at the AUBMC for agreeing to co-edit this book but most importantly for spearheading the initiative to develop the AUBMC into an academic center of excellence in the management of war injuries and in particular in children.

My deep appreciation goes out to all the books’ contributors for their hard work and patience. It also goes out to Dr. Ismael Soboh and Dr. Theresa Farahat who helped me edit this book.

But most of all, I will be forever grateful to and in awe of the children whom I have treated over the past 25 years in wars not only in Lebanon, but also in Palestine (Gaza Strip), Iraq, Syria, and Yemen. They continue to inspire me in both my work and my daily life.

Ghassan Soleiman Abu-Sittah MBcHB FRCS(Plast)

Associate Professor of Surgery

Plastic, Reconstructive and Aesthetic Surgeon

Honorary Senior Lecturer, Center for Blast Injury Studies, Imperial College London University

Visiting Senior Lecturer, Conflict & Health Research Group, Faculty of Life Sciences and Medicine, King’s College London University

Director, Conflict Medicine Program, Global Health Institute, American University of Beirut

Clinical Lead, Trauma Advisory & Operational Team, WHO-EMRO

Table of contents :

Acknowledgments
Contents
Part I: Introduction
1: The Epidemiology of the Pediatric War Injuries
1.1 Introduction
1.2 Public Health Consequences of Armed Conflict on Children
1.2.1 Geographical Spread of Children Living in Conflict Zones
1.2.2 Historical Overview
1.2.3 The Public Health Effects of Social Disruption
1.2.4 The Burden of War Wounded Children
1.2.5 Six Grave Violations
1.3 Global Epidemiology of War Injured Children
1.3.1 Blunt Injuries and Penetrating GSWs
1.3.2 Blast and Landmine Injuries
1.4 Anatomic Distribution
1.4.1 Thermal Injuries
1.4.2 Head and Spinal Injuries
1.4.3 Torso Injuries
1.4.4 Extremity Injuries
1.4.5 Ophthalmologic and Otology Injuries
1.5 Conclusion
1.5.1 Lessons to Be Gained from the Study of Epidemiology
References
2: Biodynamics of Blast Injury
2.1 Introduction
2.2 Explosive Blasts
2.3 Blast Injury Mechanisms
2.3.1 Primary Blast Injury
2.3.2 Secondary Blast Injury
2.3.3 Tertiary Blast Injury
2.3.4 Quaternary Blast Injuries
2.4 Blast Injury Characteristics in the Pediatric Population
2.5 Injury-Specific Considerations in Pediatrics
2.5.1 Thermal Burns
2.5.2 Extremity Injuries
2.5.3 Torso Injuries
2.5.4 Head and Spinal Injuries
2.5.5 Facial Injuries
2.5.6 Maxillary Sinus Fracture
2.5.7 Mandibular Fracture
2.5.8 Acoustic Injury
2.5.9 Eye Injury
References
3: Physiologic Considerations in Pediatric Population
3.1 Introduction
3.2 Anatomy and Physiology
3.2.1 Developmental Milestones: Step by Step
3.2.2 Body Habitus: Size, Shape, and Surface Area
3.2.3 Hemodynamic Considerations
3.2.4 Approach to Pediatric Trauma: What Is Different?!
3.3 Assessment
3.4 Treatment
3.4.1 Equipment
3.4.2 Pediatric Doses and Side Effects
3.4.3 Interventions
References
Part II: Acute Management
4: Resuscitation and Critical Care of the Injured Child
4.1 Introduction
4.2 Hypovolemic Shock
4.2.1 Definition and Etiology
4.3 Management
4.3.1 Venous Access
4.3.2 Fluid Resuscitation
4.3.3 Non-hemorrhagic Shock
4.3.4 Additional Considerations
4.4 Special Population
4.5 Obstructive Shock
4.5.1 Cardiac Tamponade
4.5.2 Tension Pneumothorax or Hemothorax
4.6 Neurogenic Shock: Spinal Cord Injury
4.7 In Summary (Fig. 4.2)
References
5: Nursing Management for War Injured Child
5.1 Introduction
5.2 Triage in War Zones
5.3 Emergency Signs in Pediatric Patients
5.4 Primary and Secondary Assessments
5.4.1 Primary Assessment
5.4.2 Secondary Assessment
5.5 Nursing Assessment and Management
5.5.1 Musculoskeletal Trauma
5.5.2 Cardiothoracic Trauma
5.5.3 Abdominal Trauma
5.5.4 Traumatic Brain Injury (TBI)
5.5.5 Spinal Cord Trauma
5.6 Age-Specific Consideration in Medication Administration
References
6: Airway Management in the War-Injured Child
6.1 Introduction
6.2 Anatomical and Physiological Considerations
6.2.1 Airway Anatomy
6.2.2 Physiological Considerations
6.3 Considerations in the Emergent Airway Management
6.3.1 Rapid Sequence Intubation
6.3.2 Preoxygenation
6.4 The Difficult Airway
6.4.1 Mask Ventilation
6.4.2 Supraglottic Airway Devices (SGA)
6.4.3 Direct Laryngoscopy
6.4.4 Video Laryngoscope
6.4.5 The Flexible Fiberoptic
6.4.6 Rescue Ventilation Using the Endotracheal Tube
6.4.7 Surgical Airway
6.5 Conclusion
References
7: Abdominal Injuries
7.1 Introduction
7.2 Initial Assessment and Triage
7.2.1 CABC Paradigm
7.2.2 Catastrophic Bleeding
7.2.3 Airway
7.2.4 Breathing
7.2.5 Circulation
7.2.6 Disability
7.2.7 Exposure and Environment
7.2.8 Scoring Systems
7.3 Adjuncts to Primary Survey
7.3.1 Role of FAST in Children
7.3.2 Role of DPL
7.3.3 Intravenous Access
7.3.4 Central Line Access
7.3.5 Laboratory Tests
7.4 Secondary Survey
7.5 Damage Control Resuscitation
7.6 Damage Control Surgery
7.7 Surgical Approach and Consideration for each Organ
7.7.1 Stomach
7.7.2 Diaphragmatic Injuries
7.7.3 Duodenal Injuries
7.7.4 Small Intestine
7.7.5 Colon and Rectal Injuries
7.7.6 Spleen
7.7.7 Liver
7.7.8 Pancreas
7.7.9 Adrenal
7.7.10 Kidney
7.7.11 Bladder
7.8 Conclusion
References
8: Management of Pediatric Vascular Injuries in Blasts
8.1 Introduction
8.2 Epidemiology and Anatomical Distribution of Vascular Injuries
8.3 Types of Vascular Trauma
8.4 Emergency Care
8.5 Diagnosing and Surgical Decision-Making
8.6 Management of Vascular Injuries
8.6.1 Venous Injuries
8.6.2 Arterial Injuries
8.7 Conclusion
References
9: Acute Pediatric Burn Management
9.1 Introduction
9.2 Physiological Differences
9.2.1 Airway
9.2.2 Breathing
9.2.3 Circulation
9.2.4 Neurologic
9.2.5 Skin
9.3 Burn Evaluation
9.3.1 Degree of Burns
9.3.2 Extent Evaluation
9.3.2.1 Rule of Nines
9.3.2.2 Lund and Browder Chart
9.3.2.3 Palmar Surface
9.4 Acute Management
9.4.1 Fluid Resuscitation
9.4.2 Inhalational Injuries
9.4.3 Carbon Monoxide Poisoning
9.4.4 Glycemic Control
9.4.5 Antibiotics
9.4.6 Beta-Blockers
9.4.7 Testosterone
9.4.8 Escharotomy
9.4.9 Early Excision
9.4.10 Nutritional Support
9.5 Conclusion
References
10: Head Trauma in the Pediatric Population
10.1 Introduction
10.2 Mechanisms of Injury
10.3 Imaging
10.4 Treatment: Medical
10.5 ICP Monitoring
10.6 Cerebral Perfusion Pressure
10.7 Temperature Control
10.8 Hyperosmolar Therapy
10.9 Anticonvulsants
10.10 Corticosteroids
10.11 Treatment: Surgical-Decompressive Craniectomy
10.12 Prevention, Future Considerations, and Conclusion
10.13 Case Illustration
References
Part III: Reconstruction and Rehabilitation
11: Management of Soft Tissue Defects in the Limbs
11.1 Introduction
11.2 Epidemiology
11.3 Challenges
11.4 Idiosyncrasies of Modern Combat Trauma
11.5 Timing
11.6 Polytrauma
11.7 Pre-operative Evaluation
11.8 Algorithm
11.9 Adjunct Therapy
11.10 Flap Selection
11.11 Complex Reconstruction
11.11.1 Vascular Injury
11.11.2 Bone Defects
11.12 Amputation
References
12: The Role of Microsurgery in Pediatric War Injuries
12.1 Introduction
12.2 Location of the Defect
12.2.1 Upper Extremity
12.2.2 Lower Extremity
12.2.3 Head and Neck
12.2.4 Thorax and Abdomen
12.3 Timing of Reconstruction
12.4 Choice of Flap
12.4.1 Myocutaneous Flaps
12.4.2 Fasciocutaneous Flaps
12.4.3 Perforator Flaps
12.4.4 Bone Flaps and Physeal Transfer
12.5 Radiographic Evaluation
12.6 Vessel Size and Vasospasm
12.7 Anesthesia Time
12.8 Flap Outcomes
12.9 Postoperative Anticoagulation
12.10 Complications
12.10.1 Early Complications
12.10.2 Late Complications
12.11 Special Consideration: Below the Age of 2 Years
References
13: Management and Reconstruction of Long Bone Fractures
13.1 Introduction
13.1.1 Background
13.1.2 Epidemiology
13.1.3 Mechanism
13.2 Special Considerations in the Pediatric Population
13.2.1 Caregiver Influence
13.2.2 Growth
13.2.3 Remodeling and Regeneration
13.3 Management
13.3.1 Closed Fractures
13.3.2 Blast Injuries
13.3.3 Gunshot Injuries
13.3.4 Salvage Procedures
13.3.5 Amputation
13.3.6 Rehabilitation Management
13.4 Conclusion
References
14: Reconstruction of Pediatric Craniomaxillofacial Injuries
14.1 Introduction
14.2 Mechanisms of Injury
14.3 Comparative and Developmental Anatomy in the Pediatric Patient
14.4 Injury Site
14.5 Emergency Management
14.6 Physical Examination
14.7 Imaging Evaluation
14.8 Pediatric Facial Fracture Management
14.8.1 Frontal Bone Injury
14.8.2 Orbital Fractures
14.8.3 Nasal and Nasoethmoid Fractures
14.8.4 Midface and Zygomticomaxillary Complex Fractures
14.8.5 Mandible
14.9 Soft Tissue Injuries
14.10 Complications
14.11 Long-Term Follow-Up
References
15: War-Related Amputations and Prostheses in the Pediatric Population
15.1 Introduction
15.2 Epidemiology
15.3 History
15.4 Primary Amputation Versus Limb Salvage
15.4.1 Objective Scoring Systems
15.4.2 Functional Outcomes
15.5 Level of Amputation
15.6 Transtibial Amputation
15.7 Surgical Technique
15.8 Anatomic and Physiologic Considerations in the Pediatric Patient
15.8.1 Bone Growth
15.8.2 Stump Length
15.8.3 Tissue Coverage
15.8.4 Stump Overgrowth
15.9 Prostheses
15.9.1 The Socket
15.9.2 The Suspension System
15.9.3 The Pylon
15.9.4 The Terminal Section
15.9.5 The Hand
15.9.6 The Foot
15.9.7 Power Source
References
16: Rehabilitation of the War Injured Child
16.1 Chapter Text
16.2 Outcomes After War-Related Trauma to Children
16.3 Medical Therapy
16.4 Physical Therapy
16.5 Pain Management
16.6 Scar Management
16.7 Transition to Outpatient Rehabilitation
References
17: The Microbiology of War Wounds
17.1 Introduction
17.2 Pediatric Pathophysiology of Wound Infection
17.3 Diagnosis of Infection
17.4 Bacterial Contaminants of Pediatric War Wounds
17.5 Antimicrobial Resistance
17.6 Antibiotic Prophylaxis and Management of War-Related Injuries
17.7 Major Clinical War Wound Infections in Pediatrics
17.8 Complications of Wound Infections
17.9 Conclusion
References
18: The Invisible Wounds: Mental Health Support for the War Injured Children
18.1 Background and Epidemiology
18.2 Impact of War on Children’s Mental Health
18.2.1 Stressors and Resilience
18.2.2 War and Psychopathology in Children and Adolescents
18.2.3 A complex Interplay of Factors That Perpetuate Psychological Suffering
18.3 Special Considerations in the Assessment of Children and Adolescents Exposed to War Trauma.
18.4 The Interplay Between Direct Physical Injuries, Pain, and Mental Health
18.5 Interventions for Recovery from War Trauma Among Children and Adolescents
18.5.1 Encounter with the Trauma-Affected Child or Adolescent
18.5.2 Evidence-Based Approaches for Treating War-Affected Children and Adolescents
18.6 Conclusion
References
Index