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Langcake on limb-threatening injuries


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The DFTB team are really excited to announce an upcoming video series…We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.


Sqaudron Leader Mary Langcake is an upper GI and trauma surgeon with a wealth of trauma experience based in St George Hospital, NSW.  In this lecture from 2013 she talks about limb-threatening injuries.


Here are some of the key takeaway points:

  • Severe limb-threatening trauma is rare so very few people have much experience outside the military.
  • The growing skeleton reacts differently to injury than that of an adult. Although bones may remodel to near perfect anatomical alignment the blood vessels are small and thin-walled and thus vulnerable to damage.
  • The smaller circulating volume of a child means a severe limb injury can lead to early shock.
  • These limb-threatening injuries might distract the trauma team from the basic ABC approach though management of catastrophic haemorrhage comes first.
  • Whilst direct pressure might help reduce some blood loss, tourniquets can be life and limb saving.
  • Damage control resuscitation in children involves restricted crystalloid use, early use of blood products and permissive hypotension (except in the setting of head injury).
  • Tranexamic acid should be considered in serious trauma in children.
  • Pulsed lavage may lead to worse outcomes and forced contamination of wounds so copious warm saline lavage is more appropriate.
  • Children may develop compartment syndrome with minimal external evidence of injury.
  • Consider compartment syndrome if the child appears anxious, agitated and requires far more analgesia than you would expect.
  • Multidisciplinary care is required to assess the viability of the limb as well as plan staged, operative management and rehabilitation.

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