When Doctors Warn about Vaccine Risk they are Harassed and Ruined

H1N1, Vaccines & You: Toxic Ingredients & how to Protect you & your family from the Flu

More govt propaganda about 30K – 90K deaths coming this fall to the U.S. via H1N1 http://www.usatoday.com/news/health/2… but remember this is coming from obama’s ‘advisers’ who havent been right yet &/or think its a good thing that ppl die (population control).

Do you really know what the ingredients are in a vaccine & what they do? Are they dangerous? Toxic? Do they have any long term health problems associated with them? Well watch and see.

Here is a list of the articles where I referenced info from…

Swine flu vaccine tested on children
http://www.myfoxdc.com/dpp/news/local…

Thimerosal, organic mercury, swine flu and you.
http://www.examiner.com/x-17373-Phoen…

Squalene: The Swine Flu Vaccines Dirty Little Secret Exposed
http://blogs.mercola.com/sites/vitalv…

Swine flu vaccine linked to deadly nerve disease
http://sayanythingblog.com/readers/en…

Swine flu jab link to killer nerve disease: Leaked letter reveals concern of neurologists over 25 deaths in America
http://www.dailymail.co.uk/news/artic…

Setting the people up to die: A conspiracy of silence about swine flu natural remedies
http://www.examiner.com/x-6012-State-…

Epidemic Influenza And Vitamin D
http://www.medicalnewstoday.com/artic…

Flu Vaccine Exposed: Think Twice!
http://www.youtube.com/watch?v=zCBlxq…

Vitamin D from Wikipedia
http://en.wikipedia.org/wiki/Vitamin_D

PEOPLE ITS TIME TO WAKE UP!

STOP THE CHANGE NOW!

Dr Robert Mendelsohn, M.D. Quotes

“One grandmother is worth two M.D.s.” —Robert Mendelsohn, M.D.

“The greatest threat of childhood diseases lies in the dangerous and ineffectual efforts made to prevent them through mass immunization…..There is no convincing scientific evidence that mass inoculations can be credited with eliminating any childhood disease.”–Dr Robert Mendelsohn, M.D.

“Despite the tendency of doctors to call modern medicine an ‘inexact science’, it is more accurate to say there is practically no science in modern medicine at all. Almost everything doctors do is based on a conjecture, a guess, a clinical impression, a whim, a hope, a wish, an opinion or a belief. In short, everything they do is based on anything but solid scientific evidence. Thus, medicine is not a science at all, but a belief system. Beliefs are held by every religion, including the Religion of Modern Medicine.” Robert Mendelsohn MD Preface by Hans Ruesch to 1000 Doctors (and many more) Against Vivisection

“Today your child has about as much chance of contracting diphtheria as he does of being bitten by a cobra.”–Dr Robert Mendelsohn MD

“Robert Mendelsohn had a rule: “You never hear about the dangers of a drug unless another drug to replace it is available.”–Ted Koren DC

“Modern Medicine would rather you die using its remedies than live by using what physicians call quackery”.–Dr Robert Mendelsohn, M.D.

“With the polio vaccine we are witnessing a rerun of the medical reluctance to abandon the smallpox vaccination, which remained as the only source of smallpox-related deaths for three decades after the disease had disappeared. Think of it! For thirty years kids died from smallpox vaccinations even though no longer threatened by the disease.”—-Dr Robert Mendelsohn, M.D.

“The pediatrician’s wanton prescription of powerful drugs indoctrinates children from birth with the philosophy of ‘a pill for every ill’.”… “Doctors are directly responsible for hooking millions of people on prescription drugs. They are also indirectly responsible for the plight of millions more who turn to illegal drugs because they were taught at an early age that drugs can cure anything – including psychological and emotional conditions – that ails them. ” – Robert S. Mendelsohn, M.D., How to Raise a Healthy Child…In Spite of Your Doctor.

“Being a skeptical soul, I have always believed that the most reliable way to determine what people really believe is to observe what they do, not what they say. If the greatest threat of rubella is not to children, but to the fetus yet unborn, pregnant women should be protected against rubella by making certain that their obstetricians won’t give them the disease. Yet, in a California survey reported in the Journal of the American Medical Association, more than 90 percent of the obstetrician-gynecologists refused to be vaccinated. If doctors themselves are afraid of the vaccine, why on earth should the law require that you and other parents allow them to administer it to your kids?”–Dr Mendelsohn MD

“Doctors maintain that the (MMR) inoculation is necessary to prevent measles encephalitis, which they say occurs about once in 1,000 cases. After decades of experience with measles, I question this statistic, and so do many other pediatricians. The incidence of 1/1,000 may be accurate for children who live in conditions of poverty and malnutrition, but in the middle-and upper-income brackets, if one excludes simple sleepiness from the measles itself, the incidence of true encephalitis is probably more like 1/10,000 or 1/100,000.”——Dr Mendelsohn

“I would consider the risks associated with measles vaccination unacceptable even if there were convincing evidence that the vaccine works. There isn’t. While there has been a decline in the incidence of the disease, it began long before the vaccine was introduced. In 1958 there were about 800,000 cases of measles in the United States, but by 1962-the year before a vaccine appeared-the number of cases had dropped by 300,000. During the next four years, while children were being vaccinated with an ineffective and now abandoned “killed virus” vaccine, the number of cases dropped another 300,000. In 1900 there were 13.3 measles deaths per 100,000 population. By 1955, before the first measles shot, the death rate had declined 97.7 percent to only 0.03 deaths per 100,000.”–Dr Mendelsohn MD

“There are significant risks associated with every immunization and numerous contraindictions that may make it dangerous for the shots to be given to your child….There is growing suspicion that immunization against relatively harmless childhood diseases may be responsible for the dramatic increase in autoimmune diseases since mass inoculations were introduced. These are fearful diseases such as cancer, leukemia, rheumatoid arthritis, multiple sclerosis, Lou Gehrig’s disease, lupus erthematosus, and the Guillain-Barre syndrome.” Dr Mendelsohn, M.D.

“Did you know that the whooping cough germ, Bacillus pertussis, when injected into animals, has long been known to lead to the secretion of insulin? In 1979, at the Fourth International Symposium on Pertussis, held in Bethesda, Maryland, it was shown that this same result occurs in those who have received pertussis vaccine. In their publication, “Adverse Reactions after Pertussis Vaccination,” Drs. W. Hennessen and U. Quast suggest, “It seemed of interest to examine these reactions in comparison with the hypoglycemia syndrome.. . .There was a close relation between the two.’ If your child has juvenile diabetes (a disease characterized by wide swings in blood sugar levels), ask your doctor if he has ever heard of this effect of whooping cough vaccine. Maybe it’s time to investigate whether the pertussis vaccine has anything to do with the rapidly rising number of people with juvenile diabetes, adult diabetes, and hypoglycemic all disorders of insulin metabolism.”—Dr Mendelsohn MD (the Peoples Doctor Vol 6 No10)

“Study after study has demonstrated that many women immunized against rubella as children lack evidence of immunity in blood tests given during their adolescent years. Other tests have shown a high vaccine failure rate in children given rubella, measles, and mumps shots, either separately or in combined form.”—Dr Mendelsohn

“Because routine immunizations that bring parents back for repeated office calls are the bread and butter of their specialty, pediatricians continue to defend them to the death. The question parents should be asking is: ‘Whose death?’” —–Robert Mendelsohn, MD

“For a pediatrician to attack what has become the “bread and butter” of pediatric practice is equivalent to a priest denying the infallibility of the pope.——-Dr Robert Mendelsohn, M.D.

“I’m reminded of a debate the famous pediatrician Robert Mendelsohn, MD had with a psychiatrist. The panelist asked them about the Family Bed (everyone sleeping together). “It’s a terrible idea,” said the psychiatrist. “I’d never sleep with my children. It fosters dependency, it confuses them sexually, it’s just plain wrong.” The moderator asked if Dr. Mendelsohn would care to respond. “I agree with the psychiatrist,” said Dr. Mendelsohn. “Psychiatrists should not sleep with their children. But for everyone else, it’s just wonderful. I gives infants the warmth and security they seek. It enhances emotional health and it brings the family closer.”–Ted Koren DC

Medical students are further softened up by being maliciously fatigued. The way to weaken a person’s will in order to mold him to suit your purposes is to make him work hard, especially at night, and never give him a chance to recover. You teach the rat to race. The result is a person too weak to resist the most debilitating instrument medical school uses on its students: fear.
If I had to characterize doctors, I would say their major psychological attribute is fear. They have a drive to achieve security-plus that’s never satisfied because of all the fear that’s drummed into them in medical school: fear of failure, fear of missing a diagnosis, fear of malpractice, fear of remarks by their peers, fear that they’ll have to find honest work. There was a movie some time ago that opened with a marathon dance contest. After a certain length of time all the contestants were eliminated except one. Everybody had to fail except the winner. That’s what medical school has become. Since everybody can’t win, everybody suffers from a loss of self-esteem. Everybody comes out of medical school feeling bad.
Doctors are given one reward for swallowing the fear pill so willingly and for sacrificing the healing instincts and human emotions that might help their practice: arrogance. To hide their fear, they’re taught to adopt the authoritarian attitude and demeanor of their professors. Confessions of a Medical Heretic

“Doctors turn out to be dishonest, corrupt, unethical, sick, poorly educated, and downright stupid more often than the rest of society. When I meet a doctor, I generally figure I’m meeting a person who is narrowminded, prejudiced, and fairly incapable of reasoning and deliberation. Few of the doctors I meet prove my prediction wrong.”

“The admission tests and policies of medical schools virtually guarantee that the students who get in will make poor doctors. The quantitative tests, the Medical College Admission Test, and the reliance on grade point averages funnel through a certain type of personality who is unable and unwilling to communicate with people.” “Medical school does its best to turn smart students stupid, honest students corrupt and healthy students sick. It isn’t very hard to turn a smart student into a stupid one. First of all, the admissions people make sure the professors will get weak-willed, authority-abiding students to work on. Then they give them a curriculum that is absolutely meaningless as far as healing or health are concerned.”

“I don’t advise anyone who has no symptoms to go to the doctor for a physical examination. For people with symptoms, it’s not such a good idea, either. The entire diagnostic procedure — from the moment you enter the office to the moment you leave clutching a prescription or a referral appointment — is a seldom useful ritual.”

“Almost every stage of obstetrical procedure in the hospital is part of the mechanism that enables the doctor to create his own pathology.”

“The door to the doctor’s office ought to bear a surgeon general’s warning that routine physical examinations are dangerous to your health. Why? Because doctors do not see themselves as guardians of health, and they have learned precious little about how to assure it. Instead, they are latter-day Don Quixotes, battling sometimes real but too often imaginary diseases. The disastrous difference is that doctors are not tilting at windmills. Rather, it is people who are damaged by their insistent search for dubious diseases to conquer.”

“The greatest threat of childhood diseases lies in the dangerous and ineffectual efforts made to prevent them through mass immunization…..There is no convincing scientific evidence that mass inoculations can be credited with eliminating any childhood disease.”

What does a Catholic do when he decides that his priests are no good? Sometimes he directly challenges them, but very seldom. He just leaves the Church. And that’s my answer. Leave the Church of Modern Medicine. I see a lot of people doing that today. I see a lot of people going to chiropractors, for example, who wouldn’t have been caught dead in a chiropractor’s office a few years ago. Confessions of a Medical Heretic

Vaccines: What CDC Documents and Science Reveal (DVD)

Dr. Joseph Mercola, founder of mercola.com

“… this DVD by one of the world’s leading vaccine experts is a ‘must-see’!”

Nicholas Regush, editor of Redflagsdaily.com

“…a major force in the detailed analysis of vaccine safety and efficacy issues. A premier researcher and educator!”

Dr. Tedd Koren, korenpublications.com

“Dr. Tenpenny is a gifted educator. This DVD is one that all parents facing the vaccination question NEED to watch!”

Doris J. Rapp, MD, Author of

“…a voice parents need to hear when making informed decisions about vaccines. No one does it better!”

About the Actor

Sherri J. Tenpenny, D.O. is the President and Medical Director of OsteomedII, a clinic near Cleveland, Ohio providing integrative medicine, and Director of New Medical Awareness Seminars. Dr. Tenpenny is a graduate of the University of Toledo and is Board Certified in Emergency Medicine and Osteopathic Manipulative Medicine.

Book Review "The Virus and the Vaccine: Contaminated Vaccine, Deadly Cancers, and Government Neglect"

gBook Review

Past tragedies caused by “miracle drugs” have taught the public to approach cures with caution, and vaccines, in particular, have come under public scrutiny. In The Virus and the Vaccine, journalists Debbie Bookchin and Jim Schumacher uncover the true tale of the polio vaccine and its past and present dangers. Like many medical detective stories before it, this book starts with a chilling anecdote, then flashes back to slowly set the stage for disaster. Baby boomers who only know Jonas Salk and his virus-fighting colleagues as heroes will be disturbed at how some of them downplayed concerns about a monkey virus called SV40 that was present in the polio vaccine. The links between SV40 and human cancer took a long time to define, and breakthroughs in molecular biology made the job more realistic in later decades. Nevertheless, Bookchin and Schumacher argue that a biased scientific bureaucracy in combination with a desperate public and money-hungry pharmaceutical! companies fostered the use of a vaccine that may have increased cancer risk. “The vast majority of baby boomers–almost all of whom received polio vaccine in the late 1950s and early 1960s–have potentially been exposed to the virus,” they write. But baby boomers aren’t the only ones at risk. The authors reveal that Lederle Laboratories continued to produce potentially contaminated oral polio vaccines well into the 1990s. Although the authors point fingers of blame at some specific targets, they carefully balance their accusations with reminders that public demands for cures must be balanced with careful assessment of new medical treatments. –Therese Littleton –This text refers to an out of print or unavailable edition of this title.

From Publishers Weekly

Journalists Bookchin and Schumacher argue that for nine years, from 1954 to 1963, almost every dose of polio vaccine produced in the world—and the 98 million Americans who received polio vaccinations—was contaminated with a cancer-causing virus from the monkey kidneys used to develop the vaccine. Although the polio vaccine developed by Dr. Jonas Salk virtually ended polio as a threatening disease, the authors detail how “the screening techniques and observation periods that Salk and the vaccine manufacturers employed were not capable of always catching the contaminants.” This sordid story spells out how repeated research studies showing that the “SV40” virus was in the vaccine were dismissed by federal health officials, so that “there would be no warning to consumers that the vaccine they and their children were receiving contained a live monkey virus whose effect on humans was entirely unknown.” In the second part, the authors contend that even today such organizations as the National Institutes of Health continue to dismiss study results, even though numerous studies have shown that SV40 is capable of causing cancer in humans. The final and most horrific part of the story reports that Lederle Laboratories, the sole oral vaccine supplier in the U.S. from 1977 onward, continued to use monkey kidneys possibly infected by the SV40 virus in its manufacturing process until oral polio vaccine was removed from the market as late as January 2000. This meticulously researched, levelheaded and well-written book should stir up considerable debate. Because the authors never become alarmist, this solid work of investigative reporting carries considerable weight, and deserves to be read by a large audience.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. –This text refers to an out of print or unavailable edition of this title.

From Booklist

*Starred Review* Imagine being snatched from the paralyzing jaws of polio, only to be blindsided later by the mysterious appearance of a lymphoma, mesothelioma, or brain or bone cancer that could have been prevented. According to journalists Bookchin and Schumacher, the mightiest salvo in the U.S. war against polio seems to have been contaminated with a carcinogenic virus. What’s worse, efforts within the scientific community to prevent dispensing contaminated vaccines have been systematically stonewalled from the very beginning by nothing less than the federal government, which first denied the vaccine was contaminated and then denied that the viral contaminant causes cancer in humans–a denial it continues to make. Bookchin and Schumacher document dozens of independent studies and experiments that repeatedly link SV40, a virus imbedded in the monkey kidneys that were used as a polio vaccine medium, with the above-mentioned cancers. In a page-turning narrative, they recall a nation terrorized by polio, the scramble to find a preventive or cure, and how a federal initiative led to the immunization of millions of American schoolchildren with either Salk’s or Sabin’s vaccine, neither of which, apparently, was resistant to SV40. Bookchin and Schumacher name names, which may bring them not only more keenly interested readers but also enemies from among the medical elite. Donna Chavez
Copyright © American Library Association. All rights reserved –This text refers to an out of print or unavailable edition of this title.

Product Description

‘This well-researched, well-documented book unfurls a compelling scientific saga…written with the zing of a medical thriller.’-The atlanta Journal-Constitution A gripping medical detective story, this book raises major ques-tions about vaccine safety and regulation and shows how power, politics, and prejudice influence the health policy decisions that affect our lives. Jonas Salk’s polio vaccine is regarded as a verit-able medical miracle, for it largely eradicated one of the most feared diseases of the twentieth century. But the story of the vaccine has a dark side that has never been fully told before. Between 1954 and 1963, some 98 million Americans received polio vaccinations contaminated with a carcinogenic monkey virus, known as SV40. The government downplayed the incident, and it was generally accepted that although oncogenic to lab animals, SV40 was harmless to humans. But now SV40 is showing up in human cancers, and prominent researchers are demanding a serious public health response to this forgotten polio vaccine contaminant.

From the Inside Flap

“This well-researched, well-documented book unfurls a compelling scientific saga….Not only that, it’s written with the zing of a medical thriller, featuring fully realized characters, dramatic conflicts, high-level politics and scientific egos big enough to levitate Stone Mountain.”
Atlanta Journal-Constitution
“This meticulously researched, levelheaded and well-written book should stir up considerable debate. Because the authors never became alarmist, this solid work of investigative reporting carries considerable weight, and deserves to be read by a large audience.”
Publishers Weekly
“Powerful and emotive, the book captures the joy of scientific discovery—from the dramatic fight against polio to the thrill of basic virology—with the tone of a mystery thriller.”
–Dr. Norman J. Maitland, professor of molecular biology, director of the YCR Cancer Research Unit, University of York
“A beautifully-told tale of science and a fascinating piece of medical history.  The Virus and the Vaccine reveals how science can be distorted, pushed and pulled by the pressures of politics and profits.”
–Dr. David Himmelstein, associate professor of medicine, Harvard Medical School
“Millions of Americans are unaware that government officials and leading scientists played Russian roulette with their health in the 1960s…[This] fascinating, meticulously-researched account of the coverup, and its possible long-term health effects, is a deeply disturbing chapter in the recent history of science.”
–Stephen S. Hall, New York Times Magazine science writer and author of Merchants of Immortality

From the Back Cover

The Virus and the Vaccine has its share of heroes and villains, like any good novel-except that this is not fiction. Powerful and emotive, the book captures the joy of scientific discovery-from the dramatic fight against polio to the thrill of basic virology-with the tone of a mystery thriller. It offers an inside look at how scientific thinking evolves and how scientists must struggle to overcome established dogmas.”
– Dr. Norman J. Maitland, Professor of Molecular Biology, Director of YCR Cancer Research Unit, University of York

“A beautifully-told tale of science and a fascinating piece of medical history. The Virus and the Vaccine reveals how science can be distorted, pushed and pulled by the pressures of politics and profits.”
– Dr. David Himmelstein, Associate Professor of Medicine, Harvard Medical School

“Millions of Americans are unaware that government officials and leading scientists played Russian roulette with their health in the 1960s after discovering that the original polio vaccines were contaminated with a cancer-causing monkey virus. Debbie Bookchin and Jim Schumacher’s fascinating, meticulously-researched account of the coverup, and its possible long-term health effects, is a deeply disturbing chapter in the recent history of science.”
– Stephen S. Hall, New York Times Magazine science writer and author of Merchants of Immortality
–This text refers to an out of print or unavailable edition of this title.

About the Author

Debbie Bookchin has been a journalist since 1979 and has won awards for her news, feature and investigative reporting.  She has written for The Boston Globe, The Nation, The New York Times, and numerous other publications.
Jim Schumacher is a lawyer and writer whose work has appeared in Boston Magazine, Newsday, and The Atlantic Monthly, among others.  Bookchin and Schumacher are married to each other and live in Vermont with their daughter.
The article on which this book is based was originally published in The Atlantic Monthly in 2000 and earned a selection in the HarperCollins book Best Science Writing 2001.

Recommended Readings List (Part 1)

The Vaccine Injury Program

U.S. Congress passed the National Childhood Vaccine Injury Act in 1986 and the Vaccine Compensation Amendments in 1987 and 1995. The Act establishes a compensation system for those persons who may be injured by routine vaccinations. The system is intended to be expeditious and fair. It is also intended to compensate persons with vaccine injuries without requiring the difficult individual determination of causation of injury and without a demonstration that a manufacturer was negligent or that a vaccine was defective H.R. Rep. 99-908, 99th Cong., (1986).

The Process

A claim may be made for any injury or death thought to be the result of a covered vaccine. Claims may be filed by the injured individual; or a parent, legal guardian, or trustee may file on behalf of a child or an incapacitated person. Compensable injuries are either those listed in the Vaccine Injury Table, which is found in the Code of Federal Regulations, Section 2114 of the Act, or those which petitioners can demonstrate were caused by the vaccine.

The Program is administered jointly by the Department of Health and Human Services (HHS), the U.S. Court of Federal Claims (the Court), and the Department of Justice (DOJ). The process is as follows:

First, if there is a reasonable basis for the claim, Conway, Homer & Chin-Caplan, P.C. will file a petition for compensation with the Court. Next, a physician at the Division of Vaccine Injury Compensation, HHS, reviews each petition to determine whether it meets the criteria for compensation and makes a recommendation on compensability. This recommendation is provided to the Court through a report filed by DOJ, although it is not binding. The HHS position is represented by an attorney from DOJ in hearings before a “special master” who makes the initial decision for compensation under the Program. A special master is an attorney appointed by the judges of the Court. Decisions may be appealed to the Court, then to the Federal Circuit Court of Appeals, and then to the Supreme Court.

No petition may be filed under this Program if a civil action is pending for damages related to the vaccine injury, or if damages were awarded by a court or in a settlement of a civil action against the vaccine manufacturer or administrator.

It is not a requirement to have attorney representation during this process; however, because the Rules of the Court are very specific and must be strictly followed, many petitioners have made the decision to have an attorney represent them. The Act provides for the payment of reasonable attorneys’ fees and costs, regardless of the Court’s decision on compensability, providing the case is brought in good faith and there is a reasonable basis for the claim. An attorney who files a petition must be admitted to the U.S. Court of Federal Claims Bar.


COMPENSATION THAT MAY BE AWARDED

Vaccine-Related Injury

  • Reasonable compensation for past and future unreimbursable medical, custodial care, and rehabilitation costs.
  • $250,000 cap for actual and projected pain and suffering, emotional distress.
  • Lost earnings.
  • Reasonable attorneys’ fees and costs.
  • Deadline for filing: Within 36 months after the first symptoms appeared.

Vaccine-Related Death

  • $250,000 for the estate of the deceased.
  • Reasonable attorneys’ fees and costs.
  • Deadline for filing: Within 24 months of death and within 48 months after the onset of the vaccine-related injury from which the death occurred.



What Vaccines are covered?

  • Diphtheria, pertussis, tetanus (DTP, DtaP, Tdap, DT, Td, or TT)
  • Haemophilis influenzae type b (Hib)
  • Hepatitis A (HAV)
  • Hepatitis B (HBV)
  • Trivalent influenza (TIV, LAIV)(given each year during flu season)
  • Measles-mumps-rubella (MMR, MR. M, R)
  • Meningoccal (conjugate & polysaccharide)(MCV4, MPSV4)(meningitis)
  • Polio (IPV, OPV)
  • Pneumococcal conjugate( PCV) (Streptococcus pneumoniae bacteria, cause bacterial meningitis, deaths, ear infections in children)
  • Rotovirus (RV)
  • varicella (VZV)(chickenpox)
  • Papillomavirus (HPV)(STD, cervical cancer) any combination of above vaccines

Vaccine Injury Table

The Vaccine Injury Table (Table) makes it easier for some people to get compensation. The Table lists and explains injuries/conditions that are presumed to be caused by vaccines. It also lists time periods in which the first symptom of these injuries/conditions must occur after receiving the vaccine. If the first symptom of these injuries/conditions occurs within the listed time periods, it is presumed that the vaccine was the cause of the injury or condition unless another cause is found. For example, if you received the tetanus vaccines and had a severe allergic reaction (anaphylaxis) within 4 hours after receiving the vaccine, then it is presumed that the tetanus vaccine caused the injury if no other cause is found.

If your injury/condition is not on the Table or if your injury/condition did not occur within the time period on the Table, you must prove that the vaccine caused the injury/condition. Such proof must be based on medical records or opinion, which may include expert witness testimony.

Vaccine Injury Table a
Vaccine
Adverse Event Time Interval
I. Tetanus toxoid-containing vaccines (e.g., DTaP, Tdap, DTP-Hib, DT, Td,  TT)
A.  Anaphylaxis or anaphylactic shock 1 0-4 hours
B.  Brachial neuritis 6 2-28 days
C.  Any acute complication or sequela (including death) of above events 4 Not applicable
II. Pertussis antigen-containing vaccines (e.g., DTaP, Tdap, DTP, P, DTP-Hib)
A.  Anaphylaxis or anaphylactic shock 1 0-4 hours
B.  Encephalopathy (or encephalitis) 2 0-72 hours
C.  Any acute complication or sequela (including death) of above events 4 Not applicable
III. Measles, mumps and rubella virus-containing vaccines in any combination (e.g., MMR, MR, M, R)
A.  Anaphylaxis or anaphylactic shock 1 0-4 hours
B.  Encephalopathy (or encephalitis) 2 5-15 days
C.  Any acute complication or sequela (including death) of above events 4 Not applicable
IV. Rubella virus-containing vaccines (e.g., MMR, MR, R)
A.  Chronic arthritis 5 7-42 days
B.   Any acute complication or sequela (including death) of above event 4 Not applicable
V. Measles virus-containing vaccines (e.g., MMR, MR, M)
A.   Thrombocytopenic purpura 7 7-30 days
B.  Vaccine-Strain Measles Viral Infection in an immunodeficient recipient 8 0-6 months
C.    Any acute complication or sequela (including death) of above events 4 Not applicable
VI. Polio live virus-containing vaccines (OPV)
A. Paralytic polio
  • in a non-immunodeficient recipient
0-30 days
  • in an immunodeficient recipient
0-6 months
  • in a vaccine associated community case
Not applicable
B. Vaccine-strain polio viral infection 9
  • in a non-immunodeficient recipient
0-30 days
  • in an immunodeficient recipient
0-6 months
  • in a vaccine associated community case
Not applicable
C.  Any acute complication or sequela (including death) of above events 4 Not applicable
VII. Polio inactivated-virus containing vaccines (e.g., IPV)
A   Anaphylaxis or anaphylactic shock 1 0-4 hours
B.  Any acute complication or sequela (including death) of above event 4 Not applicable
VIII. Hepatitis B antigen-containing vaccines
A.  Anaphylaxis or anaphylactic shock 1 0-4 hours
B.  Any acute complication or sequela (including death) of above event 4 Not applicable
IX. Hemophilus influenzae (type b polysaccharide conjugate vaccines)
A.  No condition specified for compensation

Not applicable
X. Varicella vaccine
A.  No condition specified for compensation

Not applicable
XI. Rotavirus vaccine
A.  No condition specified for compensation

Not applicable
XII. Pneumococcal conjugate vaccines
A.  No condition specified for compensation Not applicable
XIII. Any new vaccine recommended by the Centers for Disease Control and Prevention for routine administration to children, after publication by Secretary, HHS of a notice of coverageb c
A.  No condition specified for compensation

Not applicable

aEffective date: November 10, 2008
bAs of December 1, 2004, hepatitis A vaccines have been added to the Vaccine Injury Table (Table) under this Category.
As of July 1, 2005, trivalent influenza vaccines have been added to the Table under this Category. Trivalent influenza vaccines are given annually during the flu season either by needle and syringe or in a nasal spray.  All influenza vaccines routinely administered in the U.S. are trivalent vaccines covered under this Category.  See Federal Register Notice: April 12, 2005

c As of February 1, 2007, meningococcal (conjugate and polysaccharide) and human papillomavirus (HPV) vaccines have been added to the Table under this Category.

 Qualifications and Aids to Interpretation

(1) Anaphylaxis and anaphylactic shock mean an acute, severe, and potentially lethal systemic allergic reaction. Most cases resolve without sequelae. Signs and symptoms begin minutes to a few hours after exposure. Death, if it occurs, usually results from airway obstruction caused by laryngeal edema or bronchospasm and may be associated with cardiovascular collapse. Other significant clinical signs and symptoms may include the following: Cyanosis, hypotension, bradycardia, tachycardia, arrhythmia, edema of the pharynx and/or trachea and/or larynx with stridor and dyspnea. Autopsy findings may include acute emphysema which results from lower respiratory tract obstruction, edema of the hypopharynx, epiglottis, larynx, or trachea and minimal findings of eosinophilia in the liver, spleen and lungs. When death occurs within minutes of exposure and without signs ofrespiratory distress, there may not be significant pathologic findings.

(2) Encephalopathy. For purposes of the Vaccine Injury Table, a vaccine recipient shall be considered to have suffered an encephalopathy only if such recipient manifests, within the applicable period, an injury meeting the description below of an acute encephalopathy, and then a chronic encephalopathy persists in such person for more than 6 months beyond the date of vaccination.

(i) An acute encephalopathy is one that is sufficiently severe so as to require hospitalization (whether or not hospitalization occurred).

(A) For children less than 18 months of age who present without an associated seizure event, an acute encephalopathy is indicated by a “significantly decreased level of consciousness” (see “D” below) lasting for at least 24 hours. Those children less than 18 months of age who present following a seizure shall be viewed as having an acute encephalopathy if their significantly decreased level of consciousness persists beyond 24 hours and cannot be attributed to a postictal state (seizure) or medication.

(B) For adults and children 18 months of age or older, an acute encephalopathy is one that persists for at least 24 hours and characterized by at least two of the following:

(1) A significant change in mental status that is not medication related; specifically a confusional state, or a delirium, or a psychosis;
(2) A significantly decreased level of consciousness, which is independent of a seizure and cannot be attributed to the effects of medication; and
(3) A seizure associated with loss of consciousness.

(C) Increased intracranial pressure may be a clinical feature of acute encephalopathy in any age group.

(D) A “significantly decreased level of consciousness” is indicated by the presence of at least one of the following clinical signs for at least 24 hours or greater (see paragraphs (2)(I)(A) and (2)(I)(B) of this section for applicable timeframes):

(1) Decreased or absent response to environment (responds, if at all, only to loud voice or painful stimuli);
(2) Decreased or absent eye contact (does not fix gaze upon family members or other individuals); or
(3) Inconsistent or absent responses to external stimuli (does not recognize familiar people or things).

(E) The following clinical features alone, or in combination, do not demonstrate an acute encephalopathy or a significant change in either mental status or level of consciousness as described above: Sleepiness, irritability (fussiness), high-pitched and unusual screaming, persistent inconsolable crying, and bulging fontanelle. Seizures in themselves are not sufficient to constitute a diagnosis of encephalopathy. In the absence of other evidence of an acute encephalopathy, seizures shall not be viewed as the first symptom or manifestation of the onset of an acute encephalopathy.

(ii) Chronic encephalopathy occurs when a change in mental or neurologic status, first manifested during the applicable time period, persists for a period of at least 6 months from the date of vaccination. Individuals who return to a normal neurologic state after the acute encephalopathy shall not be presumed to have suffered residual neurologic damage from that event; any subsequent chronic encephalopathy shall not be presumed to be a sequela of the acute encephalopathy. If a preponderance of the evidence indicates that a child’s chronic encephalopathy is secondary to genetic, prenatal or perinatal factors, that chronic encephalopathy shall not be considered to be a condition set forth in the Table.
(iii) An encephalopathy shall not be considered to be a condition set forth in the Table if in a proceeding on a petition, it is shown by a preponderance of the evidence that the encephalopathy was caused by an infection, a toxin, a metabolic disturbance, a structural lesion, a genetic disorder or trauma (without regard to whether the cause of the infection, toxin, trauma, metabolic disturbance, structural lesion or genetic disorder is known). If at the time a decision is made on a petition filed under section 2111(b) of the Act for a vaccine-related injury or death, it is not possible to determine the cause by a preponderance of the evidence of an encephalopathy, the encephalopathy shall be considered to be a condition set forth in the Table.
(iv) In determining whether or not an encephalopathy is a condition set forth in the Table, the Court shall consider the entire medical record.

(3) Seizure and convulsion. For purposes of paragraphs (b)(2) of this section, the terms, “seizure” and “convulsion” include myoclonic, generalized tonic-clonic (grand mal), and simple and complex partial seizures. Absence (petit mal) seizures shall not be considered to be a condition set forth in the Table. Jerking movements or staring episodes alone are not necessarily an indication of seizure activity.

(4) Sequela. The term “sequela” means a condition or event which was actually caused by a condition listed in the Vaccine Injury Table.

(5) Chronic Arthritis. For purposes of the Vaccine Injury Table, chronic arthritis may be found in a person with no history in the 3 years prior to vaccination of arthropathy (joint disease) on the basis of:

(A) Medical documentation, recorded within 30 days after the onset, of objective signs of acute arthritis (joint swelling) that occurred between 7 and 42 days after a rubella vaccination;
(B) Medical documentation (recorded within 3 years after the onset of acute arthritis) of the persistence of objective signs of intermittent or continuous arthritis for more than 6 months following vaccination:
(C) Medical documentation of an antibody response to the rubella virus.

For purposes of the Vaccine Injury Table, the following shall not be considered as chronic arthritis: Musculoskeletal disorders such as diffuse connective tissue diseases (including but not limited to rheumatoid arthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, mixed connective tissue disease, polymyositis/dermatomyositis, fibromyalgia, necrotizing vasculitis and vasculopathies and Sjogren’s Syndrome), degenerative joint disease, infectious agents other than rubella (whether by direct invasion or as an immune reaction), metabolic and endocrine diseases, trauma, neoplasms, neuropathic disorders, bone and cartilage disorders and arthritis associated with ankylosing spondylitis, psoriasis, inflammatory bowel disease, Reiter’s syndrome, or blood disorders.

Arthralgia (joint pain) or stiffness without joint swelling shall not be viewed as chronic arthritis for purposes of the Vaccine Injury Table.

(6) Brachial neuritis is defined as dysfunction limited to the upper extremity nerve plexus (i.e., its trunks, divisions, or cords) without involvement of other peripheral (e.g., nerve roots or a single peripheral nerve) or central (e.g., spinal cord) nervous system structures. A deep, steady, often severe aching pain in the shoulder and upper arm usually heralds onset of the condition. The pain is followed in days or weeks by weakness and atrophy in upper extremity muscle groups. Sensory loss may accompany the motor deficits, but is generally a less notable clinical feature. The neuritis, or plexopathy, may be present on the same side as or the opposite side of the injection; it is sometimes bilateral, affecting both upper extremities. Weakness is required before the diagnosis can be made. Motor, sensory, and reflex findings on physical examination and the results of nerve conduction and electromyographic studies must be consistent in confirming that dysfunction is attributable to the brachial plexus. The condition should thereby be distinguishable from conditions that may give rise to dysfunction of nerve roots (i.e., radiculopathies) and peripheral nerves (i.e., including multiple mononeuropathies), as well as other peripheral and central nervous system structures (e.g., cranial neuropathies and myelopathies).

(7) Thrombocytopenic purpura is defined by a serum platelet count less than 50,000/mm3. Thrombocytopenic purpura does not include cases of thrombocytopenia associated with other causes such as hypersplenism, autoimmune disorders (including alloantibodies from previous transfusions) myelodysplasias, lymphoproliferative disorders, congenital thrombocytopenia or hemolytic uremic syndrome. This does not include cases of immune (formerly called idiopathic) thrombocytopenic purpura (ITP) that are mediated, for example, by viral or fungal infections, toxins or drugs. Thrombocytopenic purpura does not include cases of thrombocytopenia associated with disseminated intravascular coagulation, as observed with bacterial and viral infections. Viral infections include, for example, those infections secondary to Epstein Barr virus, cytomegalovirus, hepatitis A and B, rhinovirus, human immunodeficiency virus (HIV), adenovirus, and dengue virus. An antecedent viral infection may be demonstrated by clinical signs and symptoms and need not be confirmed by culture or serologic testing. Bone marrow examination, if performed, must reveal a normal or an increased number of megakaryocytes in an otherwise normal marrow.

(8) Vaccine-strain measles viral infection is defined as a disease caused by the vaccine-strain that should be determined by vaccine‑specific monoclonal antibody or polymerase chain reaction tests.

(9) Vaccine-strain polio viral infection is defined as a disease caused by poliovirus that is isolated from the affected tissue and should be determined to be the vaccine-strain by oligonucleotide or polymerase chain reaction. Isolation of poliovirus from the stool is not sufficient to establish a tissue specific infection or disease caused by vaccine-strain poliovirus.

This information reflects the current thinking of the United States Department of Health and Human Services on the topics addressed. This information is not legal advice and does not create or confer any rights for or on any person and does not operate to bind the Department or the public. The ultimate decision about the scope of the statutes authorizing the VICP is within the authority of the United States Court of Federal Claims, which is responsible for resolving claims for compensation under the VICP.



The proceeding information provided by Conway, Homer & Chin-Caplan, 16 Shawmut Street, Boston, MA 02116, Phone: 617-695-1990, Fax: 617-695-0880

Thiomersal

Thiomersal (INN) (C9H9HgNaO2S), or sodium ethylmercurithiosalicylate, commonly known in the United States as thimerosal, is an organomercury compound (approximately 49% mercury by weight) used as an antiseptic and antifungal agent.

Detailed Product Information
IUPAC name Thiomersal
Other names Mercury((o-carboxyphenyl)thio)ethyl sodium salt
Identifiers CAS number 54-64-8
EC number 200-210-4
RTECS number OV8400000
Properties Molecular formula C9H9HgNaO2S
Molar mass 404.81 g/mol
Appearance White or slightly yellow powder
Density 500 kg/m³
Melting point 232–233°C (decomposition)
Solubility in water 1000 g/l (20°C)
Hazards MSDS
External MSDS
R-phrases R26/27/28 R33 R50/53
S-phrases S13 S28 S36 S45 S60 S61
NFPA 704 1 3 1
Flash point 250°C
Except where noted otherwise, data are given for materials in their standard state (at 25 °C, 100 kPa)
Artificial induction of immunity / Immunization: Vaccines, Vaccination, and Inoculation (J07)
Antiseptics and disinfectants (D08)
Categories: ‪Carboxylic acids‬

It was invented and patented by Morris Kharasch. The pharmaceutical corporation Eli Lilly and Company gave it the trade name Merthiolate and it has been used as a preservative in vaccines, immunoglobulin preparations, skin test antigens, antivenins, ophthalmic and nasal products, and tattoo inks. Its use as a vaccine preservative is controversial, and it is being phased out from routine childhood vaccines in the United States, the European Union, and a few other countries.[1]


Content
1.0 Use
2.0 Toxicology
2.1 Allergies
2.2 Autism
3.0 History
4.0 See also
5.0 References

Use
Thiomersal’s main use is as an antiseptic and antifungal agent. In multidose injectable drug delivery systems, it prevents serious adverse effects such as the Staphylococcus infection that, in one 1928 incident, killed 12 of 21 children inoculated with a diphtheria vaccine that lacked a preservative.[2] Unlike other vaccine preservatives used at the time, thiomersal does not reduce the potency of the vaccines that it protects.[3] Bacteriostatics like thiomersal are not needed in more-expensive single-dose injectables.[4]

In the United States, countries in the European Union and a few other affluent countries, thiomersal is no longer used as a preservative in routine childhood vaccination schedules.[1] In the U.S., the only exceptions among vaccines routinely recommended for children are some formulations of the inactivated influenza vaccine for children older than two years.[5] Several vaccines that are not routinely recommended for young children do contain thiomersal, including DT (diphtheria and tetanus), Td (tetanus and diphtheria), and TT (tetanus toxoid); other vaccines may contain a trace of thiomersal from steps in manufacture.[2] Also, four rarely used treatments for pit viper, coral snake, and black widow venom still contain thiomersal.[6] Outside North America and Europe, many vaccines contain thiomersal; the World Health Organization has concluded that there is no evidence of toxicity from thiomersal in vaccines and no reason on safety grounds to change to more-expensive single-dose administration.[7]

Toxicology
Thiomersal is very toxic by inhalation, ingestion, and in contact with skin (EC hazard symbol T+), with a danger of cumulative effects. It is also very toxic to aquatic organisms and may cause long-term adverse effects in aquatic environments (EC hazard symbol N).[8] In the body, it is metabolized or degraded to ethylmercury (C2H5Hg+) and thiosalicylate.[2]

Few studies of the toxicity of thiomersal in humans have been performed. Animal experiments suggest that thiomersal rapidly dissociates to release ethylmercury after injection; that the disposition patterns of mercury are similar to those after exposure to equivalent doses of ethylmercury chloride; and that the central nervous system and the kidneys are targets, with lack of motor coordination being a common sign. Similar signs and symptoms have been observed in accidental human poisonings.

The mechanisms of toxic action are unknown. Fecal excretion accounts for most of the elimination from the body. Ethylmercury clears from blood with a half-life of about 18 days, and from the brain in about 14 days. Inorganic mercury metabolized from ethylmercury has a much longer clearance, at least 120 days; it appears to be much less toxic than the inorganic mercury produced from mercury vapor, for reasons not yet understood.[9]

Risk assessment for effects on the nervous system have been made by extrapolating from dose-response relationships for methylmercury.[9] Methylmercury and ethylmercury distributes to all body tissues, crossing the blood-brain barrier and the placental barrier, and ethylmercury also moves freely throughout the body.[10]

Concerns based on extrapolations from methylmercury caused thiomersal to be removed from U.S. childhood vaccines, starting in 1999. Since then, it has been found that ethylmercury is cleared from the body and the brain significantly faster than methylmercury, so the late-1990s risk assessments turned out to be overly conservative.[9] A 2008 study found that the half-life of blood mercury after vaccination averages 3.7 days for newborns and infants, much shorter than the 44 days for methylmercury.[11]

Allergies
Thiomersal is used in patch testing for people who have dermatitis, conjunctivitis, and other potentially allergic reactions. A 2007 study in Norway found that 1.9% of adults had a positive patch test reaction to thiomersal;[12] a higher prevalence of contact allergy (up to 6.6%) was observed in German populations.[13] Thiomersal-sensitive individuals can receive intramuscular rather than subcutaneous immunization,[14] so contact allergy is usually clinically irrelevant.[13]  Thiomersal allergy has decreased in Denmark, probably because of its exclusion from vaccines there.[15]

It was voted Allergen of the Year in 2002 by the American Contact Dermatitis Society.

Autism
Main article: Thiomersal controversy
There is no convincing evidence that thiomersal is a factor in the onset of autism.[16] Despite this, many parents, and some scientists and doctors, believe there is a connection.[17] Parents may first become aware of autistic symptoms in their child around the time of a routine vaccination, and parental concern about vaccines has led to a decreasing uptake of childhood immunizations and an increasing likelihood of measles outbreaks.[2][16][18]

More than 5,000 U.S. families have filed claims in a federal vaccine court alleging autism was caused by vaccines, most implicating thiomersal; the majority of these claims are still being adjudicated.[17]

The U.S. federal government agreed to award damages in one case, to a girl with a mitochondrial enzyme deficiency who developed autistic-like symptoms after receiving a series of vaccines,[19] some of which contained thiomersal. Many parents view this ruling as confirming that vaccines cause regressive autism;[20] however, most children with autism do not seem to have mitochondrial disorders, and the case was conceded without proof of causation.[21]

History
Morris Kharasch, a chemist at the University of Maryland, filed a patent application for thiomersal in 1927;[22] Eli Lilly later marketed the compound under the trade name Merthiolate.[3] In vitro tests conducted by Lilly investigators H.M. Powell and W.A. Jamieson found that it was forty to fifty times as effective as phenol against Staphylococcus aureus.[3] It was used to kill bacteria and prevent contamination in antiseptic ointments, creams, jellies, and sprays used by consumers and in hospitals, including nasal sprays, eye drops, contact lens solutions, immunoglobulins, and vaccines. Thiomersal was used as a preservative (bactericide) so that multidose vials of vaccines could be used instead of single-dose vials, which are more expensive. By 1938, Lilly’s assistant director of research listed thiomersal as one of the five most important drugs ever developed by the company.[3]

Thiomersal’s safety for its intended uses first came under question in the 1970s, when case reports demonstrated potential for neurotoxicity when given in large volumes as a topical antiseptic. At the time, the DPT vaccine was the only childhood vaccine that contained it; a 1976 United States Food and Drug Administration review concluded that this use of thiomersal was not dangerous.[3] Concerns about mercury arising from Minamata disease and other cases of methylmercury poisoning led U.S. authorities to lower reference doses for methylmercury in the 1990s, about the same time that autism diagnoses began rising sharply. In 1999, a new FDA analysis concluded that infants could receive as much as 187.5 micrograms of ethylmercury during the first six months;[23] lacking any standard for ethylmercury, it used methylmercury-based standards to recommend that thiomersal be removed from routine infant vaccines in the U.S., which was largely complete by summer 2001.[3] Some parents of autistic children adopted thiomersal as an explanation for the increase in reported autism cases and sued vaccine makers; the mercury-autism hypothesis is accepted widely among parents of autistic children, despite scientific studies rejecting it.[3][24]

See also
Mercurochrome

References
1. ^ a b Bigham M, Copes R (2005). “Thiomersal in vaccines: balancing the risk of adverse effects with the risk of vaccine-preventable disease”. Drug Saf 28 (2): 89–101. doi:10.2165/00002018-200528020-00001. PMID 15691220.
2. ^ a b c d “Thimerosal in vaccines”. Center for Biologics Evaluation and Research, U.S. Food and Drug Administration. 2008-06-03. Retrieved 2008-07-25.
3. ^ a b c d e f g Baker JP (2008). “Mercury, vaccines, and autism: one controversy, three histories”. Am J Public Health 98 (2): 244–53. doi:10.2105/AJPH.2007.113159. PMID 18172138.
4. ^ “Thimerosal in Vaccines: Frequently Asked Questions”. Food and Drug Administration. Retrieved 2008-03-09.
5. ^ Coordinating Center for Infectious Diseases (2007-10-26). “Thimerosal in seasonal influenza vaccine”. Centers for Disease Control and Prevention. Retrieved 2008-04-02.
6. ^ “Mercury in plasma-derived products”. U.S. Food and Drug Administration. 2004-09-09. Retrieved 2007-10-01.
7. ^ Global Advisory Committee on Vaccine Safety (2006-07-14). “Thiomersal and vaccines”. World Health Organization. Retrieved 2007-11-20.
8. ^ “Thiomersal Ph Eur, BP, USP material safety data sheet” (PDF). Merck. 2005-06-12. Retrieved 2007-10-01.
9. ^ a b c Toxicology of thiomersal:
Clarkson TW (2002). “The three modern faces of mercury”. Environ Health Perspect 110 (S1): 11–23. PMID 11834460.
Clarkson TW, Magos L (2006). “The toxicology of mercury and its chemical compounds”. Crit Rev Toxicol 36 (8): 609–62. doi:10.1080/10408440600845619. PMID 16973445.
10. ^ Clarkson TW, Vyas JB, Ballatori N (2007). “Mechanisms of mercury disposition in the body”. Am J Ind Med 50 (10): 757–64. doi:10.1002/ajim.20476. PMID 17477364.
11. ^ Pichichero ME, Gentile A, Giglio N et al. (2008). “Mercury levels in newborns and infants after receipt of thimerosal-containing vaccines”. Pediatrics 121 (2): e208–14. doi:10.1542/peds.2006-3363. PMID 18245396. Lay summary – University of Rochester Medical Center (2008-01-30).
12. ^ Dotterud LK, Smith-Sivertsen T (2007). “Allergic contact sensitization in the general adult population: a population-based study from Northern Norway”. Contact Dermatitis 56 (1): 10–5. doi:10.1111/j.1600-0536.2007.00980.x. PMID 17177703.
13. ^ a b Uter W, Ludwig A, Balda BR (2004). “The prevalence of contact allergy differed between population-based and clinic-based data”. J Clin Epidemiol 57 (6): 627–32. doi:10.1016/j.jclinepi.2003.04.002. PMID 15246132.
14. ^ Aberer W (1991). “Vaccination despite thimerosal sensitivity”. Contact Dermatitis 24 (1): 6–10. doi:10.1111/j.1600-0536.1991.tb01621.x. PMID 2044374.
15. ^ Thyssen JP, Linneberg A, Menné T, Johansen JD (2007). “The epidemiology of contact allergy in the general population—prevalence and main findings”. Contact Dermatitis 57 (5): 287–99. doi:10.1111/j.1600-0536.2007.01220.x. PMID 17937743.
16. ^ a b Doja A, Roberts W (2006). “Immunizations and autism: a review of the literature”. Can J Neurol Sci 33 (4): 341–6. PMID 17168158.
17. ^ a b Sugarman SD (2007). “Cases in vaccine court—legal battles over vaccines and autism”. N Engl J Med 357 (13): 1275–7. doi:10.1056/NEJMp078168. PMID 17898095.
18. ^ Taylor B (2006). “Vaccines and the changing epidemiology of autism”. Child Care Health Dev 32 (5): 511–9. doi:10.1111/j.1365-2214.2006.00655.x. PMID 16919130.
19. ^ Offit PA (2008). “Vaccines and autism revisited—the Hannah Poling case”. N Engl J Med 358 (20): 2089–91. doi:10.1056/NEJMp0802904. PMID 18480200.
20. ^ Harris G (2008-03-08). “Deal in an autism case fuels debate on vaccine”. NY Times.
21. ^ Honey K (2008). “Attention focuses on autism”. J Clin Invest 118 (5): 1586–7. doi:10.1172/JCI35821. PMID 18451989.
22. ^ U.S. Patent 1,672,615 “Alkyl mercuric sulphur compound and process of producing it”.
23. ^ Ball LK, Ball R, Pratt RD (2001). “An assessment of thimerosal use in childhood vaccines”. Pediatrics 107 (5): 1147–54. doi:10.1542/peds.107.5.1147. PMID 11331700.
24. ^ DeStefano F (2007). “Vaccines and autism: evidence does not support a causal association”. Clin Pharmacol Ther 82 (6): 756–9. doi:10.1038/sj.clpt.6100407. PMID 17928818.

Dr Robert Mendelsohn, M.D.

Dr Robert Mendelsohn, M.D.
Vaccine Critics

Dr Robert Mendelsohn received his Doctor of Medicine degree from the University of Chicago in 1951.  For 12 years he was an instructor at Northwest University Medical College, and an additional 12 years served as Associtae Professor of Pediatrics and Community Health and Preventive Medicine at the University of Illinois College of Medicine.

He was also President of the National Health Federation, former National Director of Project Head Starts Medical Consultation Service, and Chairman of the Medical Licensing Comittee of the State of Illinois.

He appeared on over 500 television and radio talk shows, and is the author of Confessions of a Medical Heretic, Male Practice: How Doctors Manipulate Women, and How To Raise a Healthy Child In Spite of Your Doctor

Quotes

Publications
CONFESSIONS OF A MEDICAL HERETIC By Robert S. Mendelsohn, M.D. chapter 7
The Devil’s Priests
The Medical Time Bomb of Immunisation Against Disease by Dr Robert Mendelsohn MD
Rubella vaccine linked to Epstein-Barr Virus—Dr Mendelsohn MD (1987)
Tetanus Vaccination by Dr Mendelsohn MD
Flu vaccination–Dr Mendelsohn MD
Rabies vaccine by Dr Mendelsohn MD
Bottle feeding & breast feeding
Foreword by Robert S. Mendelsohn, MD to Slaughter of the Innocent, 1982, by Hans Ruesch
Foreword to Why Suffer by Anne Wigmore

[1982] Male Practice: How Doctors Manipulate Women, ISBN 0809257211
[1987] How To Raise a Healthy Child In Spite of Your Doctor, NTC/Contemporary Publishing Company, ISBN 0809249952
Chapter headings include: Parents & Grandparents are wiser than doctors, How Doctors Can Make Healthy Kids Sick, Protecting Your Children before They Are Born, Fever: your Body’s Defense against Disease, Asthma & Allergies: Try Diet Not Drugs, Immunisation Against Disease: A medical Timebomb, Hospitals: Where Patients Go to Get Sick!
[1991] Confessions of a Medical Heretic, ISBN 0809277263
External links
NaturalChild.com – ‘The Child Who Never Sits Still’, Robert Mendelsohn, MD

mendb.jpg (23240 bytes)




 Source:

http://www.whale.to/v/mendelsohn.html

Vaccine Nation – Director’s Cut (Gary Null)

For most people, vaccinating themselves and their children seems like a good idea. Vaccines are safe, effective and are supposed to protect us against dangerous infectious diseases – Right? Wrong! What you don’t know can harm you or kill you! In this groundbreaking film, you will: * See the truth about the dangers of vaccines and their direct relationship to autoimmune diseases, infections, allergies and a massive increase of developmental learning and behavioral disorders in children, such as Autism. * Discover the truth about the history of vaccines and how they have NEVER been proven to be safe and effective for anyone. * Witness the legacy of governmental deception and cover-ups associated with vaccines. * Learn about the corruption within the scientific community and how vaccine studies are seriously flawed. * You’ll also follow heart-wrenching, real life stories of the parents and children devastated by the effects of vaccines. Join director Gary Null PhD and over 40 of the worlds foremost vaccine experts in this shocking expose’ that will shatter the truth as you know it. DVD copies are available at http://www.garynull.com

Q: Can a vaccination cause Death or Autism?

Q: Can a vaccination cause Death or Autism?

A: Yes

Q: How?

A. 1). Many vaccines (and medicines) are incorrectly administered. The person administering the vaccine fails to aspirate the syringe (draw back on the plunger to see if blood flows back into the syringe, indicating they have struck a vein). Because the veins of an infant are small and narrow, they may collapse when the syringe is aspirated, giving a FALSE indication that it is safe to administer the vaccine. As a result, the vaccine or medicine is injected directly into a vein, and circulates throughout the cardiovascular system, infiltrating the brain, intestines, and other organs. The vein may also blow up like a balloon and rupture. This may be marked by a purple area at or near the injection site. The vaccine or medicine now circulates in the blood, causing varying degrees of Hypercoagulability. In more serious cases, the increased fibrin inhibits oxygen and nutrient transport. In a weakened state, a child may succumb to asphyxia, commonly known as sudden infant death syndrome, or SIDS.

2). Even when properly administered, a vaccination can be life threatening if viral, bacterial, or fungal pathogens are already present in the body of the person to be vaccinated, and neurologically disabling if heavy metals such as mercury are present in the body, or injected as an adjuvant in another vaccine, when multiple vaccines are simultaneously administered, or other toxic loads are present.

3). According to Doctor Boyd Haley, professor and Chair of the Chemistry Department at the University of Kentucky, there is a 100 times toxic effect if aluminum and mercury appear at the same time. This means that if you give multiple vaccinations, and one or more contain an aluminum adjuvant, and just one contains a mercury adjuvant (like many vaccines containing an attenuated virus), the toxic effect is the equivalent to giving a 2,500 microgram injection of mercury. If the vaccine recipient already has the smallest trace of mercury in his body, the effect is also 100 times for a single shot of a new vaccine that now contains an aluminum adjuvant, instead of methylmercury.

Dr. Boyd Haley selected 100 rats to use in each of his experiments.

He injected 100 rats with the type of mercury used in vaccines. 1 rat out of 100 died.

He then injected 100 rats with the type of mercury used in vaccines, AND also with the type of aluminum used in the new “mercury free vaccines.” 100 out of 100 rats died.

When trace amounts of mercury are already present in the human body from vaccines, eating fish, or amalgam fillings, a “mercury free” vaccine that contains 225 micrograms of aluminum can be debilitating, cause myelin degeneration around nerves, muscle pain, chronic fatigue syndrome, and even death,

– Findings of the VAERS Court, Jan, 2009
http://www.uscfc.uscourts.gov/sites/default/files/MILLMAN.DOE012109B_0.pdf

4). Patients receiving a vaccination are virtually never asked about or tested for allergic reactions, or questioned about family history ans sensitivity to vaccine ingredients.

5). An estimated 1 in 50 humans suffer from a genetic IRAK4 impeded immune response (deficiency), which results in increased inflammation, plus increased bacterial, viral, and fungal infections. No precautions are being taken to protect the lives of these children when given a vaccine (PART OF THE WATCHDOG USA NETWORK, 2009).

Resource:
PART OF THE WATCHDOG USA NETWORK. (2009). Death By Vaccination. Retrieved from http://deathbyvaccination.com/

Needling Questions: Immunizing Kids

Kathy McManus of the Responsibility Project (2008) asks, “If you choose not to have your child vaccinated against measles, mumps, chicken pox, and other infectious diseases, does your responsibility end there?”

It’s a debate that continues as the trend for not vaccinating children increases.

Parents who believe that vaccinations are linked to autism, or who object for religious or other reasons, balk at government regulations that bar their unvaccinated children from attending school if they don’t have the required shots. One anti-vaccination group calls forced vaccination “a violation of human rights.”

But those on the opposite side of the argument say not vaccinating violates the rights of others. According to officials at the Centers for Disease Control, “The decision not to vaccinate is a decision for your child but also a decision for society.” They say that unlike other medical issues where refusing treatment affects only the patient, refusing vaccinations puts others at risk as well, including newborns and people with suppressed immune systems.

Parents of unimmunized children rely on the vast majority of kids who do get their shots, figuring there’s little polio, measles, chicken pox or other pathogens to be found among so many protected kids. But with recent measles outbreaks in four states, that protection may not be enough. “We are seeing outbreaks that look different, concentrated among intentionally unimmunized people,” says an immunization official. “I hope they’re not the beginning of a worse trend.”

Tell us what you think: When it comes to vaccinations, do parents have a responsibility beyond their own children?

Resource
McManus, Kathy (2008), The Responsibility Project, Needling Questions: Immunizing Kids, http://www.responsibilityproject.com/blog/post/needling-questions-immunizing-kids/.
June 30, 2008. By Comments (688)

Vaccine Information for Parents

Making an informed vaccination decision and taking responsibility for it is not easy. At times, it seems a lot easier to not ask questions or simply do what someone else tells us to do. But remaining uninformed and trusting blindly can be the biggest risk of all. You have the right to make informed, voluntary choices about risks you are willing to take with your life or your child’s life when it comes to making health care decisions, including vaccination decisions. Exercise your right to be an informed health care consumer.

The National Vaccine Information Center recommends obtaining information from many different sources and consulting one or more health care professionals before making a vaccination decision. NVIC’s website (www.nvic.org) is linked to many different information resources. It is important to become informed about the risks and complications of diseases as well as the risks and complications of vaccines when making a vaccination decision.

Parents: IF YOU VACCINATE, ASK EIGHT:

1. Is my child sick right now?
2. Has my child had a bad reaction to a vaccination before?
3. Does my child have a personal or family history of:
* vaccine reactions;
* convulsions or neurological disorders;
* severe allergies;
* or immune system disorders?
4. Do I know if my child is at high risk of reacting??
5. Do I know how to identify a vaccine reaction?
6. Do I know how to report a vaccine reaction?
7. Do I know the vaccine manufacturer’s name and lot number?
8. Do I know I have a choice?

Resource:
http://www.nvic.org/Vaccine-Memorial/Vaccine-Info.aspx

Support After a Child Dies

Parents aren’t supposed to experience the passing of their child.   When a child dies, a family experiences disbelief and the raw emotions of grief.  How do they cope?  Family members who have experienced this loss firsthand share thoughts and insights of the grief journey, how the child’s death has affected their lives, and how finding support from The Compassionate Friends has helped them to survive.

If you know someone who has experienced the loss of a child, The Compassionate Friends can help.  A dear friend told me after the passing of my dear sweet son, to remember to take care of myself and to get help.  His parents experienced the loss of their son, his older brother and never got help.  He explained how they didn’t get help and how it negatively affected thier lives.
 
Call or visit their Website for more information.

  • 630-990-0010 or 877-969-0010 

         (9 AM-5 PM Central or leave a voicemail)

They will assemble a packet of information pertaining to your situation.

Links to Pro Vaccine Related Sites

The following are links to pro-vaccine related sites.  Be cautious about what you read and believe. 

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Immunization-related Websites

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State and Local Health Departments

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48 Doses of 14 Vaccines Before Age 6?

Before you take the risk, find out what it is.

Birth (12 hours) – Hepatitis B
2 Months  Diphtheria, Tetanus, Pertussis, Polio, HIB, PCV, Rotavirus, Hepatitis B
4 Months – Diphtheria, Tetanus, Pertussis, Polio, HIB, PCV, Rotavirus
6 Months – Diphtheria, Tetanus, Pertussis, Polio, PCV, Rotavirus, Hepatitis B, Influenza
7 Months – Influenza
12-15 Months – HIB, PCV, Measles, Mumps, Rubella, Varicella, Hepatitis A
18 Months – Diphtheria, Tetanus, Pertussis, Hepatitis A, Influenza
3 Years – Influenza
4-6 Years – Diphtheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella, Varicella, Influenza (2)
Vaccine excipients or ingredients in trace or larger amounts depending on specific vaccine (partial list): lab altered viruses and bacteria; aluminum; mercury; formaldehyde; phenoxyethanol; gluteraldehyde; sodium borate; sodium chloride; sodium acetate; monosodium glutamate (MSG); hydrochloric acid; hydrogen peroxide; lactose; gelatin; yeast protein; egg albumin; bovine and human serum albumin; antibiotics; unidentified contaminants.







In the 1970’s, the Centers for Disease Control (CDC) and American Academy of Pediatrics (AAP) said children should get 23 doses of 7 vaccines by age 6. The first vaccinations were given at 2 months old.


Today, the CDC and AAP tell doctors to give children 48 doses of 14 vaccines by age 6. The first vaccination is given at 12 hours old in the newborn nursery. At age 2 months, a baby can receive 8 vaccines on a single day. At age 15 to 18 months, a child can receive as many as 12 vaccines on a single day.

Outstanding Question: Is the atypical manipulation of the immune system with more and more vaccines in early life setting some children up for chronic disease and disability?  IS LESS BETTER?

Please pass this information on. The information above can be down loaded in brochure form to hand out to friends, family, etc. at:  http://www.nvic.org/Downloads/4507NVIC11×17HIRES.aspx



Electronic Textbook Injuries Chapter 43 Child-resuscitation

Electronic Textbook Injuries Chapter 43 Child-resuscitation

  • Introduction
  • Epidemiology
  • Aim of trauma care
  • Classification
  • Definitions and scoring of trauma
  • Trauma team
  • Before arrival
  • Primary survey and resuscitation
  • Secondary survey
  • Definitive care
  • Trauma arrest
  • Management issues
  • Transfer
  • Conclusion

Introduction
Perhaps no other emergency creates as much anxiety as that of a critically injured child because the margin for error is so narrow. Children are not small adults and although the approach to the injured child follows a similar framework to that of adults there are many differences.

An area of similarity between children and adults is the trimodal distribution of death.
At the scene of the accident death usually occurs as a result of unsalvageable injuries such as massive head injury, high cervical spinal injury, major thoracic injury or major vessel disruption.

During the first few hours (the “Golden Hour” concept popularized by Trunkey) death and morbidity during this period are potentially preventable if attention is directed to restoring airway, breathing and circulation.

Death in the days and weeks following the accident is usually secondary to sepsis and multisystem organ failure. These late deaths may be preventable if adequate resuscitation occurs in the first few hours.

Epidemiology
Trauma is the leading cause of death in children over one year of age. Non-penetrating or blunt trauma is seen in over 90% of cases, of which motor vehicle accidents and pedestrian injury account for 70% in western countries . Head injury accounts for 60-70% of total trauma cases and is the single most important cause of death and morbidity in children. Countries such as Australia and the United Kingdom are now experiencing an increase in penetrating injury from gun shot and stabbing, most cases relating to suicide or violence in the adolescent (not dissimilar to the experience in the United States).

Aim of trauma care
An important principle in early trauma management is to get those most skilled in treating severely injured children in attendance as soon as possible.
The keys to good trauma care are:
Focus on the priorities of Airway, Breathing, Circulation and Disability.
Pay attention to details.
Re-evaluate the child frequently.
Assume that serious injuries do exist and then work systematically to exclude these injuries.

Important points include:
1. A systematic, integrated and coordinated team approach. A senior medical officer acts as team leader to oversee assessment, resuscitation and subsequent management. Each team member has a defined role, eg airway management, IV cannulation.
2. Appreciating the anatomic and physiologic aspects of the paediatric patient (Appendix L). These have implications for:
• Specific patterns of injury seen in children (frequently different from those in adults).
• IV infusion rates and drug dosages (more often weight-related in children).
• Special equipment requirements for children.
• Because of their small size and elastic skeleton children often sustain injuries to their internal organs with minimal or no external trauma.
3. Consider the mechanism of injury. Details of the accident frequently give important clues to the types and pattern of injury.
4. Recognize that the response to trauma is a dynamic process. Regular monitoring of vital signs and repeated examinations are necessary if occult injuries are not to be missed.
5. Consider the psychological impact. Trauma frequently places the child and his/her family under enormous psychological strain with possible long-term consequences. Clear communication and allowing parents to see their child early and frequently help to alleviate stress.
6. Consider the possibility of child abuse. Important clues may be found in the history or the pattern of injury seen.

Classification
The majority of blunt injuries involve a localized area or single system. Children suffering from multiple injuries often have been exposed to critical forces distributed throughout all body regions resulting in a high mortality rate.

The key to understanding traumatic injury, and therefore not missing injuries such as splenic trauma, is to understand the mechanisms of injury. Minimal forces will nearly always be associated with minor trauma that is often localized or single system in nature, while severe injury or multiple trauma must be considered when critical forces are involved. This is summarized in Fig 26.1.

There are, however, circumstances that can lead to more serious injury although the forces involved may have been considered minimal. A child who falls from a low height such as a bed and hits a very hard surface such as a concrete or tiled floor may suffer a disproportionate injury. A skull fracture leading to an extradural haematoma may go unnoticed, the child being discharged before the injury has evolved, with serious consequences. Additionally, if injuries are multiple and force is historically minimal, or explanation is unsatisfactory then non-accidental injury must be considered.

The mechanism of injury is therefore just as important in children as it is in adults. For example, in the 9 year old boy in Fig. 26.2, only critical force could cause such extensive multiple injuries. This child was hit by a bus at 60 km/hr and thrown 5 metres across the road. A good history of the mechanism of injury allowed the treating clinicians to predict the potential problems that might arise before and during the initial resuscitation and stabilization of this child.

Definitions and scoring of trauma
Multiple trauma has been defined as substantial injury to more than one organ system or life-threatening injury to a single system. The recognized standards for describing injuries are the Abbreviated Injury Score and its derivative the Injury Severity Score, which classify injuries according to anatomical site and severity. Children with an ISS >15 are considered to have major trauma with a high mortality and morbidity rate. Trauma scores were originally designed for rapid assessment and triage, for measuring progress of injury, for predicting outcome and for assisting in quality assessment. It has proved to be useful in the overall management of the trauma patient, but less sensitive for severe injury to a single organ system.

Neither of these scores is used in the field by pre-hospital staff or in the emergency department. More useful tools for assessing the severity of injury are the Paediatric Trauma Score (Table 26.1) and the revised Trauma Score (Table 26.2). The PTS was developed to reflect the unique nature of injury patterns in children and to incorporate age. It is useful in triage and in predicting outcome in children. Children with a Paediatric Trauma Score 8 or a revised Trauma Score 11 should be treated in a designated trauma centre. Although these scores have a tendency to over triage children with injury, there is no doubt that children with major trauma have a better outcome if managed in a designated trauma center.

Regardless of their trauma score children who have sustained a high-energy impact should always be assessed carefully for possible life threatening injuries.

Key points
Children with an ISS >15 are considered to have major trauma with a high mortality and morbidity rate
More useful tools for assessing the severity of injury are the Paediatric Trauma Score (Table 26.1) and the revised Trauma Score (Table 26.2).

Trauma team
Trauma management is a team activity that requires a coordinated approach, and much expertise channelled in a productive way for the optimal management of the patient. Most paediatric trauma centres have a team responsible for the initial care of children with a potential for major injury. Specialists in general surgery (often the team leader) and emergency medicine, intensive care, anesthesiology and radiology and specialist trauma nurses are all involved. At our institution the emergency physician is often the first to respond, and leads the trauma team. The make-up of the trauma team in our institution the New Children’s Hospital is seen in Fig. 26.3.

It is important for smaller hospitals without a caseload large enough to warrant a trauma team to have protocols to define major trauma and for initial management, and criteria for transfer to a trauma centre.

Before arrival
Communication with the transporting pre-hospital service is vital in order to determine the extent of the child’s injuries and the level of haemodynamic stability and the current treatment of the child. The team can be prepare for the resuscitation by estimating the child’s weight, and assembling age appropriate equipment – laryngoscopes, endotracheal tubes, suction catheters, intravenous cannula and appropriate fluid delivering devices. Various support services such as Blood Bank and operating theatres should be notified. If the child has suffered multiple injuries ensure O-negative blood is on stand-by for use immediately if necessary.

Primary survey and resuscitation
The key to successful resuscitation is to prioritize management according to injury severity. Attention should be paid first to life-threatening injuries; then limb-threatening injuries or high morbidity injuries; then minor injuries. Prioritization takes these steps:
Primary survey and resuscitation
Secondary survey
Definitive care

The initial 5-10 minutes are spent evaluating and rapidly resuscitating vital signs with immediate attention to life threatening conditions. Resuscitation and monitoring continue throughout this process and through the child’s stay in the emergency department. The secondary survey occurs during the next 20 minutes.

These priorities are summarized in the following Fig. 26.4

Primary survey and resuscitation.
Rapidly assess vital functions to identify life-threatening conditions and correct them. The priorities in order are:
A Airway with cervical spine control
B Breathing
C Circulation with control of bleeding
D Disability (brief neurological assessment)
E Exposure; completely undress the child

Details regarding the accident, vital signs, neurological status and injuries can usually be obtained from the ambulance personnel while transferring the patient to a hospital bed.

Assessment
Ask the older child: ‘What is your name?’ ‘How old are you?’, ‘What happened?’. The child who answers has a patent airway, is breathing and has adequate cerebral perfusion. Check for cyanosis, stridor, hoarseness and the free passage of air with each breath.

Intervention
Assume that there is cervical spine injury until proven otherwise by physical examination and radiology. During airway control, protect the cervical spine by one or a combination of the following:
In-line bimanual axial immobilization
A hard cervical collar (of appropriate size)
Sandbags and adhesive tape (strapping the head and trunk to a spinal board will further assist to immobilize the cervical spine)

The principles of splinting involve immobilization of a body region above and below the injury. The neck should be kept in the neutral position.

Measures to establish an open airway
Chin lift (but beware of excessive extension if risk of cervical spine injury) or jaw thrust (in spontaneously breathing, obstructed child). Avoid applying undue force on the soft tissues under the chin, which may cause upper airway obstruction
Suction (or manual removal of foreign material)
Oropharyngeal airway
Orotracheal intubation
Cricothyroidotomy

If there is any difficulty, or problems are anticipated, call for senior help. Do not delay establishing a patent airway while awaiting assistance. Intubation is not immediately necessary if a patent airway and adequate ventilation are achieved. Remember that infants (<6 months old) are obligate nasal breathers. The initial hour of resuscitation for the injured child frequently involves attention to respiratory rather than circulatory problems. Injured children, particularly with head injury may have altered consciousness or seizures, or may hypoventilate. Prompt assessment and rapid intervention are required to prevent hypoxia, secondary insult and progression to cardiopulmonary arrest. The important anatomic (Fig. 26.5) and physiologic aspects of the paediatric airway should be reviewed (see also Table 2.3). Key points The initial hour of resuscitation for the injured child frequently involves attention to respiratory rather than circulatory problems Equipment and assistance All hospitals dealing with seriously injured children should have readily available basic monitoring equipment. This includes pulse oximetry, end-tidal carbon dioxide (ETCO2), ECG and non-invasive blood pressure (NIBP). It is essential that all equipment be checked on a daily basis and also immediately prior to use. Minimum requirements for intubation are: 1. Oxygen (either cylinder or wall outlet) plus backup supply 2. Suction tubing, Yankauer sucker, Y-suction catheters 3. Paediatric breathing circuit: Either Bag-valve-mask of appropriate size Or T-piece circuit (Ayre’s or Jackson-Rees) 4. Face masks of various sizes according to age 5. Guedel oropharyngeal airways 6. Nasopharyngeal airways, laryngeal masks (optional) 7. Full range of endotracheal tubes and tape for fixation 8. Laryngoscopes Standard Macintosh (curved) blade Infant blade (many variations of straight blade) 9. Magill intubating forceps 10. Flexible introducers and stylets Many procedures performed on the injured child in emergency situations involve uncooperative patients who may be distressed by their injury, and by pain or anxiety related to the impending intervention, and by parental anxiety. When any airway intervention is required skilled assistance must be available and dedicated to the operator attempting to secure the airway. There should be ready access to equipment without leaving the patient. Other staff may be required to restrain the child or assist with other procedures. In the event of suspected cervical spine injury an additional person must assist by immobilising the neck. If there are any anticipated deviations from the usual procedure, then these should be outlined beforehand. In particular the assistant needs to be familiar with the technique of rapid sequence induction, endotracheal intubation and the use of cricoid pressure to minimize the risk of pulmonary aspiration of regurgitated stomach contents. Key points Many procedures performed on the injured child in emergency situations involve uncooperative patients who may be distressed by the injury Oropharyngeal (Guedel) airway Size determined by placing flange adjacent to incisors; tip of airway should reach angle of mandible. Insert an oropharyngeal airway directly in a child less than 1 year of age using a tongue depressor, rather than upside down and rotating 180° as in adults so that it follows the contour of the tongue. If too large, may push epiglottis over larynx; if too small may obstruct against back of tongue. Only tolerated if consciousness and protective reflexes are impaired, otherwise gagging, coughing or laryngeal spasm may occur. Nasopharyngeal airway This is a soft rubber or plastic, flanged tube that is gently inserted (well lubricated) via a nostril so that tip lies above laryngeal inlet. Great care is needed during insertion to prevent mucosal damage or adenoidal bleeding. A shortened endotracheal tube, suitably fixed, can be used as a substitute but must be clearly labelled as being nasopharyngeal rather than tracheal. Bag-valve-mask ventilation The self-inflating bag with valve attaches to an endotracheal tube or facemask. Remember to turn on the oxygen supply so that the reservoir bag is inflated (provides up to 80% FiO2). Use an adult bag (1600 ml capacity) for children over 5 years old and the paediatric bag (500 ml) for younger children and infants. Self-inflating bags should be fitted with a pressure release valve (30-40 cm H2O pressure) that can be overridden if necessary. Only use an anaesthetic breathing circuit (eg the Ayre’s T-piece, Jackson Rees circuit) if you are experienced with it. In certain difficult airway situations, in particular the obstructed airway, the T-piece circuit affords better airway control than the bag-valve-mask. First establish a clear airway, using head position, chin lift or jaw thrust as necessary depending on the size and age of the child. Suction the airway if blood or secretions are present. Infants will generally maintain a better airway with the head in a neutral position, whereas the older child will require some extension of the atlanto-occipital joint. Gentle chin lift will usually clear the airway in a small child, providing the mouth is held open. In an older child more vigorous jaw thrust may be required, using support at the angle of the mandible. Choose a face mask, either a low dead-space Rendell Baker or the softer cushioned type mask (easier if inexperienced), that fits over the bridge of the nose and extends to the cleft between chin and lower lip. It is important that the fingers (thumb and index) used to hold the mask remain at the top (where the mask connects to the bag-valve) so that pressure is distributed evenly around the base of the mask, maintaining a seal. The remaining three fingers are used to support the jaw or chin, taking care not to place any force on the soft tissues under the chin as this will tend to force the tongue up against the palate, obstructing the airway. Commence ventilation at a rate appropriate to the age of the child, achieving adequate chest movement. Laryngeal mask airway Widely used during anaesthesia, this is useful for maintaining airway especially where intubation is difficult or personnel are unskilled in intubation. Consists of large bore tube with elliptical cuffed ‘mask’ on distal end which, following insertion, rests over larynx. Cuff may be gently inflated to seal off larynx, although this does not reliably prevent aspiration. Gentle ventilation may be performed, but care must be taken to prevent gastric distension. Requires care in insertion and fixation, as torsion will cause obstruction to airflow. It is not recommended if the operator is unfamiliar with its use. Use size 1 in infants under 12 months, size 2 in 6 months to 6 years, size 2½ in 6-10 years and size 3 in >10 years.

Endotracheal tube
This is the most practical way of establishing an artificial airway for ventilation or managing obstruction. However in the injured child there may be other reasons why endotracheal intubation may be required as outlines in Table 26.3.
The standard tube is soft, gently curved and has an opening (Murphy eye) at one end to reduce the risk of lung collapse if inadvertent endobronchial placement occurs. The proximal end has a standard 15 mm adaptor, which will fit on to a breathing circuit or self-inflating bag. Most tubes have markings to indicate the length from the tip of the tube, which is bevelled to facilitate placement. In most cases there is a glottic marking. Shouldered tubes cause laryngeal trauma and are best avoided.
Use tube size 2.5 mm internal diameter in pre-term infants <1.5 kg, 3.0 mm in term infants, 3.5 mm in 3-9 months old, 4.0 mm in 9-24 months old. From age 2 years, use the formula: Internal diameter (mm) = Age/4 + 4 Have tubes one size smaller and larger. Under the age of 8-10 years uncuffed tubes are used and there must be an audible leak around the tube to ensure there is not too much pressure on the subglottis. The optimal position for the tip of the tube is mid-trachea, as there is less likelihood of spontaneous extubation or endobronchial migration. This position is approximated using the formula: Length (cm at incisor teeth) = Age/2 + 12 for an oral tube (age + 10 for age 1-5) or: Length (cm at nostril) = Age/2 + 16 for a nasal tube (age + 13 for age 1-5) Confirm position by CXR as soon as possible. The tip should be level with the body of T2, or between the clavicular heads. At least two assistants are required. Always assume the child has a full stomach. Rapid sequence induction (using an anaesthetic induction agent and rapidly acting muscle relaxant, eg suxamethonium, rocuronium or vecuronium) together with cricoid pressure is performed to minimize the risks of vomiting and aspiration. Thiopentone (3-5 mg/kg) is the anaesthetic of choice but caution should be taken in hypotensive patients when lower doses (0.5-1.0 mg/kg) should be used. Alternatively, midazolam (0.1-0.2 mg/kg) or the dissociative anaesthetic ketamine (1-2 mg/kg) may be preferred if the patient is hypotensive. Intubation Endotracheal intubation provides the following advantages: 1. Ensures lungs are ventilated while minimising gastric distension 2. Permits higher ventilatory pressures, hyperventilation and use of PEEP 3. Protects airway from aspiration of gastric contents, blood or secretions 4. Allows endotracheal administration of drugs (adrenaline, atropine) if no IV access 5. Allows suction of airway to remove secretions 6. Frees up operator (less skill required to squeeze bag) 7. Allows access to head and neck, eg assessment, venous access 8. Humidification can be provided 9. Easy to induce anaesthesia Visualization of the larynx requires alignment of three axes: oral cavity, pharynx and trachea, achieved by correct head positioning and then using a laryngoscope to displace the tongue and soft tissues while elevating the epiglottis to reveal the laryngeal inlet. For correct head position when a cervical spine injury is not a problem, extend the atlanto-occipital joint while flexing the lower cervical spine (‘sniffing the morning air’), by placing a small pillow or folded towel under the head but not the shoulders. In infants who have a larger occiput this position is achieved without a pillow, providing the head remains in the neutral position. Older children will require manual extension of the head by placing a hand on the occiput and as the head is extended the mouth opens allowing the laryngoscope to be inserted. Infants require the palm of the right hand to rest on the forehead, preventing excessive mobility, and thumb/index fingers to open the mouth. The technique for oral intubation in a trauma patient is somewhat different. The child is supine on a spinal board with a semi-rigid collar in place. Drugs are given as needed. Before paralysing the patient the anterior half of the collar is removed, and one assistant applies cricoid pressure as another holds the head in neutral position. Positive pressure ventilation may be applied with bag, mask and oxygen to pre-oxygenate in the unconscious child with cricoid pressure applied to ensure ability to ventilate. Cricoid pressure will keep gas out of the stomach. The pressure required is quite firm, such that, if applied to the bridge of the nose, would cause some discomfort in an awake person. It is best applied using index finger and thumb (or one finger alone in an infant), pressed firmly backwards against the cricoid cartilage, but not so firm that laryngeal anatomy is distorted. When muscle relaxation is achieved, oral intubation is performed, while in-line immobilization and cricoid pressure are maintained. Auscultation of both the axilla and over the epigastrium confirms correct endotracheal tube position. The cervical collar is reapplied, the tube taped, an oral airway can be inserted and positive pressure ventilation continued. Key points The technique for oral intubation in a trauma patient is somewhat different Rapid sequence intubation Rapid sequence induction is where anaesthetic and muscle relaxant are given and then airway is secured as rapidly as possible to minimize the risk of regurgitation and aspiration. It relies on the use of cricoid pressure to compress the oesophagus against the vertebral column. Cricoid pressure may also be used in unconscious patients during bag and mask ventilation to reduce gastric distension. Cricoid pressure should not be confused with the use of laryngeal pressure to bring the vocal cords into view during a difficult intubation. The correct method for rapid sequence intubation is: 1. Pre-oxygenate for 3 minutes. Have sucker working and next to patient’s head. 2. Give atropine 20 µg/kg (minimum 100 µg) in children <8 years old. 3. Give thiopentone / suxamethonium rapidly using pre-calculated dose, preferably into a running IV infusion to speed up onset. 4. Assistant applies cricoid pressure as consciousness is lost. 5. Intubation performed after suxamethonium fasciculation seen (noting that some infants may not fasciculate with suxamethonium) while cricoid pressure maintained. 6. Once intubation accomplished and confirmed, release cricoid pressure and fix tube. 7. If intubation is unsuccessful maintain cricoid pressure, oxygenate with bag and mask while allowing patient to wake up. Release cricoid only on return of reflexes or consciousness. 8. Seek further expertise before attempting intubation again. 9. Place gastric tube as soon as ETT in place and secured. Nasotracheal intubation Nasotracheal intubation is not routinely recommended for the injured child although there may be an occasion where this technique is preferred to secure the airway. Nasotracheal intubation requires considerable practice and experience particularly when performed in smaller children. In the injured child with an undifferentiated head injury in whom a base of skull fracture with disruption of the cribriform plate has occurred but not identified, there is a small risk of passing the endotracheal tube into the cranial cavity. The reasons for changing the tube are as follows: Long term fixation of a nasal tube is easier and more secure, especially when an intubated child requires transfer by air or road. Suction is easier via a nasotracheal tube, and the patient cannot bite on the tube. An awake patient, eg weaning prior to extubation, tolerates a nasal tube better. In addition to equipment for oral intubation, have a Magill forceps and tape pre-cut for fixation. Fixation is best achieved using two 5-10 cm long × 2.5 cm wide tapes prepared as ‘trouser legs’, ie split longitudinally for half their length. Intubation is accomplished in much the same manner as before, with the following differences: Ensure the patient is well sedated and muscle relaxed and pre-oxygenate for a few minutes via the OTT. A nasogastric tube should be in place. Use cricoid pressure if there is any likelihood of a full stomach. The tube (well lubricated) is gently inserted via the nostril (right side preferred) backwards not upwards until it lies in the nasopharynx before laryngoscopy. A nasal vasoconstrictor may be applied beforehand to reduce the risk of bleeding. Consider softening a PVC tube in warm water to minimize nasopharyngeal trauma. Visualize the larynx and advance the tube to the larynx. Withdraw the OTT. Gentle manipulation of the laryngoscope can then be used to align the larynx with the advancing tube. It is important to maintain the head in a neutral, even slightly flexed, position at this stage. Excessive extension displaces the laryngeal axis upward, making alignment with the tube difficult. If necessary use the Magill forceps to grasp the distal end of the tube and assist its passage into the larynx. At this point the tube tip sometimes gets caught on the anterior commissure of the larynx, and slight flexion may assist in re-aligning the tube. Once correct position is established using the criteria previously mentioned secure the tube using interlocking adhesive ‘trouser leg’ tapes following application of tincture of benzoin. As with oral intubation it is important to avoid hypoxia. Re-oxygenate with 100% oxygen and bag-valve-mask in the event that intubation is not successful. Cricothyroidotomy Cricothyroidotomy is the next option if intubation is not possible, eg due to massive facial fractures. Surgical cricothyroidotomy is restricted to children older than 12 years. Needle cricothyroidotomy, using a 14-18 gauge cannula, is indicated in younger children. Both procedures are temporising measures. All children requiring a cricothyroidotomy should have a surgical tracheostomy within two hours. Disadvantages of this technique include difficulty in ensuring correct entry to trachea, damage to larynx or trachea, and insufficient exhalation in an obstructed patient. It may however be life saving while a tracheostomy is performed. It is of no use if the obstruction is below the cricoid level, eg tracheal foreign body. As the cricoid is the narrowest part of the paediatric airway it is quite possible that cricothyroidotomy will not provide access to the trachea if a foreign body is impacted at this level. If this occurs it is recommended that the patient be intubated and the endotracheal tube used to force the foreign body into a main bronchus. The tube can then be withdrawn to mid-trachea and ventilation can proceed on one lung pending urgent bronchoscopy. With neck extended stabilize trachea using thyroid cartilage. Locate cricothyroid space below lower border of thyroid cartilage. Puncture cricothyroid membrane using large bore (14 or 16 G) IV cannula connected to 2 ml syringe and inserted at 45 inferiorly and caudally. Aspirate air to confirm correct placement; withdraw trocar from cannula. Connect a T-piece circuit with O2 (15 l/min) via a 3 mm endotracheal tube fitted directly into the IV cannula. Alternatively, cut off the end of an IV giving set, insert into the cannula, attach oxygen tube to the cut end and use the side injection port (also cut off) to administer intermittent positive pressure with your thumb on the cut end, one second on and four seconds off. Note that you still cannot ventilate adequately for long periods using such a small calibre airway. The technique is difficult to perform in a child <2 years old because of the shorter neck, and ventilation through small bore cannulas may be inadequate. Techniques using high flow jet ventilators are unsuitable in this setting and generate very high pressures in the young child, with risk of barotrauma. After age 12 years it may be easier and quicker to use a surgical approach: use a scalpel to cut transversely through to the cricothyroid membrane, open up the space with the handle and insert an endotracheal tube of appropriate size, although there may be small risk to deeper structures. This will also provide better gas exchange. Key points The technique is difficult to perform in a child <2 years old Airway problems in trauma management Head injury is a leading condition requiring airway intervention in our institution (Hahn et al. 1988). Proper initial management of the airway is fundamental to improving outcome, in particular the early correction of hypoxia and hypercapnia and the ability to induce hypocapnia as method of reducing ICP. This almost always requires endotracheal intubation using a rapid sequence technique and then commencing ventilation to improve oxygenation and normalize carbon dioxide levels. Adequate anaesthesia must be provided to cover intubation in order to prevent a sudden increase in ICP. Muscle relaxation alone is inadequate. At all times consider the possibility of cervical spine injury and an assistant should maintain in-line cervical immobilization (in a neutral position) during intubation to avoid exacerbating spinal cord injury. Cervical spine injury in children and has a high mortality and morbidity. In general, children requiring intubation can be safely managed using the standard technique for rapid sequence induction, using in-line immobilization in the neutral position without traction. While it may be preferable to intubate using an awake blind nasal or fibre-optic technique this is rarely possible (or desirable) in the injured child. It would seem prudent to allow the most accomplished operator available perform the procedure, and to avoid excessive movement or pressure on neck structures. Faciomaxillary injury may require urgent intervention to secure the airway, as swelling may worsen if intubation is delayed. Blood in the airway may make visualization difficult, and the mobility of tissues and anatomical disruption contribute to problems with ventilation using a bag and mask prior to intubation. In severe injury, eg LeFort III and bilateral mandibular fractures airway obstruction may be improved by positioning the child on their side or semi-prone with traction on mobile structures. Once anaesthesia is induced it is usually possible to displace free-floating structures using the blade of the laryngoscope. There is usually the added problem of a stomach full of swallowed blood and the risks of cervical spine injury. If obstruction is severe it may be necessary to perform an urgent tracheostomy under local anaesthesia unless expertise exists for other means of securing the airway. Airway burns may contribute to respiratory problems in several ways: carbon monoxide poisoning, oedema of the upper airway and direct thermal injury to the tracheobronchial tree from inhalation of hot gases. As a late development eschar may cause chest wall contraction and impede ventilation. 100% oxygen should be administered in the presence of suspected carbon monoxide poisoning. Close observation is essential and if there is evidence of severe airway burns early intubation and assessment with fibre-optic bronchoscopy is mandatory, as swelling may preclude later intubation if obstruction becomes severe. Key points Proper initial management of the airway is fundamental to improving outcome Breathing Assessment Expose the chest and neck. LOOK for signs of respiratory distress such as cyanosis, tachypnoea, flaring of the alae nasi, use of accessory muscles. Observe the degree and symmetry of chest wall excursion. Look for external signs of trauma such as contusions, abrasions or the paradoxical movement of a flail segment. Check the neck veins for distension. FEEL for the trachea for its relationship to the mid-line. Palpate the chest for subcutaneous emphysema and areas of tenderness. LISTEN for breath sounds. Are they normal and symmetrical? Are the heart sounds normal? Listen for grunting, stridor or wheeze. Life-saving procedures Administer high flow oxygen (12 litres/min) via a reservoir facemask, or assist ventilation with a bag-valve-mask if required. Nasal prongs do not deliver sufficient oxygen but may be a compromise in a distressed, combative child who does not allow a mask to be used. Tension pneumothorax (Fig. 26.8) is a clinical diagnosis and should immediately be relieved by inserting a 14-18 gauge over-the-needle catheter into the second intercostal space in the mid-clavicular line. Subsequently, insert a chest tube in the 4th or 5th intercostal space in the anterior axillary line. It must be remembered that once the chest has been needled to drain a pneumothorax that a chest drain is mandatory. Relieve a massive haemothorax by inserting a chest tube and administering IV fluids for resuscitation. Treat a flail segment by inserting a chest tube, even if a pneumothorax is not initially seen on CXR. Intubation may be required for associated pulmonary contusion. Cover an open pneumothorax with an occlusive dressing that is taped on three sides; this produces a ‘flutter-valve’ effect which allows air to escape from the pleural cavity on exhalation, but prevents air from entering on inspiration. Insert a chest tube at a site remote from the open wound. Appropriate sizes for chest tubes in children are: • Size 12 in infants • Sizes 16-20 in 2-10 year olds • Sizes 24-28 in 11-16 year olds Use the larger diameter tube that will pass through the intercostal space when draining a haemothorax. Assisted ventilation If breathing is inadequate, assist ventilation with a T-piece bagging circuit or self-inflating bag-valve device. For the experienced practitioner, a compressed gas driven ventilator, eg Dräger Oxylog may be used to ventilate children over 1 year of age (pressure limiting valve is used when ventilating infants). Guidelines (Rubin and Sadonohoff 1996): 1. Start with tidal volume = 10 ml/kg 2. Rate = 20/min (30/min for infants) 3. Peak airway pressure = 20 cm H20 4. Check arterial blood gases 5. Maintain paCO2 = 35-40 mmHg (30-35 mmHg if head injury) Always exclude hypoxaemia or hypovolaemia if the child is agitated and/or confused. Ventilation difficulties may be due to: • Struggling child • Gastric distension • Airway obstruction • Massive aspiration • Direct laryngeal injury • Pneumothorax with increased airway pressure • Laryngospasm • Massive pulmonary artery obstruction Key points Always exclude hypoxaemia or hypovolaemia if the child is agitated and/or confused. Circulation Life-threatening injuries Immediate life-threatening injuries are massive internal and/or external haemorrhage, cardiac tamponade and tension pneumothorax. Cardiac output is the volume of blood pumped by the heart each minute (heart rate x stroke volume), while stroke volume is the volume pumped with each contraction. In younger children the stroke volume is relatively fixed with cardiac output primarily reliant on heart rate. Blood pressure is determined by cardiac output and peripheral vascular resistance. Normal blood pressure can be maintained (Fig. 26.9) as long as the circulation compensates adequately with vasoconstriction, tachycardia, and increased cardiac contractility. When compensation fails hypotension occurs. Tachycardia persists until pre-arrest. Key points Immediate life-threatening injuries are: • massive internal and/or external haemorrhage, • cardiac tamponade and • tension pneumothorax If tachycardia in children is overlooked then shock may go unrecognized. Although cardiac output falls in an almost linear fashion as blood volume is depleted, blood pressure remains initially unchanged because of increased vascular resistance. Hypotension is often a late and sudden sign of cardiovascular decompensation in seriously injured children and young adults. Even mild hypotension must be taken seriously and treated quickly and aggressively since cardiopulmonary arrest is often imminent. A further consequence of this robust cardiac response to haemorrhage in children is the degree of peripheral vasoconstriction that may occur. Many injured children in a compensated shocked state will be pale and shut down due to vasoconstriction. Capillary refill is often prolonged early on in seriously injured children who have compensated shock, provided ambient temperature is accounted for when assessed. This increase in peripheral vascular resistance and associated vasoconstriction makes intravenous access extremely difficult in seriously injured children. Key points If tachycardia in children is overlooked then shock may go unrecognized Intravascular access (Fig. 26.10) Drug administration requires access to the circulation. If no access is present or the cannula has extravasated or become blocked, then peripheral venous cannulation should be performed. If peripheral venous cannulation attempts are unsuccessful within 90 seconds, then alternative vascular access is obtained via the intraosseous route. The antero-medial surfaces of the proximal or distal tibia are suitable sites. The needle is inserted perpendicularly to the bone surface and a screwing action is used to traverse the cortex. A loss of resistance is felt once the marrow is entered. Correct positioning of the needle, confirmed by aspiration of bone marrow or injection of saline without extravasation, is necessary to avoid compartment syndrome. When resuscitating through the intraosseous route it must be remembered that in order for fluids to be infused they will need to be pump through. Contraindications to the intraosseous route are few, however it should be avoided in the case of a significant or open fracture of the extremity (Rupert et al. 1994). The 18-gauge needle is for use in infants and small children. The 16-gauge needle is designed for older children. All drugs and resuscitative fluids may be given via the intraosseous route but only adrenaline, atropine, lignocaine and naloxone may be given via the endotracheal tube. Central venous cannulation via the subclavian or internal jugular veins should be reserved for the post-resuscitation phase. However cannulation of the external jugular or femoral veins may be attempted during resuscitation. Surgical cutdown on to a vein remains an alternative but is also time consuming. Assessment Shock (Fig. 26.11) is a clinical syndrome that results from tissue perfusion that is inadequate to meet metabolic needs. Clinically, it is manifest by changes in haemodynamic measurements, tachypnoea and poor perfusion of the skin, brain and kidneys. Shock can exist with a normotension, hypotension or hypertension. Blood pressure, pulse rate and respiratory rate are age dependent (Appendix M). Systolic BP = 80 + (2  age in years). Diastolic pressure is usually two-thirds of the systolic measurement. Children compensate extremely well for hypovolaemia. The first sign of hypovolaemia is narrowing of the blood pressure (rising diastolic pressure). Systolic hypotension occurs very late and indicates severe hypovolaemia (up to 40% of blood volume loss). Tachycardia is a very sensitive, but not specific, marker of shock. Assess pulse rate, pulse volume and the presence of distal pulses. Bradycardia is a preterminal event. Assess skin for colour, temperature, clamminess and capillary refill time (normal <2 seconds but varies according to the ambient temperature and is very observer dependent). Tachypnoea is frequently associated with hypovolaemia. Assess for ‘air hunger’ (hyperpnoea and tachypnoea). Cerebral hypoperfusion may present as depressed consciousness, lethargy, agitation or hypotonia. There may be thirst and poor urine output (<1 ml/kg/hr for infants, <0.5 ml/kg/hr for older children). Cardiac tamponade classically presents with Beck’s triad, ie systolic hypotension, jugular venous distension and muffled heart sounds. Symmetrical breath sounds and a midline trachea excludes tension pneumothorax. Life-saving interventions (Table 26.5) 1. Give high flow oxygen, monitor continuous ECG, pulse oximetry and continuous to 3 minutely non-invasive blood pressure monitoring. 2. Control haemorrhage by: •Applying direct pressure to external bleeding sites. Tourniquets should be removed as soon as possible. •Reducing fractures as soon as possible. •Recognising haemorrhage that is uncontrolled or uncontrollable and arrange urgent intravascular access and surgery. 3. Restore circulating volume. Insert two short-length, large bore IV cannulas into a large proximal vein eg cubital fossa. Collect blood for laboratory tests and cross-match. Administer warmed fluids immediately (colloid, eg Haemaccel 20 ml/kg or crystalloid, eg Hartmann’s solution 20 ml/kg). If a patient fails to respond to a second bolus, then blood (whole blood 20 ml/kg or packed cells 10 ml/kg) is required (Table 26.4). In small infants/children with refractory shock a blood glucose level should be performed early on in the resuscitation. 4. If packed cells are used, volume is made up using saline, plasma or 5% albumin. If the child is stable and blood will be available within 10-15 minutes, wait for fully cross-matched blood. If unstable, type specific blood may have to be used. If a delay of even a few minutes is critical, group O-negative blood is given. 5.Cardiac tamponade unresponsive to fluid loading is treated with urgent pericardiocentesis. Arrange rapid transfer to the operating theatre for urgent thoracotomy. Technique for pericardiocentesis: Place child supine and upright at 30-45. Ensure airway and ventilation are optimized. Continue volume loading. Prepare with antiseptic solution and infiltrate the area just below the xiphoid process with 1% lignocaine. Attach a 16-21 gauge cardiac or spinal needle to a stopcock and a 20-50 ml syringe. Attach an alligator clip leading to a precordial lead of the ECG monitor to the needle’s hub. Insert the needle just below the xiphoid process at 60-70 to the horizontal, aiming at the left shoulder, advancing slowly while maintaining gentle suction to the syringe. Advance until pericardial fluid is aspirated or epicardial contact is made as indicated by an injury pattern (ST or PR elevation or T-wave inversion). Withdraw the needle until the ECG pattern normalizes and re-advance at a more medial angle. Aspirate fluid to relieve tamponade and then insert a soft catheter via a guide-wire to allow for continued drainage. Complications of pericardiocentesis include myocardial penetration, coronary artery laceration, arrhythmias, pneumothorax and infection. 6. Military anti-shock trousers (MAST suits) are no longer recommended for use in the haemodynamically unstable patient. Their main use is pre-hospital splinting of pelvic and long-bone fractures. Occasionally, children arrive with a MAST suit on. The management of this situation is: If the suit is deflated remove it. If one leg compartment is inflated to splint a fracture, leave it inflated until the limb is examined. The suit should not be inflated for more than 90-120 minutes. If the suit is inflated for hypovolaemic shock: Insert two large bore IV cannulas and give volume replacement rapidly. Slowly deflate the abdominal compartment followed by lower limb compartments. Deflate about 1/3 of volume at a time, then recheck blood pressure. Stop deflating if systolic blood pressure drops by >10 mmHg and give more volume replacement.

Key points
Military anti-shock trousers (MAST suits) are no longer recommended for use in the haemodynamically unstable patient

Disability
Assess level of consciousness with the AVPU mnemonic:
A Alert and oriented
V responds to Verbal stimuli
P responds only to Painful stimuli
U Unresponsive

Note pupillary size and reaction to light. A unilateral, fixed dilated pupil may indicate the presence of an acute extradural or subdural haematoma. Bilateral, fixed dilated pupils indicate more serious traumatic or hypoxic brain injury.
Note any gross asymmetry in movement. A more detailed neurological examination is performed in the secondary survey. Mentally alert or aware, Pupillary activity and size should be noted.

Exposure
Undress the child fully to allow examination of the entire body. Monitor core temperature via a rectal probe.
Expose the child only as long as it takes to complete the physical examination. Maintain normothermia by using warmed IV fluids, blood warmers, warm blankets and overhead heating lamps.

By the completion of the Primary Survey and Resuscitation the patient should be connected to the following ‘lines’ for monitoring and treatment:
Oxygen via mask or endotracheal tube
End-tidal CO2 monitor if ventilated
Nasogastric or orogastric tube
Large bore IV cannula ×2
Sphygmomanometer
Pulse oximeter
ECG monitor
Chest tube
Rectal temperature probe
Urinary catheter. Examine the perineum and rectum for urethral trauma prior to insertion. Perineal haematoma, urethral meatal blood or a high-riding prostate on rectal examination indicate likely urethral trauma and contraindicate urethral catheterization. Suprapubic catheterization would be required.

Secondary survey
The important aspects of the secondary survey are:
Continuing resuscitation and monitoring. Any deterioration mandates immediate return to the airway, breathing and circulation (ABCs).
History. An AMPLE history should be obtained from the child (if possible), family, ambulance personnel, friends and bystanders:
A Allergies
M Medications, including tetanus immunization status
P Past medical history
L Last ate or drank (time)
E Events/environment related to the injury
Head to toe examination. Perform a systematic head-to-toe, front-and-back examination to detect any injuries not noted in the Primary Survey. Assess each region of the body including the ears, nose, mouth, rectum and pelvis using the ‘look, feel, listen’ and ‘tubes and fingers in every orifice’ approach. In young children, if rectal or internal vaginal examination is required, then it may be prudent to have it performed once by the most senior clinician or while the child is under general anaesthesia. The sequence of examination is:
Head
Face
Neck
Chest and shoulder
Abdomen
Pelvis
Lower limbs
Upper limbs
Central nervous system (include Glasgow coma scale, GCS)
Back
Perineum and rectum

Secondary survey
Reassess the ABCDE of the primary survey regularly or as indicated
Head: Check pupillary size, conjunctiva, reaction of pupils, fundal appearance and vision. Examine face for maxillofacial trauma. Check dentition. Examine scalp for laceration of soft tissue injury. Look for signs of basilar skull fracture. Check for symmetry of voluntary movement and neurological function of facial muscles.
Neck: Palpate cervical spine. Check for subcutaneous emphysema, abnormal tracheal position, haematoma, and localized pain. Evaluate neck veins for distension.
Chest: Check for bilateral chest excursion, asymmetry of wall motion, and flail segment. Palpate trachea midline. Palpate chest. Auscultate lung fields and cardiovascular system.
Abdomen: Repeated measurement of girth may help diagnosis of unsuspected bleeding. Inspect for ease of movement with respiration, bruises, lacerations, and bowel sounds. Palpate for localized findings. Observe and palpate flanks.
Pelvis: Palpate bony prominences for tenderness or instability. Check for laceration, haematoma, and active bleeding. Check urethral meatus for blood.
Rectum: Should be examined by a surgeon or a person responsible for the child’s care only once, checking for sphincter tone. If urethral damage is considered then the level of the prostate should be noted.
Extremities: Check for signs of fracture, dislocation, abrasion, contusion, and haematoma. Note bony instability.
Back: Examine only if spinal cord injury is not suspected.
Skin: Look for petechiae, burns, and contusions.
Neurological: In depth neurological examination including a Glasgow Coma score.

Explanatory notes for paediatric coma scale
In clinical practice because the GCS is universally used and understood in adult emergency practice in many cases extrapolate of this 3-15 score occurs to children. The concern here is that such extrapolation is at best an approximation of the child’s level of consciousness rather than an objective representation of the child’s clinical state. Although this score has not been validated we have found the modification for children of the GCS useful and highly accurate for use early on during resuscitation and stabilization.

Investigations:
a) Laboratory tests: most of these specimens should already have been collected during the resuscitation phase.
Full Blood Count
Cross-match
Coagulation studies
Electrolytes, urea, creatinine
Liver function tests. Sensitive and specific for hepatic trauma
Amylase. Not sensitive, not specific for pancreatic injury
Glucose
Creatinine Kinase. Relevant for myocardial contusion, crush injury
Arterial Blood Gases
Urinalysis for blood and myoglobin.
b) Radiology: trauma series. Most injured patients require three X-rays in the resuscitation room.
Chest X-ray
Lateral cervical spine X-ray. A normal lateral X-ray does not exclude cervical spine injury. Other views are Antero-posterior and Odontoid. Immobilization of the spine must still be maintained until more definitive assessment.
Pelvis
Other radiological investigations that may be required in the trauma patient include:
CT scan, eg head, abdomen, chest, spine (Table 26.7)
Full cervical spine series
X-rays of the extremities, thoracic spine, lumbo-sacral spine
Skull X-ray
Sternum X-ray
Urethrogram (for suspected urethral injury)
Cystogram (for suspected bladder injury)
Angiogram for suspected arterial injury; rarely, arch aortogram for suspected injury to the thoracic aorta.

Special exams
Liver/spleen scan
Pyelogram
Compartment pressure measurement
Echocardiogram
ECG in cases of chest trauma with suspected myocardial contusion.

Definitive care
After completion of the secondary survey the following issues need to be addressed:
1. Response to resuscitation
2. Prioritize injuries according to, immediate threats to life and, possible morbidity (in descending order of importance):
Airway/breathing derangement
Haemorrhage with shock
Intracranial space-occupying haemorrhage
Contained aortic disruption
Spinal cord compression
Vascular injury with distal ischaemia
Ruptured hollow viscus
Ocular injuries
Open or displaced fractures
Contaminated wounds
Other
3. Analgesia:
• Treat the cause of pain if possible, eg finding a position of comfort for a fractured limb.
• Intravenous morphine titrated carefully will relieve severe pain. The intramuscular route should be avoided if possible as the absorption may be somewhat unpredictable and erratic in the seriously injured child. Commence with a dose of 0.1-0.2 mg/kg. It does not usually mask clinical signs. Be cautious in hypotensive or lethargic children with head injury.
• Regional blocks can be very effective, eg femoral nerve block for femoral fracture.
• Nitrous oxide may be a useful adjunct, especially in orthopaedic injuries. It has been used in children as young as 16 months in the emergency department. Avoid use in head injury, pneumothorax or eye injuries.
4. Tetanus status (Table 26.8): if the child has received three doses of DTP and the last dose was administered within five years, no further action is required. Otherwise, a tetanus toxoid booster is required. If the child has not been fully immunized, or there is a doubt about immunization status, then a tetanus immunoglobulin should be administered in addition to a tetanus toxoid (use separate syringes and inject at different sites).
5. Antibiotics: give a first generation cephalosporin or penicillinase-resistant penicillin for open fractures, penetrating joint injuries, large contaminated soft tissue injuries and penetrating eye injuries. If severe penicillin allergy exists, consider clindamycin or erythromycin. Penetrating abdominal injuries and perforated hollow viscera require broad spectrum antibiotics, eg gentamicin, amoxycillin and metronidazole.
6. Fractures and dislocations: splint and, if necessary, reduce orthopaedic injuries in the Emergency Department. Early reduction will be required especially if there is neurovascular compromise.
7. Wound management: clean, dress and cover open wounds to reduce the likelihood of infection. Suture lacerations as indicated.

Trauma arrest
The outcome from children with an out-of-hospital cardiopulmonary arrest remain poor (Basket 1989, Hazibnski et al. 1994). This is also true of children who have suffered blunt trauma and are in cardiopulmonary arrest from the time of the injury. Underlying conditions to exclude if an “on the scene” arrest has occurred with a response to treatment in the pre-hospital setting include children with serious neurological injury from a major head injury or those having juvenile cervical spine injury or SCIWORA. These injuries are mostly associated with an extremely poor prognosis and this issue should be addressed. In general, trauma patients who deteriorate to the point of cardiopulmonary arrest have a poor outcome (Schoenfield and Baker 1993).

The only exception are young patients who have suffered penetrating trauma such as a stab wound to the chest who lose their vital signs in the emergency department or immediately prior to arrival.

Managing a trauma arrest follows the principles of advanced life support with a focus on volume replacement and controlling haemorrhage. Commence CPR, intubate, ventilate with 100% oxygen and insert two large bore cannula or intraosseous needles and rapidly infuse volume at 20 ml/kg aliquots. Decompress both hemithoraces either by needle thoracocentesis followed by intercostal tubes or by intercostal tubes alone. Assess the rhythm on the ECG and treat appropriately in children (Goetting 1995). The most common underlying rhythm disturbances leading to cardiopulmonary arrest in children are asystole/bradycardia and electromechanical dissociation or pulseless electrical activity (APLS 1996, Colucci and Somberg 1994). The underlying cause in almost all cases is profound hypovolaemia due to multiple injury. Unexpected hypoxia due to poor airway control should never be a cause for cardiopulmonary arrest in children in this day and age. The treatment of these rhythm disturbances uses standard protocols (Fig. 26.12). If no response then give volume to a total of 20 ml/kg. If the neck veins are distended or there is a strong suspicion of tamponade, perform a needle pericardiocentesis or go straight to thoracotomy or sub-xiphoid window. If the pericardiocentesis is successful arrange immediate transfer to surgery. It is important to remember that fluid volume resuscitation throughout the management of the cardiopulmonary arrest with crystalloid or preferably whole blood must be aggressively pursued using two large bore intravenous cannulas.

Key points
The outcome from children with an out-of-hospital cardiopulmonary arrest remain poor

Post-resuscitation stabilization
In the case of the injured child post-resuscitation stabilization will entail continued supportive therapy together with urgent transfer to the emergency operating suite. This care will need to be continued in the operating theatre, which should be prepared at the time the trauma call is put out. In most cases the cardiopulmonary arrest has occurred due to hypovolaemia as a result of near fatal injuries and every member of the trauma team will need to be involved.

Once in the intensive care unit post-resuscitation stabilization will usually entail continued supportive therapy. Continuing support will usually include mechanical ventilation with supplemental oxygen, insertion of central and arterial lines, inotrope infusion, antiarrhythmic agents, fluid therapy and possibly renal support (continuous veno-venous haemofiltration, peritoneal dialysis).

The cause of the cardiopulmonary arrest should be corrected if possible. Complications of resuscitation should also be sought, particularly if secondary deterioration occurs. A chest X-ray should be performed to check the ETT position and central venous catheter position, to exclude pneumothorax, lung collapse or aspiration and to check the cardiac outline. Investigations should include full blood count, arterial blood gas and serum biochemistry.

As earliest as possible, assessment of any neurological damage should be sought.

Emergency department thoracotomy
Emergency department thoracotomy as a technique for resuscitation of moribund thoracic trauma patients became popular in the 1960’s. Emergency department thoracotomy is a controversial procedure in children and is not practiced at our institution. Enthusiasm for this procedure has waned as evidence has accumulated that these patients do not benefit from the procedure. In blunt trauma the evidence for any benefit is very scant indeed with dismal survival rates of less than 1% in better studies (Balazs 1983). We believe that resources are best placed into areas where returns will be higher such as better pre-hospital trauma care and improving trauma systems. The resources and organisation that needs to be available to preform this technique 24 hours a day are often beyond even the financial scope of major trauma centers. It must be left up to the particular institution to weigh up the benefits of such an approach. If penetrating trauma makes up a large component of the daily trauma workload, benefits may occasionally be seen from emergency department thoracotomy.

Children with blunt trauma who sustain cardiopulmonary arrest at the scene of the injury and in whom CPR does not result in return of cardiac function are almost uniformly unsalvageable, and do not benefit from ED thoracotomy (Sheikh and Culbertson 1993). Children with penetrating trauma who suffer loss of vital signs at the scene and have no electrical cardiac activity in the ED after standard CPR in the ambulance, do not benefit from ED thoracotomy, especially if the prehospital time is longer than 20 minutes (Millham and Gringlinger 1993). Paediatric trauma resources are better placed in other more productive areas such as injury prevention.

Cessation of resuscitation
Cardiac arrest in children has a poor outcome. The decision to stop resuscitation is based on a number of variables including the pre-arrest state, response to resuscitation, reversible factors, patient and parental wishes, likely outcome and opinions of experienced staff. Senior medical staff are responsible for the decision to terminate resuscitation and should almost always be consulted.

Transfer of the injured child
Adequate attention at the referring hospital to the ABCs of resuscitation by those most experienced in paediatric care is more likely to reduce morbidity & mortality than rapid transfer to a tertiary centre.

Reasons for transfer of children:
need for expert centralized care
need for specialist services only available in a children’s hospital
the remoteness of the referring hospital
resources available in referral hospital
type of service available in the referring hospital
designated transfer criteria.

Some considerations in the transport of critically ill children (McNab 1991):
patience and attention to detail will win the day
transport methods
types of transport teams, paramedic based, specialized, pressure to ‘scoop and run’
the ‘golden hour’ concepts does not apply to the transport of critically ill children
airway problems & respiratory compromise are the most common reasons for transport
50% of critically ill children require some form of airway intervention
airway either needs: protected or stabilized
accidental extubation should never occur.

Procedures performed prior to transport:
intubation 60%
reintubation 30%
repositioning ETT 50%
ventilation 50%
chest drain insertion 0.9%.

Optimal mode of ventilation of the transported patient:
hand ventilation had 75% incidence in changes in haemodynamic status and blood gases
hand ventilation may prove a problem in trying to duplicate the mechanical ventilator settings in children
for intrahospital transport, hand ventilation is acceptable. Use a ventilator for all others: eg Oxylog.

Mode of transport:
Ground transport: short to middle distance

Helicopter: medium to long distances, limited room, ensure child stable, hypovolemia corrected, air collections drained

Fixed wing aircraft: long journeys, ensure connectors are compatible, gas supplies adequate, and child stable. Factors to consider, space, speed of transport, cost, distance, severity of illness, safety to staff and patient.

Adverse events during transport:
respiratory events: 64%, accidental tracheal extubation, occlusion of the ET tube with secretions, secondary hypoxia from hypoventilation, acute airway obstruction other than secretions, acute gastric dilatation events during transport
cardiovascular events: 24%, hypertension, hypotension, cardiac arrest, hypothermia and related events
central nervous system events: 40%
24%, secondary brain insult, seizures.

Intrahospital transport can be the greatest threat to the trauma patient (Wallen et al. 1994). Intrahospital transport even in the best hands can result in adverse events for the trauma patient mostly being changes in vital signs, alteration in ventilation or oxygenation, equipment failure and most important the sequelae of unrecognized shock during a radiology procedure. The radiology suite is notorious in being the main area where an unstable or poorly differentiated trauma patient can come to grief, particularly if shock has not been anticipated or aggressively anticipated. The following rules may help:
pretransport coordination/communication, ie have a plan, prethink what may go wrong and formulate solutions
ensure personnel who accompany the patient are aware of potential problems and their solutions
ensure equipment to accompany the patient is in working order, fully charged and that adequate oxygen & air is available. Always be a “parasite” as far as electrical power and oxygen is concerned. Only use your own battery power or gases when absolutely necessary
monitoring during transport interhospital transport, pretransport coordination, communication, accompanying personnel, equipment
constantly monitor the ABC’s

Interhospital transport checklist:
copy all patient records and radiographs
obtain transport consent
secure vascular access and ETT
stabilize cervical spine and any fractures
prepare blood products
if indicated, provide laboratory telephone number for pending laboratory results
be aware of the capabilities of the transferring hospital
be aware of the support services available
ensure appropriate monitoring during transport
constant clinical evaluation

Key points
Intrahospital transport can be the greatest threat to the trauma patient

Conclusion
Trauma is the epidemic of the late 20th century. Although it still accounts for a large number of paediatric deaths these have reduced in many western countries over the last decade. This has come about through a number of factors including improved trauma care, trauma systems and better pre-hospital care for injured children. However one area that continues to be important in reducing morbidity and mortality from trauma in children is injury prevention. Various prevention strategies such as wearing of helmets, seat belts to name just a few have in many countries made a significant impact on reducing death rates and morbidity related to trauma.

However, despite the best prevention strategies, children will continue to be injured and therefore the knowledge, skills and resources will always be needed to resuscitate and stabilize seriously injured children.

Key points
Trauma is the leading cause of death in children over one year of age
AIS, ISS, PTS and revised Trauma Score are classifications for describing site and severity of multiple trauma
Management of trauma is prioritized: primary survey (ABCDE) and resuscitation, secondary survey then definitive care

Resource:

http://www.worldortho.com/dev/index.php?option=com_content&view=article&id=2145:electronic-textbook-injuries-chapter-43-child-resuscitation&catid=1:latest

WHO approves Glaxo’s swine flu vaccine

The Associated Press
LONDON — Drug giant GlaxoSmithKline says one of its swine flu vaccines has been certified by the World Health Organization, making it available for donors to buy for developing countries.
In a statement issued Tuesday, GlaxoSmithKline PLC said WHO had approved its Canadian vaccine after examining its quality and safety data. The vaccine contains an adjuvant, a chemical compound to boost the immune system.

Last month, Glaxo advised health authorities not to use one batch of its Canadian-manufactured swine flu vaccine in case it triggered life-threatening side effects like anaphylactic shock.
Several vaccine makers have promised WHO 156 million doses of swine flu vaccine, which it hopes to start shipping to 95 poor countries this month.