Accidents and Accidents and PoisonsPoisons

Dr D. BarryDr D. Barry

POISONINGPOISONING

PoisoningPoisoning

Accidental;Accidental; pre-school age ( pre-school age (♂ > ♀)♂ > ♀)

Intentional;Intentional; > 9 years ( > 9 years (♀ > ♂)♀ > ♂)

Factitious / MFactitious / Münchausen by proxy ünchausen by proxy (rare)(rare)

IathrogenicIathrogenic

StatisticsStatistics

Accidental poisoning preventable Accidental poisoning preventable cause of morbidity and mortalitycause of morbidity and mortality

Ireland:Ireland: 3,000 annual poisons and 1,000 3,000 annual poisons and 1,000

admissions annually (1-4 yrs)admissions annually (1-4 yrs) 12 deaths 2001-200312 deaths 2001-2003

PoisoningPoisoning

National Poisons centre-Beaumount HospNational Poisons centre-Beaumount Hosp 20062006

Children<10yrs: Children<10yrs: 4466 enquiries/4726 4466 enquiries/4726 products.products.

Drugs, Household, Chemical Drugs, Household, Chemical products(cosmetic and personal hygiene)products(cosmetic and personal hygiene)

Adolescents10-19 yrs: Adolescents10-19 yrs: 899 899 enquiries/1490 products. Drugs, enquiries/1490 products. Drugs, industrial and household products industrial and household products (analgesics, anti-inflammatory)(analgesics, anti-inflammatory)

Accidental PoisoningAccidental Poisoning Infants and young children will drink or Infants and young children will drink or

eat ANYTHING!eat ANYTHING! If it looks interesting / smells good/ has a If it looks interesting / smells good/ has a

bright colour ----- They will eat / drink itbright colour ----- They will eat / drink it Substances taken are Medicines & Substances taken are Medicines &

Household Products; detergents, garden Household Products; detergents, garden agents, pesticidesagents, pesticides

Most are not taken in sufficient quantity to Most are not taken in sufficient quantity to cause harm cause harm

Children still die every year due to Children still die every year due to poisoningpoisoning

What age do children pick up What age do children pick up tablets?tablets?

What age can children open What age can children open doors/presses?doors/presses?

What age can children open What age can children open containers?containers?

Prevention: Safety Prevention: Safety InformationInformation

Child resistant containersChild resistant containers Out of reachOut of reach Lock up household substancesLock up household substances No chemicals under the kitchen sinkNo chemicals under the kitchen sink Childminders/Visitors as aboveChildminders/Visitors as above Dispose of out of date medsDispose of out of date meds Know what meds/products are in Know what meds/products are in

your houseyour house

PresentationsPresentations

Ingestion known/suspected Ingestion known/suspected Eg. toddler found by carer playing with tablets Eg. toddler found by carer playing with tablets

/ missing tablets from open container etc. / missing tablets from open container etc. Disclosure by teenager / family etcDisclosure by teenager / family etc

Symptomatic;Symptomatic; Reduced ConsciousnessReduced Consciousness Metabolic acidosis (high anion gap)Metabolic acidosis (high anion gap) ArrhythmiaArrhythmia GI upset (vomiting / abdo pain / anorexia etc)GI upset (vomiting / abdo pain / anorexia etc) SeizuresSeizures

HistoryHistory

What toxin/medication was takenWhat toxin/medication was taken Who was the witnessWho was the witness How much was takenHow much was taken What time was it takenWhat time was it taken What other medications or toxic What other medications or toxic

substance was available to the child substance was available to the child

Physical ExaminationPhysical Examination

Toxic syndromesToxic syndromes Anticholinergics Anticholinergics hot as a hare, dry as hot as a hare, dry as

a bone (dry mouth), red as a beet, blind a bone (dry mouth), red as a beet, blind as a bat (dilated pupils), mad as a as a bat (dilated pupils), mad as a hatter (delirium)hatter (delirium)

Organophosphates (cholinergic) Organophosphates (cholinergic) diarrhoea, diaphoresis, miosis, diarrhoea, diaphoresis, miosis, bradycardia, bronchosecretions, emesis, bradycardia, bronchosecretions, emesis, lacrimation, salivationlacrimation, salivation

Physical ExaminationPhysical Examination

Toxic syndromesToxic syndromes Cocaine/amphetamines Cocaine/amphetamines

(sympathomimetic) (sympathomimetic) mydriasis, mydriasis, tachycardia, hypertension, tachycardia, hypertension, hyperthermia, seizureshyperthermia, seizures

Narcotics Narcotics miosis, bradycardia, miosis, bradycardia, hypotension, hypoventilation, comahypotension, hypoventilation, coma

ManagementManagement

ManagementManagement

1)1) Stabilise patient / ResusStabilise patient / Resus2)2) Accurate history & calculate Accurate history & calculate

ingestioningestion3)3) Initial work-upInitial work-up4)4) Gastric Gastric

elimination/decontaminationelimination/decontamination5)5) Monitoring, levels, nomograms - Monitoring, levels, nomograms -

Discuss with Toxicology centreDiscuss with Toxicology centre6)6) Antidote etc.Antidote etc.7)7) Why / How did it happen follow-upWhy / How did it happen follow-up

1) Resuscitation1) Resuscitation AirwayAirway BreathingBreathing CirculationCirculation Cornerstone of management of acute Cornerstone of management of acute

poisoning is supportive carepoisoning is supportive care

2) Investigations2) Investigations

Full blood countFull blood count Urea, creatinine, electrolytesUrea, creatinine, electrolytes Blood glucoseBlood glucose Blood gasBlood gas Serum and urine for toxicologySerum and urine for toxicology

3) History3) History

What toxin/medication was takenWhat toxin/medication was taken Who was the witnessWho was the witness How much was takenHow much was taken What time was it takenWhat time was it taken What other medications or toxic What other medications or toxic

substance was available to the child substance was available to the child ((Who’s in the house & what meds Who’s in the house & what meds are they on?)are they on?)

4) Gastric 4) Gastric DecontaminationDecontamination

Gastric evacuationGastric evacuation Induction of emesisInduction of emesis Gastric lavageGastric lavage

Chemical decontaminationChemical decontamination Activated charcoalActivated charcoal CatharticsCathartics Whole bowel irrigationWhole bowel irrigation

NB NB – corrosive substances are – corrosive substances are particularly dangerous – seek expert particularly dangerous – seek expert advice first!advice first!

Induction of EmesisInduction of Emesis

Rarely done anymoreRarely done anymore Syrup of ipecac most commonly usedSyrup of ipecac most commonly used Induces vomiting in 20 - 60 minutesInduces vomiting in 20 - 60 minutes Contraindicated in:Contraindicated in:

infants less than 6 monthsinfants less than 6 months poor conscious statepoor conscious state diminished gag reflexdiminished gag reflex hydrocarbons, acids, alkalishydrocarbons, acids, alkalis

Gastric LavageGastric Lavage Large bore orogastric tube with Large bore orogastric tube with

normal saline irrigationnormal saline irrigation If conscious state is depressed, airway If conscious state is depressed, airway

protection with an endotracheal tube protection with an endotracheal tube prior to lavage is recommendedprior to lavage is recommended

Contraindicated in hydrocarbons, Contraindicated in hydrocarbons, acids and alkalis (risk of aspiration)acids and alkalis (risk of aspiration)

Most effective within 1 hour of Most effective within 1 hour of ingestion,ingestion,

Removes up to 40% of ingested toxinRemoves up to 40% of ingested toxin

Activated CharcoalActivated Charcoal Complex Molecule with large surface area; binds many Complex Molecule with large surface area; binds many

poisonspoisons Not indicatedNot indicated in heavy metal poisoning ( in heavy metal poisoning (iron,iron, lithium) lithium)

or ingestion of or ingestion of acid or alkaliacid or alkali where endoscopy may be where endoscopy may be required or required or alcohol ingestionalcohol ingestion

Promotes reabsorption from circulation into bowel & Promotes reabsorption from circulation into bowel & interrupt entero-hepatic circulation of some drugs interrupt entero-hepatic circulation of some drugs (aspirin, barbituates)(aspirin, barbituates)

Very unpalatable => give via NG / lavage tube (25-50g)Very unpalatable => give via NG / lavage tube (25-50g) typical dose SE; severe lung damage if aspiratedtypical dose SE; severe lung damage if aspirated Patient must be conscious or airway protectedPatient must be conscious or airway protected Window of opportunity; 1 hour Window of opportunity; 1 hour (↑ with salicylates)(↑ with salicylates)

Multidose charcoal-controversial Multidose charcoal-controversial

5) Monitoring, levels, 5) Monitoring, levels, nomograms nomograms

You will not know the toxicity of You will not know the toxicity of every substance / drugevery substance / drug

Poisons Information Centre provide Poisons Information Centre provide invaluable help and advice 24 hours invaluable help and advice 24 hours a daya day

Blood levels (often at 4 hours)Blood levels (often at 4 hours) May have nomogramMay have nomogram

6) Antidotes6) Antidotes

BenzodiazepinesBenzodiazepines

IronIron OpiatesOpiates ParacetamolParacetamol ββ-blockers-blockers DigoxinDigoxin

>> FlumazenilFlumazenil

>> DesfuroximineDesfuroximine

>> NaloxoneNaloxone

>> N-acetylcystineN-acetylcystine

>> Glucagon / Glucagon / AdrenalineAdrenaline

>> Fab antibodiesFab antibodies

Some Potentially Harmful Some Potentially Harmful PoisonsPoisons

ParacetamolParacetamol IronIron Aspirin (salicylates)Aspirin (salicylates) Substance abuse; Alcohol, Ecstasy, Cocaine, Substance abuse; Alcohol, Ecstasy, Cocaine,

etc.etc. Digoxin/ Antiarrhythmics/ Any Cardiac DrugDigoxin/ Antiarrhythmics/ Any Cardiac Drug Tricyclic AntidepressantsTricyclic Antidepressants BenzodiazepinesBenzodiazepines OpiatesOpiates Ethylene glycolEthylene glycol (anti-freeze/de-icer) (anti-freeze/de-icer)

ParacetamolParacetamol

Paracetamol IngestionParacetamol Ingestion Most widely available and commonly Most widely available and commonly

ingested Medicineingested Medicine Infants almost never drink enough to Infants almost never drink enough to

require Blood levels to be tested!!!require Blood levels to be tested!!! Increasing incidence of deliberate Increasing incidence of deliberate

ingestioningestion Mostly girls > 9 years oldMostly girls > 9 years old Assess Assess quantity and timingquantity and timing of ingestion of ingestion Do not trust information given; if large or Do not trust information given; if large or

unknown ingestion------ Treat as overdoseunknown ingestion------ Treat as overdose

Paracetamol ingestion; Paracetamol ingestion; symptomssymptoms

Initially asymptomatic (? Nausea)Initially asymptomatic (? Nausea)

36 hours later; 36 hours later; hepatic necrosishepatic necrosis (? (? Right subcostal pain) +/- liver Right subcostal pain) +/- liver decompensationdecompensation

Renal Failure (ATN) may occurRenal Failure (ATN) may occur

Paracetamol Overdose Paracetamol Overdose ManagementManagement

Activated Charcoal (gastric lavage not Activated Charcoal (gastric lavage not helpful) in < 1 – 4 hourhelpful) in < 1 – 4 hour

Check level at 4 hours post ingestionCheck level at 4 hours post ingestion Map on NomogramMap on Nomogram N-AcetylcysteineN-Acetylcysteine IV IV

if > treatment line on normogram (*? if > treatment line on normogram (*? High risk pt.?)High risk pt.?)

Monitor LFTs, Coag, U&E, blood levelMonitor LFTs, Coag, U&E, blood level

Iron IngestionIron Ingestion

> 20mg/kg iron ingestion; toxicity possible> 20mg/kg iron ingestion; toxicity possible > 60mg/kg – serious toxicity> 60mg/kg – serious toxicity > 150mg/kg – fatal!> 150mg/kg – fatal! Calculate Iron content of tabs & possible Calculate Iron content of tabs & possible

intakeintake Tests; Tests;

PFAPFA FBC, G&X, glucose, VBGFBC, G&X, glucose, VBG serum iron (@ 4 hours)serum iron (@ 4 hours)

Iron Ingestion; Iron Ingestion; SymptomsSymptoms

Stage 1; (30mins – 6 hours) abdo pain, Stage 1; (30mins – 6 hours) abdo pain, vomiting, diarrhoea (+/- bloody; ie. vomiting, diarrhoea (+/- bloody; ie. haemorrhagehaemorrhage

Stage 2 (10 hours – 30 hours); silent phaseStage 2 (10 hours – 30 hours); silent phase (iron absorbs & accumulates in tissues, mitochondria (iron absorbs & accumulates in tissues, mitochondria

etc.)etc.) Stage 3; cellular & mitochondrial damage;Stage 3; cellular & mitochondrial damage;

shock, encephalopathy, liver shock, encephalopathy, liver decompensationdecompensation

Hypoglycaemia, lactic acidosisHypoglycaemia, lactic acidosis Stage 4; (weeks later); Stage 4; (weeks later); GI stricturesGI strictures & &

obstruction, liver failureobstruction, liver failure

Iron Ingestion; Iron Ingestion; ManagementManagement

Stabilise; A B CStabilise; A B C

Gastric Lavage in < 1 hour Gastric Lavage in < 1 hour

Charcoal not helpfulCharcoal not helpful

Desferrioxamine (iron chelator) Desferrioxamine (iron chelator) ?PO (controversial) ?PO (controversial) IVIV

Salicylate (Aspirin)Salicylate (Aspirin)

Induces Gastric stasis!Induces Gastric stasis! Also slow/sustained release Also slow/sustained release

preparationspreparations => may be recoverable up to 12 hours => may be recoverable up to 12 hours

post ingestionpost ingestion Gastric lavage up to 4 hoursGastric lavage up to 4 hours ? Repeated charcoal doses? Repeated charcoal doses Serial blood levels (as levels can ↑ > 6 Serial blood levels (as levels can ↑ > 6

hours)hours)

Salicylate Poisoning; Salicylate Poisoning; SymptomsSymptoms

Phase 1;Phase 1; (0-12 hours)(0-12 hours) Anxiety, sweating, Anxiety, sweating, fever, tachycardia, fever, tachycardia, hyperventilationhyperventilation with with

Resp Alkalosis! Resp Alkalosis! => compensatory alkaline urine with loss of HCO=> compensatory alkaline urine with loss of HCO33

--, K, K++

Phase 2;Phase 2; (may be immediate in young (may be immediate in young children)children)

↓ ↓ K+K+ (& paradoxic aciduria) (& paradoxic aciduria) Phase 3;Phase 3; (up to 24 hours)(up to 24 hours) dehydration, dehydration, acidosis acidosis

predominates, pulmonary oedema, resp failurepredominates, pulmonary oedema, resp failure

Specific managementSpecific management

Alkalisation of Urine to aid drug Alkalisation of Urine to aid drug excretionexcretion Sodium BicarbonateSodium Bicarbonate

Fluids & K+ replacementFluids & K+ replacement Serial levels & ongoing monitoringSerial levels & ongoing monitoring Resp support!Resp support!

Ethylene GlycolEthylene Glycol Tastes sweetTastes sweet In Anti-Freeze, De-icer fluid etcIn Anti-Freeze, De-icer fluid etc Causes metabolic acidosis (high anion gap)Causes metabolic acidosis (high anion gap) Widespread cellular damage (esp. Kidneys) Widespread cellular damage (esp. Kidneys)

Haemodialysis may be neededHaemodialysis may be needed Activated Charcoal doesn’t work!Activated Charcoal doesn’t work! Metabolised by Alcohol Dehydrogenase into Metabolised by Alcohol Dehydrogenase into

toxic by-productstoxic by-products Ethanol (40%) is competitive inhibitor of Ethanol (40%) is competitive inhibitor of

Alcohol Dehydrogenase & may be used Alcohol Dehydrogenase & may be used Co-factors; thiamine, pyridoxine etc.Co-factors; thiamine, pyridoxine etc.

Caustic IngestionsCaustic Ingestions

Eg. Acids / alkalis / batteriesEg. Acids / alkalis / batteries Burns in mouthBurns in mouth necrosis of oesophagus necrosis of oesophagus strictures commonstrictures common Lung damage when aspiratedLung damage when aspirated

No emesis / lavage / charcoal etc. No emesis / lavage / charcoal etc.

7) Follow-up of Poison 7) Follow-up of Poison IngestionIngestion

Must consider; why did this happen?Must consider; why did this happen? NB – social historyNB – social history

Carers? Carers? Supervision concern / Neglect?Supervision concern / Neglect? Housing etc. Housing etc. Child-proofing the homeChild-proofing the home

Social Worker InvolvementSocial Worker Involvement Psyche involvement if deliberatePsyche involvement if deliberate

Possible Metabolic Possible Metabolic abnormalitiesabnormalities

Metabolic acidosis Metabolic acidosis

(high anion gap)(high anion gap) SalicylatesSalicylates IronIron Ethanol, methanol, Ethanol, methanol,

ethylene glycolethylene glycol IronIron

HypoglycaemiaHypoglycaemia Iron poisoningIron poisoning Alcohol poisoningAlcohol poisoning

HypokalaemiaHypokalaemia SalicylatesSalicylates ΒΒ-blockers-blockers

HyperkalaemiaHyperkalaemia digoxindigoxin

Childhood Childhood AccidentsAccidents

Dr. D BarryDr. D Barry

Childhood accidentsChildhood accidents Leading cause of death and disability in Leading cause of death and disability in

children and young adultschildren and young adults

More than 5 million deaths per year More than 5 million deaths per year worldwideworldwide

Lack of global attention to childhood Lack of global attention to childhood injuriesinjuries

Leading cause of death in children over 1 Leading cause of death in children over 1 yearyear

Childhood Mortality by Childhood Mortality by AgeAge

0%

5%

10%

15%

20%

25%

30%

< 1 year 1 - 4 years > 5 years

SIDSCongenital anomalyInfectonNeoplasmsAccidents

Accident typesAccident types

FallsFalls DrowningDrowning BurnsBurns ChokingChoking RTARTA

*****NB – when to consider *****NB – when to consider NAINAI **********

FALLSFALLS

Children Fall all the timeChildren Fall all the time Toddlers ( 1 – 3 Years) especiallyToddlers ( 1 – 3 Years) especially Babies roll over, fall off beds , climb Babies roll over, fall off beds , climb

out of cots, fall out of high chairs out of cots, fall out of high chairs etc.etc.

Fractures are uncommonFractures are uncommon Detailed HistoryDetailed History Detailed Detailed FULL FULL ExaminationExamination

FallsFalls

Clinical assessment will direct further Clinical assessment will direct further investigations ( if any)investigations ( if any)

Many children < 1 Year with a head Many children < 1 Year with a head injury are observed as inpatients to injury are observed as inpatients to ensure they remain wellensure they remain well

All are referred to social work All are referred to social work > 99% are > 99% are Genuine AccidentsGenuine Accidents But be Vigilant; ? NAI / safety But be Vigilant; ? NAI / safety

concernsconcerns

Fractures in ChildrenFractures in Children

Signs;Signs; tenderness, tenderness, swelling, swelling, deformity, deformity, ↓ ↓ use use etc.etc.

Consider;Consider; does the history fit the injury? NAIdoes the history fit the injury? NAI Underlying condition predisposing bone Underlying condition predisposing bone

to #to #

ManagementManagement

X-ray (AP / lateral)X-ray (AP / lateral)

RestRest Immobilise & ProtectImmobilise & Protect AnalgesiaAnalgesia PhysiotherapyPhysiotherapy

Consider – antibiotics / tetanus etc. Consider – antibiotics / tetanus etc.

What’s this?What’s this?

Salter-Harris #Salter-Harris #

Growth Plates – vulnerable to # Growth Plates – vulnerable to # Joint capsule, surrounding ligaments Joint capsule, surrounding ligaments

tendons etc stronger than cartilaginous tendons etc stronger than cartilaginous growth plategrowth plate

Shearing / Avulsion therefore possibleShearing / Avulsion therefore possible Types 1 - 5Types 1 - 5

Salter-Harris FractureSalter-Harris Fracture

What’s going to happen What’s going to happen here?here?

Pulled elbowPulled elbow

‘‘nursemaid’s’ elbownursemaid’s’ elbow Sudden pull on hand with elbow Sudden pull on hand with elbow

extendedextended Radial head subluxesRadial head subluxes Child holds forearm unwilling to move itChild holds forearm unwilling to move it Reduced simply by supinating forearm, Reduced simply by supinating forearm,

then flex!then flex! Immediate recovery!Immediate recovery!

Pulled elbowPulled elbow

What’s this?What’s this?

Toddler’s fractureToddler’s fracture

Shaft of tibiaShaft of tibia 9 months – 3 years9 months – 3 years Low –energy forcesLow –energy forces Spiral appearance, non-displacedSpiral appearance, non-displaced Limp / not weight bearingLimp / not weight bearing

DrowningDrowning

Leading cause of Accidental Death Leading cause of Accidental Death worldwide < 15 yr worldwide < 15 yr

2% mortality < 4 yr olds2% mortality < 4 yr olds ““the process of experiencing respiratory the process of experiencing respiratory

impairment from submersion/immersion impairment from submersion/immersion in liquid”in liquid”

PREVENTION;PREVENTION; Water Safety, Life Guards etc.Water Safety, Life Guards etc. Supervision while swimming and in the bath Supervision while swimming and in the bath Known epileptics – must be supervisedKnown epileptics – must be supervised

Drowning PathologyDrowning Pathology Upon submersion; apnoea, bradycardiaUpon submersion; apnoea, bradycardia Hypoxia, Acidosis (due to apnoea) -> Hypoxia, Acidosis (due to apnoea) ->

tachyc.tachyc. 20 secs – 5 mins; fluid inhaled20 secs – 5 mins; fluid inhaled Laryngeal spasm (as fluid hits glottis)Laryngeal spasm (as fluid hits glottis) AlvoelitisAlvoelitis Pulmonary oedema (up to 12-24 hours Pulmonary oedema (up to 12-24 hours

later)later) Hypothermia common* Hypothermia common* +/- injuries incurred (esp. C-spine injury)+/- injuries incurred (esp. C-spine injury)

Drowning; What type Drowning; What type water?water?

Salt water; pulls fluid into air spaces by Salt water; pulls fluid into air spaces by osmotic gradient => this washes away osmotic gradient => this washes away surfactantsurfactant

Freshwater; disrupts alveolar surfactant Freshwater; disrupts alveolar surfactant => alveoli collapse. Fluid transudes into => alveoli collapse. Fluid transudes into air spacesair spaces

Dirty/Contaminated? – consider what Dirty/Contaminated? – consider what antibiotic choiceantibiotic choice

Burns / ScaldsBurns / Scalds

Burns / ScaldsBurns / Scalds

Most common less than 5 years oldMost common less than 5 years old Major source of morbidity & Major source of morbidity &

mortalitymortality Scalds most commonly from cups of Scalds most commonly from cups of

tea, bath water etc.tea, bath water etc.

Burns / ScaldsBurns / Scalds

Prevention through practical Prevention through practical household measures and Public household measures and Public Health Campaigns are the most Health Campaigns are the most important factorsimportant factors

Management of Burns / Scalds----Management of Burns / Scalds----

(covered by Mr. Orr)(covered by Mr. Orr)

Choking/ Strangulation/ Choking/ Strangulation/ SuffocationSuffocation

Toddlers & young children particularly at Toddlers & young children particularly at riskrisk

Choking on aspirated food/ small toysChoking on aspirated food/ small toys Accidental strangulation of infants– Accidental strangulation of infants–

entangled inentangled in any cord/ telephone wire etc.any cord/ telephone wire etc.

Increasing incidence of both accidental Increasing incidence of both accidental and intentional hanging in teenage boysand intentional hanging in teenage boys

Choking/ Strangulation/ Choking/ Strangulation/ SuffocationSuffocation

PreventionPrevention

Public Health CampaignsPublic Health Campaigns

Parent & Child EducationParent & Child Education

Choking; ManagementChoking; Management

Back blows x 5Back blows x 5 Chest thrusts x 5Chest thrusts x 5 Check mouthCheck mouth Mouth to MouthMouth to Mouth Back blows x 5Back blows x 5 Abdominal thrusts x 5 (not < 1 year)Abdominal thrusts x 5 (not < 1 year) Heimlich manouvre (older child)Heimlich manouvre (older child)

Foreign bodiesForeign bodies

Road Traffic AccidentsRoad Traffic Accidents

Most common cause of accidental Most common cause of accidental death in Childrendeath in Children

4 out of 5 children who die in RTA s 4 out of 5 children who die in RTA s are not properly restrainedare not properly restrained

Booster Seats

Road Traffic AccidentsRoad Traffic AccidentsPedestrians & CyclistsPedestrians & Cyclists

Speed in school and residential areas Speed in school and residential areas major factormajor factor

Greatest risk; Boys 5 -10 years old;Greatest risk; Boys 5 -10 years old; Unable to judge car speed and lack of Unable to judge car speed and lack of

danger awarenessdanger awareness Seat Belt Laws Need to be enforced Seat Belt Laws Need to be enforced

more strictlymore strictly Ongoing campaign has improved Ongoing campaign has improved

compliancecompliance

PreventionPrevention

School / Residential Zone speed limit School / Residential Zone speed limit reduction and reduction and enforcementenforcement

Supervision & Education of ChildrenSupervision & Education of Children

Helmets and cycle lanes for Helmets and cycle lanes for cyclists------------ Not useful if cyclists cyclists------------ Not useful if cyclists are ignored by motoristsare ignored by motorists

Questions?Questions?