25 Trauma and Foreign Bodies Flashcards
T/F: In kids, the incidence of FB aspiration is equal b/w right and left bronchus
True (left bronchus not as obliquely angled in kids as in adults)
T/F: Airway FB are more common than esophageal
False
M/c esoph FB in kids < 5 yo
coins
M/c dx inappropriately given to a child with an airway FB
Asthma
What are the 2 types of nontraumatic CSF leaks
High pressure and nl pressure
M/c cause of CSF leak
nonsurgical trauma
What percent of CSF leaks are from nontraumatic causes
3-4%
What percent of basilar skull fx result in CSF leak
10-30%
What percent of pts with CSF leak 2/2 nonsurg trauma will get meningitis
10-25%
What is mortality rate of pts who develop meningitis w/ traumatic CSF leak
10%
What percent of CSF leaks are cranionasal?
80%
T/F: cranio-aural CSF leaks are more likely to spontaneously close than cranionasal CSF leaks
True
What is medical MAN of CSF leaks
Elevate HOB Antitussives Laxatives Anti-hypertensives Analgesics Bed rest Lumbar drain
What is a serious complication of lumbar drainage?
Tension pneumocephalus
What percent of skull fx involve t bone
20%
What is m/c mechanism of CHL in longitudinal t bone fx
IS joint dislocation
Incidence of facial nerve injury after transverse t bone fx
40-50%
What type of t bone fx accounts for majority of facial nerve injuries
Longitudinal, just bc it is so much more common
Incidence of FN paralysis in pts with longitudinal t bone fx
20-25%
M/c etiologies of nerve dysfunction after longitudinal t bone fx
Edema and intraneural hemorrhage
M/c area of FN injury following trauma
Perigeniculate area
Strongest predictor of poor recovery of FN fnc following t bone trauma
Immediate onset of paralysis in pt w/ closed head injury
What type of t bone fx most likely if the blow is to the occiput
transverse
Typical course of fx line in transverse t bone fx
foramen magnum across petrous apex across IAC and otic capsule to foramen spinosum or lacerum
Where are the laceration and bony disruption in EAC most often found after longitudinal fx
tympanosquamous suture line (posterior and superior)
Where does longitudinal fx line course in relation to otic capsule
anterior
M/c etiology of dizziness after longitudinal t bone fx
BPPV
When should middle ear exploration and ossicular reconstruction be performed after t bone fx
at least 3 mo after injury
M/c type of t bone fx in kids
Obliquely oriented fx
Which LeFort involves infra-orbital rim
LeFort II
Sequelae of untreated maxillary fx
Midface retrusion, facial elongation, anterior open bite deformity
Sequelae of untreated lateral zygomatic arch fx
Inc midfacial width and malar flattening
What is a type I NOE
Single, noncomminuted central segment fx
What is a type II NOE
comminuted, but identifiable, central fragment
What is a type III NOE
Severely comminuted fx with disruption of medial canthal tendon or too small a central fragment to be repaired directly
How do type I, II, III NOE fx differ in terms of MAN
I: Microplates
II: transnasal wires in addition to plate fixation
III: at least two sets of transnasal wires and may require bone graftin
What are the different types of ZMC fx
Type A: isolated to one component of the tetrapod (arch, lateral orbit, or inferior orbital rim) – least common
B: injury to all 4
C: Complex fx with comminution of zygomatic bone
What are the different classes of mandible fx
Class I: b/w 2 teeth
II: teeth are present on only one side of the fx
III: Edentulous area
Which parts of the mandible are most commonly fx
Condyle (36%)
Body (21%)
Angle (20%)
Mechanism for b/l condylar fx
anterior blow to chin
What percent of mandible fx are a/w other injuries
40-60%
Optimal tx for nondisplaced condylar fx
Nl occlusion: soft diet and close obs
B/l or u/l with malocclusion: MMF 3 wks then elastics for 2 wks
Absolute indications for open reduction of condylar fx
- Displacement of fractured fragments into middle cranial fossa
- inadequate reduction with MMF
- lateral extracapsular displacement of condyle
- foreign body (bullet) embedded in joint
Relative indicatinos for open reduction condylar fx
- B/l condylar fx in edentulous pt when MMF not possible
- Condylar fx when MMF is not recommended for medical reasons
- B/l condylar fx a/w midface fx
Appropriate MAN for deep puncture wound from dog or cat bite
Postexposure rabies ppx should be considered for all bites. If animal is healthy, should be quarantined for 10 days to exclude rabies. If animal unavailable or suspected rapid, immediate vaccination and Ig therapy.
Also antibiotic coverage for pasteurella multocida
What type of neurologic sequelae usu results from isolated u/l vertebral artery injury
none
After carotid artery injury, when is it too late to attempt revascularization
when coma has occurred beyond 3 hours, if an anemic infarction has occurred, or if no vascular back flow is present
Strongest predictor of negative outcome in trauma pt
Arterial hypoTN < 90 mmHg
Transcatheter arterial embolization is most useful in MAN of what neck injury
Gunshot to zone III
What is major advantage of immediate aggressive recon to face after high energy gunshot wound
less soft tissue scarring and contracture
What are the m/c injuries a/w facial trauma in kids
dental injuries
M/c mandible fx in kids
condyle
What are 3 types of condylar fx
- Intracapsular crush fx of condylar head
- High condylar fx through neck above sigmoid notch
- Low subcondylar fx (m/c)
Usual tx for condylar fx in kids
soft diet
Indications for open reduction of condylar fx in kids
When fractured condyle directly interferes with jaw mvmt; when fx reduces the height of ramus and results in open-bite deformity; when condyle is dislocated into MCF
T/F: A mandible fx in a child is much more likely to be a/w other injuries than in an adult
True
Among kids, which mandible fx results in highest incidence of dentofacial abnlities
Intracapsular crush fx of condyle
What is difference in tooth viability when comparing plates vs wires for fixation of mandible fx
Significant increase in nonviability of teeth in line and adjacent to fx of the mandible treated by plates compared with those treated with wires
What is best way to treat mandible fx in infants < 2 yo
Acrylic splints x 2-3 wks
What are tx options for mandible fx in kids b/w 2-5 yo
Interdental eyelet wiring, arch bars, cap splints, or soft diet
Which teeth can be used in kids b/w 5-8 for immobilization
deciduous molars
Which teeth can be used in kids b/w 7-11 for immobilization
Primary molars and incisors
How long should immobilization be maintained in kids
2-3 wks
In a child, what is the tx for an incomplete monocortical crack of the mandibular body with nl occlusion and mvmt
soft diet
when can bicortical plates be used in kids
when permanent dentition is present
what structure is most likely to be fractured after blunt trauma to the anterior neck
thyroid cartilage
which types of laryngeal injuries are best managed medically
edema; small hematoma with intact mucosa; small glottic or supraglottic lacerations not involving the free margin of the VF or the anterior commissure and w/o cartilage exposure; single nondisplaced thyroid cartilage fx
What does medical MAN of laryngeal fx consist of
24 hrs or more of airway obs, voice rest, elevation of head, humidified air, H2 blockers, steroids, abx if lacerations are present
Which types of layrngeal injuries require open exploration and repair
Lacerations involving the free margin of the vocal cord or anterior commissure; large mucosal lacerations with exposed cartilage; multiple displaced cartilage fractures; avulsed or dislocated arytenoids; vocal cord immobility.
When should open laryngeal exploration be performed after injury
w/in 24 hrs
What injuries are more commonly associated with laryngotracheal separation than with other laryngeal injuries?
Subglottic stenosis and b/l RLN injury
Which types of laryngeal injuries are more common in kids than in adults
Soft tissue injury with edema, arytenoid dislocation, and recurrent laryngeal nerve injury; telescoping injuries where the cricoid becomes displaced under the thyroid.
In what age is caustic ingestion m/c
18-24 months and 20-30 yo
What are the 3 stages of injury after caustic ingestion
- necrosis, bacterial invasion, sloughing of mucosa
- granulation tissue and reepithelialization (day 5- several wks)
- Scar formation and contraction
How does injury differ after ingestion of acidic substances v basic
Acid - coagulation necrosis (the eschar limits the depth of injury)
Base - liquefactive necrosis and deeper injury
Where is most likely site of injury after ingestion of acid
stomach
“After caustic ingestion, what sign is most likely to signal the development of a complication?
drooling
What is most likely consequence of ingesting hair relaxer
no long term sequelae
What percent of pts w/o OP burn will have evidence of esoph burn
8-20%
Onces ABCs have been stabilized what is acute MAN of caustic injury
“Prevent ongoing injury with irrigation of eyes, skin, and mouth, +/− flushing of the esophagus and stomach with water or milk <15 mL/kg (nasogastric tube placement is controversial). Surgical exploration is indicated for perforation, mediastinitis, or peritonitis.
What should be done for pt who has ingested a battery
If battery in esoph – immediate esophagoscopy
If in stomach – allow it to pass
True/False: Inducing emesis and activated charcoal are contraindicated in the management of caustic ingestion.
True
MAN of pts w/ evidence of grade 1 caustic injury (superficial) on endoscopic exam
no intervention; schedule for esophagogram in 3 wks
MAN of pts w/ evidence of grade 2 or 3 caustic injury (transmucosal or transmural) on endoscopic exam
Esophageal rest (NPO), reflux precautions, +/− steroids, +/− antibiotics, +/− lathyrogens, +/− subcutaneous heparin, +/− nasogastric tube, +/− prophylactic bougienage.
What are the CI to steroid use in caustic injury
Grade 3 burns, esophageal or gastric perforation
What percent of kids with esophageal burns will develop esophageal stricture
7-15%
Why should all pts w/ h/o caustic ingestion be followed for life with repeated esophagograms and endoscopy?
Risk of SCCa of the esophagus is 1000 times that of the general population
What percent of pts with esophageal stricture will develop esoph CA
1-4%
What are the typical features of esoph CA occurring after esoph stricture from burn injury
Usu SCCa, w/ onset 25-70 yrs postinjury occurring w/in scar tissue with a lower incidence of distant mets and higher chance of cure with surgical resection
