Accidents

Question 1

Near Drowning
Define
Pathophysiology [4]

Answer 1

Respiratory impairment from submersion or emersion in liquid

Pathophys:

1. Initial gasp with possible aspiration then apnoea exceeds breaking point to stimulate hyperventilation causing aspiration and laryngospasm.
2. Hypoxia and acidosis cause LOC and cardiac arrest.
3. When pulmonary oedema occurs, there is surfactant loss causing atelectasis and exudate blooding of alveoli. Pulmonary vessels constrict in response to hypoxia causing intravascular pressure to rise and more fluid to enter alveoli and consequently a V/Q mismatch.
4. Hypothermia slows metabolic rate meaning respiration slowed even more causing further hypoxia and hypercapnia

Question 2

Near drowning: initial first aid [3]

Answer 2

Remove from water
ABDCDE
Prevent heat loss by replacing wet clothes with dry warm blankets

Question 3

Near drowning Ix [3]

Answer 3

• ECG (ischaemic changes, arrhythmias (VF, asystole in hypothermia), J waves of hypothermia)
• Bloods (ABG, U&E and creatinine, glucose, osmolality, alcohol, LFTs, coagulation screen, blood cultures)
• CXR and C-spine XR +/- CT head

Question 4

Near drowning hospital mx

Answer 4

o Instigate or continue resuscitation as required: intubation if unconscious
o Inhaled 100% oxygen and IV access
o Mx of hypothermia: passive or active re-warming
o Mx of hypoglycaemia, hypovolaemia and hypotension (shock)

Question 5

Near drowning subsequent hospital mx [6]

Answer 5

6hr observation
Further HDU/ITU support
Respiratory support
NGT
Urinary catheter
Dialysis if AKI

Question 6

Head injury when is an urgent CT head needed (1 hour) [5]

Answer 6

o	Witnessed LOC lasting > 5 mins 
o	Anterograde or retrograde amnesia > 5 mins 
o	Abnormal drowsiness 
o	>3 discrete vomiting episodes
o	Dangerous mechanism of injury

Question 7

Multiply injured child management

Answer 7

• Primary survey: CABCDEG
catastrophic haemorrhage, airway with C spine and oxygen, breathing with ventilation, disability, exposure and environment, glucose

Do a head to toe examination
Always consider NAI
NICU transfer for definitive care

Question 8

Non-accidental injury signs [3]

Forms of NAI [9]

Answer 8

Late presentation
Hx changes on repeating
Hx inconsistent w/ findings or child’s development

Forms:

• Abusive head trauma
• Burns and scalds
• Fractures
• Bruises
• Fabricated or induced illness
• Poisoning
• Neglect
• Emotional abuse
• Sexual abuse

Question 9

Abusive head trauma [2]

Triad [3]

Answer 9

Shaking causes intracranial bleed > retinal hemorrhage, neck, c-spine injury

Triad:
- RETINAL HAEMORRHAGE, SUBDURAL HAEMATOMA, ENCEPHALOPATHY

Question 10

Sudden and unexplained death in an infant
Epidemiology
Ax [4]
Risk factors [6]
Preventative measures [5]

Answer 10

Ep: incidence halved by “back to sleep campaign”
Ax: prone sleeping, infection, cardiac, infanticide, metabolic (apnoea)
RFs: prone sleeping, parental smoking, bed sharing, hyperthermia and head covering, prematurity
Prev: back to sleep, no smoking, breastfeeding, lie at bottom of cot, don’t overwrap