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Paediatrics - SCHP Oral Viva > Child with Trauma / Burns > Flashcards

Child with Trauma / Burns Flashcards

1
Q

Relevant history for trauma?

A
  • MIST
    • Mechanism
    • Injury/illness
    • Signs/symptoms
    • Treatment
  • AMPLE
    • Allergies
    • Medications
    • Past medical history/ Pregnancy
    • Last meal
    • Events/ Environment
  • Events and Environment
    • Timing
    • Nature of the forces involved
    • Protective and safety apparatus
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2
Q

Relevant examinations and investigations?

A
  • Primary survey
    • Airway with cervical spine control
    • Breathing and ventilation
    • Circulation with haemorrhage control
    • Disability and neurological assessment
    • Exposure with Environmental control
  • Head to toe
  • Fingers or instrument in every opening
  • Assume injury present until excluded by clinical examination or investigation
  • Bloods
  • X-rays
    • Lateral cervical spine
    • Chest
    • Pelvis
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3
Q

What are some anatomical differences between a baby/child and adult?

A
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4
Q

What is available to manage the airway?

A
  • Basic airway manoeuvres
    • Chin lift
    • Jaw thrust
  • Oral and nasopharyngeal airways
  • Intubation
  • Surgical airway
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5
Q

When being suspicious of airway injuries, what should you be looking for?

A
  • Fall onto sharp object
  • Running/riding into wires
  • Penetrating neck injury
  • Facial burns
  • Burns resuscitation
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6
Q

What are some signs of airway obstruction?

A
  • Injury to face, neck, mandible
  • Swelling of tongue, pharynx, mouth
  • Restlessness
  • Cyanosis
  • Accessory muscles
  • Wheeze, stridor, dysphonia
  • Respiratory distress
  • Low saturations
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7
Q

How would you investigate suspected cervical spine injuries?

A
  • Rare in children
    • Serious consequences if missed
  • Assume present
    • Collar
    • Sandbags and tape
  • Beware distracting injury
  • Cervical spine series
    • Lateral C spine
    • AP C spine
    • Odontoid peg views
  • Swimmers view
  • CT
  • MRI
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8
Q

What are the differences when assessing breathing in children compared to adults?

A
  • Anatomical differences
    • Horizontal ribs
    • Diaphragmatic breathers
    • Fewer Type I fibres
    • Small airways
  • Respiratory rate more rapid than adult
  • Tidal volume proportionally the same
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9
Q

What do you check for in Breathing in the context of trauma?

A
  • Airway obstruction/injury
  • Chest injury
  • Head injury
  • Aspiration
  • Burns
  • Shock/acidosis
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10
Q

How do you manage impaired breathing in the context of trauma?

A
  • Airway secure
  • If ventilated, aim:
    • Respiratory rate 20 to 30 breaths per minute
    • Tidal volume 7-10 mL per kg
  • Treat problems as identified
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11
Q

Describe management of circulation in the context of trauma

A
  • Information
    • Circulating volume 80 mls/kg
    • Infant has small stroke volume, thus has high heart rate
    • Blood pressure varies with age
  • Management
    • Control haemorrhage
    • Vascular access
      • Percutaneous
      • Cut-down
      • Intra-osseous
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12
Q

How do you assess and manage Disability in the context of trauma?

A
  • Assessment
    • More difficult to assess in children as:
      • May not be able to communicate
      • Behaviour may regress because of stressful situation
    • Paediatric GCS - Best verbal response
      • 5 Coos and babbles
      • 4 Irritable cry
      • 3 Cries to pain
      • 2 Moans to pain
      • 1 No response
  • Management
    • Optimise ABCs
    • Discuss further investigations and management with neurosurgeon
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13
Q

How do you assess and manage Exposure and Environment?

A
  • Assess
    • Head to toe examination of whole body
    • Common sites to miss injuries:
      • Scalp
      • Neck
      • Hands
      • Back and perineum
    • Large surface area to body ratio
      • Risk of hypothermia
  • Management
    • Warm the patient
      • Overhead heater
      • Warm blanket
      • Warm fluids
    • Can remove collar to examine neck with immobilisation
    • Log-roll patient
    • Analgesia
      • Caregiver or good nurse with an explanation
      • Local anaesthetic blocks
      • Morphine - analgesic and anxiolytic
        • Titrate small doses IV as a bolus
    • Multitrauma the rule
      • Thorough secondary survey
      • Repeat as tertiary survey the next day
    • Growing and developing
      • Long-term review required
      • Optimal management to avoid morbidity
    • Beware non-accidental injury
      • Inconsistent history which varies
      • Delayed presentation
      • Physical signs of abuse and neglect
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14
Q

What are some causes of burns in children?

A
  • 50% Scald
  • 30% Contact/Friction
  • 15% Flame
  • 2% Electrical
  • 2% Chemical
  • 1% Sun
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15
Q

How long does it take to cause full thickness burns with hot water at:

  • 60C
  • 55C
  • 50C
A
  • The average temperature of domestic hot water is 70C.
  • At 60C it takes one second for hot water to cause full thickness burn
  • At 55C it takes 10 seconds
  • At 50C it takes five minutes.
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16
Q

What is the response to burn injuries?

A
  • Proportional to % TBSA Burn and Depth
  • Local response (TBSA <10%)
    • Tissue injury and oedema
      • At site of burn
  • Generalised systemic response (TBSA >10%)
    • Tissue injury Plus
    • Systemic inflammatory response (SIRS)
17
Q

In systemic inflammatory response (SIRS), what are the effects of inflammatory mediators?

A
  • Inflammatory mediators are produced locally in minor burns (<10%) and act systemically in a major burns (>10%).
  • Inflammatory mediators cause
    • Increased microvascular permeability which results in: local production of oedema at the burn site, generalised loss of intra vascular water and electrolytes development of shock
    • Increase in body temperature
    • Inhibition of immune response
    • Pulmonary oedema + ARDS
    • Paralytic ileus + gastric erosions
    • Hypermetabolism - Increase in calorie requirement - 50% increase in 25% burn,100% increase in 40% burns
18
Q

How do you prevent SIRS in burns?

A
  • Stabilisation of burn wound
  • Cerium Nitrate (inhibitory effect on LPC)
  • Immediate Surgical excision of all burnt tissue and wound closure.
19
Q

What are the effects of SIRS on the airway?

A
  • Upper Airway swelling
    • Direct heat- rare
    • Scalds or flame burns of the anterior neck cause secondary soft tissue swelling which compresses the airway.
    • Children are particularly vulnerable and may require intubation.
  • Lower Airway
    • Smoke inhalation causes toxic damage to the bronchial tree chemical burn of the airway and to alveoli
    • ARDS pulmonary oedema + interstitial inflammation
  • Systemic intoxication
    • CO
    • HCN
20
Q

What are the effects of SIRS on circulation?

A
  • Loss of fluid form the circulation
    • Hypovolemic shock
  • Circumferential burns
    • Limbs
      • cause constriction and distal ischaemia
      • Elevate
      • assess peripheral circulation
    • Torso – consider respiratory compromise from restriction of thoracic and abdominal excursion
      • Consider escharotomy if no improvement
21
Q

How do you treat an asymptomatic child with a scald to the anterior neck?

  • (a) May develop upper airway obstruction?
  • (b) May need intubation?
  • (c) Requires referral to a Burns Unit?
A
  • First Aid
    • Give at scene or after Primary Survey
    • Remove clothes - Cool the burn
    • Running water from cold tap Immerse in River/Sea/Pool
    • Avoid hypothermia
  • Assessment of the burnt patient: Primary Survey
    • Airway (Cervical Spine control)
    • Breathing
    • Circulation
    • Disability (Neurological Assessment)
    • Environment (Expose and assess area of burn)
    • Fluid (Calculate using modified formula)
  • Assessment of the burn
    • Body surface area of burns % TBSA (with Wallace Rule of Nines)
    • Depth exclude superficial burns (erythema) from calculation
    • Circumferential - Limbs / torso
    • Compartment syndrome (Limbs in electrical abdominal in all major burns)
  • Resuscitation
    • Intravenous
    • Intraosseous
    • Oral
    • Begin as soon as possible and calculate amount from the time of the burn
22
Q

Describe the Wallace Rule of Nines (TBSA for burns)

23
Q

How do you calculate fluid resuscitation for burns?

A
  • 2 large bore cannulae non burnt skin
  • Modified Parkland Formula
  • 3mL x kg x % burn in the first 24 hours calculated from the time of the burn (Hartman’s solution or Normal Saline)
    • 1/2 in first 8hrs, next 1/2 in 16 hrs (+ maintenance)
    • Adjust volume to maintain urine output of 1 mls / kg / hr
    • Maintenance in Children (N Saline + 5% dextrose)
      • 100 mls/kg up to 10kg.
      • 50 mls/kg up to 20 kg
      • 20 mls/kg >20 kg
24
Q

What causes haemochromogenuria and how do you manage?

A
  • Haemochromogenuria - dark red, black urine. Caused by
    • High Voltage electrical Injury
    • Extensive deep burn
    • Crush injury
  • Myoglobinuria
    • Haemoglobin and myoglobin are excreted into the urine
  • Management
    • Increase fluid volume to double urine output
    • If necessary add Mannitol
25
Q

Describe the depth of burn classification

A
  • Erythema: Epidermis intact no blisters
  • Superficial Dermal: Regeneration from intact basal epidermal layer
  • Mid Dermal: Regeneration from epidermal appendages hair follicles sebaceous and sweat glands
  • Deep Dermal: Destruction of dermal capillary plexus
  • Deep: White/ charred/ waxy.
26
Q

What factors do you consider when assessing the depth of burns?

A
  • Mechanism of injury
  • Length of exposure
  • Temperature of heat source
  • Colour
  • Pain
  • Blistering
  • Capillary return, hair follicles
  • Appearance changes with progression from superficial to deep
    • Erythema
    • Blistering may be delayed look- for Nikolski’s sign
    • Pink, blanching
    • Red, non-blanching
    • Leathery or charred.
  • Early appearances are deceptive
27
Q

Describe erythema burn

A
  • Surface of skin red but not broken
  • Caused by flash flame injury, sunburn, or scald injury
  • No intervention required
  • Apply moisturiser regularly.
28
Q

Describe superficial dermal burns

A
  • Blister, Redness, Moist, Painful, Oedema
  • Re-epithelialisation within 14 days with minimal to no scarring
29
Q

Describe the treatment for different depths of burns

A
  • Superficial: Moisturise
  • Superficial dermal: Burns dressing, Expect healing <10 days
  • Mid dermal: Burns dressing, Expect healing 14-21 days
  • Deep dermal: Skin graft
  • Full thickness: Immediate Skin graft
30
Q

What are the principles of burns dressings?

A
  • Provide an optimal environment for wound healing and reepithelialisation
  • Provide an antimicrobial environment
    • Silver dressings
  • Minimise frequency of dressings changes
    • Long acting silver dressings ( Acticoat.Mepilex Ag)
  • Early determination of depth
    • Laser Doppler
  • Minimise pain
    • Prepare -Use Distraction therapy
    • Analgesia- Opiates /N20/ Intra nasal fentanyl
    • Presence of an Anaesthetist useful
31
Q

What are the principles of wound closure?

A
  • Autografts
    • When donor sites are available try to graft early if burns are not healing <14 days
    • Grafts may be meshed if donor skin is limited.
  • Lack of donor sites in a major burn may require :
    • Temporary skin substitutes
    • 1 Bioengineered dressings
      • Biobrane/ BTM ( Biodegradable Temporising Maitrix)
    • 2 Allograft
      • Cadaveric skin
      • Fresh in nutrient media (1 week)
      • Cryopreserved –196 degrees C (1 year)
    • Cultured epithelial autografts (CEA)
      • Suspension (10^6 cells/sq. cm.-1 week)
      • Sheets (10/10 cm. 3weeks)
    • Bioengineered Dermal templates
      • Integra
32
Q

List multidisciplinary management for burns

Paediatrics - SCHP Oral Viva (14 decks)

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