MSK, Trauma, Burns, Maltreatment Flashcards
What are the different types of trauma?
- Non-accidental
- Abdominal trauma: Splenic, Pancreatic, Liver, and Renal lacerations
- Thoracic/chest
- Burns
- MSK injuries
What is included in the primary survey during a trauma evaluation?
- Airway
- Breathing
- Circulation
- Disability/Neurological evaluation
- Exposure
What is included in the secondary survey during a trauma evaluation?
- Vital Signs
- History
- Thorough head to toe exam and diagnostics
How can I estimate circulating blood volume?
- Estimated blood valume based on age
o Preterm Neonate 100 ml/kg
o Full term infant 90 ml/kg
o Infant 80 ml/kg
o Child 75 ml/kg
o Teens – Adults 70ml/kg - So a little bit of blood loss on a child is actually quite significant on their total circulating blood volume which reduces their systemic perfusion.
What are signs of shock?
- Tachycardia – Early Sign
- Hypotension – Late Sign
- Bradycardia – Ominous Sign
When do I suspect non-accidental trauma?
- When there is an unusual presentation of trauma or an age-based injury that does not make sense. You should always evaluate if the injury matches the story/history.
- Injuries/fractures with multiple stages of healing.
What should my evaluation include in a possible non-accidental trauma?
- Cutaneous findings such as bruising, lacerations, abrasions, burns (assess their location and shape such as does this have the shape of an iron or a cigarette burn.)
- Assess for ear injuries which are extremely rare in children (usually occur with pulling/plucking of the ear by someone else).
- Skeletal Fractures – skull, rib, femur. Look at the age of the child and the likelihood. (ex. Can a 1 month old roll off the bed – they don’t roll until at least 2 months. It is not likely).
- Abdominal trauma is rare but possible. Usually from blunt force trauma such as MVA
- Funduscopic evaluation for retinal hemorrhage of any child with suspected shaking or traumatic brain injury of questionable mechanism.
What diagnostics should be ordered if non-accidental trauma is suspected?
- CXR/abdominal XR.
- Skeletal survey
- Eye Exam/funduscopic exam for retinal hemorrhages.
- Brain CT scan.
What are symptoms of a spleen injury and what diagnostics should be ordered?
- The most common abdominal injury in children – usually from blunt trauma to the upper abdomen or lower thorax since the spleen is not adequately protected by the rib cage.
- S/S: pain in left shoulder, LUQ or left part of chest (bruising or abrasions may be noted to site). N/V. Mass may be palpable to LUQ.
- LABS: hemoglobin/hematocrit
- Diagnostics: Abdominal CT for diagnosis. Sometimes CXR may show fractures to left lower ribs or pleural effusion.
What is the treatment of splenic laceration?
- 95% of splenic lacerations are managed non-operative.
- Monitoring of patient and of H&H (q4-6hrs) is the standard of care.
Treatment is based on grade (graded from 1-5)
What is needed if child requires a splenectomy?
- Prophylactic antibiotics indicated for children over 4 years of age and in some cases if they are under 4 years of age.
- Post-Op: monitor for bleeding, thrombosis, infection, fistula formation
What are the symptoms of a liver laceration and its’ diagnostics?
- Major cause of death in children with blunt trauma – highest risk for injury
- Associated with significant blood loss, exsanguination (right lobe more prevalent than left lobe)
- S/S: Acute abdominal tenderness due to hemoperitoneum. Pain to right shoulder or RUQ tenderness. If there is bleeding or fractured ribs, you may notice bruising, seatbelt marking and abrasions. Hypotension. Tachycardia. It can also be associated with pelvic and rib fractures.
- Diagnostics: CBC, liver function test, U/S, CT.
How are liver lacerations treated?
- Non-operative: Monitor patient and H&H every 4-6hours. NPO status.
o May ambulate once AST and ALT are within normal limits. Blood products may be given if indicated. - Operative management: Operate if hemodynamically unstable – usually to control bleeding.
How are liver lacerations graded?
- Grades I – VI (VI – avulsion of liver).
What are the symptoms off a pancreatic laceration and its diagnostics?
- Associated with high morbidity and mortality.
- S/S: soft tissue contusion in Upper Quadrant, handlebar marking, tenderness to lower ribs and costal margins, epigastric tenderness, lower thoracic spine fracture, signs of peritonitis, vomiting.
- Diagnostics: CT with grading of injury, amylase and lipase labs.
What are they symptoms of renal lacerations and its diagnostics?
- S/S: Contusion, hematoma or bruising of flank or back. Abdominal or flank tenderness. Palpable mass. Stab wounds posterior to anterior axillary line.
- Diagnostics: CT, UA -Hematuria, intravenous pyelogram.
- Use the American Association of Surgery Trauma Renal Injury Scale to grade.
What are some misc. results of trauma?
- Abdominal Compartment Syndrome. It is life threatening. Results in coagulopathies, acidosis, hypothermia, bowel edema. Bladder pressures should be monitored.
What are some results of chest wall trauma?
o Second leading cause of pediatric trauma associated death.
o Has little cutaneous evidence of injury.
o Rarely occurs as singular insult and is often associated with other injuries.
* Pneumothorax: Tachypnea, dyspnea, unequal breath sounds, hypoxia, chest pain. They vary in size – not all require interventions. Treatment: Evaluation of air – depending on size and symptoms.
o A tension pneumothorax is an emergency (pressure or cardiac space)– it is acute, results in shifting of mediastinum and impacts cardiorespiratory functioning. Decompression can be lifesaving.
o Open pneumothorax: open wound on chest
o Closed: confined to pleural space.
* Hemothorax: Tachypnea, Dyspnea, unequal breath sounds, anemia. Treatment is evacuation of blood which depends on size and symptoms.
* Lung contusion: tachypnea, respiratory distress, hypoxia. Diagnostics: initial radiography may be normal but after 24 hours, it will show defined geographic consolidation that is not specific to contusion (may appear as if it were atelectasis, aspiration, infection, etc.). Treatment: is supportive. It improves as blood is absorbed. It may happen between 24-48 hours. However, most resolve in 7-10 days.
Why are rib fractures a possible sign of abuse?
- Rib fractures in children are not common due to their pliable chest so this should always raise suspicion.
- The risk for mortality increased with each linear rib that is fractured. It is usually associated with other trauma/injuries such as head, thoracic, and solid organ.
- You should always rule out disease of the bone (uncommon), and should include the evaluation of other injuries and for signs of abuse and pain management.
- Treatment includes pain management.
What are some signs of cardiac tamponade?
- It compresses the heart which compromises venous return to the heart and cardiac output.
- S/S: Obstructive Shock, Hypotension, Tachycardia, Distention of neck veins, muffled heart sounds, pulsus paradoxus (exaggerated fall in patients blood pressure during inspiration by greater than 10 mm Hg).
- Diagnostics: CXR (enlarged cardiac silhouette) and ECHO (appears black against gray muscle).
- Treatment: Pericardiocentesis, and blood transfusion (in some case).
What is the first line management for burn injuries?
- Airway: facial burns, singed eyebrows, stridor, hypoxia, wheezing, carbon sputum, hoarseness, mucous membrane and tongue swelling.
- Breathing, Circulation: particle aspiration and CO inhalation causing hypoxia and difficulty breathing.
- Primary and Secondary Trauma Surveys. (consult burn surgeon)
