Paediatric trauma Flashcards
Unintentional injuries make up what percentage of all child injury deaths?
95%
What age group is most at risk of unintentional injury?
Young children under 5
Child deaths from unintentional injury are most commonly the result of what four things?
Car crashes, child pedestrians being hit by motor vehicles, drowning, and house fires
Hospitalization of young children from unintentional injury and most commonly the result of what five things?
Falls, poisoning, scalding, choking, and dog bites.
What are the leading causes of hospitalization for school aged children?
Falls, cutting and piercing injuries, car passenger injuries, and pedestrian injuries.
Where is the most common place for young children to be injured?
In their own home.
Higher metabolic rate in pediatrics results in greater consumption of oxygen and other metabolites. What physiological responses accommodate this?
Higher heart and respiratory rates.
The larger surface area to body mass ratio in paeds results in…
Greater heat loss for infants and children.
Pediatrics have ____ glucose requirements but ____ glycogen stores.
Increased; decreased.
The smaller the child, the greater the likelihood a single impact will…
Injure multiple organ systems.
The smaller body mass of a child results in what secondary to the traumatic impact?
Greater forces applied per unit body area.
The ribs of an infant are positioned more ____ than those of an adult.
Horizontally.
What is the significance of infant rib position with regard to inspiration and tidal volume?
With inspiration the ribs only move up, rather than up-and-out like adults. This limits the capacity to increase tidal volumes.
What is the chief physiological response to hypoxia in paeds and why?
Tachypnoea, due to limited pulmonary compliance and greater chest wall compliance.
Why do infants and young children exhaust more quickly than adults?
Because of the small a number of fatigue-resistant type I fibers in their respiratory muscles.
Infants are what kind of breathers?
Diaphragmatic.
Is hypotension necessary to define shock?
No, though the misconception persists.
What is the definition of shock?
A life threatening condition characterized by inadequate delivery of oxygen and nutrients to vital organs relative to their metabolic demand.
Inadequate oxygen delivery typically results from ____ ____ ____ but may also be caused by ____ ____ ____.
Poor tissue perfusion; increased metabolic demand.
Shock must be recognized by what four symptoms before hypotension?
Tachycardia, poor skin color, altered conscious level, and prolonged capillary refill BEFORE hypotension occurs.
Hypotension is a ____ and ____ sign of hypovolaemia in children.
Late; critical.
What is the blood volume of paeds?
80-90 mL/kg
What is the blood volume of adults?
65-70 mL/kg
To increase cardiac output infants are limited to increasing their ____ ____ as they are unable to increase ____ ____.
Heart rate; cardiac output.
What two common experiences in paediatric trauma cause elevation of the diaphragm and severely compromise vital capacity?
Aerophagia and gastric distension.
Elevation of the diaphragm and compromised vital capacity can predispose infants and young children to the sudden development of what when fatigued?
Apnea
At least ____% of children dying with multiple trauma have significant head injuries, compared with ____% of adults.
80%; 50%
Head stability in paeds is dependent on the ____ rather than bony structure.
Ligamentous
The unmyelinated brain is more susceptible to what kind of injuries?
Shear injuries
Why are paed brains more prone to acceleration/deceleration injury?
High water content (88% compared to 77% in adults), making the brain softer
Children tend to have a higher incidence of what kind of brain injury?
Diffuse axonal injury
Children with severe head injury are more likely than adults to have ____ ____.
Intracranial hypertension
Intracranial hypertension can contribute to what two things?
Ischaemia and herniation
Children are more prone to a unique form of brain injury called ____ ____ ____.
Malignant brain oedema
Malignant brain oedema is said to be due to what three things?
Osmolar shifts and oedema at the cellular level
Blood-brain barrier breakdown
Secondary injury/insults
Predisposition to cerebral hyperaemia and resulting intracranial hypertension makes children more vulnerable to…
Secondary brain injury.
True or false: infants form the only age group that can go into shock solely due to head injury.
True
The cervical spine fulcrum changes from ____ to ____ in toddlers two ____ to ____ by ages 8 to 12 years.
C2-C3; C5-C6
True or false: children can have spinal nerve injury without damage to the vertebrae.
True
What does SCIWORA stand for?
Spinal chord injury without radiographic abnormality.
Why are rib fractures a serious sign in paediatric trauma?
Increased elasticity and chest wall compliance mean blunt chest trauma may not result in a rib fracture, but the force can be transmitted through the ribs to underlying structures. A force significant enough to fracture ribs is a marker of increased morbidity and mortality.
Increased mobility of the mediastinum increases the likelihood that an injured child with blunt chest trauma may develop what two complications?
Develop a tension pneumothorax from a simple pneumothorax, and transect a small mediastinum vessel as the mediastinum shifts.
What are the six lethal forms of chest trauma?
Airway obstruction, open pneumothorax, tension pneumothorax, massive haemothorax, flail chest, and cardiac tamponade.
What are the six hidden forms of chest trama?
Cardiac contusions, aortic disruption, tracheobronchial disruption, oesophageal disruption, diaphragmatic tear, and pulmonary contusion.
Why is traumatic asphyxia observed in children?
Flexible thorax and absence of valves in the venous system of the inferior and superior vena cava.
What might occur if the glottis is closed and the thoracoabdominal muscles are transferred at the time of chest injury?
Increased intrathoracic pressure is transmitted through the central venous system to organs like the brain, liver, spleen, and kidneys.
Where does the paed abdominal region begin?
At the level of the nipple.
Why is abdominal trauma more likely to result in liver or spleen damage in the child compared to the adult?
These organs take up a greater proportion of the abdominal cavity in children, and the diaphragm of the child is flatter and less dome-shaped than that of an adult and consequently tends to push the liver and spleen lower below the rib cage.
The bladder in infants is what kind of organ?
Intra-abdominal
Kidneys are less protected and more mobile, making them more susceptible to what kind of injury?
Deceleration
Approximately ___% of extremity fractures in children involve disruptions of the growth plate.
15%
When do epiphyseal plates fuse?
When children reach skeletal maturity, which occurs after puberty.
Describe a type I fracture.
A complete physeal fracture with or without displacement.
Describe a type II fracture.
A physeal fracture that extends through the metaphysis, producing a chip fracture of the metaphysis which may be very small.
Describe a type III fracture.
A physeal fracture that extends through the epiphysis.
Describe a type IV fracture.
A physeal fracture plus epiphyseal and metaphyseal fractures.
Describe a type V fracture.
A compression fracture of the growth plate.
What is the general rule of open fractures and blood loss?
Open fractures double the blood loss.
A single open femoral fracture may result in ____% loss of circulating blood volume.
40%
List the 5 significant differences between paediatric and adult burn victims.
- Children have increased airway vulnerability
- Children are more susceptible to carbon monoxide intoxication
- Children have an increased risk of hypothermia
- Children have different body-to-surface proportions than adults which affects the estimation of the extent of the burn
- A child’s skin is much thinner than an adult’s which makes children more prone to deeper, more severe thermal injuries
What is eschar and how is it formed?
Full thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue called eschar.
As a result of its inelasticity, eschar results in…
Burn-induced compartment syndrome.
____% of all children with severe head injury will have an accompanying cervical spine injury.
20%
True or false: isolated head injury or isolated femur fracture generally do not cause hypotension in paeds.
True
What are the points of Waddell’s Triad?
Typical pattern of injuries affecting the 1) upper leg, 2) chest/abdomen, and 3) head
What are the two greatest initial threats to paediatric patient survival?
Respiratory failure and shock.
List some signs of significant blood loss.
Heart rate - marked or increasing tachycardia or relative bradycardia
Systolic BP - falling
Capillary refill time - increased to 4-5 seconds
Respiratory rate - tachypnoea unrelated to thoracic problem
Mental state - ALOC unrelated to head injury
What are the age ranges for the three modified GCS?
Infant <1
Child 1-4
Adult 4+
What should be avoided and corrected immediately upon identification when managing TBI?
Hypoxaemia
What kind of solution should be used to treat hypotension for paediatric TBI patients?
Isotonic
What systolic BP should be aimed for when treating hypotension in the paediatric TBI patient?
Higher than the fifth percentile for their age.
What is the formula for approximating the 5th percentile of a paediatric pt’s systolic BP?
(Age x 2) + 70
Paediatrics with TBI should be assessed frequently for clinical signs of ____ ____.
Cerebral herniation.
What are the clinical signs of cerebral herniation?
- Dilated and unreactive pupils
- Asymmetric pupils
- A motor exam that identifies either extensor posturing or no response
- Progressive neurologic deterioration (a decrease in the GCS of more than 2 points from the patient’s prior best score in patients with initial GCS <9)
Patients should be maintained with normal breathing rates (ETCO2 35-40mmHg) and hyperventilation (ETCO2 <35mmHg) should be avoided unless what?
The patient show signs of cerebral herniation.
Should hyperventilation be continued when clinical signs herniation resolve?
No, it should be discontinued.
How many breaths per minute in infants <1 constitutes hyperventilation?
30 breaths per minute.
How many breaths per minute in a child constitutes hyperventilation?
25 breaths per minute.
What is the ETCO2 range goal of hyperventilation?
30 - 35 mmHg
What might give cause for recognition of need for pain relief or control?
- A description from the child or parent/carer
- Behavioral changes such as crying, guarding injured part, and facial grimacing
- Physiological changes such as pallor, tachycardia, and tachypnoea which are observed by the paramedic
- An expectation of pain because the pathophysiology involved such as fracture, burn, or other significant trauma or condition
Failure to provide adequate pain management to infants and children can cause fluctuations in what five things?
- HR
- BP
- ICP
- SPO2
- Stress hormone levels
True or false: inadequate early pain management may contribute chronic pain syndromes.
True
True or false: you do not need to assess the precise degree of pain in order to treat it.
True.
For neonates and infants, pain assessment tools often rely on:
Behavioral observations by caregivers and paramedics, and physiological changes in the patient.
What is the FLACC scale?
A behaviour scale that can be used for children under 3 years of age or who are unable to communicate.
An infant who is not consoled when rocked or held by parents or who cannot sustain sucking activity without crying is generally experiencing ____ ____.
Significant pain.
What are some additional pain responses in young infants?
- Signs of agitation
- Increased reactivity to stimulation
- Tremulous or clonic movements
What materials are needed for intranasal fentanyl?
- 1mL or 3mL syringe
- Drawing up needle
- Atomiser
- Vial of fentanyl
What additional pain interventions are offered by a CCP?
- Increased morphine dose
- Ketamine
- Consult for midazolam
