Paeds Trauma Flashcards
What is the highest risk group for burns?
1-3yrs approx 50%
Second peak in adolescents 11-15
Much higher in boys vs girls
What is the most common cause of burns?
Scalding in all age groups (approx 75%) except for adolescents which is flame burns
What is the Parkland formula for fluid replacement in paeds?
The daily volume of fluid required
Burns % x Weight (Kg) x 4mls
Ie child with 10% burns who is 10kgs needs 400mls
1/2 given in the 1st 8hrs, other 1/2 given in the next 16hrs
What conditions predispose to cervical spine injury (CSI)?
Trisomy 21
Previous C-spine injury/surgery
Achondroplasia
Osteogenesis imperfecta
Hypermobility syndromes (Ehlers Danlos syndrome, Marfans etc)
What are the high risk mechanisms for C-spine injury?
Axial load to the head
Ejection from a vehicle
Improper restraint in an MVA
MVA >60km/hr
Rollover/head on collision
MVA with other passenger death
Pedestrian vs vehicle
Fall >3m or twice height
Kicked by or fall from a horse
Substantial torso injury
What are the signs of increased ICP in infants?
Full fontanel
Split sutures
Altered conscious state
Paradoxical irritability
Persistent emesis
Setting sun sign (upward gaze paresis, always appear to be looking down)
What are the 2 main types of extracranial head haematomas in children?
Caput succedaneum
- Freely mobile, crosses suture line
Cephalohaematoma
- Blood under periosteum and doesn’t cross suture lines
In infants scalp bleeds can be profuse and lead to shock due to large heads relative to small circulating volume
What are injuries typically associated with NAI?
Extensor surface scalding sparing the flexor surface
Metaphysial humerus corner fractures
What are suspicious points on history for NAI?
- No history, unwitnessed or inconsistent history regarding injury
- Mechanism incompatible with childs age or developmental ability
- Unreasonable delay in seeking medical care
- Stating another child caused the injury
- Child displaying harmful, regressed or sexual behaviours
- History of family violence or child abuse
- Recurrent presentations with odd injuries/stories
- Child appears afraid or not wanting to interact with caregiver
What is the TEN 4 FACES mnemonic for child abuse injury pattern?
TEN (bruising in child <4)
T- Thoracic
E- Ears
N- Neck
4
- any bruising in a child <4-6 months
FACES (injury pattern in any child)
F- Frenulum in mouth
A- angle of jaw
C- Cheek
E- Eyelids
S- Scleral injury
What are the risk factors for NAI?
Child
- Any disability
- Mental health problems
- Failure to thrive
- prematurity/low birth weight
- Unwanted child
- Frequent crying
Environment
- Domestic violence
- Unrelated adult male in the home
- Isolation
- Low SES
- Animal cruelty
- Abuse of other siblings
Care Giver
- Unplanned pregnancy
- Young or single parent
- Psychiatric illness
- Substance abuse
- Low SES/poor education
- Care giver abused as a child
What is a Toddlers fracture?
A minimal or undisplaced spiral fracture, most often affecting the tibia
*Spiral fractures of the femur are suspicious for NAI
Usually in ages 9 months - 3 yrs
Thought to be caused be new stressors placed on growing bone
Usually present with irritabilty and poor weight bearing but may not localise pain to the tibia
What is the typical dosing of blood products in massive haemorrhoage in paediatrics?
10-20ml/kg PRBC
10-20ml/kg FFP
5-10ml/kg pooled platelets
5-10ml/kg Cryo
What are the typical initial interventions for a paediatric major trauma?
Airway support and supplemental 02
C-spine precautions
Pelvic binder/long bone splints
2x large bore IV access
Ideally blood use, consider massive transfusion protocol
Replace calcium if transfusing
IV TXA 15ml/kg over 10mins, then 2mg/kg/hr for 8hrs
Warmed fluids/blankets/air to prevent hypothermia
What are the biochemical and physiological targets in during massive transfusion?
Temp >35
ph > 7.2
Calc >1.1mmol/L
Hb >70g/L
INR <1.5
lactate <4
Base excess >6
Fibrinogen >1.5g/L
Platelelets >50
APTT <1.5x normal
What is the PECARN rule for intraabominal injury (IAI)?
- Evidence of abdominal wall trauma or seat belt sign?
- GCS <14 and blunt abdo wall trauma?
- Abdominal tenderness?
- Any of thoracic trauma, subjective abdo pain, vomiting and decreased breath sounds?
If no to all then very low risk
What is the PECARN rule for head injury in age <2?
- GCS <14, AMS or palpable skull #
- Severe mechanism
- non-frontal scalp haematoma
LOC >5secs or not acting normally?
If no to all the above then very low risk
What is the PECARN rule for head injury >2yo?
- GCS <14, AMS or signs of basilar skull fracture?
- Severe mechanism?
- Any LOC?
- Vomiting or severe headache?
If no to all then very low risk
Whys is the NEXUS score used for paediatric C-spine?
Validated for children with 100% sensitivity and 100% NPV
NSAID mnemonic
N- Neurology?
S- Spinal tednerness?
A- Altered mental state?
I- Intoxication?
D- Distracting injury?
How is the C-spine scored in children <5yrs?
NEXUS but intoxication is replaced with torticollis
NSATD
Neurology?
Spinal tenderness?
AMS?
Tortiollis?
Distracting injury?
What are some of the differences between adults and children with trauma?
Prone to hypoxia
- Increased 02 consumption, diaphragmatic breathing, low FRC
Pliable ribs
- less rib fractures but more damage to thoracic structures
Response to blood loss
- Hypotension is pre-arrest sign of haemorrhagic shock
Narro airway
- Prone to obstruction
Anterior larynx
- Difficult intubation
Smaller patient
- Multiple systems injured
Increase surface area:mass
- Prone to hypothermia
Development
- Paediatric GCS/AVPU
What are the doses of blood products in paediatrics?
PRBC
- 10ml/kg
Cryoprecipitate
- 5-10ml/kg
FFP
- 10-20ml/kg
Platelets
- 10ml/kg
If you say 10ml/kg for all then technically you are correct
In order of frequency what are the most common features of paediatric concussion syndrome?
Headache- 93%
Dizziness- 75%
Difficulty concentrating- 57%
Confusion- 46%
Vision change- 38%
Nausea- 29%
Drowsiness- 27%
How is paediatric concussion diagnosed?
A history of trauma mechanism
- Either direct blow to head or blow to body with rapid head rotation
Typical concussive symptoms
- Onset soon after injury
- Represents a change from baseline
Standardised assessment
- Neurological symptoms and signs, balance testing, neuropsychology
Exclusion of intracranial injuries
- Clinic findings and course
- Or neuroimaging
How should a family and child be counselled when diagnosed with concussion syndrome?
Avoid further injury
Graduated return to sport
Graduated return to school
- Return to learn
- Once patients can concentrate on a task and tolerate auditory/visual stimulation for >30-45 mins (the typical length of a school period)
Symptomatic management
A brief period of physical rest, approx 24-48hrs
What is the general management of a paediatric traumatic cardiac arrest (TCA)?
- Commence CPR whilst assessing for reversible causes of arrest
- Control obvious bleeding ie tourniquet, long bone splinting, pelvic binder direct pressure
- Bilateral pleural decompression (finger thoracostomy controversial, use thoracostomies in 1st instance)
- IV blood products 20ml/kg at 1:1:1 ratio
- Secure airway with ETT, 1.0 Fi02
- 15mg/kg IV TXA
- Ideally, maintain spinal precuations
- Consider alternative cause such as APLS cause, continue APLS for at least 10mins post TCA interventions
- If all conditions met then proceed to ED resuscitative thoracotomy
In a paediatric traumatic cardiac arrest, what factors influence the decision to cease resuscitative interventions?
- Lack of response to life saving trauma interventions
- Prolonged duration (ie >10mins) of traumatic cardiac arrest
- Persistently low CO2
- Cardiac standstill on POCUS
- No reversible medical causes found
- No specific indications for prolonged CPR ie drowning, hypothermia
- No social indications for prolonged CPR ie family in attendance
How are straddle injuries classified and how do they normally present?
Classification
- Penetrating vs blunt
- Penetrating normally need surgery and more suspicious for NAI
Females
- Normally anterior involving the clitoral hood, labia minor and mons
- Vulvar haematomas and superficial lacerations are common
- May have difficulty urinating due to haematoma pushin on urethral meatus
Abuse concerns females
- Injuries to the hymen or posterior fourchette
- True vaginal bleeding (not just from external laceration
- Perineal lacerations
- haematuria or blood at meatus without obvious external cause (suggests pelvic fracture)
Males
- Mild scrotal swelling and bruising
Abuse concerns males
- Patterned injuries
- haematuria/blood meatus
- Absent cremasteric reflex
- large lacerations or bruising
- Isolated anal injuries
What is the difference in indication for massive transfusion protocol for kids aged < and >5?
<5 years old
- >20ml/kg or >2 units in 1-2 hrs with further losses anticipated
> 5years old
- >40ml/kg or >4units in 1-2hrs with further losses anticipated
Massive haemorrhage Definition
- Same all age groups
- >50% TBV in 3-4hrs
- >100% TBV in 24hrs
