Pediatric Injuries Flashcards
Leading cause of death in pediatrics
Injury
Blunt or penetrating more common
Blunt
Most common cause of injuries in… - 0 to 14 yo? - 1 to 18 yo?
Falls in 0-14 MVA in 1-18
Second most common cause fatal injuries in kids 1-14:
Drowning
Second most common cause fatal injuries in kids 15-18:
Firearms
Most common traumatic injuries in pediatrics:
Head > extremities > torso > spine
Different injury responses kids have compared to adults and the anatomic / physiological reason for it:
(1) Multiple injuries are more common –> Overall smaller body size / more compact organs (2) Higher frequency of head trauma –> proportionally bigger heads. (3) Greater propensity for spinal cord injuries without radiologic abnormality (SCIWORA) –> Flatter facets joints, more elastic cervical ligaments. (4) Normal blood pressure early in shock –> high degree of compensatory vasoconstriction (5) Greater heat loss from exposed body surfaces causing them to get cold much faster –> larger body surface area/mass ratio. (6) Higher risk of intra-abdominal injury and bleeding –> abdominal organs more anterior and less subcutaneous fat
Main psychological differences between kids and adults and why this is important in an ER:
- Fear, pain, and anxiety are more widespread. - Parental separation can cause major stress. - Stranger anxiety can cause major stress. - Lack of ability to reason. *** Especially things like widespread fear, etc, can make it difficult to determine if there is an altered mental status, or the kid is just scared.
Role of “Child Life Representative”
Person who helps calm parents and distract kids during trauma scenarios.
Primary Survey =
The life support phase of pediatric trauma care: - goal is to immediately recognize and intervene on airway compromise and unrecognized hemorrhage. - A, B, C, D, E’s
ABCDE in primary survey:
A - airway patency and C-spine B - “breathing,” oxygenation, and ventilation. C - “Circulation,” signs of shock, hemorrhage control, vascular access. D - “Disability/D-stick” pupils, AVPU, GCS, glucose stick. E - “Exposure and Environmental control” Completely undress patient while preventing hypothermia.
“AVPU”
An easier GCS Score: Alert Voice Painful stimuli Unresponsive
Secondary Survey =
head-to-toe evaluation performed after the trauma and which the examiner will yell out to the rest of the team: (1) HEENT (2) Neck (3) Chest (4) Cardiac (5) Abdomen (6) MSK (7) Genitourinary (8) Back
HEENT components of 2º survey:
Scalp eye trauma hemotympanum septal hematoma facial bone fractures dental trauma.
Neck components of 2º survey:
cervical spine tenderness subcutaneous crepitus stepoffs swelling
Chest components of 2º survey:
tenderness equal chest rise
Cardiac components of 2º survey:
Heart sounds Murmurs Rubs Gallops
Abdominal components of 2º survey:
distension tenderness BS
Musculoskeletal components of 2º survey:
swelling tenderness crepitus deformities pelvic instability
Genitourinary components of 2º survey:
Urethral bleeding Rectal exam Vaginal bleeding
Back components of 2º survey:
Tenderness Crepitus Stepoffs Swelling Axillae
What to do in 1º and 2º surveys if there is a change in patient status:
Reassess
A 4 yo boy darts into the street and is struck by a car. EMS arrives to find him unresponsive, pale and tachypneic but without increased work of breathing. ** What do you do next?
Perform 1º and 2º survey
Indications for intubation:
Intubation generally rare in peds Indicated when: - unable to control airway - decompensated shock - GCS ≤ 8
Method for fluid resuscitation in kids:
2 boluses of 20cc/kg crystalloids - if still no response move to blood
Wadell Triad:
Seen in pedestrian kids hit by a motor-vehicle: (1) Closed Head Injury (2) Intra-abdominal injury (3) Mid-shaft femur fracture
Max-normal pulse rate in: - Infants - Preschool - Adolescents
- Infants: 140-160 - Preschool: 120 - Adolescent: 100
Minimum-normal systolic BP in: - Infants - Preschool - Adolescents
- Infants: 70-80 - Preschool: 70 + 2(age in yrs) - Adolescent: 90-100
Max-normal respiratory in: - Infants - Preschool - Adolescents
- Infants: 40 - Preschool: 30 - Adolescent: 20
Reason a drop in BP is VERY concerning in pediatrics:
kids can ramp up their SVR a ton in cases of hemorrhage and therefore BP only drops once a significant amount of fluid has been lost.
Best IV access in pediatrics:
2 IV lines
Imaging modalities used in pediatric emergencies and relative importance:
Plain films - the main trauma films which include CXR, cervical spine, and pelvis.
FAST Exam - not used a ton in pediatrics
CT - head, C-spine, abdomen, pelvis
FAST Exam in pediatrics advantages and disadvantages:
- Advantages:
- Fast
- Inexpensive
- Non-invasive
- Radiation
- Disadvantages:
- Sensitivity poor in peds
- Not good for visceral injuries
Pediatric Trauma – Case 1
Findings
- Radiology:
- Chest: Normal
- AP pelvis: Normal
- CT head: Normal
- CT C – spine: Normal
• CT abdomen: Grade II liver and spleen lacerations; moderate blood in peritoneal cavity; renal contusion but bilaterally functioning kidneys.
Patient has been stabilized with 40 cc/kg of crystalloid and 10 cc/kg of PRBC’s.
Patient is more alert, slightly agitated.
Does this patient need operative management?
***Next step in this patient:
No, most blunt trauma solid organ injuries can be treated without operation with careful management in the ICU.
Additionally, this patient is clearly improving and hemodynamically stable.
Pediatric Trauma – Case 2
11 yo girl falls off skate board and struck her head. May have had brief LOC. Comes into the house and mother notes an abrasion and contusion on her forehead and acting dazed.
Vomits several times.
Previously healthy; no other obvious injuries.
On arrival in ED:
- Alert, GCS 15.
- Has amnesia about events around fall. • No C – spine tenderness
- No other obvious injuries
(1) Does this child need a CT scan?
**(2) What other investigations, if any? **
(1) No great consensus on this, but in this patient we probably should since she did experience LOC.
(2) Take a good history and physical because this can really parse-out whether the patient should receive a CT or not:
Leading cause of trauma death and disability:
TBI
ICI prevalence with GCS of 15, 14, and 13:
15 - ICI prevalence of 2-3%
14 - ICI prevalence of 7-8%
13 - ICI prevalence of 25%
LOC an independent preditor of ICI?
What is an idependepent predictor of ICI?
LOC is not
Seizure is
Typical mechanism of ICI:
Fall
Patients at greatest risk of TBI:
Infants due to very large head
Rate of TBI from abuse:
25-30% of BHT in kidsn younger than 2yrs are from abuse
10% of all infants in ED for head trauma have been abused
Hallmark of history in abused kids:
Parents can’t recall the history
Sign to look for in patients with otherwise asymptomatic TBi:
scalp hematoma
Risk of CT scanning kids:
Higher risk of lethal and non-lethal malignancies
Signs and symptoms in potential TBI patient over 2yo which indicate need for CT
AMS
LOC
Hx of Vomiting
Mechanism of Injury
Signs of basilar skull fracture
Severe headache
Signs and symptoms in potential TBI patient younger than 2yo which indicate need for CT
AMS
Scalp Hematoma
LOC greater than 5 seconds
Mechanism of injury
Palpable or skull fracture
Acting normally per parent
How bones and other musculoskeletal structures differ in kids and what this means in terms of injury types:
Ligaments are stronger than bones - fractures are more common than sprains.
Thick and strong periosteum - unique fractures occur such as “buckle,” “greenstick,” and “bowing.”
Active periosteum - promotes callus, union, remodeling
Growth Plates - fractures are common and cause developmental issues.
What you should always do for kids before you perform musculoskeletal assessment for fractures:
Procedural sedation
Radiographic Eval of Fractures:
What needs to be scanned?
Splints?
Next step if fracture found?
Joints above and below fracture need to be scanned in addition to the fracture.
Splint should be removed before scan, but given analgesia/sedation beforehand.
Call ortho if fracture found
Features of fracture description:
Anatomic location (physeal involvement?)
Open vs closed
incomplete vs complete
Displacement and Angulation
Types of position and alignment combos for fractures:
Good position and alignment
Angulated with little displacement
Completely displaced with good alignment
Displaced and angulated
Describe the different Salter-Harris Classifications:
The fractures are more severe as you move from I to V
Buckle Fracture =
AKA Torus (“swelling”) fracture
There is a buckling of the cortex of the bone causing a swelling.
The fracture happens as force is placed on the longitundinal axis of the bone and causes buckling.
It typically happens at the distal radius.
Boxer’s Fracture =
fracture of 4th and/or fifth metacarpal after punching something.
Presents with finger malrotation
Most common pediatric elbow fx:
Supracondylar fracture
Supracondylar Fractures
Part of exam which is most important:
Types of fractures:
neurovascular exam is very important.
Types I-III
Type I Supracondylar Fracture
Other name?
Radiographic signs?
Treatment?
Gartland Type
Fat pad and periosteum are altered.
Posterior elbow splint
Type II Supracondylar Fracture
Define
Management:
Displaced with the posterior periosteum intact and anterior humeral line displaced.
Ortho consult–they will perform open or closed reduction with percutaneous pin placement
Type 3 Supracondylar Fractures:
Define
Complications
Management
displaced fracture with disruption of anterior and posterior periosteum–loss of contact between fragements.
Neurovascular compromise or compartment syndrome.
Ortho consult
Avulsion Fractures:
Etiology
Most common sites
Treatment
Sudden traction forces by muscles result in avulsion of apophysis
Ischial tuberosity > ASIS > AIIS > Lesser trochanter > Iliac Crest
Treat with non-weight bearing crutches
Toddler’s Fracture
- Define
- Cause
- Presenting signs and symptoms
- Exam findings
- Treatment
- Non-displaced spiral or oblique fx through the distal 3rd of the tibia
- Unwitnessed fall / minor trauma caused by trying to turn around too quickly.
- Limp / refusal to walk
- Exam will be normal except pain on gentle twisting of the LE or heel tap.
- Treat with short or long leg cast for 3-4 weeks, and an ortho follow-up in 1 week since incident.
