Pediatric trauma Flashcards
Most common cause of death and disability in childhood
Trauma
Most common trauma mechanism and most common cause of traumatic death in childhood
Most common - falls
Death - RTC
Why do children have different injury patterns and are more likely to have multi system injury than adults
Same kinetic energy transferred across a smaller volume
Children vs adult general physiological differences
Greater SA:volume -> incr heat loss
- hat, blanket, warmed fluids
Incr O2 extraction
Incr glucose utilisation
Smaller glycogen stores
Child vs adult airway differences
Large occiput causes neck flexion when supine
Soft trachea
Smaller airway - more likely to obstruct
Larger tongue -> obstruction more likely
Infants are obligate nasal breathers
Small Cricothyroid membrane
Funnel shaped larynx -> more likely to retain foreign body
Large tonsils and Eden oils - more likely to bleed during instrumentation
Why are surgical airway more difficult in kids
Small Cricothyroid membrane
Why should a pad be placed under a child’s shoulders
Prevents flexion of neck when supine due to large occiput
Why is nasal trauma particularly a problem in infants
Infants are obligate nasal breathers
Are OPs or NPs better in kids
OP (inserted without turn)
Why is bleeding more likely when using instruments while establishing airway in kids
Large tonsils and adenoids
Intubation considerations in kids
Narrow supraglottic region - more prone to dynamic collapse
Higher and more anterior larynx
Shorter trachea - endobronchial intubation more likely
Horse shoe shaped epiglottis
Why should a straight blade be used for intubation kids
Higher and more anterior larynx
Larynx position in kids and adults
Kids C2-3
Adults C6-7
What about a child’s epiglottis makes intubation more difficult
More horse shoe shapex
Child vs adult breathing differences
Quicker diapragm muscle failure -> apnoea more likely
Incr dependence on diapragm for ventilation
More elastic ribs - dissipate Ek to underlying structures
Mobile mediastinum - tension pneumothorax more severe
Short neck - hard to detect deviation
More likely to hear transmitted sounds on auscultation
Less able to incr vital capacity
Large stomach - prone to inflation in vent
tension pneumothorax issues in kids
mediastinum more mobile than in adults causing rapid ventilators and circ collapse
Shorter neck makes detecting tracheal deviation difficult
Why should you listen to a child’s chest in the axillae
Helps avoid issues of transmitted sounds
Why are kids less able to increase vital capacity
Chest wall circumference doesn’t change much during respiration (ribs go up and down more than in and out)
Ribs are more horizontally aligned
Why are kids more reliant on increasing RR in compensation
Less able to incr vital capacity than adults
Issues from inflating stomach during assisted breaths
Decreased lung inflation
Vomiting
Decreased venous return
How to prevent/manage inflation of stomach during assisted breaths
Ventilate to chest rise
Decompress stomach w OGT
Child vs adult circulation differences
Lower systemic vascular resistance
Infants unable to increase stroke volume
Can compensate for 30% loss in circ vol by incr HR -> hypotension is late sign
Bradycardia is ore terminal sign
Vascular access more difficult-> IO
Blood vol relatively larger but absolutely smaller
What aspect of cardiac output compensation can infants not do
Increase stroke volume
Why is hypotension and bradycardia late signs of decompensation in children
Kids can compensate for 30% loss of circ vol by increasing HR alone, so BP falling is late and bradycardia is pre terminal
What fluid bolus does JRCALC suggest for kids
5ml/kg ideally warmed
Why is IV access more difficult in kids
Smaller vessels
More subcutaneous tissue
Why should multiple sampling be avoided in kids
Smaller blood volume
How does circulating volume differ in kids and adults
Relative volume larger
Absolute volume smaller
Neurological differences in kids and adults
Larger head: body ratio - higher COG + more likely to be target
Brain less myelinated and higher water content -> incr shearing forces + seizures
Thinner cranial bones
Cranial bones more pliable and sutures may be open
Neurological differences in kids and adults
Larger head: body ratio - higher COG + more likely to be target
Brain less myelinated and higher water content -> incr shearing forces + seizures
Thinner cranial bones
Cranial bones more pliable and sutures may be open
Why are children more at risk of traumatic seizures
Brain less myelinated and higher water content -> increased shearing forces -> increased seizures
Why are children more prone to brain parenchyma injury
More pliable cranial bones
Sutures may not be fused
Cranial bones thinner
Larger head:body so head more likely to be energy transfer target
Abdominal differences in kids vs adults
More anterior liver and spleen
More horizontal diapragm pushes liver and spleen downwards
Intraabbdominal bladder
Cartilaginous rib at bottom of thorax might damage abdo structures
Larger solid organs
Less protective musculature
Less subcutaneous tissue
More mobile kidneys
Liver and spleen differences in kids
More anterior
Pushes down by more horizontal liver
Larger - take up more space in abdo cavity than in adults so more likely injury target
Does full abdo exam include PR in kids
No, but includes genital exM
London major trauma indications for transfer to MTC in kids under 12
Traumatic death in same passenger compartment
Uninterrupted fall over twice pt height
Trapped under vehicle or large object
Bullseye or damage to A-post of car from striking pt
Bike injury causing abdo &/or groin pain (thrown from or handlebar injury)
Ejection from vehicle
Fall from or trampled by large animal
Kids vs adults orthopaedic differences
Growth plates not fused - limb length deformity possible
Tenuous spinal cord blood supply
Larger head size -> greater flex/ext injury
More flexible interspinous ligaments
Smaller neck muscle mass
SCI less common but likely to be higher in young kids
Fulcrum height higher
Incomplete ossification
Larger pre dental space
Pseudo subluxation of C2 on C3
Changes in prevertebral space w resp
Flatter and more horizontal facet joints
Why are neck Ligamentous injuries more common than fractures in kids
Smaller neck muscle mass
How does SCI pattern differ between kids and adults
Less common in kids, but likely to be above C3 if it does happen
Adult SCI pattern from 15yrz
Why does neck imaging in kids require specialist interpretation
Incomplete ossification
What spinal level is psuedosubluxation common in kids
C2 on C3
In 40% kids aged 8 to 12
What spinal level is psuedosubluxation common in kids
C2 on C3
In 40% kids aged 8 to 12
Is spinal immobilisation required in kids
Controversial but ‘essential’ in JRCALC
Definite requirement for spinal immobilisation in kids
Paralysis
Priapism
Restricted spinal rotation
Neck pain
Paraesthesia
Ptosis
Torticollis
Unexplained hypotension (even if resolved)
Down’s syndrome
Kids vs adults psychological differences
Regressive behaviours more likely
Continue to grow during rehab phase
60% have personality changes at 1 yr
50% have cognitive impairment at 1 yr
Why is ionising radiation avoided in kids
Higher increase in lifetime cancer risk
Psychological Considerations when treating kids
Keep NOK in field of vision and earshot
Expose ‘piece meal’ to avoid embarrassment and hypothermia
Be suspicious if child doesn’t cry on vascular access
Bubbles and stickers :)
Paediatric neurology red flags
Obvious extracranial head injury
Decr motor score
Pupil abnormality
Blood glucose abnormality
Recurrent vomiting
Seizure (esp more than 20 mins after event)
Irritable child
At what age should a child be able to obey commands
12 months
What injury should be assumed in a child with a head injury
Neck injury
What vein may be used for access in kids less than 10 days old
Umbilical vein
What veins may be used for access in children
Femoral vein
Saphenous vein cutdown
Umbilical vein (less than 10 days old)
What investigation is needed after IO
X ray of limb after IO removed
What medical investigations are needed in suspected non accidental injury
Skeletal survey
Retinal photography
Strategies to help with age / doses for kidskin
Page for age cards
Use child’s clothes for age if no one can confirm age
Important aspects of paediatric trauma mx
Oxygenate
IO access
BP
Keep warm
Treat pain
Correct age on pre alert
Why should blood glucose be checked regularly in kids
Incr glucose utilisation
Smaller glycogen reserves
Positioning to improve airway mx in kids
Pad under shoulder
Why is a child’s larynx more likely to retain a foreign body
Funnel shaped
Why is an ET tube more likely to move/dislodge when manoeuvring of transporting a child
Narrow supraglottic region
What complication is more likely when intubating a child due to a shorter trachea
Endobronchial intubation
What cardiac complication can be up induced by suction in a child
Bradycardia
How should bradycardia in a child be treated
Oxygen
(NOT ATROPINE)
How can inflation of the stomach by assisted breathing cause cardiac arrest
Decreased venous return
What is a possible cause of bradycardia in children
Hypoxia
Why are abdo organs more at risk in kids
Less abdo muscles and fat
What sign on the abdomen is a red flag in children
Bruising on abdo wall
What can be used to immobilise a small child instead of a backboard
Car seat
Why should kids with Down syndrome be immobilised
Incr risk of subluxation of C2 on C3 or c3 on c4
What spinal level is the fulcrum in toddlers and kids
Toddlers - c2-3
Kids c5-6
