Pediatric trauma Flashcards by Bel Luscombe

Most common cause of death and disability in childhood

Trauma

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Most common trauma mechanism and most common cause of traumatic death in childhood

Most common - falls
Death - RTC

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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

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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

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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

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Why are surgical airway more difficult in kids

Small Cricothyroid membrane

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Why should a pad be placed under a child’s shoulders

Prevents flexion of neck when supine due to large occiput

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Why is nasal trauma particularly a problem in infants

Infants are obligate nasal breathers

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Are OPs or NPs better in kids

OP (inserted without turn)

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Why is bleeding more likely when using instruments while establishing airway in kids

Large tonsils and adenoids

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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

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Why should a straight blade be used for intubation kids

Higher and more anterior larynx

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Larynx position in kids and adults

Kids C2-3
Adults C6-7

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What about a child’s epiglottis makes intubation more difficult

More horse shoe shapex

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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

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tension pneumothorax issues in kids

mediastinum more mobile than in adults causing rapid ventilators and circ collapse
Shorter neck makes detecting tracheal deviation difficult

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Why should you listen to a child’s chest in the axillae

Helps avoid issues of transmitted sounds

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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

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Why are kids more reliant on increasing RR in compensation

Less able to incr vital capacity than adults

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Issues from inflating stomach during assisted breaths

Decreased lung inflation
Vomiting
Decreased venous return

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How to prevent/manage inflation of stomach during assisted breaths

Ventilate to chest rise
Decompress stomach w OGT

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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

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What aspect of cardiac output compensation can infants not do

Increase stroke volume

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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

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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

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