the injured child Flashcards
why is injury in children important
- major trauma relatively rare
- leading cause of death and disability
- >1y/o: pedestrian trauma w/ resulting head trauma is the commonest cause of death and disability
- <1y/o: NAI is the commonest cause of death and disability
demographics of severely injured children
<1y/o - 20-25% of pts (NAI!)
lowers to ~5% between 1-10y/o
slow increase to 10-15% by 15y/o
injury mechanism - 1-15y/o
RTC
falls <2m/>2m
assault
NAI under 2y/o
other
injury type (AIS 3+)
most common - head injury (>70% pts)
then from highest to lowest % of pts:
thoracic injury
abdo injury
limb/pelvis injury
polytrauma
spinal injury
why do children get injured
interaction between:
- stage of development: anatomical, behavioural, locomotor, physiological, psychological
- environment
- those around them
things to consider:
- audio visual clues, written warnings, climbing, inquisitive nature, playing, risky behaviour
INJURY PREVENTION IS KEY
why do children injure differently
- different anatomical features
- different physiological and psychological responses to injury
- different spectrum of injury patterns
- not all children are the same: neonates → adolescents
why is the size of children important
- relatively greater amount of energy is absorbed for the same force of impact
- large SA:vol → heat loss significant in small children
- big head
skeleton in children
- imcompletely calcified
- soft and springy
- deforms rather than breaks
- poor at absorbing energy
PROVIDES LESS PROTECTION FOR VITAL ORGANS
tissues and internal organs in children
less elastic connective tissue → shearing and degloving
crowding of poorly protected vital organs
- liver, spleen and bladder and intra-abdo
- single impact can injure multiple organs
- relatively thin abdo wall
metabolism in children
thermoregulation
- little brown fat and immature shivering
- environmental considerations e.g. RTCs
hypoglycaemia
- little glycogen stored in liver
- exacerbated by hypothermia and vice versa
- develops relatively quickly in sick children
injuries patterns in children
SCIWORA - spinal cord injury w/o radiological abnormality
lap belt syndrome - abdo wall bruising from seatbelt, likely to have significant shoulder injury
what is the aim of trauma resuscitation
- restore normal tissue oxygenation ASAP
- stabilise the patient and reverse shock
- prevent early trauma mortality
damage control resus: aims to maintain circulating vol, control haemorrhage and correct the lethal triad (coagulopathy, acidosis, hypothermia) until definitive intervention is appropriate
how to approach trauma resuscitation
team work - trauma call (code red, paeds trauma call), who is involved, assign team roles, don’t forget parents
preparation
challenges
1y and 2y survey
preparation for trauma resus
WETFLAG - weight, energy, tube size and length, fluids, lorazepam, adrenaline, glucose
equipment - tubes, blood warmer, pelvic binder
major haemorrhage protocol
drug calculations
trakcare
challenges in trauma resus
communication difficulties - too young/afraid to describe symptoms, have to rely on non-verbal cues, don’t understand what is happening, good rapport essential
fear affects vital signs
distressed parents
effects on staff
vital signs in children
trauma resus - 1y survey
cABCDE - ATOFMC
- catastrophic haemorrhage control
- airway + c spine - MILS
- breathing
- circulation
- disability
- exposure
assessing the airway
do they have a clear airway, any intervention needed
catastrophic haemorrhage control
C spine and MILS
SCIWORA
assessment of breathing
RR
sats
air entry, percussion
chest wall abnormalities, bruising, obvious external injury
potential traumatic chest injuries
tension pneumothorax
haemothorax
open pneumothorax
pulmonary contusions
flail chest
assessment of circulation
look for sources of haemorrhage - blood on the floor + 4 more (pelvis, abdo, chest, thigh/long bones)
good IVA
major haemorrhage protocol
pelvic/femoral splint
pallor, HR, pulse
assessing for disability
communication
GCS
neuro exam
assessing for exposure
expose fully
keep warm
DEFG!
imaging in trauma
CT - focused unless full body necessary
x-ray - 1st line unless CT is necessary
US
re-examination
2y survey in trauma resus
top to toe assessment
pick up other injuries that aren’t immediately life threatening but still require management
help decrease morbidity
tertiary survey
management of fractures
analgesia
hx - thorough
consider mechanism
examine all of joint - don’t start with the sore bit, force transmits in children so injury might not be right beside area fell onto for example
distraction
what type of fracture is this
buckle fracture of distal radius
what is a buckle fracture
bending of cortex rather than crack through the bone
stable fracture and heals well
can be splinted for ~3wks
what type of fracture is this
supracondylar fracture
blood in joints on left image - indicates fracture even if not visible
how do supracondylar fractures tend to occur
fall onto elbow/hand
fall comes out at distal humerus
Garland classification for severity
can be associated nerve injuries to hand
what type of fracture is this
greenstick fracture
what is a greenstick fracture
bendy bones don’t break all the way through
fracture on one side of the bone, intact cortex on the otherside
heal well
what type of fracture is this and how do they tend to occur
clavicle
fall onto the hands/shoulder
management of clavicle fracture
sling/shoulder brace
what type of fracture is this
Toddler’s fracture of the tibia
what is a Toddler’s fracture of the tibia
subtle crack in tibia
mainly clinical diagnosis - tenderness on tibia, not weight bearing
growth plate injuries classification
Salter-Harris
indicates how likely they are to affect growth later in life
soft tissue wounds in children - types and management
finger and toes
head injuries
- tissue glue, steri strips, LAT gel (local anaesthetic), theatre and sedation if suturing
burns and scalds in children - management
first aid is important; check for irrigation - 20 mins of cooling, helpful up to 3hrs after injury
chemical burns - good irrigation and pH balance
COBIS burns guidance
functional capacity e.g. burns on hands and fingers might affect future function
plastics referral and follow up
good hx, consider NAI - is mechanism consistent w/ injury
management of head injury
NICE guidance for imaging and risk assessment
don’t forget NAI - significant head trauma <1y/o
concussion - ACORN (after concussion return to normality)
sport - headway advice website
drowning in children
uncommon but high risk of mortality
hx important in children - were they seen to drown, how long has resus been going on already, when did it start
complicated by hypothermia - not dead until warm and dead
supportive care - good airway and ventilation, ECMO
