Trauma

Question 1

Nonaccidental trauma

Answer 1

Any unusual presentation of trauma or age based injury that doesn’t make sense. Fundoscopic evaluation for retinal hemorrhage of any child with suspected shaking or traumatic brain injury of questionable mechanism.

Question 2

Splenic Laceration

Answer 2

THE MOST COMMON ABDOMINAL INJURY IN CHILDHOOD!

Caused by blunt trauma to upper abdomen or lower thorax. Spleen is not adequately protected by rib cage.

S/S: Pain in left shoulder, LUQ or left part of chest; bruising, abrasions, nausea, vomiting. A mass may be palpable in LUQ - decreased hematocrit and presence of leukocytosis.

Dx: CT, but CXR may show fractures to left lower ribs or pleural effusion.

Spleen may be preserved via non-operative measures; recommended for child with stable vitals, requires < 1/2 blood volume replacement and is free of abd injuries that require surgery. Monitor in ICU for at least 24 hrs; frequent H & H, strict bedrest. If operable, must vaccinate against HIB, Neisseria meningitis postoperatively; PCN prophylaxis.

Question 3

Liver Laceration

Answer 3

MAJOR CAUSE OF DEATH IN CHILDREN WITH BLUNT TRAUMA, HIGHEST RISK OF INJURY!
- Associated with significant blood loss, exsanguination. Right lobe more prevalent than left lobe.

S/S: Acute abdominal tenderness due to hemoperitoneum, pain in right shoulder or RUQ tenderness. Bruising, seatbelt markings and abrasions, hypotension and tachycardia, if bleeding and fractured ribs can be associated with pelvic or rib fractures.

Dx: CBC, UA, Liver Function Tests, Ultrasound, CT.

Non-Operative Management: NPO status, H & H q4-6 hours, can ambulate after AST and ALT are WNL, blood products if indicated.

Operative Management: If hemodynamically unstable!
- often to control bleeding!

Question 4

Pancreatic Injury/Laceration

Answer 4

Associated with high morbidity and mortality.

Findings: Soft tissue contusion in upper quadrant, handlebar marking, tenderness to lower ribs and costal margin, epigastric tenderness, lower thoracic spine fracture, signs of peritonitis, vomiting.

Dx: CT with grading of injury, amylase and lipase labs.

Question 5

Kidney Laceration

Answer 5

Sx: Contusion, hematoma, or bruising of flank or back, abdominal or flank tenderness, palpable mass, stab wounds posterior to anterior axillary line.

Dx: CT, UA for hematuria, Intravenous Pyelogram

Question 6

Abdominal Compartment Syndrome

Answer 6

Life-threatening complication of abdominal trauma.

• Results in coagulopathies, acidosis, hypothermia, bowel edema.
• Monitor bladder pressures.

Question 7

Burns

Answer 7

Occur as a result of chemical or thermal injury. The outcome is often based on layer of skin involved with burns to the subcutaneous layer or third layer posing the most problems with wound healing.

Three layers of skin are involved: Epidermis, dermis, and subcutaneous layers. Nerve damage occurs in the dermis, which is the area that contains most of the vital characteristics and components that support function.

Question 8

Burns: First Line Management

Answer 8

1. Airway
2. Breathing
3. Circulation
4. Primary Trauma Survey
5. Secondary Trauma Survey

Primary and secondary trauma surveys determine systemic response to burns, involved skin surfaces, and other organ dysfunction. Evaluation by a burn surgeon is the best evidence-based method for determining burn depth.

Question 9

Burns: Airway

Answer 9

Potential for inhalation injury.

• Carbon monoxide poisoning and acute lung injury.
• Facial burns, singed eyebrows, stridor, wheezing, hypoxia, carbon sputum, hoarseness, mucus membrane and tongue swelling.

Question 10

Burns: Breathing and Circulation

Answer 10

Pulmonary injury from particle aspiration and carbon monoxide inhalation causes hypoxia and difficulty breathing.

Question 11

Burns: Assessment

Answer 11

Includes laboratory and radiological evaluation

• Carboxyhemoglobin, CBC, CMP with Albumin, Blood Gas
• Urine pH and myoglobin is indicated for children with electrical burns along with an EKG

Question 12

Superficial Burns

Answer 12

Involving only the epidermis

- Minor in severity

Question 13

Partial Thickness Burns

Answer 13

Extending through the epidermis into the dermis, blister formation distinguishes a partial thickness burn from a superficial burn.

Question 14

Full Thickness Burns

Answer 14

Extends through the dermis.

• Skin is white, yellow, brown, or black in appearance, no blisters, skin is hard
• Minimal or no pain

Question 15

Deep Full Thickness Burns

Answer 15

Extends through all layers of the skin

- May involve fascia, tendons, muscle, and bone

Question 16

Zones of Local Injury

Answer 16

Constitute the physiologic response to injury

Systemic response is determined by the TBSA (total body surface area) of the burn, calculated by the Rule of Nines.

Fluid shifts occur 12-48 hours after injury, resulting in metabolic compromise and electrolyte instability. Compartment syndrome can occur as diffuse edema in an extremity, orbital, or abdominal region.

Fluid resuscitation assists in preventing rhabdomyolysis and subsequent renal failure. Hyperglycemia management is important with management of protein loss.

Question 17

Zone of Coagulation

Answer 17

Cells in this area receive the maximum contact with the heat source
- Necrosis ensues

Question 18

Zone of Stasis

Answer 18

Decreased blood supply, high risk for burn wound progression without fluid resuscitation

Question 19

Zone of Hyperemia

Answer 19

Cells sustain minimal injury, mild inflammation, spontaneously heal in 7-10 days

Question 20

Burns: Antimicrobial Therapy

Answer 20

Importance of preventing bacterial overgrowth and systemic function from local source.

Question 21

Burns: Topical Therapy

Answer 21

Silvadene ointment or cream: water soluble, bacteriocidal activity against gram positive and negative bacteria and yeast.

Should not be used for young infants or sulfa-sensitive children!

Silver containing dressing are silver containing hydrocolloid dressings that can assist in preventing frequent dressing changes and provide antimicrobial therapy.

Question 22

Burns: Pain Management

Answer 22

Combination of fentanyl and benzodiazepines can potentiate delirium, so this combination should be avoided in hospitalized children with burns.

Beta blockers have assisted in decreasing hospital stay and increased burn wound healing.

Question 23

Fracture

Answer 23

Physeal and growth plate fractures need immediate and specialized care!
- Use Salter-Harris fracture classification to determine growth plate involvement.

Question 24

Class I: Epiphyseal Plate Fractures

Answer 24

Complete separation without fracture.

Management: Closed reduction and cast.

Question 25

Class II: Epiphyseal Plate Fractures

Answer 25

Most common - separation of plate with fracture.

Management: Closed reduction and cast.

Question 26

Class III: Epiphyseal Plate Fractures

Answer 26

Fracture through part of plate extending to joint.

Management: Open reduction and internal fixation.

Question 27

Class IV: Epiphyseal Plate Fractures

Answer 27

Fracture completely through plate.

Management: Open reduction and internal fixation.

Question 28

Class V: Epiphyseal Plate Fractures

Answer 28

Crush injury to area of plate that is non-displaced with no fracture line visible on xray.

Management: Immobilization and non-weight bearing for a minimum of 3 weeks.

Question 29

Compartment Syndrome

Answer 29

Pressure-related medical emergency that compromises tissue within a closed, inflamed space limiting perfusion with inadequate blood flow to capillaries leading to tissue ischemia.

Situation requires immediate treatment if pressures exceeds normal limits > 30-35mmHg

• Castings or bandages are removed with any question of status, keeping extremity level.
• Can result from many medical problems including fractures, burns, venomous bites, IV or IO infiltrates, thromboembolitic events, athletes involved in heavy training.

S/S: Three P’s (Paralysis, Pallor, Pulselessness)
- Preceding the 3 P’s are 3 A’s (Anxiety, Agitation, and Analgesic Requirement)

Tx: Elevate extremity, remove bandages and dressings, administer oxygen and pain medication. If signs and symptoms are excessive, emergent fasciotomy may be performed.

Question 30

Slipped Capital Femoral Epiphyses (SCFE)

Answer 30

Separation of the growth plate in the proximal femoral head.

S/S: Between ages of 12-15, African American or Hispanic, obese. Acute disease includes sudden exacerbation with hip, thigh, or knee pain, limited internal rotation and obligated external rotation.

Dx: Plain radiographs of pelvis. May need CT or MRI.

Tx: Surgical pinning or fixation.

Question 31

Osteomyelitis

Answer 31

Infection of the bone from a variety of etiologies, most common infective organism is Staph aureus.

S/S: Presentation is variable. Recent injury or infection, localized pain in involved bone or extremity with discrete tenderness at the site of infection.

Dx: CBC-D, ESR, CRP, BCX, plain xray, MRI.

Tx: IV antibiotics, but unknown documented time frame. Average length of treatment is 5-23 days.
- Surgical drainage is sometimes necessary.

Question 32

Septic Arthritis

Answer 32

Infection of the synovial space of the joint.

S/S: Pain to the affected area, fever, nonuse of extremity, limp or refusal to bear weight.

Dx: CBC-D, ESR, BCx, bone scan

Tx: IV antibiotics
- May require surgical intervention for drainage of joint.

Question 33

Spinal Fusion/Scoliosis Repair

Answer 33

Spinal deformity repair.

S/S: Intraoperative concerns include blood loss, hypotension, respiratory instability and kidney function, SIADH can occur intra or post-operatively as a result of volume replacement and spinal manipulation.

Tx: Pain management, fluid and electrolyte monitoring and replacement, intake and output, neurologic assessment for first 24 hours.

Question 34

Toxic Synovitis

Answer 34

Transient monoarticular synovitis as inflammatory condition that affects large joint spaces.
- Usually hip

S/S: Pain in the area of the affected joint, limping (antalgic) gait, and refusal to bear weight.

Dx: CBC-D, ESR, CRP, MRI or bone scan.

Tx: Symptom-based treatment, NSAIDS for pain, rest, and limited activity of the joint.