Trauma ✅ Flashcards
What is the most common cause of death in injured children?
Head injury
What is the principal determinant of outcome in multisystem trauma?
Severity of any head injury
What is the most common cause of severe head injury in young children?
Falls
What is the most common cause of severe head injury in older children?
Road traffic collisions, particularly from cycling accidents
What should be considered in all infants presenting with a head injury?
NAI
What can damage to the CNS caused by head injury be divided into?
- Primary
- Secondary
What is a primary head injury?
An injured sustained as a direct consequence of the impact, causing disruption of the intracranial contents
Give 2 types of primary head injury
- Diffuse axonal injury
- Vascular trauma
Why is diffuse axonal injury an important condition?
it is one of the most serious forms of primary neuronal injury, and is associated with high mortality and neurodisability
Why is DAI such a serious condition?
Because it results in widespread injury in the brain, not just in one specific area
What causes DAI?
Traumatic shearing forces due to rapid acceleration, deceleration, and/or rotation of the brain
What happens as the brain moves rapidly backwards and forwards in the skull?
The axons are disrupted, particularly at the grey-white matter junction
What do the clinical manifestations of DAI depend on?
The site and severity of axonal damage
What is a predominant feature of DAI?
Loss of consciousness
What imaging is useful in DAI?
MRI (not seen on CT)
How can trauma lead to vascular injury?
The force of impact may cause injury to intracranial blood vessels, leading to bleeding within the skull
What is an extra-axial bleed?
One occurring outside the brain
Of what type are most traumatic extra-axial bleeds?
- Extradural
- Subdural
Where does blood accumulate in extradural haematomas?
Between dura mater and skull
Are extradural haematomas usually arterial or venous?
Arterial
Which vessel in particular commonly causes extradural haematomas?
Middle meningeal artery
What is the result of extradural haematomas commonly being arterial bleeds?
They develop rapidly
Where is the bleeding in subdural haematomas?
Between the dura mater and arachnoid mater
Are subdural haematomas usually arterial of venous?
Venous
What is the result of subdural haematomas usually being venous?
They develop more slowly
What is the most common source of bleeding in subdural haematomas?
Bridging veins in the dural region
What can subdural and extradural haematoma lead to?
Raised ICP as the brain enlarges
What can the raised ICP in subdural and extradural haematoma lead to?
Mass effect and compression of brain tissue
What kind of haematoma is seen in non-accidental head injury?
Subural
When should suspicion be raised that a subdural haematoma is caused by non-accidental injury?
Incidental finding, or finding inconsistent with history given
Can traumatic subarachnoid haemorrhages occur in children?
Yes
What do traumatic subarachnoid haemorrhages often develop in close proximity to?
Cerebral contusions or skull fractures
What is a secondary head injury?
Further damage to the brain that can occur minutes to days after the original injury
Why is it important to recognise secondary head injury?
They are often either preventable or treatable, and failure to minimise its effects results in a poorer outcome
What is required to prevent/recognise secondary head injury?
Patients with significant traumatic brain injury need extremely close monitoring, especially in initial period after the injury
What is the aim of close monitoring following significant traumatic brain injury?
Prevention and treatment of complications which may give rise to secondary injury
What is true of the vast majority of paediatric head injuries?
They are mild
How is it decided if a child with a head injury requires neuroimaging?
Various criteria, related to both the history and examination, are used to try and predict the likelihood of intracranial pathology
Which factors, when present alone, indicate the need for CT scan following traumatic head injury?
- Suspicion of NAI
- Post-traumatic seizure
- GCS <14 on arrival at ED, or <15 if under 1 year old
- Suspected open or depressed skull fracture
- Evidence of basal skull fracture
- Focal neurological deficit
- Presence of bruise or swelling >5cm in diameter in children aged <1 year
Which factors, when 2+ present, indicate the need for CT scan following traumatic head injury?
- Witnessed LoC >5 mins
- Abnormal drowsiness
- > 2 discrete episodes of vomiting
- Amnesia >5 mins
- Dangerous mechanism of injury
What are the advantages of using the NICE criteria for CT scan following traumatic head injury?
They have excellent sensitivity
What are the disadvantages of using the NICE criteria for CT head following traumatic head injury?
They have poor specificity and results in a significant number of normal scans
What is the aim of resuscitation in a child with severe head injury?
Maximise cerebral perfusion whilst minimising the effect of raised ICP
What is the outcome of a severe traumatic brain injury?
Likely to have a very long period of recovery, with intensive rehabilitation therapy, but likely to recover some function
What are the most common long-term sequelae of severe traumatic head injuries?
Cognitive, behavioural, and psychiatric problems
What can cognitive problems following traumatic brain injury lead ti?
Difficulty with memory, learning, and language
What behavioural and psychiatric problems may result from a traumatic brain injury?
- Personality changes
- Lack of inhibition
- Depression
What do the outcomes of severe traumatic brain injury vary depending on?
- Severity of injury
- Age of child
- Pre-morbid condition
What is the most common cause of spinal cord injury in children?
Road traffic collisions
What does the most common cervical fracture involve?
The first 2 vertebrae
What kind of spinal cord injury is almost exclusively a paediatric problem?
Spinal cord injury without radiologic abnormality (SCIWORA)
What does SCIWORA result from?
The elasticity of the cervical spine allowing significant cord injury in the absence of x-ray changes
What are the most common causes of thoracic injury in children?
- Road traffic accidents
- Falls
Are chest injuries more commonly caused by penetrating trauma or blunt trauma?
Blunt trauma
What do chest injuries usually occur in conjunction with?
Trauma to other body parts
How does the chest wall of children compare to adults?
It is much more complaint
What is the result of the chest wall of children being much more compliant than that of adults?
It leads to transfer of impact energy to underlying organs and structures with minimal, if any, external sign of injury or fracture
What does the presence of rib fractures or mediastinal injury indicate?
A very significant and high energy impact
What are the common thoracic injuries in children?
- Lung contusions
- Pneumothoraces
What causes lung contusions?
Energy being transferred rapidly into the lungs, causing haemorrhage and oedema in the lung tissue
How common is great vessel trauma in thoracic injury?
Very rare
Why are children more vulnerable to major abdominal injuries?
- Pliable rib cages, which provide little protection to solid organs
- Solid organs proportionally larger than in adults
- Abdominal wall thin and provides less impact absorption
Are abdominal injuries more commonly caused by blunt or penetrating trauma?
Blunt
What are the most common causes of abdominal injuries?
- Road traffic collisions
- Set belt restraint
- Handlebar injury
What is the result of intra-abdominal organs bleeding readily?
Can result in hypovolaemia and circulatory collapse
What can acceleration and deceleration forces cause?
Injury to organs, which are moved rapidly and may come into contact with the spine
Why are abdominal injuries dangerous?
They can be life-threatening and difficult to diagnose quickly in the absence of external signs
What abdominal organ injuries manifest rapidly?
- Spleen
- Liver
What abdominal organ injuries don’t become clinically evident for several days?
- Bowel
- Pancreatic
What is required as a result of the difficulty in diagnosing abdominal injuries?
An active approach to identifying abdominal injury, especially in high mechanism injuries
What is a useful tool in detecting abdominal injuries?
Focused abdominal sonography for trauma (FAST)
What is the limitation of FAST scanning?
- Can miss major solid organ injury
- Must be combined with clinical judgement
