Approach to acute paediatrics, Injured child

Question 1

How are children different to adults?

Answer 1

• Anatomically
• Physiologically
• Compensate well & decompensate quickly
• Communication challenges
• Parents usually present (& anxious)

Question 2

How is a child’s airway different?

Answer 2

Large head to body size, short necks & large tongue

Obligate nasal breathers
- Nasal passages easily obstructed

Compressible floor of mouth and trachea

High anterior larynx

Question 3

What are the breathing differences in children and how is that relevant in increased resp work?

Answer 3

Small total surface area for air tissue interface

Lower airways small- easily obstructed

Diaphragmatic breathing

Fewer type I (slow twitch) fibres- easy fatigue

Soft non-calcified bones- v. compliant chest wall- recession and in-drawing

Horizontal ribs- less expansion

Question 4

How does children’s respiration differ (think metabolic, curve shifts etc)?

Answer 4

Higher metabolic rate/ oxygen consumption
(Respiratory rate higher and gradually falls)

Oxygen dissociation curve shifted left in neonates (HbF predominance)-Neonates tolerate slightly lower saturations

Immature lung vulnerable to insult

Apnoea may occur in babies

Question 5

What is the circulating blood volume of a baby?

Answer 5

70-80ml/kg

Small loss can make a big difference

Question 6

Circulation changes from in utero to ex-utero: what can remain open?

Answer 6

PDAs/PFO may remain open for several months

Question 7

SV ..?.. with size

Answer 7

INCREASES

HR higher and graduallly falls

Question 8

What happens to SVR from birth?

Answer 8

It progressively rises

• BP lower & rises
• Special cuffs/charts needed for different ages

Question 9

Falling BP is a late sign in children how does this contrast to adults?

Answer 9

Relatively maintained compared to adults

Question 10

What does bradycardia (<60) indicate?

Answer 10

Life threatening pathology (but may be seen in anorexia)

Manage as arrest if no response/poor perfusion

Question 11

What does it mean for calculations that there is a huge variation in shape and size of children?

Answer 11

Calculations are done by weight/age

Question 12

Why are children more prone to rapid heat loss/hypothermia?

Answer 12

Large SA:weight ratio

Question 13

Why are babies more susceptible to infections?

Answer 13

Immature immune system at birth

Question 14

If VIW causes a deteriation in a child what action should be taken?

Answer 14

Increase O2
Nebulised salbutamol & oral steroids

Senior advice:
- IV access + saline bolus
- Check bloods (FBC/CRP)
- Capillary or venous gas & CXR
- Stop feeds & start IV fluids
- Closer monitoring in HDU

Question 15

What is an ISS?

Answer 15

Injury severity score

> 15 generally indicates a pretty significant injury that normally requires intervention

Question 16

Why do children get injured?

Answer 16

Interaction between:

Stage of development
(Anatomical, behavioural, locomotor, physiological, psychological)

Their environment

Those around them

Think about:
Audio-visual cues, written warnings, climbing, inquisitive nature, playing, risky behaviour

Question 17

Why do children injure differently?

Answer 17

• Different anatomical features & different physiological & psychological responses to injury
• Different spectrum of injury patterns
• Not all children are the same (neonates—adolescents)

Question 18

Does the skeleton deform rather than break?

Answer 18

Yes-soft, springy

Incompletely calcified

Provides less protection for vital organs

Question 19

Organs packed in a smaller space how can this relate to damage in an injury?

Answer 19

Less elastic connective tissue
- Shearing and de-gloving

Crowding of poorly protected vital organs
- Liver, spleen, bladder are intra-abdominal
- Single impact injure multiple organs

Question 20

Organs packed in a smaller space how can this relate to damage in an injury?

Answer 20

Less elastic connective tissue
- Shearing and de-gloving

Crowding of poorly protected vital organs
- Liver, spleen, bladder are intra-abdominal
- Single impact injure multiple organs

Question 21

How does children’s metabolism differ to adults in relation to coping with injury?

Answer 21

Thermoregulation
- Little brown fat and immature shivering
- Pokilothermic
- Environmental considerations e.g. RTCs

Hypoglycaemia
- Little glycogen stored in liver
- Exacerbated by hypothermia and vice versa
- Develops quickly in sick children

Question 22

What injury patterns present?

Answer 22

• Waddell’s triad
• SCIWORA (spinal cord injury w/o radiological abnormality)
• Lap belt syndrome

Question 23

What does ATOMFC stand for (for trauma primary survey)?

Answer 23

Airway obstruction
Tension pneumothorax
Open chest wound
Massive haemothorax
Flail chest
Cardiac tamponade

Question 24

How is a fracture dealt with in A&E?

Answer 24

• Analgesia
• Hx
• Consider mechanism
• Examine all of joint-Don’t start with sore bit
• Distraction

Question 25

What are some common fractures seen?

Answer 25

• Buckle fracture of distal radius (tis a wee bone bend)-stable fracture-splint
• Supracondylar fractures
• Greenstick fractures
• Clavicle fracture
• Toddler’s fracture of tibia-generally analgesia
• Growth plate injuries-some can cause growth arrest-need surgical intervention

Question 26

What classification system is used for growth plate injuries?

Answer 26

Salter Harris Classification

Question 27

What is used for wounds in children?

Answer 27

• Tissue glue
• LAT gel
• Theatre & sedation

Question 28

How is a burn/scald dealt with?

Answer 28

• First aid-run under water
• Chemical burns-irrigate
• COBIS-guidance
• Functional
• Plastics

Question 29

What should be considered in a head injury?

Answer 29

• NICE guidelines
• NAI
• Concussion-ACORN (advice)
• Sport-Headway

Question 30

How should drowning cases be managed?

Answer 30

Hx is important

Hypothermia

Supportive care-ECMO