Paediatric BLS and Trauma

Question 1

Outline the steps of resuscitation of a newborn

Answer 1

DAM I ResusCitAte (RCA)

Dry
Assess (APGAR)
Meconium in mouth (suck if presence)
Inflation breath 5 (via mask)
Reassess (APGAR)
Compression (if HR<60)
Adrenaline

Question 2

Airway suction should not be performed unless there is obviously thick meconium causing obstruction - why is this?

Answer 2

May cause reflex bradycardia in babies

Question 3

What are the basic steps of paediatric life support?

Answer 3

unresponsive? = shout for help
open airway, look, listen, feel for breathing
give 5 rescue breaths
check for signs of circulation
15 chest compressions:2 rescue breaths

Question 4

How should you check for pulses in infants vs children?

Answer 4

infants = use brachial or femoral pulse
children = use femoral pulse

Question 5

What technique should be used for chest compression in infants and children?

Answer 5

in infants: use a two-thumb encircling technique for chest compression
in children: compress the lower half of the sternum

Question 6

What is the rate and depth of paediatric chest compressions?

Answer 6

100-120/min

1/3 of the anterior–posterior dimension of the chest

Question 7

A child only responding to pain suggests what GCS score?

Answer 7

less than 8 = INTUBATE

Question 8

What are decorticate and decerebrate positions?

Answer 8

decorticate - arms flexed to chest
decerebrate - arms extended and externally rotated = WORSE

Question 9

What are the ‘big five’ of paeditaric ED?

Answer 9

hypoxia
hypotension - children compensate very well until they are about to arrest
silent chest
unequal pupils
posturing - decorticate / decerebrate

Question 10

How should bite injuries be investigated and managed?

Answer 10

Investigations:
Photographs of the wound
Any purulent material present should be swabbed
Routine bloods (including FBC and CRP)
X ray : to ensure no residual foreign material is deep within the wound, as well as ensuring no fracture is present

Management:
Cleaning
Oral antibiotics
Debridement and washout if indicated
Tetanus immunisation if a patient has not had a booster within the last 10 years

Question 11

How should suspected C spine injuries be investigated in children?

Answer 11

MRI (as opposed to CT in adults)

Question 12

How should C spine fractures be managed?

Answer 12

3-point C-spine immobilisation
Rigid collar / halo vest
If unstable = operative mx

Question 13

Describe the typical displacement of clavicular fractures in kids

Answer 13

The medial fragment will often displace superiorly, due to the pull of the sternocleidomastoid muscle, whilst the lateral fragment will displace inferiorly from the weight of the arm.

Question 14

What should you look for on examination of a clavicular fracture?

Answer 14

Due to the subcutaneous location of the clavicle, it is important to specifically look for open injuries or threatened skin (appearing as tented, tethered, white, and non-blanching skin)

Ensure to check the neurovascular status of the upper limb - in case of brachial plexus injuries

Also check for surgical emphysema, which may indicate a pneumothorax.

Question 15

How should clavicular fractures be investigated and managed?

Answer 15

Plain film anteroposterior and modified-axial radiographs of the affected clavicle should be performed

most clavicle fractures can be treated conservatively- sling and early mobilisation of the shoulder, heals in 4-6 weeks

Where fractures have failed to unite - open-reduction internal-fixation (ORIF)

Question 16

Complications of clavicular fractures?

Answer 16

non-union
neurovascular injury
any puncture injury

Question 17

Supracondylar humeral fractures are a common paediatric elbow injury. How do they occur?

Answer 17

The peak age of incidence is 5-7 years. The most common mechanism of injury is falling on an outstretched hand with the elbow in extension

Question 18

How should supracondylar humeral fractures be investigated?

Answer 18

plain film radiographs - (AP) and lateral views of the elbow

Subtle signs on plain film radiograph for a supracondylar fracture include:
Posterior fat pad sign (lucency visible on the lateral view)
Displacement of the anterior humeral line (in children >5yrs, this should intersect the middle third of the capitellum)

Question 19

How should supracondylar humeral fractures be managed?

Answer 19

Patients with supracondylar fractures with associated neurovascular compromise on presentation need immediate closed reduction

In children, this will be performed in theatre; the reduction is then secured with K-wire fixation (which can be removed in clinic after 3-4 weeks).

Question 20

Complications of supracondylar humeral fractures?

Answer 20

Nerve palsies
The anterior interosseous nerve is most commonly affected by the initial injury, however ulnar nerve palsy is the most common post-operative complication (at risk during insertion of the medial K-wire)

Malunion
In some cases, patients may even develop a cubitus varus deformity (often termed “gunstock deformity”), whereby the extended forearm deviates towards the midline.

A Volkmann’s contracture can occur following vascular compromise
wrist and hand held in permanent flexion, as a claw-like deformity