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Flashcards in Paediatric Truma Deck (54)
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1

Head Injuries - Epidemiology

1-2% of ED presentations are head injuries 2/3 are trivial Leading cause of death in 1-15 year olds Boys 2:1 chance of head injury and 4:1 change of fatal head inury

2

Head injuries - types

Bony injury and TBI

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Types and causes of Traumatic Brain Injury

Primary and Secondary TBI Primary = occurs at time of impact Secondary = from secondary causes - Hypoxia - Hypoglycaemia - Hypovolaemia - Reperfusion injury

4

Different Anatomy of Head

- Anterior fontanelle. Closes by 15 months. (Allows for slow increase of intracranial content, but limited accomodation for rapid increase following head injury. - Cartilaginous soft bone. Head injury more likely to cause depressed skull fracture or focal brain trauma than inadults (In adults diffuse brain trauma more common) - Larger head - More adherent Dura - extradural haematoma less common

5

Paediatric GCS - Verbal Response

5 - Coos, babbles 4 - Irritable 3 - Cries to pain 2 - Moans to pain 1 - No response

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GCS - indicates severity of TBI

14 - 15 = Mild TBI 9 - 13 = Moderate TBI 3 - 8 = Severe TBI GCS < 14 requires head CT to rule out intracranial haemorrhage

7

Cerebral Perfusion Pressure and Intracranial Pressure

CCP in children is 50-60mmHg CCP = MAP - ICP

8

What causes decreases in CCP?

Decreased MAP Increased ICP

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What is the Monro-Kellie Doctrine

Cranial compartment is incompressible and as such the volume inside is also fixed. Increase in volume of one cranial constituent is compensated by decreased volume of another until compensation can no longer occur ant ICP rises

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Signs if increased ICP

Headache Vomiting Bulging fontanelle Blurred vision/papillodema Seizures

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What is Cushing's triad

Sign of increase in ICP - Bradycardia - Hypertension - Irregular breathing, from brain stem compression

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Signs of Brain herniation

Symptoms of raised ICP Cushing's triad Ipsilateral or bilateral pupillary dilation - from compression of third cranial nerve Hemiparesis Decerebrate posturing

13

Extradural Haematoma - Define

collection of blood between skull and dura (uncommon in children due to more adherent dura)

14

Extradural Haematoma - Causes

Most common - middle meningeal artery injury Other - injury to middle meningeal vein, diblioc vein or venous sinuses Injury from traumatic blunt injury (fall) - may occur from relatively short fall

15

Subdural Haematoma - Define

Collection of blood between dura and parenchyma

16

Subdural Haematoma - Causes

Injury to cortical bridging veins Mechanism - high velocity shearing injuries (acceleration/deceleration), 'shaking' injuries

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Subarachnoid Haemorrhage - Define

Injury to vessels in subarachnoid space

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Diffuse Axonal Injury - Define

Injury to white matter of brain. Usually occurs at grey/white interface

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Diffuse Axonal Injury - Mechanisms

motor vehicle accident infected injuries

20

Blunt Neck Injury - Mechanism and Pattern of injury

Common causes - MVA - Sports Related Injuries - Hanging - Inflicted injuries Vessel damage less likely in blunt injury vs penetrating injury

21

Penetrating Neck Injury - Epidemiology

Low velocity = major pathology in 50% of cases High veolcity - Major pathology in 90% of cases

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Zones of the neck

o Zone 1: area between the thoracic inlet and the cricoid cartilage. o Zone 2: area between the cricoid cartilage and the angle of the mandible. o Zone 3: area between the angle of the mandible and the base of the skull.

23

Penetrating Neck Injury - vessel injury

Vessel injury is a common complication. Especially injury to: o Common, internal and external carotid arteries o Internal and external jugular veins o Innominate vessels o Subclavian vessels

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Consequences of missed penetrating neck injury

airway obstruction, delayed haemorrhage, neurological compromise and deep neck infection

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Canadian C-Spine Rule

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26

NEXUS criteria

National Emergency X-radiography Utilisation Study Absence of all of the following indicates that there is a low risk of c-spine injury and no need for c-spine x-rays: 1. midline cervical tenderness 2. altered level of alertness 3. focal neurological injury 4. presence of a distracting injury 5. evidence of intoxication.

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Thoracic Injury - Anatomical Differences

- More compliant chest pall and incompletely calcified rib cage = rib fracture less common and pulmonary injury may be present without obvious external injury - Mobile mediastinum = increased risk of simple pneumothorax progressing to tension pneumothorax. Also at risk of great vessel damage

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Thoracic Injury - Life threatening

ATOMFC Airway Obstruction Tension Pneumothorax Open pneumothorax Massive haemothorax Flail Chest Cardiac Tamponade

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Thoracic Injury - common injuries in children

pulmonary contusion rib fracture pneumothorax haemothorax cardiac injury vascular injury

30

Thoracic Injury - Signs

- Signs of respiratory distress - Tachypnoea, increased WOB, low oxygen saturation - Distended neck veins - Chest wall findings - crepitus, subcutaneous emphysema, focal tenderness on sternum, ribs or scapula, abbrasions, or lacerations - Open wounds Paradoxical chest wall movement - Abnormal chest auscultation

31

Thoracic Injury - Signs of cardiac injury

- dysrhythmia secondary to cardiac contusion. - hypotension due to blood loss or tamponade. - distant or muffled heart tones suggest haemopericardium – difficult to detect in the noise-filled environment associated with the early assessment and resuscitation of a multiply-injured child.

32

Pneumothorax - Management of simple pneumothorax

- Placement of intercostal catheter (HOSPITAL) - Close observation with high flow oxygen in situ (only in small pneumothoraces)

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Tension Pneumothorax - Differences in children

- Children more likely to progress to tension pneumothorax due to mobile mediastinum

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Haemothorax - Mechanism

Significant bleeding in pleural cavity Cause - injury to intercostal/internal mammary vessels or via injury to lung parenchyma

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Pulmonary Contusion - Epidemiology and Presentation

>50% of children with thoracic injury severe enough to require admission will have pulmonary contusion Presentation: - External signs of thoracic injury - Increased respiratory effort - Hypoxia - Abnormal Breath sounds (crackles) MAY be present - CXR will often show areas of consolidation

36

Aortic Injury - Mechanism

Blunt trauma to Mediastinum More common injury in: - MVA - Adolescents than younger children - Front seat occupants

37

ED Thoracotomy - Used for

o Release pericardial tamponade o Control massive haemorrhage o Control massive haemorrhage o Control a massive air embolism (usually from a laceration the hilar region) o Perform open cardiac massage

38

Abdominal Injury - Anatomical Differences

o Proportionally larger solid organs o Less protective abdominal wall (less cutaneous fat, and less protective abdominal wall muscles) o Horizontal diaphragm that predisposes to lower lying and more anteriorly placed spleen and liver o Flexible (more cartilaginous) rib cage, which allows for compression of solid organs

39

Abdominal Injury - Seatbelt Syndrome

Pattern of Injury o small and large bowel and associated mesentery o stomach o liver o spleen o pancreas o kidneys o lumbar vertebra injury (chance fracture) with associated spinal cord injury o pelvic fractures.

40

Abdominal Injury - Handlebar Injury

78% of children who suffer direct blow to abdominal wall

41

Abdominal Injury - Management

General - IV access - Warming IV solutions  to prevent hypothermia - IV analgesia - Bladder catheterisation (hospital) to facilitate monitoring of urine output may be useful in some cases

42

Pelvis Injury - Epidemiology

Rare - accounts for high proportion of fatalities Half as frequent as adults

43

Pelvis Injury - Different Anatomy

- bones are less brittle, covered with periosteum - posterior ligaments are relatively stronger than the adjacent bone - bone growth centres are present - pelvic volume is relatively small - Greater amount of kinetic energy required to cause fracture o Single fractures (as opposed to double fractures in adults) is more common - Pelvic organs can be damaged without obvious fracture

44

Pelvic Injury - Mechanisms of Injury

- Lateral compression - Antrerioposterior compression - Vertical shear

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Pelvic Injury - Management

- Wrap pelvis with pelvic binder/sheet - Tape knees and ankles while flexing hops - External fixation and angiography also successful for controlling haemorrhage

46

Burns - Epidmeiology

- Third leading cause of unintentional death in all ages - Scald injuries = most common - Most common age = 1-2 years - 70% - preschool age - Most fatal burns occur from house fires  cause of death usually smoke inhalation

47

Burns - Pathophysiology

- Thermal injury denatures and coagulates proteins leads to irreversible tissue destruction - Surrounding zone of coagulation is area of decreased tissue perfusion = potentially salvageable - Main factors that determine severity o Temperature o Duration of contact Systemic response – vasoactive mediators are released from damaged tissue. Increased capillary permeability which results in extravasation of fluid into the interstitial space around the burn. Patients with large burns (>15% for young children, and >20% for older children and adolescents) develop systemic responses to these mediators. Systemic capillary leak usually persists for 18-24 hours, after which vascular integrity improves. Similarly it is not uncommon for these patients to become febrile during this time period. All of these factors make it difficult to determine early sepsis from an expected systemic response.

48

Burns - Pattern of Injury

o Scalds  water at below boiling point and contact for less than 4 seconds. Scalds from liquids at higher temperature or in children incapable of minimising contact time = most serious injuries o Flame burns  high temperatures

49

Burns - Fluid Resus

o any burn > 10% in an infant 0 – 18 months o any burn > 15% in a child over 18 months. Parkinsons Formula 4mL/kg/% burn

50

Burns - Percentage Surface Area

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51

Orthapaedic Fractures - Types (Table)

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52

Orthapaedic Fractures - Types (Diagram)

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53

Submersion Injury - Pathologies that lead to drowning

- epilepsy/seizures - cardiac arrhythmia e.g. long QT - panicking - syncope - ethanol in adolescents - non-accidental injury

54

Submersion Injury - Post Drowning Pathologies

- spinal cord injury - head injury - hypoxic ischemic encephalopathy - aspiration and pneumonia - haemolysis and hyponatremia post freshwater drowning are possible but rare.