Pediatric Maxillofacial Trauma Flashcards
(332 cards)
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Pediatric
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Maxillofacial Trauma
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Part I
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Ahmed Abushahba
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BDS
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MDSc
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Lecturer of Oral and Maxillofacial Surgery
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Faculty of Dentistry
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Tanta UniversityLearning objectives
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• Be familiar with the special considerations cranio-maxillofacial
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trauma in pediatric population.
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• Describe some common patterns for soft tissue injuries
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• Understand and apply the general principles for managing common
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facial fractures.
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• Appreciate the role of dental surgeons in the management of
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pediatric maxillofacial traumatized patients.
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• Explain the effects of maxillofacial injuries in children on their growth
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and development.
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• Pediatric trauma is often preventable.
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• General anatomic and physiological distinctives:
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oPediatric patients are not just small adults!
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• General anatomic and physiological distinctives:
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oPediatric patients are not just small adults!
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They have a large body surface to
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volume ratio which is a source of
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heat loss (hypothermia )
especially
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the head which is proportionately
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biggest when the child is born and
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decreases thereafter
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• General anatomic and physiological distinctives:
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Pediatric patients are not just small adults!
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1. 2. 3. 4. 5. Large body surface area
small body size→
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↑more forces of injury delivered to small body
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and more organs
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Large cranium/body ratio→ ↑head trauma risk
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and ↑cervical strain
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Elastic skeleton: less frank fractures and more
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concealed internal injuries
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Short pliable neck
large tongue
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nasal breathers→ difficult airway
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Increased peripheral resistance and reflex
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tachycardia
less reserve→ rapid response to
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hypovolemia and rapid CVS collapse with ↑
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blood loss
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• Epidemiological and etiological aspects
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o Generally
trauma is the leading cause of
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death in children!
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o Pediatric facial fractures are relatively rare;
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however
more children die from head injury!
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o Pediatric population accounts for 1.5-15% of
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all facial fractures (what about dentoalveolar
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and nasal fractures?!)
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o Follows a bimodal distribution of incidence:
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▪ Early (2-5 years) then a peak in adolescence
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▪ Males > females
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• Epidemiological and etiological aspects
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o Causes varies with age:
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▪ < 5 years: less causes
more supervision
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and less independence (low velocity
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accidents secondary to falls from low
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heights
playground equipment
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toys)
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▪ Socioeconomic context! (motor
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vehicle/cycle accidents
animal
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dog/donkey bites!)
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• Epidemiological and etiological aspects
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o Causes varies with age:
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▪ < 5 years: less causes
more supervision
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and less independence (low velocity
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accidents secondary to falls from low
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heights
playground equipment
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toys)
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▪ Socioeconomic context! (motor
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vehicle/cycle accidents
animal
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dog/donkey bites!)
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• Epidemiological and etiological aspects
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o Causes varies with age:
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▪ < 5 years: less causes
more supervision
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and less independence (low velocity
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accidents secondary to falls from low
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heights
playground equipment
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toys)
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▪ Socioeconomic context! (motor
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vehicle/cycle accidents
dog bites
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bites
horse kicks)
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• Epidemiological and etiological aspects
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o Causes varies with age:
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▪ > 5 years: more activity
mobile
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risk-taking
violent behavior of
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teenagers
sports and recreational
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activities.
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• Epidemiological and etiological aspects
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o Causes varies with age:
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▪ Any age: Child abuse!!
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Unfortunately
most epidemiologic
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surveys of physical abuse in
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children show that the abuser is
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often an immediate family member.
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• Prevention
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• The use of age- and weight specific protective restraints
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• lower speed limits
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• strict alcohol abuse laws
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• The use of air bags
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• Proper helmets/sports guards
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• Awareness of child abuse and reporting!
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• Facial growth and development
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Posnick JC .
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6 months 11 years 20 years
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Ongoing craniomaxillofacial growth results in a changing anatomy
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Children have:
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1. a thinner cortex and greater
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thickness of medullary
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bone
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2. a higher cranial -to-facial
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ratio (8:1 in infants versus
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2:1 in adults)
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3. more facial adipose tissue
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(the buccal and labial fat
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pads)
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4. more elastic bone (lending
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to greenstick fracture)
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5. Underdeveloped paranasal
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sinuses.
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• Facial growth and development
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Dr. Melvin Moss
originator of the
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functional matrix hypothesis.
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“bones do not growbut are grown”
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• Facial growth and development
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o During infancy and early childhood there is
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a significant increase in head circumference
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to accommodate brain growth.
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o By the end of the sixth year of life
90% of
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cranial growth has occurred
the sutures are
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well articulated
and orbital maturity is
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almost reached.
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o Palatal
premaxillary
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suture growth is complete
with
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obliteration of sutures by the age of 8 to 12.
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• Facial growth and development
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The lower two thirds of the face exhibits
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downward and forward growth
which exposes
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the bones of the face to injury.
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Eruption of deciduous teeth occurs in the first
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2 years of life
and eruption of the permanent
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dentition is complete by the age of 12 to 13.
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Permanent tooth eruption accounts for much
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of the vertical growth of the lower two thirds
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of the face.
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• Facial growth and development
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o Mixed dentition:
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▪ Teeth buds→ weakness areas
limit
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certain plates and screws placement
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▪ Difficult maxillomandibular fixation
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(MMF)
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▪ ongoing growth and eruption of the
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permanent dentition can often
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compensate for minor inaccuracies in
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reduction and fixation.
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• Physical evaluation
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o High index of suspicion for multiple injuries
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which are often unnoticed
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o Always assume cervical spine injury
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o Airway compromise/collapse is very likely
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o Worsening hypoxia in children due to
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increased respiratory rate and oxygen
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consumption
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• Physical evaluation
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o Follow the established routines as outlined
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in ATLS (Advanced Trauma Life Support)
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o Dynamically proceeds simultaneously and
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fluidly—A—airway;B—breathing;C—
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circulation; and cervical spine;D—
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disability; andE—exposure.
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o There is the well-known ‘golden hour’ in
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adult ATLS
but it is the ‘ platinum half -hour’
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in children when immediate and meaningful
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assessments and treatment must take place
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(Primary survey)
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• A — Airway
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o Airway loss or obstruction → rapid
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deterioration or death in the injured child.
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o Stepwise evaluation and procedures are as
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follows:
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1. Clear secretions
foreign bodies
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teeth or tissue
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2. 3. 4. Assess patency and ability to maintain such
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Have a low threshold for intubation
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Cricothyrotomy should be avoided (<12yrs)
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5. Constant cervical spine protection
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(Primary survey)
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• B — Breathing
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o Assess the ability to not only maintain the
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airway but also the quality of respiration.
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o should also include the following:
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1. Oxygen administration to all patients
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initially
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2. 3. Blow-by or hood for infants
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100% oxygen by high-flow mask or non-
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rebreathing mask for children not able to
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maintain patency
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4. Monitor end-tidal CO2 and exchange
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(keep <40)4/16/2025 OMFS_4th_2024-2025_Ahmed Abushahba1. 2. 3. 4. 5. 6. The initial management of pediatric trauma patients
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(Primary survey)
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• C — Circulation
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o Hypovolemia detection is key!
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o Blood loss→ ↑ HR (initially)
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o ↑ ↑blood loss→ ↓BP→ quickly leads to
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collapse if not reversed!!
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Total blood volume is roughly 80 ml/kg in the child patient
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Place 2 IV lines
pediatric urethral catheter
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Initial fluid resuscitation by 20 ml/kg of warmed
isotonic solution (normal
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saline or lactated Ringers) over 15–20 minutes with revaluation of volume
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status.
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Achieve volume stability as noted by blood pressure increase
return of
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pulses
capillary refill <2 seconds and improved sensorium; reversal of
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sunken fontanelles and increased skin turgor are late indications of
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normotension.
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Obtain cross-matched or O-negative blood for transfusion
initial bolus of
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10–20 ml/kg
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Defer further studies until stabilized4/16/2025 OMFS_4th_2024-2025_Ahmed AbushahbaThe initial management of pediatric trauma patients
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(Primary survey)
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• D — Disability
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Identify potential life-threatening injuries:
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• Fractures
open or with significant deformity
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• GCS for children may be utilized with modification for verbal
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responses:
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(a) Appropriate words
smiling
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(b) Cries but is consolable—4
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(c) Persistently irritable—3
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(d) Restless
agitated
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(e) None—1
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AVPU to quickly assess disability;
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score of ‘P’ or ‘U’ suggests GCS <8
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(a) A—alert
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(b) V—response to verbal
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(c) P—response to painful stimuli
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(d) U—unresponsive
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(Primary survey)
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• E — Exposure
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Identify any other areas of injury and threat to resuscitation and survival:
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1. Examination in a warmed room with overhead warmers
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2. Dress open fractures and wounds
especially burns.
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3. A trained person should stabilize the cervical spine while the neck is examined
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(Secondary survey)
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A more comprehensive examination:
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1. Head and neck injuries?
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2. Septal hematoma↑↑ risk!!
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3. CSF leak?
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4. Cranial nerve examination (optic
oculomotor
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5. Neck (tracheal deviation
hematoma
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6. Chest rise (bilateral
symmetry)?
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7. Abdominal injuries?
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8. Vascular integrity (peripheral pulse
temperature)? Etc..!
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Tetanus toxoid
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booster or TIG?!
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Imaging
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Computed tomography (CT) scans→ current standard of
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care for cranio-facial trauma
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Axial
coronal
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Panorex (OPG)→ Mandibular condyles
teeth buds
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CT scan of epidural hematoma (arrows)
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• Craniomaxillofacial injuries in
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children
especially younger age
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mostly soft tissue in nature
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(avulsion
laceration
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• Facial skeleton is often spared d.t.
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its elasticity!
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AbushahbaHard Tissue Injuries- Pediatric cranio-maxillofacial fractures
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Age
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Cranial fractures > facial fractures 6-7 years Paranasal sinuses
elongation of
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the face
and eruption of teeth
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Facial fractures > cranial fractures
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Cranial fractures
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In young children:
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• Fractures vs suture lines!
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• Growing skull fractures
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o Rare complication for pediatric cranial #
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o Linear fracture with underlying dural
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tear
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o leptomeningeal cyst or brain herniation
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o delayed onset neurological deficits and
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cranial defect.
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Maxillofacial fractures
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1. 2. 3. Most common→ Nasal fractures (45% approx.)
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2nd most common→ mandibular fractures (32%)
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3rd → orbital fractures (approx. 15%)
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Nasal fractures
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• Pediatric nasal bone is more elastic/compliant→ more forces to
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soft tissues→ more edema
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• The septum is relatively more rigidly attached→ septal injury
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• Septal injuries can lead to:
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o Perichondral tear → septal hematoma (Emergency!!)
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o Nasal obstruction/deformity
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o If untreated → growth disturbance
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(cartilage separated from bony septum)
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4/16/2025 OMFS_4th_2024-2025_Ahmed AbushahbaHard Tissue Injuries- Pediatric cranio-maxillofacial fractures
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Nasal fractures
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• If not associated with septal injury→ Less is more
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• more aggressive surgical intervention may adversely
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affect the naso-septal growth center.
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• Closed reduction is attempted whenever possible!
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• External splints can be used (moulded thermoplastic
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splint)
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• When combined with intranasal packing
consider
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antibiotic coverage (to avoid toxic shock syndrome)
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Nasal fractures
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• Open reduction is spared for:
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o Old fractures (2-3 weeks)
N.B. children heal more quickly than adults
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o Failed/inadequate closed reduction
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o Need to address septum
