the injured child

Question 1

why is injury in children important

Answer 1

• major trauma relatively rare
  
  • leading cause of death and disability
• >1y/o: pedestrian trauma w/ resulting head trauma is the commonest cause of death and disability
• <1y/o: NAI is the commonest cause of death and disability

Question 2

demographics of severely injured children

Answer 2

<1y/o - 20-25% of pts (NAI!)

lowers to ~5% between 1-10y/o

slow increase to 10-15% by 15y/o

Question 3

injury mechanism - 1-15y/o

Answer 3

RTC

falls <2m/>2m

assault

NAI under 2y/o

other

Question 4

injury type (AIS 3+)

Answer 4

most common - head injury (>70% pts)

then from highest to lowest % of pts:

thoracic injury

abdo injury

limb/pelvis injury

polytrauma

spinal injury

Question 5

why do children get injured

Answer 5

interaction between:

• stage of development: anatomical, behavioural, locomotor, physiological, psychological
• environment
• those around them

things to consider:

• audio visual clues, written warnings, climbing, inquisitive nature, playing, risky behaviour

INJURY PREVENTION IS KEY

Question 6

why do children injure differently

Answer 6

• different anatomical features
• different physiological and psychological responses to injury
• different spectrum of injury patterns
• not all children are the same: neonates → adolescents

Question 7

why is the size of children important

Answer 7

• relatively greater amount of energy is absorbed for the same force of impact
• large SA:vol → heat loss significant in small children
• big head

Question 8

skeleton in children

Answer 8

• imcompletely calcified
  
  • soft and springy
  • deforms rather than breaks
  • poor at absorbing energy

PROVIDES LESS PROTECTION FOR VITAL ORGANS

Question 9

tissues and internal organs in children

Answer 9

less elastic connective tissue → shearing and degloving

crowding of poorly protected vital organs

• liver, spleen and bladder and intra-abdo
• single impact can injure multiple organs
• relatively thin abdo wall

Question 10

metabolism in children

Answer 10

thermoregulation

• little brown fat and immature shivering
• environmental considerations e.g. RTCs

hypoglycaemia

• little glycogen stored in liver
• exacerbated by hypothermia and vice versa
• develops relatively quickly in sick children

Question 11

injuries patterns in children

Answer 11

SCIWORA - spinal cord injury w/o radiological abnormality

lap belt syndrome - abdo wall bruising from seatbelt, likely to have significant shoulder injury

Question 12

what is the aim of trauma resuscitation

Answer 12

• restore normal tissue oxygenation ASAP
• stabilise the patient and reverse shock
• prevent early trauma mortality

damage control resus: aims to maintain circulating vol, control haemorrhage and correct the lethal triad (coagulopathy, acidosis, hypothermia) until definitive intervention is appropriate

Question 13

how to approach trauma resuscitation

Answer 13

team work - trauma call (code red, paeds trauma call), who is involved, assign team roles, don’t forget parents

preparation

challenges

1y and 2y survey

Question 14

preparation for trauma resus

Answer 14

WETFLAG - weight, energy, tube size and length, fluids, lorazepam, adrenaline, glucose

equipment - tubes, blood warmer, pelvic binder

major haemorrhage protocol

drug calculations

trakcare

Question 15

challenges in trauma resus

Answer 15

communication difficulties - too young/afraid to describe symptoms, have to rely on non-verbal cues, don’t understand what is happening, good rapport essential

fear affects vital signs

distressed parents

effects on staff

Question 16

vital signs in children

Answer 16

Question 17

trauma resus - 1y survey

Answer 17

cABCDE - ATOFMC

• catastrophic haemorrhage control
• airway + c spine - MILS
• breathing
• circulation
• disability
• exposure

Question 18

assessing the airway

Answer 18

do they have a clear airway, any intervention needed

catastrophic haemorrhage control

C spine and MILS

SCIWORA

Question 19

assessment of breathing

Answer 19

RR

sats

air entry, percussion

chest wall abnormalities, bruising, obvious external injury

Question 20

potential traumatic chest injuries

Answer 20

tension pneumothorax

haemothorax

open pneumothorax

pulmonary contusions

flail chest

Question 21

assessment of circulation

Answer 21

look for sources of haemorrhage - blood on the floor + 4 more (pelvis, abdo, chest, thigh/long bones)

good IVA

major haemorrhage protocol

pelvic/femoral splint

pallor, HR, pulse

Question 22

assessing for disability

Answer 22

communication

GCS

neuro exam

Question 23

assessing for exposure

Answer 23

expose fully

keep warm

DEFG!

Question 24

imaging in trauma

Answer 24

CT - focused unless full body necessary

x-ray - 1st line unless CT is necessary

US

re-examination

Question 25

2y survey in trauma resus

Answer 25

top to toe assessment pick up other injuries that aren't immediately life threatening but still require management help decrease morbidity tertiary survey

Question 26

management of fractures

Answer 26

analgesia hx - thorough consider mechanism examine all of joint - don't start with the sore bit, force transmits in children so injury might not be right beside area fell onto for example distraction

Question 27

what type of fracture is this

Answer 27

buckle fracture of distal radius

Question 28

what is a buckle fracture

Answer 28

bending of cortex rather than crack through the bone stable fracture and heals well can be splinted for ~3wks

Question 29

what type of fracture is this

Answer 29

supracondylar fracture blood in joints on left image - indicates fracture even if not visible

Question 30

how do supracondylar fractures tend to occur

Answer 30

fall onto elbow/hand fall comes out at distal humerus Garland classification for severity can be associated nerve injuries to hand

Question 31

what type of fracture is this

Answer 31

greenstick fracture

Question 32

what is a greenstick fracture

Answer 32

bendy bones don't break all the way through fracture on one side of the bone, intact cortex on the otherside heal well

Question 33

what type of fracture is this and how do they tend to occur

Answer 33

clavicle fall onto the hands/shoulder

Question 34

management of clavicle fracture

Answer 34

sling/shoulder brace

Question 35

what type of fracture is this

Answer 35

Toddler's fracture of the tibia

Question 36

what is a Toddler's fracture of the tibia

Answer 36

subtle crack in tibia mainly clinical diagnosis - tenderness on tibia, not weight bearing

Question 37

growth plate injuries classification

Answer 37

Salter-Harris indicates how likely they are to affect growth later in life

Question 38

soft tissue wounds in children - types and management

Answer 38

finger and toes head injuries * tissue glue, steri strips, LAT gel (local anaesthetic), theatre and sedation if suturing

Question 39

burns and scalds in children - management

Answer 39

first aid is important; check for irrigation - 20 mins of cooling, helpful up to 3hrs after injury chemical burns - good irrigation and pH balance COBIS burns guidance functional capacity e.g. burns on hands and fingers might affect future function plastics referral and follow up good hx, consider NAI - is mechanism consistent w/ injury

Question 40

management of head injury

Answer 40

NICE guidance for imaging and risk assessment don't forget NAI - significant head trauma \<1y/o concussion - ACORN (after concussion return to normality) sport - headway advice website

Question 41

drowning in children

Answer 41

uncommon but high risk of mortality hx important in children - were they seen to drown, how long has resus been going on already, when did it start complicated by hypothermia - not dead until warm and dead supportive care - good airway and ventilation, ECMO