Trauma

Question 1

What are the major mechanisms of traumatic injury child older than 1y?

Answer 1

• transport
• drowning
• burns

Question 2

What are the common forces causing paediatric trauma?

Answer 2

• MVA
• Car v kid
• Fall from height

Question 3

What are the common sources of pressure causing trauma?

Answer 3

• Lap seat belt syndrome
• Handle bar
• MBA

Question 4

Why are children more vulnerable to abdominal injury from blunt force trauma?

Answer 4

• More exposed organs: ribs are more compliant in kids, and they are more exposed. Vulnerable organs of both solid and hollow
• Less protective habitus
• Smaller torso: less body fat

Question 5

What are the red flags for abdo trauma injuries?

Answer 5

• abdo tenderness
• ecchymosis
• abrasions
• femoral fracture
• GCS below 13

Question 6

Why are gastric tubes indicated in paediatric trauma?

Answer 6

•Gastric tube * very important to put in (NOT naso gastric or oro gastric due to risk of perforation)
○ Purpose: prevents acute gastric dilatation
○ Prevents vomiting and aspiration
○ Improves imaging quality
○ Improves ventilation

Question 7

Why is paediatric intubation more difficult

Answer 7

• 1. Shape of the epiglottis is horseshoe shaped and projects posterior at 45o
• 2. Cricoid ring is the narrowest point in the airway:
• -a). cannot confirm the size of the ET tube by visualising
• -b).the cuff of the ET tube sit at the level of cricoid ring, which then takes up valuable airway diameter.
• -c). tissue in this area is susceptible to oedema
• 3. Trachea is short: increases risk of dislodgement of ET tube
• 4. Cervical spine: larger occiput so head forward flexed when supine

Question 8

How does the paediatric airway differ from adult?

Answer 8

• 1. Smaller: greater risk of obstruction
• 2. Larger tongue and smaller oral cavity
• 3. Infants have larger occiput - head flexed when supine
• 4. Infants nose breathers
• 5. Trachea more cartilaginous and soft
• 6. Larynx is higher and more anterior

Question 9

How are children different in respect to breathing?

Answer 9

• 1. Infant ribs more horizontal therefore only move up with inspiration, not up and out. Limits ability to increase TV
• 2. Diaphragmatic breathing in infancy therefore must decompress stomach
• 3. Thin compliant chest well = intercostal retraction
• 4. Fewer Type I fibres in respiratory muscles

Question 10

Assessment of breathing?

Answer 10

1. Look: mvt
2. Listen: crackles
3. Feel: crepitus, surgical emphysema
4. Percuss

Question 11

What is the purpose of breathing assessment?

Answer 11

• Effort of breathing - more or less (respiratory failure)
• Efficacy of breathing - O2 saturation, chest expansion,
- Effects of respiratory inadequacy

Question 12

What are the indications for intubation and ventilation?

Answer 12

• Persistent airway obstruction
• Predicted obstruction (e.g. inhalation, burns)
• Loss of airway reflexes
• Inadequate ventilatory effort or increase fatigue (resp muscle failure)
• Disrupted ventilatory mechanism (e.g. large flail)
• Persisten hypoxia despite O2
• Controlled ventilation to manage raised ICP
• GCS below 8

Question 13

Why do you intubate at GCS below 8?

Answer 13

No muscle tone to expectorate vomit so high risk of aspiration

Question 14

How does blood volume differ in kids?

Answer 14

• 80-90ml/kg v 65-70ml/kg
• Therefore relatively small volumes of blood will constitute significant blood loss in small children ie a 100mL experienced by 5kg child = 10% of TBV
Implication: must monitor and record all blood loss

Question 15

How are children different in circulation?

Answer 15

• Systemic vascular resistance lower
• Hypotension late sign (good comp)
• Fixed SV (limited to HR to inc CO)
• Smaller vessels and more subcut therefore difficult to get access

Question 16

Mx to prevent secondary neurological insult?

Answer 16

Preventing secondary insult to brain:
• Elevate bed to 30 degrees
• Oxygen levels are stable
• CO2 normal
• Glucose normal
• Maintain BP normal
• Release neck cuff 
• Maintain temperature

Question 17

What does blown pupil indicate?

Answer 17

Tentorial herniation

Question 18

How do children differ wrt Exposure?

Answer 18

• Smaller size: multiple systems injured
• Higher BMR and SA: greater O2 consumption
• Increased glucose but decreased glycogen: must monitor BSL

Question 19

Why is temp control important?

Answer 19

Hyperthermia bad neuro; hypothermia wont clot

Question 20

What are the adjuncts to the primary survey?

Answer 20

• Establish monitoring 
• Send blood for cross match and tests 
	• FBE
	• UEC
	• LFT 
	• Lipase 
	• Cross match 
• C spine, CXR and pelvic XR  (+ anything else important of consequence to primary survey)
• Consider US of abdomen and chest
• Consider gastric and bladder catheters 
Analgesia!!

Question 21

What are the pre terminal signs?

Answer 21

Breathing: cyanotic (= sats below 85%); silent chest.
CV: hTN, bradycardia below 60.
Start CPR or will arrest.

Question 22

Why is surgery less common in children following trauma?

Answer 22

Natural haemostasis after abdo trauma is common i.e. ruptured liver or spleen self coagulates and rarely needs surgical intervention

Question 23

Mx splenic rupture?

Answer 23

○ Monitor with assessment of Hb and need for for transfusion
○ Pain management
○ IV fluids
Avoid further trauma: no school for a period and no contact sport to avoid secondary rupture from capsule

Question 24

Hx suggesting epigastric or pancreatic trauma?

Answer 24

Hx of focal high velocity trauma. Duodenum and pancreas both retroperitoneal and fixed in front of spinal column - cannot disperse with force = injury.