Trauma

Question 1

Leading cause of death and disability in children:

Answer 1

Trauma MVC (passenger and ped struck) leading cause of death from injury. Drowning second leading cause of death from injury. Burns and smoke inhalation fourth leading cause. Falls are the most common mechanism of injury. PEM Secrets

Question 2

Associated patterns of injury: Automobile occupant Pedestrian struck Fall from height Fall off bicycle

Answer 2

Table 58-1 PEM Secrets

Question 3

Blunt neck trauma:

Characteristics of pediatric airway making laryngotracheal injuries more or less common in children:

Name 5 blunt mechanisms of laryngotrachial injury:

Clinical Presentation:

Answer 3

Incidence of laryngotracheal injury secondary to blunt neck injury in trauma patients is < 1% - it is even more rare in pediatric patients.

Pediatric patients are less likely to sustain laryngotracheal injuries because:

• They are less likely to be involved in MVCs or interpersonal violence
• Larynx is higher so the mandibular arch provides protection
• Laryngeal cartilages are more pliable and less likely to fracture

However:

• The airway is more narrow and the mucosa less adhered to surrounding cartilage so it is more prone to soft tissue injury, edema, hematoma, and obstruction

Mechanism of injury:

• Clothesline injury (ATV, dirtbike, sports and martial arts)
• MVC with sudden deceleration (unrestrained passenger thrown forward, head extended, neck to drashboard, trachea crushed against cervical spine)
• Direct trauma in interpersonal violence
• Blunt thoracic trauma (AP pressure, increase in transverse diameter of chest, lateral traction of trachea, linear rupture)
• Strangulation from hanging

Clinical Presentation:

• Symptoms: dysphagia, dyspnea, dysphonia, hemoptysis, cough, anterior neck pain
• Signs: hoarse voice, respiratory distress, neck edema, abrasions, ecchymoses, loss of laryngeal landmarks, palpable cartilage fractures
• Relatively asymptomatic patients can become rapidly unstable

Airway management in laryngotracheal injuries from blunt neck trauma in children. Pediatric Anesthesia 2015.

Question 4

Classification of blunt laryngotracheal injuries:

Answer 4

• Groups I and II are managed conservatively
• Groups III to V require surgical intervention

Airway management in laryngotracheal injuries from blunt neck trauma in children. Pediatric Anesthesia 2015.

Question 5

Initial airway management in laryngotracheal injury:

Answer 5

• Does the patient have an airway (ETT or tracheostomy)?
  
  • Yes: Confirm position of ETT or tracheostomy. Get CXR and x-ray c-spine, flexible fiberoptic tracheoscopy and bronchoscopy
  • No: Is the airway stable?
    
    • Yes: Detailed H and P. Assess extent of injury with flex fiberoptic laryngoscopy. Get CT neck in patients with substantial soft tissue injury or edema (or if won’t tolerate laryngoscopy)
    • No: Controversial. Options include:
      
      • Orotracheal intubation under direct visualization with a smaller tube or with fiberoptic tracheoscopy. NO PARALYTIC. Keep breathing spontaneously.
      • Elective tracheostomy (almost impossible in children)
      • Is there an ENT surgeon and OR immediately available?
        
        • Yes: Go to the OR for rigid bronchoscopy
        • No: Most experienced emergency physician should attempt flexible fiberoptic tracheoscopy and intubation. Emergency needle cricothyroidotomy or tracheostomy should be reserved for last ditch effort.

Airway management in laryngotracheal injuries from blunt neck trauma in children. Pediatric Anesthesia 2015.