Trauma in children

Jamie Ranse: Critical Care Education Coordinator, Staff Development Unit, ACT Health.

TRAUMA IN CHILDREN

• Trauma• Trauma process

– Primary assessment– Secondary assessment

• Injuries in trauma

overview

• Leading cause of death and disability• More than all other causes combined• Majority accidental, therefore preventable

– MVA

– Falls

– Drowning

– Burns

• Differences in injury patterns and pathology, mechanisms and responses to adults

trauma

• Primary survey– Resuscitation

• Secondary survey– Emergency treatment

• Definitive care

trauma process

• Systematic approach• Airway (and c-spine)• Breathing• Circulation• Disability• Exposure

trauma process:primary assessment

MANAGE PROBLEMS AS

THEY ARE FOUND

Interventions• Positioning• Clearance• Airway adjuncts• Intubation

- Size

- Cuffed v uncuffed

• Surgical airway

trauma process:primary assessment - airway

• Assume c-spine injury• Don’t use head tilt or chin lift


• Hard collar• Sandbags and tape / head blocks / in-line• Difficult to clinically clear c-spine in children


• Effort of breathing• Efficacy of breathing• Effects of respiratory inadequacies

trauma process:primary assessment - breathing

Interventions• Positioning• High flow oxygen• Regular monitoring• Bag-mask ventilation• Anticipate the need for intubation

- Impending airway compromise- Inadequate support from bag-mask- Requires controlled ventilation

• ?PEEP

trauma process:primary assessment - breathing

Differences in children• Myocardium• Compensation• Body water• Surface area• Venous access

trauma process:primary assessment - circulation

• Observe– Skin colour– Work of breathing– Mental status– Hydration status

• Palpation– Pulse characteristics– Capillary refill – Blood pressure

• Auscultation– Chest / heart


CONSIDER

INTERNAL BLEEDING

Interventions• Arrest life threatening haemorrhage • CPR• Venous access

– 2 x large bore – Consider IO

• Consider fluid resuscitation– 10ml/kg


Broad categories


• GCS v AVPU• Pupils• Listen to parents

• Limb posture and movements• Limb reflexes• Neurological signs

trauma process:primary assessment - disability

• As complete as possible• Consider heat loss• Consider embarrassment

trauma process:primary assessment - exposure

• Only commence following completion of primary assessment and primary interventions

• If casualty deteriorates during secondary assessment – abandon and repeat ABCDE

• Head to toe, front to back

trauma process:secondary assessment

• Observation• Palpation• (Percussion)• Auscultation

trauma process:secondary assessment

Differences • Increased likelihood of injury in trauma

- Larger head - Lax ligament

• Fulcrum is at C1-2 not C6-7

injuries in trauma:spinal trauma

Assessment• Motor • Sensory• Positioning


Management


Background• 20% of children with severe head injury have a

spinal injury • Head injury present in 75% of children with

multi-system trauma

injuries in trauma:head trauma

Assessment• External head examination• CSF leak• Mini-neurological examination

- LOC- Pupils and visual- Muscle strength and power - ROM- Sensation

• ICP



Best motor response

Spontaneous or obeys verbal command 6

Localises to pain or withdraws to touch 5

Withdraws from pain 4

Abnormal flexion to pain3

Abnormal extension to pain 2

No response to pain1

Best verbal response

Alert, babbles, coos, words to usual ability 5

Less than usual words spontaneous irritable cry4

Cries only to pain3

Moans to pain2


Eye opening

Spontaneously4

To verbal stimuli3

To pain2

No verbal response1

< 4 Years of age


Best motor response

Obeys verbal command 6

Localises to pain 5

Withdraws from pain 4

Abnormal flexion to pain3

Abnormal extension to pain 2


Best verbal response

Orientated and converses5

Disorientated and converses4

Inappropriate words3

Incomprehensible sounds 2


Eye opening

Spontaneously4

To verbal stimuli3

To pain2

No verbal response1

> 4 Years of age

Differences• Elastic chest wall leads to significant damage

without external signs of injury or fractured ribs• Mobile mediastinum allows significant

displacement/compression with even simple pneumothorax, small haemothorax

injuries in trauma:chest trauma

Assessment• Effort of breathing• Efficacy of breathing• Effects of respiratory inadequacies



Management • Primary survey• Primary interventions

Immediate / Life threatening injuries• Tension pneumothorax• Open pneumothorax • Haemopneumothorax • Flail chest• Cardiac temponade


Differences• Less rib protection• Thinner abdominal wall

- Less fat and muscle to protect organs

• Horizontal diaphragm• Bladder position – abdominal


Assessment• Bruising v no bruising• Urine output

injuries in trauma:abdominal trauma

Management • Analgesia• Posture• IV Fluids

injuries in trauma:abdominal trauma

Assessment• Neurovascular

- Colour- Warmth- Movement- Sensation- Capillary refill

- Pain

injuries in trauma:skeletal trauma

Management• Analgesia• Immobilisation• IV fluids

injuries in trauma:skeletal trauma

• Back-up• Safe transport• Reassurance

injuries in trauma:general care

Assessment• Trauma• Trauma process

- Primary Assessment- Secondary Assessment

• Injuries in trauma

trauma process:summary

Jamie Ranse: Critical Care Education Coordinator, Staff Development Unit, ACT Health.

BURNS IN CHILDREN

• Normal skin• Definitions• Assessment• Management

overview

• Protection• Temperature regulation• Cutaneous sensation• Metabolic functions• Blood reservoir• Excretion

normal skin

• Epidermis develops from the ectoderm• Foetus - lanugo and vernix• Newborn skin - thin• Childhood - thickens and more subcutaneous fat

deposited• Sebaceous glands activated, terminal hairs

appear

normal skin

• Superficial– Dry, red, blanches and refills, little or no oedema – Painful

definitions

• Partial thickness– Blisters, moist, oedema, blanches & refills, mottled

pink or red, very painful– Superficial (epidermis and part of dermis)– Deep (resembles full thickness but sweat glands and

hair follicle intact)

definitions

• Full thickness– Tough, leathery, marbled, pale white brown tan or

black– Doesn’t blanch on pressure– Dull, dry, oedema– Pain varies but often severe

definitions

assessment

management

case study

• Called to 1yo ♂ with burns from boiling H2O

• A – clear and open• B – tachypnoea• C – mild tachycardia• D – no deficit• E – burn to chest, neck and inside upper arms.

case study

• Calculate fluid resuscitation requirements

• Calculate fluid maintenance requirements

Documents

Trauma in children