Trauma in children

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  • Differences – large surface area in comparison to adults, - small airway - compliant skeleton - abdominal organs more susceptible to injury Teenages – risk taking, toddler – exploring and lack of judgement
  • Clearance – gentle suction Intubation – age/4 +4 - cuffed v uncuffed INFANT - Neutral, with chin lift CHILD – Sniffing, with chin lift Tidal volume 7 -10ml/kg
  • Would not do all of this in the primary survey
  • Everyone gets O2 Everyone gets IV access Consider: Volume expansion Inotropic drugs
  • Fulcrum higher until age 8
  • Positioning Head tilt (high C) prayer positioning (arms accross chest – c4or 6)
  • Brusising = severe injury No bruising = possibility of injury
  • Protection chemical - sebum - antibacterial; pH physical - keratin and lipid layer biological - phagocytes Temp - vasculature and sweat glands Cutaneous - receptors for temperature, touch, pressure and pain Metabolic - Vitamin D synthesized from cholesterol by epidermal cells Blood reservoir - extensive vascular supply Excretion - sweat contains small amounts of nitrogenous wastes
  • Ectoderm, 1 of 3 basic tissue types in uterus development – also nervous tissue. Lanugo – downy hair Vernix - Fatty substance made up of epithelial cells that covers fetal skin inside the uterus, white, greasy, cheese-like substance. Sebaceiys – Oil glands activated
  • Trauma in children

    1. 1. TRAUMA IN CHILDREN Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health.
    2. 2. <ul><li>Trauma </li></ul><ul><li>Trauma process </li></ul><ul><ul><li>Primary assessment </li></ul></ul><ul><ul><li>Secondary assessment </li></ul></ul><ul><li>Injuries in trauma </li></ul>overview
    3. 3. <ul><li>Leading cause of death and disability </li></ul><ul><li>More than all other causes combined </li></ul><ul><li>Majority accidental, therefore preventable </li></ul><ul><ul><li>MVA </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Drowning </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><li>Differences in injury patterns and pathology, mechanisms and responses to adults </li></ul>trauma
    4. 4. <ul><li>Primary survey </li></ul><ul><ul><li>Resuscitation </li></ul></ul><ul><li>Secondary survey </li></ul><ul><ul><li>Emergency treatment </li></ul></ul><ul><li>Definitive care </li></ul>trauma process
    5. 5. trauma process: primary assessment <ul><li>Systematic approach </li></ul><ul><li>Airway (and c-spine) </li></ul><ul><li>Breathing </li></ul><ul><li>Circulation </li></ul><ul><li>Disability </li></ul><ul><li>Exposure </li></ul>MANAGE PROBLEMS AS THEY ARE FOUND
    6. 6. trauma process: primary assessment - airway <ul><li>Interventions </li></ul><ul><li>Positioning </li></ul><ul><li>Clearance </li></ul><ul><li>Airway adjuncts </li></ul><ul><li>Intubation </li></ul><ul><ul><li>- Size </li></ul></ul><ul><ul><li>- Cuffed v uncuffed </li></ul></ul><ul><li>Surgical airway </li></ul>
    7. 7. trauma process: primary assessment - airway <ul><li>Assume c-spine injury </li></ul><ul><li>Don’t use head tilt or chin lift </li></ul>
    8. 8. trauma process: primary assessment - airway <ul><li>Hard collar </li></ul><ul><li>Sandbags and tape / head blocks / in-line </li></ul><ul><li>Difficult to clinically clear c-spine in children </li></ul>
    9. 9. trauma process: primary assessment - breathing <ul><li>Effort of breathing </li></ul><ul><li>Efficacy of breathing </li></ul><ul><li>Effects of respiratory inadequacies </li></ul>
    10. 10. trauma process: primary assessment - breathing <ul><li>Interventions </li></ul><ul><li>Positioning </li></ul><ul><li>High flow oxygen </li></ul><ul><li>Regular monitoring </li></ul><ul><li>Bag-mask ventilation </li></ul><ul><li>Anticipate the need for intubation </li></ul><ul><ul><li>Impending airway compromise </li></ul></ul><ul><ul><li>Inadequate support from bag-mask </li></ul></ul><ul><ul><li>Requires controlled ventilation </li></ul></ul><ul><li>?PEEP </li></ul>
    11. 11. trauma process: primary assessment - circulation <ul><li>Differences in children </li></ul><ul><li>Myocardium </li></ul><ul><li>Compensation </li></ul><ul><li>Body water </li></ul><ul><li>Surface area </li></ul><ul><li>Venous access </li></ul>
    12. 12. <ul><li>Observe </li></ul><ul><ul><li>Skin colour </li></ul></ul><ul><ul><li>Work of breathing </li></ul></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><li>Hydration status </li></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Pulse characteristics </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><li>Auscultation </li></ul><ul><ul><li>Chest / heart </li></ul></ul>trauma process: primary assessment - circulation CONSIDER INTERNAL BLEEDING
    13. 13. <ul><li>Interventions </li></ul><ul><li>Arrest life threatening haemorrhage </li></ul><ul><li>CPR </li></ul><ul><li>Venous access </li></ul><ul><ul><li>2 x large bore </li></ul></ul><ul><ul><li>Consider IO </li></ul></ul><ul><li>Consider fluid resuscitation </li></ul><ul><ul><li>10ml/kg </li></ul></ul>trauma process: primary assessment - circulation
    14. 14. <ul><li>Broad categories </li></ul>trauma process: primary assessment - circulation
    15. 15. trauma process: primary assessment - disability <ul><li>GCS v AVPU </li></ul><ul><li>Pupils </li></ul><ul><li>Listen to parents </li></ul><ul><li>Limb posture and movements </li></ul><ul><li>Limb reflexes </li></ul><ul><li>Neurological signs </li></ul>
    16. 16. trauma process: primary assessment - exposure <ul><li>As complete as possible </li></ul><ul><li>Consider heat loss </li></ul><ul><li>Consider embarrassment </li></ul>
    17. 17. trauma process: secondary assessment <ul><li>Only commence following completion of primary assessment and primary interventions </li></ul><ul><li>If casualty deteriorates during secondary assessment – abandon and repeat ABCDE </li></ul><ul><li>Head to toe, front to back </li></ul>
    18. 18. trauma process: secondary assessment <ul><li>Observation </li></ul><ul><li>Palpation </li></ul><ul><li>(Percussion) </li></ul><ul><li>Auscultation </li></ul>
    19. 19. injuries in trauma: spinal trauma <ul><li>Differences </li></ul><ul><li>Increased likelihood of injury in trauma </li></ul><ul><ul><li>Larger head </li></ul></ul><ul><ul><li>Lax ligament </li></ul></ul><ul><li>Fulcrum is at C1-2 not C6-7 </li></ul>
    20. 20. injuries in trauma: spinal trauma <ul><li>Assessment </li></ul><ul><li>Motor </li></ul><ul><li>Sensory </li></ul><ul><li>Positioning </li></ul>
    21. 21. injuries in trauma: spinal trauma Management
    22. 22. injuries in trauma: head trauma <ul><li>Background </li></ul><ul><li>20% of children with severe head injury have a spinal injury </li></ul><ul><li>Head injury present in 75% of children with multi-system trauma </li></ul>
    23. 23. injuries in trauma: head trauma <ul><li>Assessment </li></ul><ul><li>External head examination </li></ul><ul><li>CSF leak </li></ul><ul><li>Mini-neurological examination </li></ul><ul><ul><li>LOC </li></ul></ul><ul><ul><li>Pupils and visual </li></ul></ul><ul><ul><li>Muscle strength and power </li></ul></ul><ul><ul><li>ROM </li></ul></ul><ul><ul><li>Sensation </li></ul></ul><ul><li>ICP </li></ul>
    24. 24. injuries in trauma: head trauma Best motor response Spontaneous or obeys verbal command 6 Localises to pain or withdraws to touch 5 Withdraws from pain 4 Abnormal flexion to pain 3 Abnormal extension to pain 2 No response to pain 1 Best verbal response Alert, babbles, coos, words to usual ability 5 Less than usual words spontaneous irritable cry 4 Cries only to pain 3 Moans to pain 2 No response to pain 1 Eye opening Spontaneously 4 To verbal stimuli 3 To pain 2 No verbal response 1 < 4 Years of age
    25. 25. injuries in trauma: head trauma Best motor response Obeys verbal command 6 Localises to pain 5 Withdraws from pain 4 Abnormal flexion to pain 3 Abnormal extension to pain 2 No response to pain 1 Best verbal response Orientated and converses 5 Disorientated and converses 4 Inappropriate words 3 Incomprehensible sounds 2 No response to pain 1 Eye opening Spontaneously 4 To verbal stimuli 3 To pain 2 No verbal response 1 > 4 Years of age
    26. 26. injuries in trauma: chest trauma <ul><li>Differences </li></ul><ul><li>Elastic chest wall leads to significant damage without external signs of injury or fractured ribs </li></ul><ul><li>Mobile mediastinum allows significant displacement/compression with even simple pneumothorax, small haemothorax </li></ul>
    27. 27. injuries in trauma: chest trauma <ul><li>Assessment </li></ul><ul><li>Effort of breathing </li></ul><ul><li>Efficacy of breathing </li></ul><ul><li>Effects of respiratory inadequacies </li></ul>
    28. 28. injuries in trauma: chest trauma
    29. 29. injuries in trauma: chest trauma <ul><li>Management </li></ul><ul><li>Primary survey </li></ul><ul><li>Primary interventions </li></ul><ul><li>Immediate / Life threatening injuries </li></ul><ul><li>Tension pneumothorax </li></ul><ul><li>Open pneumothorax </li></ul><ul><li>Haemopneumothorax </li></ul><ul><li>Flail chest </li></ul><ul><li>Cardiac temponade </li></ul>
    30. 30. injuries in trauma: chest trauma <ul><li>Differences </li></ul><ul><li>Less rib protection </li></ul><ul><li>Thinner abdominal wall </li></ul><ul><ul><li>Less fat and muscle to protect organs </li></ul></ul><ul><li>Horizontal diaphragm </li></ul><ul><li>Bladder position – abdominal </li></ul>
    31. 31. injuries in trauma: abdominal trauma <ul><li>Assessment </li></ul><ul><li>Bruising v no bruising </li></ul><ul><li>Urine output </li></ul>
    32. 32. injuries in trauma: abdominal trauma <ul><li>Management </li></ul><ul><li>Analgesia </li></ul><ul><li>Posture </li></ul><ul><li>IV Fluids </li></ul>
    33. 33. injuries in trauma: skeletal trauma <ul><li>Assessment </li></ul><ul><li>Neurovascular </li></ul><ul><ul><li>Colour </li></ul></ul><ul><ul><li>Warmth </li></ul></ul><ul><ul><li>Movement </li></ul></ul><ul><ul><li>Sensation </li></ul></ul><ul><ul><li>Capillary refill </li></ul></ul><ul><ul><li>Pain </li></ul></ul>
    34. 34. injuries in trauma: skeletal trauma <ul><li>Management </li></ul><ul><li>Analgesia </li></ul><ul><li>Immobilisation </li></ul><ul><li>IV fluids </li></ul>
    35. 35. injuries in trauma: general care <ul><li>Back-up </li></ul><ul><li>Safe transport </li></ul><ul><li>Reassurance </li></ul>
    36. 36. trauma process: summary <ul><li>Assessment </li></ul><ul><li>Trauma </li></ul><ul><li>Trauma process </li></ul><ul><ul><li>- Primary Assessment </li></ul></ul><ul><ul><li>Secondary Assessment </li></ul></ul><ul><li>Injuries in trauma </li></ul>
    37. 37. BURNS IN CHILDREN Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health.
    38. 38. <ul><li>Normal skin </li></ul><ul><li>Definitions </li></ul><ul><li>Assessment </li></ul><ul><li>Management </li></ul>overview
    39. 39. <ul><li>Protection </li></ul><ul><li>Temperature regulation </li></ul><ul><li>Cutaneous sensation </li></ul><ul><li>Metabolic functions </li></ul><ul><li>Blood reservoir </li></ul><ul><li>Excretion </li></ul>normal skin
    40. 40. <ul><li>Epidermis develops from the ectoderm </li></ul><ul><li>Foetus - lanugo and vernix </li></ul><ul><li>Newborn skin - thin </li></ul><ul><li>Childhood - thickens and more subcutaneous fat deposited </li></ul><ul><li>Sebaceous glands activated, terminal hairs appear </li></ul>normal skin
    41. 41. <ul><li>Superficial </li></ul><ul><ul><li>Dry, red, blanches and refills, little or no oedema </li></ul></ul><ul><ul><li>Painful </li></ul></ul>definitions
    42. 42. <ul><li>Partial thickness </li></ul><ul><ul><li>Blisters, moist, oedema, blanches & refills, mottled pink or red, very painful </li></ul></ul><ul><ul><li>Superficial (epidermis and part of dermis) </li></ul></ul><ul><ul><li>Deep (resembles full thickness but sweat glands and hair follicle intact) </li></ul></ul>definitions
    43. 43. <ul><li>Full thickness </li></ul><ul><ul><li>Tough, leathery, marbled, pale white brown tan or black </li></ul></ul><ul><ul><li>Doesn’t blanch on pressure </li></ul></ul><ul><ul><li>Dull, dry, oedema </li></ul></ul><ul><ul><li>Pain varies but often severe </li></ul></ul>definitions
    44. 44. assessment
    45. 45. management
    46. 46. case study <ul><li>Called to 1yo ♂ with burns from boiling H 2 O </li></ul><ul><li>A – clear and open </li></ul><ul><li>B – tachypnoea </li></ul><ul><li>C – mild tachycardia </li></ul><ul><li>D – no deficit </li></ul><ul><li>E – burn to chest, neck and inside upper arms. </li></ul>
    47. 47. case study <ul><li>Calculate fluid resuscitation requirements </li></ul><ul><li>Calculate fluid maintenance requirements </li></ul>

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