Trauma (peds): Difference between revisions
m (Rossdonaldson1 moved page Trauma (Peds) to Trauma (peds)) |
No edit summary |
||
| Line 9: | Line 9: | ||
**No decreased breath sounds | **No decreased breath sounds | ||
*suspect physical abuse (cause of 60% femur fx if <1y & 100% non-supracond hum fx <3y), skeletal survey if <3y & suspect abuse. | |||
*missed inj common, usu d/t aloc, etoh. kids usu decr b/c we are hypervigilent. most common is muscskel so MUST xray joint above & below injured ext!! If BHT or ortho & nd OR r/o abd inj 1st!! | |||
*Re-exam is key, try & do gd secondary survey before OR. | |||
*Lat c-s xr alone misses 15% of fx! nd all 3 views. | |||
==Clinical Features== | |||
*Peds triad is appearance, work of breathing & circulation (skin color) | *Peds triad is appearance, work of breathing & circulation (skin color) | ||
*Childs size allows for dist of injuries, thus mutliple trauma is common & internal organs more susceptible to injury d/t more ant placement of liver & spleen (& less protective muscle & fat), Kidenys also less well protected and more mobile=more prone to decel injury | *Childs size allows for dist of injuries, thus mutliple trauma is common & internal organs more susceptible to injury d/t more ant placement of liver & spleen (& less protective muscle & fat), Kidenys also less well protected and more mobile=more prone to decel injury | ||
*Wadell Triad in auto/ped= CHI, abd inj, femur Fx | *Wadell Triad in auto/ped= CHI, abd inj, femur Fx | ||
== | ==Management== | ||
===Airway/Breathing=== | |||
*Cricoid ring is narrowest part of airway allowing for uncuffed tubes up to 6.0 ETT or up to about 8 yrs | *Cricoid ring is narrowest part of airway allowing for uncuffed tubes up to 6.0 ETT or up to about 8 yrs | ||
== | ===Circulation=== | ||
*Key is to recognize & Rx shock early (before decr BP), s/s of shock= child may have lost 25% of BV | *Key is to recognize & Rx shock early (before decr BP), s/s of shock= child may have lost 25% of BV | ||
*BP not usu helpful sign of blood loss in peds, can be in shock w/ incr, decr or nl BP b/c kids are more effective at incre HR & SVR (pp=key) | *BP not usu helpful sign of blood loss in peds, can be in shock w/ incr, decr or nl BP b/c kids are more effective at incre HR & SVR (pp=key) | ||
*In field stop bleeding w/ pressure & elevation, MAST never shown to help kids | *In field stop bleeding w/ pressure & elevation, MAST never shown to help kids | ||
*In ED give IVF @ 20cc/kg, if unresponsive after 40cc/kg give PRBC @ 10cc/kg (can start w/ PRBC if presents in decompensated shock & multip inj suspected) | *In ED give IVF @ 20cc/kg, if unresponsive after 40cc/kg give PRBC @ 10cc/kg (can start w/ PRBC if presents in decompensated shock & multip inj suspected) | ||
*Chest Tube in Peds is 4 X ETT | *Chest Tube in Peds is 4 X ETT | ||
*Dip urine if NO blood stop, if blood send UA (+blood on dip= NO correlation w/ RBCs), if on UA >20 RBC's do CT to chk kidneys (Renal inj common, followed by bladder, urethra/ureteral are xtremely rare | *Dip urine if NO blood stop, if blood send UA (+blood on dip= NO correlation w/ RBCs), if on UA >20 RBC's do CT to chk kidneys (Renal inj common, followed by bladder, urethra/ureteral are xtremely rare | ||
*In sick trauma can skip c/s and just immobilize! | *In sick trauma can skip c/s and just immobilize! | ||
*CT A/P is study of choice but may miss hollow visceral injury (may take 1-2 days to see periton. signs) | *CT A/P is study of choice but may miss hollow visceral injury (may take 1-2 days to see periton. signs) | ||
*Shock w/ no response to IVF, think T-PTX or card tamponade | *Shock w/ no response to IVF, think T-PTX or card tamponade | ||
*Unstable pts, no response to IVF/PRBC= OR! | *Unstable pts, no response to IVF/PRBC= OR! | ||
== | ===Disability=== | ||
*SCIWORA (2-21% of pts<8yr w/ spinal inj) | *SCIWORA (2-21% of pts<8yr w/ spinal inj) | ||
*C/S increased preodontoid space (up to 4-5mm vs 3mm in adult) | *C/S increased preodontoid space (up to 4-5mm vs 3mm in adult) | ||
*pseudosubluxation C2 on C3 in 40% (up to teens), chk for true sublux by drawing line from ant cortical margin of spinous process (spinolaminar) of C1 to spinolaminar line of C3 (line of Swischuk), if line is >1-2mm from ant cort margin of C2 spinous process suspect TRUE sublux OR Fx! | *pseudosubluxation C2 on C3 in 40% (up to teens), chk for true sublux by drawing line from ant cortical margin of spinous process (spinolaminar) of C1 to spinolaminar line of C3 (line of Swischuk), if line is >1-2mm from ant cort margin of C2 spinous process suspect TRUE sublux OR Fx! | ||
*Chance Fx (L spine Fx) from forward flexion over lap belt (usu of L1-L4), 50% assoc w/ intraabdominal inj! | *Chance Fx (L spine Fx) from forward flexion over lap belt (usu of L1-L4), 50% assoc w/ intraabdominal inj! | ||
*80% of peds trauma deaths assoc w/ neurologic inj (see HCT/Head trauma memo) | *80% of peds trauma deaths assoc w/ neurologic inj (see HCT/Head trauma memo) | ||
==See Also== | ==See Also== | ||
Revision as of 13:36, 19 December 2015
Background
- Significant intra-abdominal injury after blunt torso trauma highly unlikely (0.1%) if all of the following are true:
- Glasgow coma scale ≥14
- No evidence of abdominal wall trauma or seat belt sign
- No abdominal tenderness
- No complaints of abdominal pain
- No vomiting
- No thoracic wall trauma
- No decreased breath sounds
- suspect physical abuse (cause of 60% femur fx if <1y & 100% non-supracond hum fx <3y), skeletal survey if <3y & suspect abuse.
- missed inj common, usu d/t aloc, etoh. kids usu decr b/c we are hypervigilent. most common is muscskel so MUST xray joint above & below injured ext!! If BHT or ortho & nd OR r/o abd inj 1st!!
- Re-exam is key, try & do gd secondary survey before OR.
- Lat c-s xr alone misses 15% of fx! nd all 3 views.
Clinical Features
- Peds triad is appearance, work of breathing & circulation (skin color)
- Childs size allows for dist of injuries, thus mutliple trauma is common & internal organs more susceptible to injury d/t more ant placement of liver & spleen (& less protective muscle & fat), Kidenys also less well protected and more mobile=more prone to decel injury
- Wadell Triad in auto/ped= CHI, abd inj, femur Fx
Management
Airway/Breathing
- Cricoid ring is narrowest part of airway allowing for uncuffed tubes up to 6.0 ETT or up to about 8 yrs
Circulation
- Key is to recognize & Rx shock early (before decr BP), s/s of shock= child may have lost 25% of BV
- BP not usu helpful sign of blood loss in peds, can be in shock w/ incr, decr or nl BP b/c kids are more effective at incre HR & SVR (pp=key)
- In field stop bleeding w/ pressure & elevation, MAST never shown to help kids
- In ED give IVF @ 20cc/kg, if unresponsive after 40cc/kg give PRBC @ 10cc/kg (can start w/ PRBC if presents in decompensated shock & multip inj suspected)
- Chest Tube in Peds is 4 X ETT
- Dip urine if NO blood stop, if blood send UA (+blood on dip= NO correlation w/ RBCs), if on UA >20 RBC's do CT to chk kidneys (Renal inj common, followed by bladder, urethra/ureteral are xtremely rare
- In sick trauma can skip c/s and just immobilize!
- CT A/P is study of choice but may miss hollow visceral injury (may take 1-2 days to see periton. signs)
- Shock w/ no response to IVF, think T-PTX or card tamponade
- Unstable pts, no response to IVF/PRBC= OR!
Disability
- SCIWORA (2-21% of pts<8yr w/ spinal inj)
- C/S increased preodontoid space (up to 4-5mm vs 3mm in adult)
- pseudosubluxation C2 on C3 in 40% (up to teens), chk for true sublux by drawing line from ant cortical margin of spinous process (spinolaminar) of C1 to spinolaminar line of C3 (line of Swischuk), if line is >1-2mm from ant cort margin of C2 spinous process suspect TRUE sublux OR Fx!
- Chance Fx (L spine Fx) from forward flexion over lap belt (usu of L1-L4), 50% assoc w/ intraabdominal inj!
- 80% of peds trauma deaths assoc w/ neurologic inj (see HCT/Head trauma memo)
See Also
Source
- Holmes JF et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med. 2013
- Gausche 2004