|
https://upload.orthobullets.com/topic/4124/images/radiograph ped cspine.jpg
https://upload.orthobullets.com/topic/4124/images/mri peds cspine.jpg
https://upload.orthobullets.com/topic/4124/images/pediatric spine board..jpg
https://upload.orthobullets.com/topic/4124/images/pts.jpg
Epidemiology
  • Trauma is most common cause of death in children > 1 years old
  • Epidemiology
    • mortality rate is approximately 20%
    • CNS injuries have highest overall morbidity and mortality 
    • spine fractures have highest morbidity/mortality among musculoskeletal injuries 
      • cervical spine injuries more common in children <8-years-old 
        • due to fact that restraints do not fit young children 
  • Pathophysiology
    • falls and motor vehicle accidents most common
Transport
  • Occipital cut-out needed in spine board when transporting children <8 y.o.  
    • larger head size can flex unstable cervical spine leading to injury during transport
  • Help tips
    • Broselow tape = estimate medication doses, size of equipment, shock voltage for defibrillator
    • ETT = (age/4) + 4 or (age+16)/4 = uncuffed
    • BP = 80 + (age x 2)
    • chest tube = 4 x ETT
    • blood volume = 70 x wt (kg) or 75 - 80 mL/kg 
  • Intraosseous lines commonly needed due to difficulty obtaining venous access 
    • children may remain hemodynamically stable even after significant blood loss
      • hypovolemic shock may result from inadequate fluid resuscitation
    • "triad of death" reflects inadequate resusitation and is characterized by:
      • acidosis
      • hypothermia
      • coagulopathy
ATLS with Children
  • Overview
    • should follow ATLS protocol  
      • Airway
      • Breathing
      • Circulation
      • Disability
      • Exposure
Airway
  • Smaller airway
    • greater risk of airway obstruction with foreign bodies
    • small amounts of swelling will result in a relatively greater reduction in airway diameter
  • Larger tongue, floppy epiglottis
  • Larger occiput
    • flexes the head forward when placed supine on a flat surface
    • to achieve a neutral position, it may be necessary to lift the chin or place a pad under the torso of the infant (or head cut out)
  • Larynx is higher and more anterior
    • sits at the level of the C2-C3 vertebrae body in the young child, compared with C6-C7 in the adult.
      • positioning of the larynx makes its visualisation in the paediatric airway more difficult than in the adult.
Breathing
  • Most common cause of cardiorespiratory arrest is hypoventilation
  • Ribs positioned more horizontally
    • with inspiration the ribs only move up, and not up-and-out, like the adult rib cage. 
    • limits the capacity to increase tidal volumes
  • Diaphragmatic breathing
  • Fewer Type 1 fibres in respiratory muscles
    • smaller number of fatigue-resistant, Type I fibres in their respiratory muscles
    • exhaust more quickly than adults
  • Respiratory rate varies with age
    • higher oxygen demand =  higher respiratory rates
Circulation
  • Initial bolus = 20ml/kg NS
  • After two boluses = 10ml/kg of PRBC’s
  • Blood volume is relatively larger, but absolute volume is smaller
    • small volumes of blood will constitute significant blood loss in small children
      • example = 100ml hemorrhage experienced by a 5 kg child represents the loss of approximately 10% of their total blood volume.
  • Systemic vascular resistance is lower
    • increases from birth to adulthood
  • Hypotension is a late sign
    • remain normotensive until they are losing large intravascular volumes
      • 25-30% of blood volume before signs of shock
  • Smaller vessels / more subcutaneous tissue
    • difficult to obtain vascular access due to small veins and increased subcutaneous tissue 
  • IV access more difficult – consider intraosseus
Disability
  • Open sutures, presence of fontanelle
  • Thinner cranial bones
    • thinner cranial bones of children do not afford as much protection to the brain tissue
  • Head relatively larger
    • higher center of gravity =  higher incidence of head and neck trauma
Exposure
  • Relatively small size
    • large head and organs
  • Higher BMR and surface area
    • greater consumption of oxygen and other metabolites
    • higher respiratory and heart rates
    • larger surface-area to body-mass ratio results in greater heat loss 
  • Increased glucose requirements but decreased glycogen stores
    • higher metabolic rate 
    • small glycogen stores
Pediatric Scoring Systems
  • Pediatric trauma score (PTS) 
    • PTS<0=100% mortality
    • PTS of 1-4=40% mortality
    • PTS of 5-8=7% mortality
      • PTS less than or equal to 8 should be sent to designated peds trauma center
  • Pediatric Galsgow Coma Scale 
    • GCS<8 correlates with a higher rate of mortality
  • O2 sat at presentation and GCS 72hrs post-injury are both prognostic of long-term neurologic recovery
Injuries
  • Head and neck 
    • ICP can be elevated by pain
      • it is possible to decrease ICP by fracture fixation
    • heterotopic ossification is more common following traumatic brain injury
      • increased serum alkaline phosphatase heralds onset of HO
      • NSAID prophylaxis is indicated in these situations
  • Peripheral nerve injuries 
    • most common in closed fractures
      • obtain EMG if no return of function 2-3 months after injury
 

Please rate topic.

Average 2.9 of 38 Ratings

Questions (6)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ05.241) Which of the following injuries is associated with the highest risk of morbidity and mortality in a pediatric trauma patient? Review Topic

QID: 1127
1

Pelvic fracture

34%

(305/899)

2

Scapula fracture

13%

(113/899)

3

Spine fracture

52%

(465/899)

4

Femur fracture

2%

(14/899)

5

Tibia fracture

0%

(1/899)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ10.34) A 4-year-old child involved in a motor vehicle collision sustains multiple injuries including splenic rupture, bilateral open femur fractures, lumbar burst fracture with compression of the neural elements, and a closed head injury requiring a ventriculostomy. Of these injuries, which is likely to cause the greatest long-term morbidity? Review Topic

QID: 3122
1

Traumatic brain injury

87%

(1795/2060)

2

Peripheral nerve injury

1%

(25/2060)

3

Vertebral column injury

10%

(196/2060)

4

Intra-abdominal injury

1%

(17/2060)

5

Open fractures

1%

(26/2060)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ11.62) A 5-year-old female presents after being struck by a vehicle in her driveway. She has multiple injuries, including a right femur fracture, and open book pelvis injury, and bilateral clavicle fractures. Peripheral IV access is not able to be obtained in the trauma bay after multiple attempts, and the patients blood pressure is 110/70. Which of the following is the most appropriate method to obtain vascular access in this patient? Review Topic

QID: 3485
1

Placement of an intraosseous infusion device

91%

(2265/2499)

2

Peripherally inserted central catheter (PICC) placement in the upper extremity

2%

(51/2499)

3

Femoral venous cutdown

3%

(65/2499)

4

Subclavian central line placement

3%

(69/2499)

5

Continued attempts at obtaining peripheral IV access

2%

(43/2499)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ10.192) How many milliliters(mL) of intravascular blood volume are present per kilogram of body weight in a healthy 5-year-old child? Review Topic

QID: 3284
1

40-50 mL

12%

(290/2436)

2

75-80 mL

56%

(1372/2436)

3

90-95 mL

16%

(379/2436)

4

110-120 mL

13%

(317/2436)

5

140-150 mL

3%

(70/2436)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
ARTICLES (11)
Topic COMMENTS (3)
Private Note