Trauma



Trauma





Trauma Systems

Marcella D. Bono



Trauma Survey

Marcella D. Bono


Background



  • Unintentional injuries are the number one killer of children 1 to 19 years of age.




Abdominal Trauma

Kristen Hittle


Abdominal Trauma: Liver Laceration, Pancreas Laceration, and Splenic Laceration


Background



  • Abdominal trauma is the primary cause of morbidity and mortality.


  • The spleen is the most commonly injured organ; however, the liver is also at high risk due to its large size and anatomical location.


  • Pancreatic injuries are challenging to diagnose with initial imaging, and symptoms often present hours after the original trauma.



Etiology/Types



  • Blunt injury: motor vehicle collisions, falls, bicycle accidents, all-terrain vehicle accidents, sports injuries, nonaccidental trauma.


  • Penetrating injury: firearms, stabbings, impalement.


Clinical Presentation



  • Abdominal pain, distension, tenderness, guarding, ecchymosis (e.g., “seat belt sign” or handlebar marking), abrasions, referred pain (Kehr sign), signs of a penetrating wound, hypotension, and tachycardia.


Diagnostic Evaluation



  • Abdominal computed tomography (CT) with and without contrast.


  • Abdominal ultrasound (focused assessment with sonography for trauma).


  • Diagnostic peritoneal lavage.


  • Magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography for pancreatic injuries.


Management



  • Based on grade of injury and hemodynamic status.


  • Nonoperative.



    • Liver and Spleen: bed rest, serial abdominal examinations, hemodynamic monitoring, nothing by mouth (NPO), maintenance IV fluids, frequent hemoglobin and hematocrit monitoring, transfusions as indicated.


    • Pancreas: bed rest, serial abdominal examinations, hemodynamic monitoring, NPO, Salem sump placement for gastric decompression, parenteral nutrition, elemental enteral nutrition, octreotide infusion.


  • Operative.



    • Liver: hepatic artery embolization, exploratory laparotomy.


    • Spleen: repair, partial splenectomy, total splenectomy.


    • Pancreas: endoscopic stent placement, laparotomy with pancreatectomy, Whipple procedure (pancreaticoduodenectomy).


Pediatric Burns

Elizabeth Leachman


Background



  • Leading cause of injury-related death in children of all ages.


  • Flame, scald, contact, cold, and radiation burns are the most common types of burns in childhood.


  • Scald burns are the most common cause of burns in infants, toddlers, and preschoolers.


  • Contact burns are most common in toddlers.


  • Curiosity and naivety lead to most burn injuries in school-age and teenage children.


  • Burns are dynamic injuries and often evolve into deeper injuries over time.


  • Most burns have a combination of depths. The center of the burn usually demonstrates a higher degree of burn than the periphery.


  • The depth of the burn is directly related to the etiology of the burn and the amount of time the skin is in contact with the source.


  • Special characteristics of children.



    • Thinner skin and the less resistance to heat.


    • Slower reflexes.


    • Greater body surface area and percentage of water in relation to weight.


    • Lower tolerance of hypothermia.


    • Accentuated metabolism which can lead to metabolic acidosis.



Etiology



  • Scald burn: caused when skin comes in contact with hot fluid such as coffee, tea, or soup.


  • Contact burn: caused when skin touches a hot object such as a stove, iron, grill, or muffler.


  • Mechanical burn: friction with a surface such as a treadmill, rope, or pavement.


  • Flame burn: contact with fire.


  • Electrical burn: occurs when electrical current travels from the contact site into the body. In children, these burns most often occur when the child inserts a metal object, such as a hair pin, into a household electrical socket. There is usually an entrance and exit wound.


  • Chemical burn: occurs when skin comes in contact with strong acids (e.g., drain and toilet cleaners) or strong alkalis (e.g., fertilizers, detergents, oven cleaners).



  • Inhalation burn: Hot gases or smoke results in burns in the oropharynx.



Clinical Presentation



  • Superficial burn: involves the outer layer epidermis which results in pain and erythema. The tissue remains intact and the burn usually heals without scarring in 4 to 5 days.


  • Superficial partial-thickness burn: involves the epidermis and superficial layer of the dermis, causing blistering, erythema, blanching, and pain. Typically heals in 7 to 10 days. Scarring is minimal.


  • Deep partial-thickness burn: involves the epidermis and more than 50% of the dermis, which causes destruction of nerve endings and is erythematous, moist, nonblanching, and less painful. Typically heals in 2 to 3 weeks and causes scarring.


  • Full-thickness burn: involves the entire epidermis and dermis which appears white, waxy, nonblanching, and is insensate due to the complete destruction of nerve fibers. Typically takes over a month to heal with significant scarring.


Evaluation



  • Initial evaluation: airway, breathing, and circulation, followed by disability and evaluation of the burn (depth and total body surface area [TBSA]).


  • During evaluation, address thermoregulation with heat lamps or warmed fluids. A sheet or blanket will also limit burn exposure to the environment and decrease pain.


  • TBSA in children is calculated using the Lund and Browder chart or palmar surface. The child’s palm, including fingers, is approximately 0.8% to 1% of the TBSA.


Management



  • Superficial burns: thin layer of moisturizer every 6 to 8 hours.


  • Superficial partial-thickness burns: Xeroform, Mepilex AG.



    • Xeroform: petrolatum gauze infused with 3% bismuth tribromophenate.


    • Mepilex AG: silver-impregnated antimicrobial dressing, lasts 5 to 7 days.


  • Deep partial-thickness burns: Mepitel and Acticoat.



    • Acticoat: silver-impregnated rayon/polyester/polyethylene mesh. Active release of antimicrobial silver ions into burn wound when moistened; lasts 3 to 7 days. Antimicrobial activity up to 96 hours.


  • Full-thickness burns: silver sulfadiazine, skin grafting.



    • Silver sulfadiazine 1% cream: absorbed into epidermis and dermis. Bactericidal against gram-positive and gram-negative organisms, fungi, and some viruses.


  • Tetanus: booster injection if >5 years since the last tetanus vaccine.



    • <7 years: DTaP.


    • >7 years: Tdap or Td if child has already received one Tdap. Latest recommendations can be found on the CDC website at: www.cdc.gov/vaccines/


    • If contraindication to pertussis vaccine: Td.


    • Not previously immunized: Tetanus IG plus appropriate tetanus vaccine.


  • Partial-thickness burns <10% of TBSA and full-thickness burns <2% TBSA can usually be managed in the outpatient setting.


  • Partial-thickness burns 10% to 20% and full-thickness burns >5% should be admitted to the hospital.


  • Burns >10% TBSA require intravenous crystalloid fluid resuscitation.


  • Patients with burns greater than 15% should be resuscitated using the Parkland formula.



    • Parkland formula: 4 mL × TBSA (% burned) × Body weight (kg).


    • Administer half of the volume in the first 8 hours.


    • Administer second half of the formula in the remaining 16 hours.


    • Titrate fluid resuscitation to achieve urine output of 1 mL/kg/hour.


    • Maintenance fluid (normal saline, lactated Ringer) added for children <5 years of age. Normal saline or lactated Ringer plus 5% dextrose added for children <20 kg.


  • Consulting services: physical therapy for mobility, occupational therapy for splint fabrication, nutrition, case management, social work, child life, plastic surgery.



Drowning/Submersion Injuries

Alexandra K. Yockey


Background



  • Approximately 3,500 fatal unintentional drownings annually; approximately 10 deaths per day. The number of unreported or nonfatal submersions may be several hundred times higher.



  • Children at the greatest risk of submersion injuries are <5 years of age; another peak in incidence is between 16 and 24 years of age; males predominate in all age groups, and minority children are at higher risk than whites.


  • Factors impacting submersion injury: alcohol or drug consumption, lack of supervision, lack of protective barriers, trauma, and lack of ability to swim.


  • Only a few inches of water are required for a child to drown, making bathtubs and other small reservoirs of water (e.g., toilets or buckets) just as deadly as large bodies of water.




Clinical Presentation



  • Varies based on length of submersion, temperature, and degree of hypoxia, along with possible causes of drowning (e.g., seizure, trauma, or arrhythmia).


  • Children may present to the emergency department (ED) asymptomatic. A thorough evaluation is still required as even mild hypoxia can increase permeability of pulmonary capillaries, with alveolar fluid leak and surfactant damage.


  • Respiratory dysfunction may take hours to manifest, making it crucial for children to be observed for a prolonged time frame after submersion incident. Pulse oximetry should be monitored; if abnormal or in the presence of respiratory distress, arterial blood gas (ABG) values and chest radiograph should be obtained.


  • Symptomatic patients present anywhere on a continuum of symptoms: anxiety, vomiting, cough, wheezing, hypothermia, altered mental status, metabolic acidosis, respiratory failure, and finally respiratory/cardiac arrest.


Evaluation



  • ABCs (airway, breathing, and circulation) algorithm for pediatric advanced life support. ABG values are helpful in evaluating the degree of hypoxemia in children who have been submerged; should be obtained on all symptomatic children and those with a prolonged event who are asymptomatic.


  • Vital signs: heart rate, respiratory rate, blood pressure, temperature, and pulse oximetry on every submersion victim.


  • Chest radiograph: evaluation for atelectasis, pulmonary edema, and aspiration.


  • Further imaging and testing will depend on the degree of deterioration and other coinciding injuries related to the incident.


Management Occurs in Three Phases



  • Prehospital: Rescue victim from the source of submersion. Immediate resuscitation by witnesses is proven to increase survival rates. Unlike standard basic life support, which is very compression driven, opening and maintaining the airway is priority.



    • Routine cervical spine immobilization is not indicated unless there is obvious trauma.


    • The basic life support algorithm should be initiated if the child is not breathing and/or pulseless. Supplemental oxygen should be administered to all submersion victims. All submersion victims should be taken to the hospital for evaluation regardless of severity of injury.


  • ED: First priority is establishing an airway. Indications for intubation include unconscious child, peripheral arterial carbon dioxide (Paco2) levels >50 mmHg, inability to maintain peripheral arterial oxygen (Pao2) >90% with supplemental oxygen. Positive end-expiratory pressure should be used to prevent atelectasis and overcome intrapulmonary shunting.



    • Noninvasive ventilation with either continuous positive airway pressure or bilevel positive airway pressure may be indicated in alert patients with ongoing respiratory symptoms despite supplemental oxygen.


    • Chest radiograph is indicated on all submersion victims.


    • Gastric decompression via orogastric or nasogastric tubes should be placed to minimize aspiration risk in patients with altered level of consciousness.


    • Hypothermia can be both protective and harmful. Remove all wet clothing and cover patient. Evaluate for hypothermia, hypoglycemia, and electrolyte abnormalities; common in submersion injuries.



  • Inpatient: focus of hospitalization is supportive; primary goal is preventing secondary cerebral injury. The initial cerebral ischemic injury occurs during the time a victim is submerged. Secondary cerebral injury occurs later from prolonged hypoxemia, cerebral edema, acidosis, hypovolemia, seizures, and electrolyte imbalances.



    • Respiratory treatments and interventions should be tailored by clinical condition and ABG values once in a controlled environment.


    • Hypercapnia should be avoided; increased cerebral hypertension further compounds cerebral edema.


    • Aspiration pneumonitis can further complicate pulmonary status; antibiotic therapy for aspiration is controversial.


    • Normalize blood pressure; vasoactive agents may be required. Hypotension decreases blood flow to the brain, further compromising oxygenation, potentially resulting in poor neurologic outcomes. poor neurologic outcomes.


    • Hypervolemia can exacerbate pulmonary edema and should be avoided. The use of diuretics and fluid restriction may be indicated in some cases.


    • Hypermetabolic states (e.g., seizure and fever) should be treated aggressively to avoid secondary brain insults/injury.


    • Electroencephalography (EEG) should be used to detect subclinical seizures, especially in patients requiring neuromuscular blocking agents.



Pneumothorax Resulting from Trauma

Anne Vasiliadis


Background



  • Air leak syndromes include any pathology in which air enters a normally closed space within the thorax.



Incidence



  • Chest trauma is infrequent in children; responsible for 4% to 8% of all pediatric traumas. Blunt injuries are responsible for 85% of chest injuries.


  • May occur as a result of increased intrathoracic pressure (e.g., mechanical ventilation).



Clinical Presentation



  • History of blunt trauma, fall, or other trauma event.


  • Review of symptoms: typically pleuritic chest pain (e.g., sharp and worse with inspiration), dyspnea, or may be asymptomatic. The chest pain usually resolves or changes to a dull pain within 1 to 3 days despite the persistence of the pneumothorax.



Clinical Findings



  • Hypoxia.


  • Tachycardia.


  • Increased peak inspiratory pressures or decreased expired tidal volumes (if on mechanical ventilation).


  • Tension pneumothorax: tracheal deviation, asphyxia, and decreased cardiac output leading to hypotension, tachycardia, and hypoxemia. A medical emergency requiring immediate intervention.


Diagnostic Evaluation



  • Radiography: Diagnosis is typically confirmed with a posterioanterior chest radiograph. A lateral decubitus radiograph may be needed if suspicion is high with normal posterioanterior radiograph. CT is not necessary to diagnose pneumothorax, but may help identify underlying blebs/bullae or very small pneumothoraces not detected by radiography (Figure 12.1).


  • Estimation of size: Clinical history is not a reliable indicator of size. There are multiple equations for calculating size of pneumothorax in adults, but these methods are not accurate in the pediatric population.


  • Laboratory findings: ABG analysis may reveal decreased Pao2.


Management



  • Treatment is dictated by the type and size of pneumothorax and clinical condition of the patient.


  • Observation: Clinically stable patients may only require observation with pulse oximetry and cardiorespiratory monitoring. During observation, patient should receive 100% oxygen delivered via face mask to wash out nitrogen from pleural space.


  • Needle aspiration: Air is aspirated via a temporary needle inserted at the second intercostal space, midclavicular line.


  • Thoracostomy tube: Catheter is placed in the pleural space at fourth, fifth, or sixth intercostal space at the midaxillary line and connected to water seal or suction.







FIGURE 12.1 • Pneumothorax Chest Radiograph. Large left pneumothorax in otherwise healthy 16-year-old boy.



Pulmonary Contusions

Catherine Walsh



Background



  • Most common traumatic chest injury in children.


  • Early diagnosis and intervention may improve outcomes.


  • Fewer short- and long-term complications in pediatric populations than in adults.


Etiology



  • Pulmonary contusions are the most common pediatric thoracic trauma injury.


  • Children are more likely to have pulmonary contusions without other chest wall injury (e.g., rib fractures) due to high chest wall compliance.


  • Child thorax offers less protection to lung tissue than adult.


  • Flail chest and scapular fractures are rare in children, but are almost always associated with pulmonary contusions.


  • Most commonly seen in children struck by vehicles.


  • Associated with blunt chest wall trauma.


  • Suspect in patients who have sustained falls, rapid deceleration, or blast injuries. Due to severe mechanism of injury (MOI), patients frequently sustain damage to other body systems.



Clinical Presentation



  • Initial presentation may be subtle. Symptoms may include tachypnea, hypoxemia, hypercarbia, hemoptysis, and respiratory distress.


  • May be associated sign of chest wall injury.


  • ABG may be normal or demonstrate hypoxemia.


  • Delayed presentation may occur as symptoms peak 24 to 48 hours after injury.


Diagnostic Evaluation



  • Goal of primary evaluation is to identify potential life-threatening conditions.


  • High suspicion determined by mechanism and type of injury.


  • Radiographic findings of consolidation: Chest radiography and CT are the primary forms of testing. Bedside ultrasound can be used for unstable patients.


  • Chest radiography:



    • Irregular opacification in area of chest wall injury/impact.


    • Chest radiograph changes may not be noted until 4 to 6 hours after injury, and changes may not appropriately reflect extent of injury.



    • Enlargement of contusion in the first 24 hours after injury is likely indicative of increased morbidity.


    • May underestimate severity of ventilation/perfusion mismatch.


    • May be difficult to separate degree of contusion from other conditions including aspiration, pneumonia, and fluid overload (Figure 12.2).


  • CT.



    • Highly sensitive, but may detect mild and asymptomatic contusions.


    • More accurate in differentiating other causes of consolidation. Subpleural sparing is seen in pulmonary contusions but unlikely with atelectasis or pneumonia.


    • Better able to calculate extent of injury and predict need for respiratory support.


Management



  • PRIMARY management is supportive. Most children with pulmonary contusions require no intervention.


  • Address life-threatening injuries and ensure oxygenation, ventilation, cardiovascular support.


  • Close monitoring; injury evolves over first 24 to 48 hours after injury.






    FIGURE 12.2 • Pulmonary Contusion Chest Radiograph. This 3-year-old child was struck by a car. The radiograph shows the pulmonary contusion, looking much like pneumonia. Note the malpositioned nasogastric tube and the resultant distended abdomen.


  • Supplemental oxygen for hypoxia.


  • Pulmonary toilet, fluid management, and pain control are essential.


  • Fluids:



    • Judicious fluid administration. Avoid underresuscitation, which may result in hypovolemia and hypoxemia; overresuscitation may result in pulmonary edema.


  • No benefit of prophylactic antibiotics or corticosteroids.


  • Intubation:



    • Most commonly used for patients with extra-thoracic injuries.


    • For patients requiring respiratory support, the goal is to maximize oxygenation and minimize secondary lung injury.


    • Use of positive pressure improves alveolar recruitment.


    • Single lung ventilation for unilateral injuries may improve oxygenation and ventilation/perfusion mismatch.


  • Pain may contribute to hypoventilation, atelectasis, and respiratory deterioration.



    • Patients with boney chest wall injury may benefit from regional analgesia.


  • Positioning.



    • Frequently change patient position.


    • Prone position and injured lung in dependent position may improve perfusion.


  • Complications include pneumonia and acute respiratory distress syndrome.



    • Risk for pneumonia due to blood in alveolar space and decreased pulmonary toilet. Appropriate antibiotic coverage for patients with fever with worsening respiratory function.


  • Long-term consequences rarely seen in children.



Limb Trauma: Fractures and Sprains

Cathy Haut


Background



  • Unintentional or accidental limb injuries occur as a result of sports injuries, motor vehicle accidents (MVAs), and falls.


  • More than 3.5 million children <14 years of age are injured each year playing sports or involved in recreational activities.


  • When evaluating limb trauma, it is important to note the MOI, which represents the effect that energy has on human tissue, thus the expected severity of the injury.



  • Fractures are extremely common injuries sustained by children as a result of trauma, with lifetime risk of sustaining a fracture, 42% to 60% of boys and 27% to 40% of girls sustaining fractures during childhood.


Fractures



Etiology/Types



  • Epiphyseal injuries occur most frequently with distal radius and ulnar fractures, excluding phalangeal fractures. The MOI is usually a fall on an arm or hand; ages 11 to 15 years are the most common group affected with injury to the radius and ulna.


  • Forearm and wrists are the most common fracture sites in children >5 years of age, and categories include fracture dislocations, midshaft, and distal fractures.


  • Clavicle fractures occur frequently in children resulting from a fall landing on the shoulder.


  • Humerus fractures include the supracondylar site and can be associated with an acute vascular injury. Injury to the shaft of the humerus results from twisting mechanism. Distal humeral fractures occur more often in the lateral epicondyle.


  • Young children and adolescents sustain femur fractures which are often associated with a MVA involving high-energy force.


  • Tibial fractures are diaphyseal in school-age children and nondisplaced often from MVAs and sports injuries.


  • Ankle fractures, often the result of direct trauma, are more likely to involve the tibia and fibula than the talus.


  • Foot fractures involve the metatarsals and phalanges and are usually not displaced.


  • Pelvic fractures, uncommon in children, are usually the result of a crush-type injury or high-energy force. Abdominal hemorrhage and damage to other soft tissue in the abdominal area should be suspected with pelvic fracture.


  • Hip fractures can result in avascular necrosis of the femoral head, damage to the physis with growth arrest, malunion, and nonunion. Hip fractures are uncommon except for pelvic avulsion fractures occurring in adolescent boys.


  • Spinal fractures, rare in children, most often involve the cervical spine, from significant direct trauma in MVA, fall, or pedestrian-struck MVA.


Classification of Fractures



  • Either open or closed.



    • Open: Wound communicates with fracture.



      • Result of high-energy trauma or penetrating wound.


    • Closed: Skin is intact.


Explanation of Classification or Type of Fractures



  • Plastic deformation: a bending of the bone which causes a small fracture that does not cross the bone. Most common in the ulna.


  • Buckle (torus) fractures: fracture on the tension side of the bone near the softer metaphyseal bone; crosses the bone and buckles the harder bone on the opposite side, causing a bulge.


  • Greenstick fracture: Bone is bent with an initial fracture which does not go through bone.


  • Complete fracture: involves total width of bone.


  • Spiral: occurs from a rotational or twisting force.


  • Oblique: viewed diagonally across the diaphysis.


  • Transverse is usually diaphyseal.


  • Epiphyseal: through the physis or growth plate.



Clinical Presentation



  • History of injury or trauma.


  • Inability to stand, walk, or use injured part, with substantial pain or point tenderness.


  • Visible or palpable limb deformity and ecchymosis, crepitus, or grating.


  • Spontaneous onset of pain (usually seen with pathologic fractures).


  • Local swelling and marked tenderness, possible movement between bone fragments, muscle spasm.


Diagnostic Evaluation



  • Radiographs of suspected limb fractures should include the joint above and below the injury.


  • Comparison views of the opposite extremity are often obtained to help distinguish the fracture line from the growth plate.


  • In some situations, oblique radiographs are warranted in order to identify a fracture that is difficult to detect.


  • Further radiologic studies may be indicated in certain instances to evaluate a fracture: ultrasound, tomography, CT, magnetic resonance imaging (MRI), bone scan, fluoroscopy.


  • Vascular assessment may include the use of Doppler studies, compartment pressure monitoring, and/or angiography.


Management



  • Dependent on the type of fracture, location, and the age of the child.


  • Treatment may consist of immobilization by cast, splint, or brace, closed reduction followed by a period of immobilization in a cast or splint, or open reduction with or without internal fixation, and usually followed by a period of immobilization in a cast or splint. Closed reduction and percutaneous pinning followed by a period of immobilization. Closed or open reduction and application of an external fixator.



  • Traction (i.e., skin, skeletal) followed by a period of immobilization.


  • Immobilization for most fractures ≤12 weeks.


  • Simple fractures that are closed and nondisplaced can heal enough to be free from immobilization within 3 weeks.


Potential Complications from Fractures or Treatment of Fractures



  • Infection, avascular necrosis, vascular injuries, delayed union, nonunion, malunion, epiphyseal arrest, nerve and visceral injuries, tendon and joint injuries, fat embolism, compartment syndrome (see Musculoskeletal section), osteoarthritis, reflex sympathetic dystrophy.


Sprains



Etiology



  • Typical causes are falls or sports-related injury, mostly in basketball, running, and soccer, grades I to III. Ankle sprains constitute approximately 25% of all sports-related injuries; 75% of sprains involve the ankle.



    • Grade I: minimal discomfort, minimal or no loss of function.


    • Grade II: ligaments are partially torn with tenderness, swelling, and ecchymosis with mild-to-moderate loss of function.


    • Grade III: completely torn ligament with unstable joint, significant tenderness, swelling, and ecchymosis with loss of function.



Clinical Presentation



  • History of feeling a tear or hearing a pop with activity, swelling, and pain, typically in the wrist or ankle.


  • Pain and swelling in shoulder, knee, or elbow can also indicate sprain, but these areas are much less common.


Diagnostic Studies



  • Imaging is not usually indicated for a sprain.


  • Ottawa ankle rules provide guidelines for deciding about radiography: Radiographies are ordered only if there is point tenderness on the lateral or medial malleolus and the distal 6 cm of the posterior edge of the tibia or fibula or if inability to bear weight or take four unassisted steps in the examination room.


Management



  • Provide relief of discomfort with ice, rest, and nonsteroidal anti-inflammatory drugs or acetaminophen, maintain joint stability with Ace wrap or splint, and minimize swelling.


  • RICE: rest, ice, compression, elevation.


  • Complete healing should occur between 4 and 6 weeks.



Ophthalmic and Facial Trauma

Cathy Haut


Background



  • Young children are more susceptible to facial trauma due to their greater cranial mass to body ratio.


  • MOI is important to assist in determining the severity of injuries.



Types



  • Eye and orbital injuries.


  • Midface, nose, and jaw injuries.


  • Malocclusion of the jaw with mandibular fracture.



Clinical Presentation



  • History of injury: fall, sports-related, or MVA.


  • Pain, bleeding, bruising.


Diagnostic Studies

Jan 30, 2021 | Posted by in NURSING | Comments Off on Trauma
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