Clinical diagnosis:
Resuscitation:
Can contain substantial proportion of child's blood volume. Signs:
Resuscitation:
Resuscitation:
AP/PA CXRs do not show rib fractures reliably and should not be relied on for diagnosis. Signs:
Resuscitation:
After either penetrating or blunt injury, progressive reduction in cardiac output. Signs:
Resuscitation:
Diagnosis of exclusion! CXR may show consolidation or be normal. High flow oxygen and consider ventilation.
Airleak which persists despite chest drain. Refer cardiothoracic surgeon.
Shocked, asymmetrical pulses, Wide mediastinum. Urgent angiography and refer cardiothoracic surgeon.
NGT in bizarre position (usually left sided rupture), hypoxia, shock.
Injuries caused by direct contact, or rapid deceleration. Straddling injuries may rupture urethra. Major injury can occur without obvious external signs, so visible bruising (esp with lumbar spine fracture) is predictive of bowel perforation. Rectal examination should only be done by operating surgeon. NG drainage and urinary catherisation will assist assessment by decompressing the abdomen. Acute gastric dilatation is common, so an NG tube should be passed early, aspirated frequently and left on free drainage. Urinary catherisation should be performed only if a child cannot pass urine spontaneously, or if continous accurate output measurement is required. Blood at the urethral meatus or bruising in the scrotum/perineum suggests urethral damage and the suprapubic route should be used. The catheter should be silastic and as small as possible to reduce later stricture formation.
Double contrast CT best! Diagnostic peritoneal lavage?:
Haemorrhage is often self-limiting, but non-operative management requires:
Laparotomy is indicated for:
Infants can sustain large sub/extradural haemorrhage without signs, may present as shock.
Risk factors for serious injury:
Besides the usual primary survey, the head should be carefully inspected and palpated. Look for evidence of basal skull fracture eg blood/CSF from nose/ear, haemotympanum, panda eyes, or Battle's sign (bruising over the mastoid). A dilated non-reactive pupil indicates third nerve dysfunction; the cause is an ipsilateral haematoma until proven otherwise. Fundi should be examined using an ophthalmoscope: papilloedema may not be seen in acute raised intracranial pressure (RICP) but retinal haemorrhages suggest abuse in a young infant with other unexplained injuries.
SXR for:
The role of the SXR in children is less clear than in adults. CT is indicated for:
CT should also be considered if:
Secondary brain injury is prevented by maintaining ventilation and circulationm, and by avoiding raised intracranial pressure. Children with GCS <9 should be intubated after rapid induction of anaesthesia. Capnography must be used. Normocapnia is now the aim, and hyperventilation is reserved for the patient with signs of significantly raised ICP. Shock should be treated vigorously to avoid hypoperfusion.
Witholding analgesia may contribute to deterioration by leading to a rise in intracranial pressure. Following initial assessment, IV morpnine should administered and the dose titrated against response. If necessary the drug effects can be rapidly reversed with naloxone. Local anaesthetic techniques may be useful for other injuries.
If airway, breathing and circulation are satisfactory then there must be increased ICP. Urgent neurosurgical referral and CT scan are indicated. In the meantime:
A focal seizure should be considered a focal sign. A generalized convulsion has less significance. Seizure activity raises ICP in both paralysed and non-paralysed patients. The diagnosis is difficult in the former but should be suspected if there is a sharp increase in heart rate and BP and pupil dilatation. Seizures should be treated if they have not stopped within 5 minutes. See Treatment.
Neuro referral –
Quality of transfer is better than speed and as much time as necessary should be spent preparing the child, with attention to:
Life threatening injuries:
These should all be treated immediately.
Resistant shock - Urgent orthopaedic referral, ?external fixator, ?embolize bleeding vessels.
Control haemorrhage by direct pressure and by correct splinting. If unsuccessful, then emergency orhopaedic opinion should be sought. Angiography may be necessary.
Inspect extremities for discoloration, bruising, swelling, deformity. Gentle palpation for tenderness, also check limb temperature, perfusion and pulses. Active range of motion if cooperative, otherwise avoid passive movements.
Caused by traction or penetrating injury (?internal, by end of fractured bone). Suggested by:
If these signs are present, urgent investigation and treatment should be commenced. Stabilize any fracture, ensure splints are not restrictive, consult vascular surgeon and consider angio.
Typically developing over a period of hous following a crush injury. Classically:
Pulses disappear LATE by which time irreversible changes have usually occurred. Treat by releasing constricting bandages etc, if ineffective then urgent fasciotomy should be performed.
Any wound near a fracture should be assumed to communicate with the fracture. Remove gross contamination, the cover with a sterile dressing. Bleeding should be controlled by direct pressure. Give broad spectrum antibiotics and check tetanus status.
Always consider non-accidental injury if the history is not consistent witht he injury pattern. Fracture-dislocations can be difficult to distinguish clinically and even on x-ray in young children: comparative XR of unaffected side may be helpful, else ultrasound or arthrogram. Dislocations should be reduced as soon as possible in case of neurovascular injury. Epiphyseal fractures should be managed by an orthopaedic surgeon.
Deal with life threatening problems identified during the primary survey first.
Severely angulated fractures should be aligned with gentle traction, then splinting one joint above and below site. XRs should only be done after splints in place. Check distal perfusion before and after. Analgesia will be necessary, using Entonox or IV opiates. Femoral nerve block is very effective for femoral fractures.
Fractures (suspected or definite) should be immobilised to control pain and prevent further injury. Splintage is a most effective way and may reduce need for analgesia. If pain increases after immobilisation, then an ischaemic injury and/or compartment syndrome must be excluded.
Spinal injury may be present even with a normal XR (up to 55% of complete cord injuries!), so must be presumed until excluded radiologially and clinically. On the C-spine XR:
Torticollis may reflect atlantoaxial subluxation. CR/MRI may be necessary to demonstrate.
Injuries to the thoracic and lumbar spine may cause wedge or beak shaped compression fractures, often over multiple levels. The most important clinical sign is a sensory level, but neurological assessment is difficult in children and such a level may only become appartent after repeated examination. Immobilisation should be maintained until a full neurological assessment can be carried out, and if in doubt MRI should be done.