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Trauma

Trauma is the leading cause of death in children more than one year of age. The key to trauma is to prevent it. Anticipatory guidance, seat-belts, don’t have open windows on third stories where children are likely to plummet to their death. The scenario I’m going to present to you is kind of an abbreviated advanced trauma/life support scenario. What you want to do is pick up injuries that are likely to be life threatening or cause long term morbidity quickly and treat them effectively.

The primary survey; it’s very easy to get distracted by the fractured femur sticking out of the thigh, the foot that’s twisted on backwards. Other than blood loss, that’s not going to kill them. What’s going to kill them is the fact that while you are looking at their ankle they quit breathing. So be very systematic in your assessment; airway, breathing, maintain cervical spine precautions with the airway. Cervical spine injuries in children with survivable injuries are relatively uncommon. That doesn’t mean you should ignore them. I would not let someone asphyxiate because you are concerned about intubating them. Breathing; listen to the lungs for asymmetry. Think about pneumothorax, hemothorax. Circulation; IV access and fluid resuscitation.

Pupillary response and lateralizing weakness; you are looking for very gross neurologic changes. You are not writing letters in the palm of their hand and asking them what they are. This is a very quick neurologic survey to make sure that they don’t have any potentially life threatening or long term morbidity-threatening problems.

The Glasgow coma scale is used frequently to assess trauma victims in the field, through the EMS system, through the emergency department, oftentimes to the anesthetic suite if the patient is at all awake, and into the ICU. It is nice because it is relatively simple, it’s relatively consistent between observers and it provides a numerical scale that can be followed between multiple different people who are assuming and maybe passing on care to another team.

Okay, you’ve stabilized your patient, you’ve done your primary survey. As you’ve discovered problems, such as a pneumothorax, hemothorax, respiratory arrest, you’ve dealt with it, you’ve moved on. Now you are going to go back for a secondary survey and look for a little bit more subtle findings, generally in a head-to-toe approach. You are going to look at the head, palpate it, look for hematomas, other signs that may lead you to suspect emerging intracranial pathology.

Some of your radiologic studies may show something like this. This picture was actually very nice because it came with all these arrows on it. Although this one is not subtle, that’s a big epidural hematoma, a kind of lens-shaped. Not at all subtle. This also is not very subtle. You can see something that you may see on examination, which is a big overlying cephalhematoma, and then and intraparenchymal contusion and bleed.

Okay, moving on in our dash through critical care. Near drowning; depending on what state you live in, it may in fact be the leading cause of death of young children. Certainly in California, Arizona, many of the southern states, near drowning, or drowning is the cause of death. If you’ve drowned you can’t near-drown, I guess. We are going to talk a little bit about the epidemiology, the pathophysiology, some of the clinical findings, your management and what is the prognosis of children who have immersion events.

Near drowning again demonstrates that toddlers and adolescents share many things in common. Near drowning has two bi-modal peaks during those age ranges. Even in the young children, the 2-5-year-old there is a very impressive male to female predominance. Four times as many boys as little girls end up drowning. In the adolescents it’s very often high risk behavior that results in drownings. Alcohol is oftentimes involved, or other drugs. Oftentimes diving off of high cliffs or other places where there are associated traumatic injuries as well.

What’s the pathophysiology of near drowning? It’s really an anoxic ischemic injury that is preceded typically with anoxia being the primary event, as the patient is unable to ventilate. It’s hard to breathe when you are under water. If you are getting no oxygen, your heart and brain don’t do so well.