Study Points

Care of the Pediatric Trauma Patient

Course #92073 - $90 • 15 Hours/Credits

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Learning Tools - Study Points
Study Points

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  1. Describe the impact of pediatric trauma on society and health care.
  2. Describe the types of pediatric injuries sustained with a given mode of trauma, and identify the most common injuries occurring in various age groupings.
  3. Identify unique anatomic or physiologic differences in children, when compared to adult patients.
  4. Describe the levels of pediatric trauma care and how to prepare an emergency department for treatment of the injured child.
  5. Discuss the components of the primary survey of a pediatric trauma patient.
  6. Outline the secondary survey, and identify controversies in pediatric shock trauma management.
  7. Differentiate between mild, moderate, and severe head injuries that may occur in pediatric patients.
  8. Describe the unique traumatic injuries to the spine that occur in children and measures to treat these injuries.
  9. Differentiate the types of cardiothoracic trauma, and list appropriate management for each type.
  10. Identify the signs, symptoms, and management of pediatric abdominal and genitourinary trauma.
  11. Recognize the risks and appropriate interventions in the management of orthopedic pediatric trauma.
  12. Discuss the appropriate management of traumatic amputation and soft tissue trauma in pediatric patients.
  13. List the signs and symptoms and appropriate interventions for post-traumatic respiratory distress syndrome in children.
  14. Describe the identification and treatment of multiple organ dysfunction syndrome (MODS).
  15. Differentiate the various types of renal failure that occur following trauma in the child.
  16. Outline the role of interpreters when caring for patients whose families speak a language other than English.
  1. The mortality rate for children sustaining trauma is approximately

    INTRODUCTION

    Although the statistics remain sobering, it is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children. Due to the implementation of rapid field resuscitation and early transport to a center specializing in pediatric trauma care, the overall mortality rate due to traumatic injury is approximately 8% [8].

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  2. The greatest risk of traumatic injury to children occurs during

    BIOMECHANICS OF PEDIATRIC TRAUMA

    As noted, the largest risk of injury occurs during the school-age years (7 to 12 years of age). These children are developing a sense of independence and freedom, which predisposes them to new risks. Many school-age children are injured while riding in a motor vehicle. A unique injury in children is known as "lap belt complex," whereby the child sustains injury secondary to the lap belt restraint.

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  3. Mechanisms of injury sustained by teenagers include

    BIOMECHANICS OF PEDIATRIC TRAUMA

    Many teenagers (13 to 19 years of age) are injured in automobiles. As these children begin to drive, the risk of both driver and occupant injuries becomes more common. Studies have shown the incidence of injury increases with the number of peers in an automobile, thus reigniting the debate regarding restricting driving privileges of young, newly licensed drivers.

    Many socioeconomic and cultural influences impact the type and incidence of trauma. Urban children have a higher incidence of violence; the presence of youth gangs, alcohol use, and drug use is highest in this environment. Patterns of behavior and injury are also impacted by the race of the child; young non-Hispanic black individuals 15 to 19 years of age have the highest proportion of homicide deaths, frequently precipitated by firearms [12].

    The suicide rate in teenage individuals increased threefold between 1950 and 1990; it began to decrease in the late 1990s, but since 2000 the incidence has increased annually [3,13]. Suicide is the second leading cause of death for children 10 to 14 years of age and adolescents 15 to 24 years of age [3]. In 2015, adolescents and young adults 15 to 24 years of age had a suicide rate of 12.5%, with the highest rate (15.1%) among white youths [13]. Native American/Alaskan Native youths had the second highest rate for suicide deaths [13]. Hispanic youths are more likely to attempt suicide than non-Hispanic black or white children.

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  4. When an automobile passenger is unrestrained, the incidence of head injury increases by more than

    BIOMECHANICS OF PEDIATRIC TRAUMA

    Many children are injured in MVAs whether they are restrained or not [2]. Unrestrained children often suffer numerous injuries when a MVA occurs. At the time of the crash, the unrestrained child becomes a projectile and is either thrown around the interior of the vehicle, impacting with the hard frame, or is ejected, suffering multiple injuries upon impact with the ground. The incidence of head injury increases by more than 300% when a passenger is unrestrained.

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  5. The leading cause of mild traumatic brain injury (MTBI) in children is

    BIOMECHANICS OF PEDIATRIC TRAUMA

    Each year in the United States, approximately 250,000 children and adolescents are injured while riding bicycles and 120 die [3]. Bicycles are the leading cause of mild traumatic brain injury (MTBI) in children [26]. Small children on three-wheeled bikes may not be seen in a rearview mirror and may be run over by a car or truck, commonly in their own driveway. Older school-age children are also frequently injured on bikes, and the use of helmets should be stressed in this population. It is important that the helmet fits correctly so that it is not dislodged during a fall. Many helmets are too loose, which negates the protection they can afford. A chinstrap should be tight enough to allow only a finger to be slipped between the strap and the chin.

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  6. Unique parameters of the child's abdominal system include

    BIOMECHANICS OF PEDIATRIC TRAUMA

    A thin-walled abdomen without musculature to protect the abdominal organs leads to frequent rupture of these organs. In addition, the horizontal diaphragm does little to protect the liver and the spleen from injury. With fewer fat deposits around the abdominal and retroperitoneal organs, the organs are at risk for developing tears of the major vessels supplying them. Once injury has occurred, bowel sounds are of little value as bowel function is labile and bowel tones are frequently absent regardless of the extent of injury. The size of the abdominal organs is proportionately larger, with the exception of the stomach, which is small with a small capacity. Stomach distention leads to upward displacement of the diaphragm, causing respiratory distress.

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  7. Preparing the emergency department for the pediatric trauma victim includes which of the following steps?

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    Physically, the department should be prepared with the equipment of appropriate size to meet the special requirements of the young patient being admitted. The Committee on Pediatric Emergency Medicine prepared a list of recommendations for equipment to be available for treating pediatric patients [39]. Often, the report from the prehospital personnel will provide the age of the child, which allows an estimation of the size and weight. Although formulas for estimation exist, the use of the Broselow tape is now recommended to ensure age and weight-appropriate interventions. Immediate weighing of the child upon admission is not critical in the case of the trauma patient because appropriate estimation can be achieved utilizing this method. When the patient is stabilized, an accurate weight can be obtained.

    Personnel trained in pediatric trauma resuscitation should be notified and present at the bedside upon arrival of the patient in the emergency department. A pediatric resuscitation cart should be readily available to provide the appropriate size equipment for the patient. A cart that is color coded to match the Broselow tape can be helpful in expediting equipment acquisition.

    Social workers, clergy, or other personnel can provide excellent support to the family. These individuals should be trained in providing general information on what is being done for the patient and how long it may be before the family members can visit with the child. Specific information regarding injuries and outcomes should be provided at the discretion of the attending physician; however, availability of general information will go a long way in helping the family adjust to the situation at hand.

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  8. Stabilization of the airway in a traumatically injured child younger than 8 years of age includes which of the following tenets?

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    Airway management of the child is critical and must be obtained as rapidly as possible. The limited size of the pediatric airway increases the risk of rapid deterioration and subsequent difficulties in managing the airway. Although the occurrence of spinal cord injury is rare in young children, all pediatric trauma patients should be managed as if a spinal cord injury exists [41]. This requires utilizing the jaw-thrust maneuver to open the airway while maintaining alignment of the cervical spine. Once positioned, the airway should be examined for debris, such as loose teeth, blood, or saliva, that can be mechanically removed.

    For the child who is unable to maintain a patent airway, endotracheal intubation via the orotracheal approach should be instituted. The appropriate size tube should be utilized. Anatomic differences between adult and pediatric airways make endotracheal intubation more challenging in the child. During trauma resuscitation, the care provider with the most experience at pediatric intubations should be assigned the responsibility of securing the airway. It is strongly recommended that those with less experience should defer this responsibility.

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  9. What are the seven steps (the Seven Ps) in performing rapid sequence intubation in children?

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    RAPID SEQUENCE INTUBATION PROTOCOL FOR CHILDREN (THE SEVEN Ps)

    Aspects of IntubationSequence of Events
    Preparation
    Ensure adequate IV access (preferably two IV lines).
    Test suction and oxygen equipment.
    Prepare endotracheal tube (ETT) (check cuff patency).
    Assemble equipment (e.g., drugs prepared in syringes, laryngoscope ready).
    Initiate pulse oximetry, if not already done.
    Optimize the patient's position for intubation access.
    Assess for possible difficult airway.
    Preoxygenation
    Apply 100% oxygen for five minutes of normal breathing.
    If time does not permit, administer eight vital capacity breaths (maximum volume patient can take) with 100% oxygen.
    Pretreatment
    Consider atropine 0.01 mg/kg IV.
    Consider lidocaine 1.0–1.5 mg/kg IV in patients with severe reactive airway disease or patients with increased ICP.
    Consider administering a rapid fluid bolus to mitigate the hypotensive effect of anesthesia.
    Paralysis and induction
    After two minutes of last pretreatment drug, administer sedative/anesthetic and neuromuscular blocking agent/paralytic.
    Sedative/anesthetic choices may include (usually only one is administered) sodium thiopentone (5–8 mg/kg), propofol (2.5 mg/kg), ketamine (1–2 mg/kg), or midazolam (0.1–0.2 mg/kg).
    Administer rocuronium (0.6–1.2 mg/kg). Succinylcholine is not recommended for children.
    Protection and positioning
    As patient loses consciousness, perform the Sellick maneuver (i.e., cricoid pressure) and maintain this position until ETT is in place and cuff is inflated.
    Maintain in-line stabilization. A neutral position is acceptable if cervical spine injury is suspected, but in its absence, the "sniffing" position is preferable, as it brings the axes of the larynx, pharynx, and mouth into alignment.
    Placement with proof
    Approximately 45 seconds after administration of the paralytic agent, proceed with intubation.
    Inflate cuff and confirm tube placement.
    Post-intubation managementSecure tube, measure and report blood pressure and other vital signs, and initiate mechanical ventilation. Continue long-term sedation/paralysis/analgesia, as indicated.
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  10. In children, whole blood can be administered at a rate of

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    Volume replacement in children is based on a milliliter per kilogram basis with initial resuscitation started at 10–20 mL/kg with warmed IV fluid. This fluid is administered rapidly and the child monitored for adequacy of resuscitation. In the child with ongoing blood loss, IV fluids can be increased to 50–60 mL/kg; however, at this point, blood administration should be considered. Whole blood is administered at 20 mL/kg, while packed red blood cells can be administered at 10 mL/kg diluted with an equal amount of normal saline.

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  11. The secondary survey of the child should include

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    The secondary survey is a systematic head-to-toe assessment of the traumatic injuries sustained. Ecchymosis and other signs of underlying injury should be identified. Although not all traumatic injuries are clear-cut and initially obvious, mechanisms of injury help direct the physician in identifying potential injuries.

    Beginning at the head of the child, the scalp is palpated and assessed for lacerations and irregularities in the shape of the skull. In infants, the fontanelles should be palpated for fullness and/or widening. The facial structures should be assessed for integrity or instability. The eyes should be examined for foreign bodies or other abnormalities. Drainage of cerebral spinal fluid (CSF) from the nose and ears should be identified. The mouth should be inspected for lost or loose teeth, bleeding, and secretions.

    Neurologic assessment should include the patient's level of consciousness, Glasgow Coma Scale (GCS) score, and pupillary response. Intact brain stem reflexes indicate an intact neurologic pathway. Evaluation of the corneal and gag reflexes should be obtained as part of the neurologic assessment. Motor and sensory function should be evaluated.

    The neck should have been secured in a hard collar by prehospital personnel. At this point, the collar may be removed while an additional person ensures neck alignment. The neck is assessed for deformity, swelling, and pain. Range of motion should not be assessed until a clear cervical spine x-ray has been obtained.

    The chest is evaluated for bilateral, symmetrical chest movements with ventilation. Auscultation should include assessment of breath and heart sounds. Shoulder harness ecchymosis should be looked for if the mechanism of injury suggests this pattern of injury. Although pediatric rib fractures are rare, integrity of the rib cage must be determined. When the child reaches adolescence, the incidence of rib fractures increases.

    The abdomen should be palpated. Any obvious injury should be assessed last. Beginning the assessment in a nonpainful area will ensure better cooperation from the child. Increasing abdominal distention is an early sign of underlying injury in a child and should be documented and followed as care progresses.

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  12. Pain management and anxiety reduction of the child includes the administration of

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    A final step in the resuscitative process should be the institution of pain control and anxiety-reduction measures. Many physicians prefer to delay administering narcotics until the secondary survey is complete and all injuries have been identified. At this point, the child can be administered morphine (0.1 mg/kg) or fentanyl (1 mcg/kg) and midazolam (0.05–0.1 mg/kg) as needed [40,46,124]. Assessment of the effectiveness of these pain control measures should be performed. If the child continues to complain of pain, additional medications should be considered [48].

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  13. Minimal volume, delayed resuscitation technique is supported in some patients because aggressive volume replacement can

    OVERVIEW OF EMERGENCY PEDIATRIC TRAUMA CARE

    Aggressive fluid resuscitation has been the protocol for many years, first being supported by the American College of Surgeons in the Advanced Trauma Life Support courses. However, there has been interest in what is known as "minimal volume, delayed resuscitation" in a specific group of patients. The rationale for this resuscitation technique is that maximum fluid resuscitation will increase bleeding, prevent clot formation, or dislodge forming clots. The use of this type of resuscitation is supported in patients with ruptured abdominal aortic aneurysms (a very rare injury in children) and in patients with penetrating truncal trauma (as seen in gunshot wounds). After the injuries have been stabilized and bleeding has been controlled, aggressive volume resuscitation is then initiated to restore normal hemovolemia.

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  14. Which type of injury occurs at the time of trauma to the head?

    TRAUMA TO THE HEAD AND FACE

    When the head is injured, it is important to remember that two types of injury are possible: primary and secondary. Primary injury is that injury to the head and brain that occurs at the time of trauma. Healthcare professionals have little control regarding the development of this type of injury, with the exception of education regarding prevention. Secondary injuries occur as a result of the trauma; examples include cerebral edema, bony fragments, and delayed vascular injury. Different portions of the brain demonstrate different responses to injury. For example, the area of primary trauma may exhibit vasospasm, while another area may develop vascular leak as a result of secondary injury. Trauma care of injuries to the head and brain is directed at preventing or controlling the development of secondary injury.

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  15. The majority of pediatric skull fractures are

    TRAUMA TO THE HEAD AND FACE

    Skull fractures are described by their type: linear, depressed, compound, basilar, ping-pong ball, and growing. Seventy-five percent of pediatric skull fractures are linear fractures, or simple cracks in the bone [60]. If no underlying injury develops, the child will have complete resolution of the fracture site. Over time, this fracture line may completely disappear from x-ray as remodeling of the skull occurs.

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  16. Which of the following types of skull fractures are unique to the pediatric population?

    TRAUMA TO THE HEAD AND FACE

    Two types of skull fractures are unique to the pediatric trauma victim. The "ping-pong ball" fracture is a dent in the skull; the segment is depressed but no fracture lines are evident on x-ray. The "ping-pong ball" designation was coined when someone noticed that the appearance of this type of fracture is similar to that of a ping-pong ball when it is indented. This type of fracture is only seen in small children, generally younger than 2 years of age, due to the minimal mineralization of the skull. The inherent risk of this depressed segment is the underlying damage to the cranial tissue. The depressed segment is commonly surgically elevated to reduce its impingement into the cranial vault and to prevent the formation of cosmetic deformities.

    Another unique skull fracture in children is the growing fracture, also known as a leptomeningeal cyst. This type of fracture occurs when the dura is torn and there is accumulation of CSF in the extradural space. If this cyst develops, the fracture site appears to be growing as the cyst increases in volume. Over time, if not recognized and treated, the cyst can enlarge to the point of producing brain tissue compression. Obscuring the diagnosis is the inability to visualize the dura on plain skull radiographs. MRI is the best method for dural integrity evaluation, although availability and cost issues often make this modality less practical in some locations. Patients with a higher risk of dural tears and subsequent cyst formation are those with a diastasis of 3 mm or greater and a young age. Ultrasound is also used to diagnose these tears. Normally, ultrasound waves do not penetrate an intact skull, but an opening (fracture) will allow the beam to pass through, and the practitioner can examine the integrity of the dura [61].

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  17. Which of the following types of injury to neural tissue is the most mild form?

    TRAUMA TO THE HEAD AND FACE

    Injury to the neural tissue can vary in severity from a concussion, the mildest form, to a contusion or a diffuse axonal injury, producing severe, profound coma. A concussion produces a temporary disruption of cerebral function, generally lasting less than one day. The term MTBI is often used interchangeably with the term concussion.

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  18. Which of the following subdural hematomas occurs within the first two weeks following injury?

    TRAUMA TO THE HEAD AND FACE

    Disruption of the cerebral vasculature produces a cerebral hematoma or hemorrhage. Accumulation of blood between the dura and arachnoid layers produces a subdural hematoma, the most common type of intracranial hemorrhage in children. Subdural hematomas are generally venous in origin and are classified in three categories: acute, subacute, and chronic. The child with an acute subdural will present with immediate alterations in cerebral functioning. A subacute subdural hematoma develops within two weeks of injury and is defined by a progressing decrease in level of consciousness during this time frame. A chronic subdural hematoma is commonly diagnosed months later when a child is evaluated for changes in personality, behavior, and/or cognition or an onset of seizures. The actual cranial insult may have been forgotten by the time of diagnosis.

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  19. A hemorrhage that occurs when blood is deposited between the arachnoid and meningeal layers is known as a

    TRAUMA TO THE HEAD AND FACE

    Subarachnoid hemorrhage occurs when blood is deposited between the arachnoid and meningeal layers. Violent shaking of a child, such as in abusive treatment, can produce this type of intracranial hemorrhage. If a subarachnoid hemorrhage is suspected, a lumbar puncture will provide confirmation. However, lumbar punctures should be avoided in patients with epidural or subdural hematomas and should only be performed when these types of intracranial hemorrhages have been first ruled out and there is no evidence of increased ICP.

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  20. When assessing a patient who is 3 years of age using the Glasgow Coma Scale, a motor response to pain only would be issued a score of

    TRAUMA TO THE HEAD AND FACE

    PEDIATRIC GLASGOW COMA SCALE

    ScoreResponses by Age
    Eyes Opening
     Patient >1 year of agePatient <1 year of age
    4SpontaneouslySpontaneously
    3To verbal commandTo shout
    2To painTo pain
    1No responseNo response
    Motor Response
     Patient >1 year of agePatient <1 year of age
    6ObeysSpontaneous
    5Localizes painLocalizes pain
    4Flexion-withdrawalFlexion-withdrawal
    3Flexion-abnormal (e.g., decorticate rigidity)Flexion-abnormal (e.g., decorticate rigidity)
    2To painTo pain
    1No responseNo response
    Verbal Response
     Patient >5 years of agePatient 2 to 5 years of agePatient<23 months of age
    5Oriented and conversesAppropriate words or phrasesSmiles, coos, or cries appropriately
    4Disoriented and conversesInappropriate wordsCries and consolable
    3Inappropriate wordsPersistent cries and/or screamsPersistent inappropriate crying and/or screaming
    2Incomprehensible soundsGruntsGrunts or is agitated or restless
    1No responseNo responseNo response
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  21. Following injury to the head arising from blunt trauma, which of the following conditions would indicate a diagnosis of MTBI?

    TRAUMA TO THE HEAD AND FACE

    A child who is profoundly comatose is obviously one who has sustained major injury. However, MTBI is much more difficult to accurately assess. The CDC defines MTBI as "the occurrence of injury to the head arising from blunt trauma or acceleration or deceleration forces" [66]. One or more of the following conditions must also be present for diagnosis of MTBI [66]:

    • Temporary confusion, disorientation, or impaired consciousness

    • Loss of memory during the time immediately before, during, or after injury

    • A period of unconsciousness lasting no longer than 30 minutes

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  22. The two mainstays of the management of head trauma are the control of hypoxemia and

    TRAUMA TO THE HEAD AND FACE

    Signs and symptoms suggestive of moderate-to-severe brain injury include a loss, or decreasing level, of consciousness, focal neurologic abnormalities, and coma. Management of neurotrauma in this population is based upon two mainstays of treatment: controlling hypotension and controlling hypoxemia. Initial resuscitative efforts should be directed at preventing these two complications, beginning in the field and progressing through the emergency department and into the critical care unit.

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  23. One of the more common sequelae to brain injuries in children is the development of post-traumatic

    TRAUMA TO THE HEAD AND FACE

    One of the more common sequelae to brain injuries in children is the development of post-traumatic seizures. The incidence ranges from 1% to 6%; the more severe the injury, the greater the risk of seizure development. The injuries with the highest risk of seizure development are those that penetrate the dura, cause intracranial hemorrhage, or produce prolonged (>12 hours) unconsciousness [63].

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  24. The assessment parameter that would help identify a spinal cord injury at the level of C7 would be

    TRAUMA TO THE SPINE AND SPINAL CORD

    RAPID NEUROLOGIC ASSESSMENT OF SPINAL CORD INJURIES

    Assessment ParameterLevel of Function
    Elbow flexionC5
    Dorsiflexion of wristC6
    Extension of the elbowC7
    Flexion of the middle finger phalanx of the middle fingerC8
    Abduction of the little fingerT1
    Flexion of the hipL2
    Extension of the kneeL3
    Dorsiflexion of the ankleL4
    Dorsiflexion of the great toeL5
    Flexion of the ankleS1
    Bowel and bladder functionS2–4
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  25. A child who presents with a weak, thready pulse; signs of shock; and distant heart sounds may have sustained

    CARDIOTHORACIC TRAUMA

    Children with tamponade will present with a weak, thready, rapid pulse. Signs of shock may develop as the cardiovascular system begins to fail. Beck's triad of symptoms (late signs of compromise) includes a decreased blood pressure with a narrow pulse pressure, distended neck veins, and distant heart sounds. These symptoms are documented in only 10% to 30% of cases, although these signs are considered "classic" signs of tamponade.

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  26. Sudden death in a child athlete following a modest blow to the chest is most commonly caused by

    CARDIOTHORACIC TRAUMA

    There has been increased interest in sudden cardiac death in children (known as commotio cordis), especially during athletic competition or exertion. More than 90% of these deaths occur in male patients [82]. Some of these deaths occur when there is a sudden, blunt, modest blow to the mid-chest. Although this type of trauma occurs more frequently during sports, some occur during normal daily activities [82]. The patient has no evidence of cardiac damage or disease in most cases, and death is secondary to ventricular fibrillation. It is suspected that the impact occurs during repolarization of the cardiac cycle, a time window of less than 1/100 of a second. On autopsy, those children who had no clinical signs of cardiac disease had evidence of hypertrophic cardiomyopathy or a congenital coronary artery anomaly. Only 25% of resuscitations are successful [83].

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  27. What percentage of patients sustaining blunt thoracic trauma will also have a concurrent cervical injury?

    CARDIOTHORACIC TRAUMA

    When caring for the child with blunt thoracic trauma, it should be remembered that 12% of patients will have a concurrent cervical injury and should be treated with cervical spinal precautions. Although 85% of the injuries can be managed conservatively or with a chest tube, the goal of management is ventilatory support and improvement in the oxygenation status of the child. Without adequate pain control, these measures will be more difficult to attain; pain control should be instituted early and continued throughout the course of care.

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  28. Which of the following forms of trauma is the leading cause of unrecognized fatal injury to children?

    ABDOMINAL AND GENITOURINARY TRAUMA

    Abdominal and GU trauma is the leading cause of unrecognized fatal injury in children. Although the incidence of death from these injuries remains low, a missed injury can have a devastating outcome. The majority of children who die after sustaining abdominal trauma expire from an associated injury, most commonly head injury. The focus of trauma care has changed from immediate surgical intervention to a nonoperative, wait-and-see approach in children with solid organ injury.

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  29. Which of the following diagnostic studies is the modality of choice in assessing extent of injury following blunt abdominal trauma in stable patients?

    ABDOMINAL AND GENITOURINARY TRAUMA

    CT scans are the diagnostic modality of choice in stable patients who have sustained blunt abdominal trauma [38]. With the increasing availability of CT scanners, the incidence of exploratory laparotomies has decreased significantly. CT scans allow for identification of many injuries, as well as grading the severity of injury. This information is utilized in making choices on how to best manage the patient. The disadvantage of CT scans is the decreased sensitivity and specificity in recognizing trauma to the pancreas, bowel, bladder, and mesentery. Utilization of contrast material, both orally and intravenously, can improve the diagnostic capabilities in some patients; however, the risk of aspiration following oral contrast administration is of concern. Patients sustaining penetrating trauma may benefit from a quick abdominal x-ray, allowing for identification of free air or foreign bodies.

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  30. Which of the following statements is TRUE regarding trauma to the liver?

    ABDOMINAL AND GENITOURINARY TRAUMA

    Hepatic injuries are common in children due to the size and prominent location of the liver. Although splenic injuries are more common, hepatic injuries have the highest mortality. Liver injuries are similarly graded on a scale of I to V, with V being the most life-threatening injury associated with massive hemorrhage. The symptoms of liver injury include right upper quadrant pain and tenderness. Increasing abdominal girth in children may be an indicator of increasing intra-abdominal volume. Persistent hypovolemia in spite of adequate volume replacement may indicate massive hemorrhage.

    If the child is stable, the trend in hepatic trauma management is to monitor the child and treat the injury nonoperatively. Patient selection for nonoperative management is based primarily upon the hemodynamic stability of the patient, not the grade of injury. The impetus for nonoperative management is the fact that patients who are treated without surgery have a lower mortality rate, require fewer transfusions, and have less risk of post-operative infection [95].

    Delayed bleeding is rare after liver injury. Following the hematocrit and hemoglobin levels will allow for identification of ongoing blood loss. For those patients with continued bleeding, arterial embolization to control bleeding has met with success. This method of stabilization prevents the surgical stress associated with exploratory laparotomy.

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  31. The majority of traumatic injuries sustained by children are

    MUSCULOSKELETAL AND SOFT TISSUE TRAUMA

    The majority of traumatic injuries sustained by children are orthopedic injuries. Fortunately, children have the distinct advantage of rapid bone growth, leading to faster healing. The thick periosteum in children allows for less fracture displacement, fewer open fractures, and more stability of fractured extremities. Children also respond better to treatment, with post-casting joint stiffness and muscle atrophy being minimal.

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  32. Utilizing the Salter-Harris classification of fracture types, an injury that affects only physis would be classified as a

    MUSCULOSKELETAL AND SOFT TISSUE TRAUMA

    SALTER-HARRIS CLASSIFICATION OF ORTHOPEDIC FRACTURES IN CHILDREN

    TypeInjured AreaOutcome
    IPhysis onlyExcellent
    IIPhysis and metaphysisUsually excellent
    IIIPhysis and epiphysisRisk of long-term sequelae
    IVPhysis, epiphysis and metaphysisGrowth abnormalities, deformity
    VCompression of epiphyseal plateEarly closure, growth retardation
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  33. What percentage of multiple pelvic fractures are associated with abdominal and/or genitourinary trauma?

    MUSCULOSKELETAL AND SOFT TISSUE TRAUMA

    Another life-threatening fracture is a pelvic fracture. Although rare in children, the risk of death with these injuries is high. Pelvic fractures in children are secondary to compression type forces, causing displacement of the pelvic ring and injury to surrounding organs and vasculature. Eighty percent of pelvic fractures that have multiple fracture sites have associated abdominal or GU trauma. Ruptured bladder is common, especially in the child who had a full bladder at the time of injury.

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  34. Which of the following is considered an appropriate intervention for the management of traumatic amputation?

    MUSCULOSKELETAL AND SOFT TISSUE TRAUMA

    Care of traumatic amputations requires attention to a number of issues. First and foremost, the child should be stabilized, life-threatening injuries must be treated, and ongoing blood loss must be controlled. After these priority injuries are managed, the child should be prepared for transport. The newly formed stump should be gently cleansed and pressure dressings applied to control bleeding. Debridement should not be undertaken without surgical consult. The stump should be elevated to reduce swelling. If time permits, x-rays of the amputated part and the stump can be obtained; this will assist in decision making prior to surgical reattachment.

    The amputated part should also be properly handled to prevent tissue destruction while awaiting surgical repair. The part should be gently cleansed and wrapped in slightly moistened gauze. It is important to prevent the amputated part from becoming saturated, either with blood or serous drainage. The wrapped part should be placed in a plastic bag and the bag placed into a plastic container, such as a urine cup or emesis basin. This plastic container should then be placed on ice in an ice cooler. The part should not be buried in ice. If the part becomes too cold, frostbite can develop, rendering the part unacceptable for replantation.

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  35. Post-traumatic respiratory distress syndrome has which of the following pathophysiologic characteristics?

    MEDICAL SEQUELAE OF PEDIATRIC TRAUMA

    Post-traumatic respiratory distress syndrome occurs following pulmonary injury, leading to pulmonary congestion. As the disease progresses, there is increased mucus formation and a loss of surfactant. The syndrome has four pathophysiologic characteristics:

    • A systemic inflammatory response with the release of mediators

    • An alteration in the alveolar-capillary membrane

    • Changes in airway diameter

    • A disruption in systemic oxygen transport and utilization

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  36. The chest x-ray of a child with post-traumatic respiratory distress syndrome will usually demonstrate

    MEDICAL SEQUELAE OF PEDIATRIC TRAUMA

    Chest x-ray usually demonstrates diffuse bilateral infiltrates with a normal lung next to a severely injured lung. There will be no evidence of congestive heart failure as is seen with other respiratory distress syndromes. In the initial stages, the lungs are dry. The child is dyspneic and tachypneic, leading to a respiratory alkalotic state with a decreasing PaCO2 level. Within 24 to 48 hours, the child becomes severely dyspneic and hypoxemic. Chest x-ray evidence will develop, and if recognized and treated early, resolution will occur. In severe cases, the child develops irreversible hypoxemia and death occurs within two weeks. For those children who survive this insult, the prognosis is good, with a return to normal pulmonary function; however, complete resolution can take up to one year.

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  37. Multiple organ dysfunction syndrome (MODS) is defined as

    MEDICAL SEQUELAE OF PEDIATRIC TRAUMA

    MODS is defined as progressive deterioration of two or more organ systems over a short time period [115]. This organ failure is initiated by systemic inflammatory response syndrome (SIRS), which is a systemic response to a variety of insults, including trauma. SIRS causes the release of mediators that either facilitate cell-to-cell interaction or cause direct tissue damage. The etiologic factors in trauma include: sepsis; persistent, prolonged hypovolemic shock; multiple transfusions; and extensive tissue damage [115]. Descriptive scoring systems have been established for pediatric MODS based on severity of symptoms in five organ systems: cardiovascular (lactic acid), respiratory (PaCO2/fraction inspired O2 ratio), hepatic (bilirubin), hematologic (fibrinogen), and renal (blood urea nitrogen or BUN) [116].

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  38. Most commonly, the first organ failure in MODS is

    MEDICAL SEQUELAE OF PEDIATRIC TRAUMA

    The defining characteristics of MODS are organ specific [115]. Most commonly, pulmonary failure develops first and is characterized by respiratory failure with a PaCO2 greater than 50 mm Hg, an alveolar-arterial oxygen difference (AaDO2) gradient greater than 350 mm Hg, and ventilator dependence. At day six or seven, hepatic failure begins to develop and is defined by a bilirubin of greater than 6 mg/dL, a prothrombin time of more than four seconds greater than the control, and jaundice. If the bilirubin is greater than 8 mg/dL, the syndrome carries a mortality of 90% or greater.

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  39. In MODS, when four or more organs have failed, mortality is approximately

    MEDICAL SEQUELAE OF PEDIATRIC TRAUMA

    Mortality is dependent upon how many organ systems are involved. With two organ systems involved, the mortality rate is approximately 67% to 78% [117]. When four or more organs fail, mortality approaches 100% [117]. The keys to combating this mortality are prevention, early recognition, and controlling mediator release.

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  40. Treatment goals for the management of acute renal failure include maintenance of

    MEDICAL SEQUELAE OF PEDIATRIC TRAUMA

    The treatment goals include maintaining a normal circulating volume, normal electrolyte values, and vascular stability. In cases of prerenal failure, adequate fluid administration may be all that is necessary to reverse the impending failure. In some cases, a furosemide or mannitol challenge may be administered to prevent acute tubular necrosis from developing during the oliguric phase.

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