Trauma (Case 44)

Chapter 86 Trauma (Case 44)



Paul M. Shore, MD, MS




Case


A 6-year-old pedestrian child has been hit by a car traveling at moderate speed (30 mph)




Differential Diagnosis











Chest injuries Spinal cord injury
Abdominal injuries Traumatic brain injury (TBI)


Speaking Intelligently


I approach the trauma patient with the assumption that immediately life-threatening injuries exist, and it is up to me and the trauma team to identify and treat them. I follow protocols outlined by the American College of Surgeons in their Advanced Trauma Life Support course. The patient is first approached with a primary survey looking at the ABCDEs, in which immediately life-threatening injuries to the airway, breathing, and circulation are recognized and treated aggressively. Next, a secondary survey is undertaken, and a more thorough examination is performed. Radiographic and laboratory examination may follow, and injuries not apparent on physical examination are identified. Finally, a disposition is determined as to where the patient will receive further definitive management (e.g., surgery) or stabilization (e.g., home, ward, or intensive care unit).



Patient Care



Clinical Thinking



• Primary Survey (A,B,C,D,Es)

• Airway: The patient’s airway may be obstructed by direct trauma, debris, or by neurologic impairment (e.g., coma or seizure). If the airway is patent, proceed to “breathing.” If not, obtain a patent airway. Caution must also be taken to maintain a stable cervical spine during any airway procedures.

• Breathing: “Breathing” refers to the act of respiration, which may be impaired by direct trauma to the thorax or neurologic impairment. If the patient’s breathing is adequate, proceed to “circulation.” If not, identify and treat the problem immediately.

• Circulation: “Circulation” refers to the patient’s blood volume and cardiac function. Patients should have two large-bore peripheral IVs placed immediately upon arrival, and isotonic crystalloid should be administered. Control any obvious source of external bleeding with externally applied pressure.

• Disability: Gross neurologic disability should be recognized during the primary survey. The patient’s level of consciousness should be assessed using the Glasgow Coma Scale (GCS). If the GCS is ≤8 or deteriorating, the trachea should be intubated under the assumption that airway patency or respiratory drive will soon be lost. Examine the pupils: if anisocoria is present without eye trauma, the patient should be treated immediately for intracranial hypertension. A cervical collar should be placed on the patient to immobilize the neck.

• Exposure: The patient’s clothing is removed to facilitate a complete physical examination.

• Secondary Survey

• Proceed to the secondary survey only if the complete primary survey has identified no immediately life-threatening injuries.

• The secondary survey should be a careful, systematic, head-to-toe evaluation of the patient with careful attention paid to all potential injuries.

• Always logroll the patient (keeping the neck stable) to examine the back.

• Radiographic examination of the patient should be done in the trauma room and should include plain films of the chest, cervical spine, and pelvis if injury to these areas is suspected. Clinical findings or mechanism of injury should guide the need for computed tomography (CT) scans of the head, neck, chest, abdomen, or pelvis following the initial stabilization. Blood can be drawn for a laboratory panel (see below) while IV access is obtained.

• All historical and physical examination findings should be recorded on a flow sheet designed specifically for acute trauma. The leader of the team should therefore call out each finding (including normal findings) as they are identified.

• Occult Trauma
• Nonaccidental trauma (child abuse) patients often present with a history of trauma that may be inaccurate, conflicting, or entirely absent, and their arrival to medical attention may be delayed. They may present with symptoms that are nonspecific or subtle, such as vomiting, irritability, or “not acting right.”

• Near-drowning typically causes hypoxic-ischemic injury. However, because the events of a near-drowning are often unwitnessed (e.g., patient found at the bottom of a pool), a traumatic injury may have occurred.

• Patterns of Injury
• Various mechanisms often produce patterns of injury that may increase the clinical suspicion of particular injuries. For example, automobile passengers restrained with a seat belt may have injuries to the liver, spleen, intestines, pelvis, or lower spine that are heralded by abdominal bruising that traces the seat belt.

• Pediatric Considerations
• Compared with those of adults, the heads of children, particularly infants, are larger relative to their bodies. Children are therefore more likely to sustain cervical spine injuries.

• The skeletons of children have much more cartilage than adults, making them more flexible. Organ injury, such as pulmonary or cardiac contusions, can therefore occur without overlying fractures to herald them. Spinal cord injuries can occur without bony fractures (known as spinal cord injury without radiographic abnormality, or SCIWORA). Fractures of long bones often involve cartilaginous growth plates.

• Both adults and children can exsanguinate internally, into the chest, abdomen, retroperitoneum, pelvis, or thighs. Infants can also exsanguinate into the head (into the brain or, more commonly, into the subgaleal potential space).


History



• History of the patient should focus on age, relevant past medical history, allergies, and last meal.

• History of the trauma should focus on details of the mechanism may provide clues to the pattern and severity of injuries.

• History of prehospital care should focus on patient complaints and interventions by emergency medical services providers.


Physical Examination



• Vital signs: Tachycardia should be considered as a sign of hypovolemia and impending hypovolemic/hemorrhagic shock; tachypnea, particularly with desaturation, should be considered as a sign of hemothorax, pneumothorax, pulmonary contusion, or airway compromise. Hypopnea indicates central nervous system dysfunction.
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Trauma (Case 44)

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