Accidents

Accidents / Emergencies

•A common cause of childhood hospitalization •Serious head trauma usually secondary to motor vehicle accidents, sports, recreation, and violence Presentation •Varies according to the injury •With or without Neurologic deficit •Some stabilize, some deteriorate •Children with neurologic deficits may have a history of a lucid interval and relapse into coma, or they may have remained abnormal after the

Physical examination •Vary according to the injury •Linear or depressed skull fractures •Basilar skull fractures associated with Battle sign, hemotympanum, and CSF rhinorrhea and otorrhea

Cerebral concussion The most common head injury seen in children •History of brief (seconds to minutes) unconsciousness, then normal arousal •Disturbance of vision and equilibrium Grade I Confusion, no amnesia, no loss of consciousness Grade II Confusion and amnesia, no loss of consciousness Grade III Confusion, amnesia and loss of consciousness

Grade I concussion, if asymptomatic, Return to contact sports in 20 minutes Grade II concussion, if asymptomatic for 1 week, Return to contact sports in 1 week Grade III concussion, if asymptomatic for 1 week Return to contact sports in 1 month

A second-time grade I concussion, return to play contact sports in 2 weeks after being asymptomatic for a week, and a second-time grade II, return to play contact sports 1 month after being asymptomatic for a week If repeated concussions after contact sports, grade I (X3), grade II (X2), grade III (X2), then season is over

Mild concussion •Not associated with any sequelae •A slightly greater injury can be associated with both antegrade and retrograde amnesia •Amount of time that the amnesia is present correlates with the severity of the injury •Some may develop the postconcussion syndrome, which includes memory difficulties, dizziness, and depression

Epidural hematoma •A rapidly accumulating hematoma between the dura and the cranium •A history of head trauma with loss of consciousness, then a lucid period, followed by loss of consciousness •Clinical onset occurs over minutes to hours •Many patients associated with laceration of the middle meningeal artery •A lenticular extracerebral hemorrhage noted on CT of head •Death a potential complication •Prognosis good if treated (surgical evacuation) early

Subdural hematoma •A tearing of a bridging vein between the cerebral cortex and a draining venous sinus •May be caused by arterial lacerations on the brain’s surface •May have a H/O loss of consciousness, but recover •Clinical onset occurs over hours •A crescent-shaped hemorrhage compressing the brain will be noted on CT of the head •Surgical evacuation is the treatment •Complications include uncal herniation, focal neurologic deficits, and death •Prognosis guarded

Cerebral contusion •Bruising of the brain parenchyma •Occur in the frontal and temporal lobes •Multiple low-density areas and punctate hemorrhages noted on the CT of the head •Goal is to treat increased intracranial pressure •Prognosis guarded

Assess pupillary size and reaction to light and the level of consciousness AVPU System for Evaluation of Level of Consciousness:

A V P U

Alert Responsive to Voice Responsive to Pain Unresponsive

Pediatric Glasgow Coma Scale

•A score less than 8 usually indicates central nervous system depression requiring positive pressure ventilation

Diagnostic tests CT of the head performed on •Children who have a history of loss of consciousness for >1 min •Children for whom the time of loss of consciousness is unknown •Children with abnormal neurologic findings •Those who have a neurologic status that is deteriorating Cervical spine films if associated neck injury

Treatment •ABC’s •Bleeding controlled if present •High suspicion for a cervical spine injury if bruises on the back or neck, or if back pain or pain radiating to the arms •If cervical spine injury suspected, the patient should be immobilized and a cervical collar applied

Management of increased ICP If GCS < 8, then Monitor ICP If ICP elevated, proceed through following steps: First tier of therapy: •Sedation, analgesia, elevate head of bed •Drain CSF via ventriculostomy if present •Mannitol or 3% saline to maintain osmolarity >320 •Hyperventilation to PCO2 of 30 – 35 mm Hg If ICP remains elevated, proceed to second tier therapy •Decompressive craniectomy •Barbiturate therapy •Hypervintilation to PCO2 < 30 mm Hg

Complication/ follow-up Head injury patients have: •Drowsiness (but easily aroused), •Headaches, •Vomiting This is of no concern if the neurologic examination normal and consciousness preserved

If symptoms persist > 1 or 2 days, a CT of the head should be performed If CT shows abnormalities (eg,EDH, SDH, ICH), then neurosurgical consultation for possible intervention

Complication/ follow-up (contd…) •In some, transient neurologic disturbance, lasting minutes to hours and causing occipital blindness and a state of confusion •Malignant posttraumatic cerebral swelling posttraumatic seizures •Child with worsening neurologic signs (change in level of consciousness, respirations, blood pressure, pulse, seizures, etc) must be suspected of having SAH or SDH

Complication/ follow-up (contd…) •Recovery in children with neurologic deficits will vary •Child with neurologic deficits who improve daily or within days of the injury more likely to recover completely •Children who are vegetative for months are less likely to improve •Most patients without neurologic deficits have full recovery

CT scan of head

CT scan of head

CT scan of head

CT scan of head

CT scan of head

CT scan of head

•Drowning defined as death within 24 h of submersion •Near drowning defined as survival >24 h after submersion whether a person later survives or not •Submersion causes hypoxia, aspiration, and hypothermia •Asphyxia may occur with or without pulmonary aspiration •Fluid may be aspirated into the lungs or laryngospasm may prevent aspiration

Risk factors/ etiology •Drowning the leading cause of accidental deaths in children > 1 year old •Most infants and toddlers drown at home in pools, bathtubs, hot tubs, and buckets •Adolescent boys, because of their risk-taking behaviours and alcohol and drug use, also at high risk for drowning •98% of drowning occurs in freshwater

Drowning safety in children

Presentation •Varies according to the circumstances surrounding the drowning or near drowning •Children with brief submersions may be awake and alert on arrival, yet others may have respiratory distress or cardiopulmonary arrest

Physical examination •Varies according to the presentation •Vital signs to be monitored •GCS should be assessed •Drowning in freshwater may have more lung damage secondary to the hypotonic fluid washing out surfactant •Drowning in saltwater may be prone to more pulmonary edema

Diagnostic tests CXR, ABG, Pulse oximetry Treatment •Patients who receive CPR at the scene have a better outcome •There should not be an attempt to drain the lungs •Heimlich maneuver or abdominal thrusts and back blows should only be administered if one is suspecting a foreign body

Treatment (contd…) •Cervical spine should be protected with a cervical collar if the patient has altered mental stats or suspected traumatic injury •Cricoid pressure and nasogastric or orogastric decompression should be performed to decrease the risk of emesis and aspiration •ECG monitoring done to diagnose and treat any arrhythmias (asystole, VF, VT or bradycardia)

Treatment (contd…) •Hypothermia should be treated as patients with severe hypothermia may look clinically dead but in rare cases have full recovery •Isotonic fluid given ( electrolyte imbalances rarely seen on arrival to ER) •Dextrose-containing solutions should be given to children who are hypoglycemic

Treatment (contd…) •β 2-agonist therapy may help children with bronchospasm •Prophylactic antibiotics not recommended unless the child has been exposed to contaminated water •Establish an airway and deliver O2 to prevent further hypoxia

Complications/ follow-up •Neurologic injury the main cause of mortality and morbidity for drowning and near drowning victims •ARDS, pneumothorax, pneumomediastinum, pulmonary edema •Rhabdomyolysis after cold saltwater drowing

•Result from an act, process, instance, or result of burning that causes injury from fire, heat, electricity, caustics, or some types of radiation Risk factors/ etiology •Burns the second leading cause of death in children •Scald burns accounts for 85% of the burns in children <4 years of age •Child abuse should be suspected if the history doe not match the burn pattern that would be expected on physical examination

First-degree burns •Involve only the epidermis •Skin is painful and erythematous Second-degree burns •Involve both the epidermis and dermis •Painful blisters usually associated with superficial second-degree burns •Deep second-degree burns may be white and painless and may require grafting •May progress to a full-thickness burn with wound sepsis

Third-degree burns •Full-thickness burns that involve the epidermis and all of the dermis •Painless •Require grafting

Diagnostic tests •Estimation of BSA of the burn should be performed This can be done using •Burn charts for children of different ages (<14 years) or •By using the “rule of nines” used in adults for those children >14 years •“Rule of palm” may be used for burns <10% of BSA, in which the child’s palm equals 1% of the child’s BSA

Treatment •Parkland formula used for fluid resuscitation for children 4 ml of Ringer’s lactate X % BSA burn X body wt in kg •One half the fluid should be given in the first 8 h calculated from the hour that the injury first occurred •Second half of the fluid should be given during

Treatment (contd…) •Do not apply cold water to a person with extensive burn •Pain medication administered in small, frequent doses by the IV route only •Prophylactic antibiotics if secondary infection Complications/ follow-up •The extent and severity of burn injury may change over the first several days of the injury