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 Alert
V Responsive to Voice
P Responsive to Pain
U 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