On the Field Management of Pediatric Trauma

Transcription

1 On the Field Management of Pediatric Trauma Kyle Nagle, MD MPH University of Colorado Department of Orthopedics Children s Hospital Colorado Orthopedics Institute

2 Disclosures I have no conflicts of interest or financial support to disclose. 2

3 Objectives Review basics of trauma care Review important similarities and differences between field management of pediatric and adult trauma Highlight some specific injuries and conditions that may impact pediatric athletes 3

4 Kids Are Not Little Adults! Or are they? 4

5 Same Foundation Basic Trauma Care A Airway B Breathing C Circulation D Disability E Environment/Expose 5

6 Anatomic and physiologic differences between kids and adults Different relative sizes of body parts Growing bones presence of physes, often weak point Neurologic and muscular development Decreased coordination and strength Emotional and cognitive developmental stages Risk assessment/avoidance and response to injuries Role of parents and involved adults 6

7 Importance of history What happened Where is pain Importance of re-eval From parents and spectators as well as patient 7

8 Larger Surface area to Volume SA = 4(pi)r 2 V = 4/3(pi)r 3 8

9 Skeletally Immature Metaphysis Physis (growth plate) Epiphysis (pressure) Apophysis (traction)

10 Basic fracture care Assess Neurovascular status Stabilize in appropriate position Immobilize joint above and below Younger athletes more likely to have upper extremity fractures Older gradually more likely to have lower extremity fractures 10

11 Ligament injuries On field management similar Ligaments in kids may be stronger than bone, particularly physis Lateral ankle sprain vs physeal fx of distal fibula Palpate physes around joint before testing ligaments If tender over physis, treat as fracture Splint, remove from play until further eval 11

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13 Salter Harris I Distal Fibula 10yo boy inverts ankle during basketball game Pain and swelling localized to the distal fibula 13

14 Salter Harris II Distal Femoral Physis 12yo girl playing soccer, struck on lateral side of knee with valgus stress Immediate swelling Unable to bear weight on that leg Tenderness over distal femoral physis, proximal to attachment of LCL 14

15 Tibial Spine Fracture Similar mechanism to ACL tear If MOI, splint and refer for xrays 15

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17 Apophyseal Avulsion Injuries Sudden, violent muscle contraction (sprinting/jumping) or uncontrolled stretch Often feel pop Tenderness over apophysis Treat as avulsion fracture until proven otherwise 17

18 ASIS-Sartorius 18

19 Ischial Apophyseal Avulsion Fracture 19

20 Tibial Tubercle Avulsion 15yo girl in sprint race Feels sharp blow to the front of her shin Localized pain and swelling of anterior knee and tibial tubercle Unable to fully extend knee 20

21 Musculoskeletal Developmental Differences 21

22 Size and Weight of Head 22

23 Concussions in Young Athletes Similar mechanisms of injury Detecting can be more difficult Various stages of cognitive and emotional development Athletes may not recognize their own symptoms 23

24 Concussion Child SCAT3 ages

25 Sideline Cognitive Tests 522 high school athletes, PPPE Seven consecutive or 11 with one mistake 51% serial 7 s, 79% serial 3 s 89% months in reverse Young CC et al. Clin J Sports Med 1997

26 If You Do Not Know Athlete s Baseline Neuropsychological Status, It Is Difficult To Judge Normal When in Doubt, Sit Them Out DO NOT ALLOW THE ATHLETE TO RETURN TO PLAY ON THE DAY OF INJURY AND UNTIL COMPLETELY ASYMPTOMATIC

27 Neurologic Development and Concussion Longer recovery time in adolescents compared to collegiate athletes Younger athletes take longer to recover Developing brain MAY be more susceptible to injury and long term sequalae Field, 2003; Pellman 2006; Lovell, 2003; Lovell, 2004; McCrea, 2003; Sim, 2008

28 Developmental Differences of Kids Cognitive Ability to recount MOI Emotional Responses to injuries varied Can be difficult to assess degree of injury Often based off prior experience and response from involved adults Repeat exams can be helpful in assessment and reassuring to patient 28

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30 Parents for better or for worse Be prepared for their presence Or not Can be calming factor or escalating factor Be prepared to be involved with them or factor them into situation If escalating, identify someone to calmly and politely guide them to watch from a distance Parental figures can be coaches, ATC s etc 30

31 Take Home Points Emergency trauma care for pediatrics and adults similar ABCDE s Keep in mind some important differences Open physes and potential for fracture Different presentation of concussion Remember developmental needs of kids Individual cognitive and emotional response Parental involvement 31

32 Thanks!