Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 10 n Pediatric Trauma
CT and MRI scans should not be used as routine
screening modalities for evaluation of the pediatric
cervical spine; rather plain radiographs should be
performed as the initial imaging tool. Indications
for the use of CT or MRI scans include the inability
to completely evaluate the cervical spine with plain
films, delineating abnormalities seen on plain films,
neurologic findings on physical exam, and assessment
of the spine in children with traumatic brain injuries
CT scan may not detect the ligamentous injuries that
are more common in children.
Spinal cord injuries in children are treated in the same
way as spinal cord injuries in adults. Consultation with
a spine surgeon should be obtained early. (Also see
Chapter 7: Spine and Spinal Cord Trauma and Appendix
G: Disability Skills.)
Musculoskeletal Trauma
The initial priorities for managing skeletal trauma
in children are similar to those for the adult. Additional
concerns involve potential injury to the child’s
growth plates.
History
The patient’s history is vital in evaluation of musculoskeletal
trauma. In younger children, x-ray diagnosis
of fractures and dislocations is difficult due to the
lack of mineralization around the epiphysis and the
presence of a physis (growth plate). Information
about the magnitude, mechanism, and time of the
injury facilitates better correlation of the physical
and x-ray findings. Radiographic evidence of
fractures of differing ages should alert clinicians
to possible child maltreatment, as should lowerextremity
fractures in children who are too young
to walk.
Blood Loss
Blood loss associated with longbone and pelvic
fractures is proportionately less in children than in
adults. Blood loss related to an isolated closed femur
fracture that is treated appropriately is associated
with an average fall in hematocrit of 4 percentage
points, which is not enough to cause shock. Therefore,
hemodynamic instability in the presence of an isolated
femur fracture should prompt evaluation for other
sources of blood loss, which usually will be found
within the abdomen.
Special Considerations of the
Immature Skeleton
Bones lengthen as new bone is laid down by the physis
near the articular surfaces. Injuries to, or adjacent
to, this area before the physis has closed can retard
normal growth or alter the development of the bone in
an abnormal way. Crush injuries to the physis, which
are often difficult to recognize radiographically, have
the worst prognosis.
The immature, pliable nature of bones in children can
lead to “greenstick” fractures, which are incomplete
with angulation maintained by cortical splinters on
the concave surface. The torus, or “buckle,” fracture
that is seen in small children involves angulation due
to cortical impaction with a radiolucent fracture line.
Both types of fractures may suggest maltreatment
in patients with vague, inconsistent, or conflicting
histories. Supracondylar fractures at the elbow or knee
have a high propensity for vascular injury as well as
injury to the growth plate.
Fracture splinting
Simple splinting of fractured extremities in children
usually is sufficient until definitive orthopedic
evaluation can be performed. Injured extremities
with evidence of vascular compromise require
emergency evaluation to prevent the adverse
sequelae of ischemia. A single attempt to reduce the
fracture to restore blood flow is appropriate, followed by
simple splinting or traction splinting of the extremity.
(Also see Chapter 8: Musculoskeletal Trauma and
Appendix G: Disability Skills.)
Pitfall
Difficulty identifying
fractures
Missed child
maltreatment
prevention
• Recognize the
limitations of
radiographs in
identifying injuries,
especially at growth
plates.
• Use the patient’s history,
behavior, mechanism
of injury, and physical
examination findings
to develop an index of
suspicion.
• Be suspicious when the
mechanism and injury
are not aligned.
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