Shaken baby syndrome

Non-accidental head trauma in infants is the leading cause of infant death from injury. Clinical features that suggest head trauma (also known as shaken baby syndrome or shaken impact syndrome) include the triad consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Abusive head injuries are among the most common causes of serious and lethal injuries in children. These injuries may result from impact or shaking or a combination of these mechanisms. These mechanisms cause the child's head to undergo acceleration/ deceleration movements, which may create inertial movement of the brain within the cranial compartment.     

“Occult Trauma in the Pediatric Patient: When Is Radiography Necessary?”

The leading cause of death in children and young adults is traumatic injury. An understanding of mechanism and kinematics is critical to determine the potential for serious injury as serious injuries in a child may not be evident initially. An unclear presentation may require radiographic examination to rule out serious injury. This article will help the reader identify mechanisms of injury that suggest further assessment in the pediatric trauma patient, discuss indications for radiography, and discuss environmental and personal challenges to and facilitators of pediatric trauma care.     

Snowboarding injuries in children and adolescents.

To study snowboarding injuries in children and adolescents, a 6-year retrospective study was conducted of patients 18 years old and younger admitted to a pediatric trauma center after snowboarding accidents. The study was designed to identify the most severely injured patients. Comparison was made to data from a recent comparable study of skiing injuries. Twenty-seven patients were identified, all but one male and none under 10 years old. Nineteen were injured in a fall, 6 collided with a stationary object, one collided with a skier, and in one case the mechanism of injury was unclear. The average pediatric trauma score was 10.5, and the average injury severity score 10.2. Most of the 12 head injuries were minor. Most extremity fractures were to the upper extremity. There were two lumbar vertebral burst fractures, suggesting that the sport may predispose to this injury. There were no deaths. When compared with skiing, in snowboarding the overall severity of injury is lower, collision is a less common mechanism of injury and results in less serious injury, head injuries are less severe, the relative frequency of upper extremity fracture is higher, abdominal injuries are caused by falls rather than collisions, and facial injuries are less common. These differences are predictable on the basis of differences in the equipment. However, it is too early to say that snowboarding has less potential for life-threatening injury than skiing. Expected changes in the mix of participants, with an increase in the average skill level over time, may well result in different patterns, mechanisms, and severity of injury.     

Thoracic trauma in children

Thoracic trauma is usually accompanied by other body system injury, most frequently head and skeletal injury. Developmental changes throughout childhood make the consequences of such injuries more severe, as children develop respiratory and circulatory compromise quickly. Blunt trauma predominates in pediatric thoracic trauma. Trauma to the thoracic cavity may involve fractures of the ribs or injuries where the ribs remain intact. Trauma involving the pleural space affects ventilation that may evolve into circulatory failure if not addressed promptly. Pulmonary contusion is among the most frequent and most fatal of thoracic injuries. Rupture of the tracheobronchial tree, esophagus, or diaphragm may have both short- and long-term consequences. Trauma to the heart and/or great vessels may be fatal at the scene of the accident, in the emergency department, or in the intensive care unit. Pain management is an essential part of caring for children with thoracic injury. A variety of methods have become available within the past several years that promote better pain relief and shorter recovery periods with less side effects. Nursing care of the child with PCA, epidural analgesia, or intercostal nerve blocks requires specific knowledge and assessment skills. Nonpharmacologic methods of pain relief may be used as an adjunct to pharmacologic methods.     

Childhood sledding injuries

Sledding is only rarely thought of as a potentially dangerous childhood activity. However, serious injuries and occasional deaths do occur. A review of patients 18 years old and younger admitted to a pediatric trauma center following a sledding accident from 1991 to 1997 was conducted. By design this study was expected to identify the most seriously injured patients. Twenty-five patients were identified, all but four younger than 13. Seventeen were boys. The mechanisms of injury were: collision with stationary object, 15; sled-sled collision, 1; struck by sled, 2; going off jump, 3; foot caught under sled or on ground, 3; fall off sled being towed by snowmobile, 1. The average pediatric trauma score was 10.5, and the average injury severity score 10.6. There were no deaths. The injuries were: head, 11; long bone/extremity, all lower, 10; abdomen, 5; chest, 1; facial, 2; spinal, 1. Five patients sustained multiple injuries. A surprisingly high number, 5, had pre-existing neurological conditions that could have played a contributory role in the accident. Sledding is predominantly an activity of children, and occasional serious injuries occur. Most are preventable. Obeying the simple caveat that sledding should only be done in clear areas away from stationary objects would eliminate the great majority of serious injuries.     

Bicycle injuries and safety helmets in children. Review of research

Bicycle injuries are the most common cause of serious head injury in children, and most of these injuries are preventable. The protective effect of bicycle helmets is well documented, but many child bicyclists do not wear them. This article summarizes the current state of research on bicycle injuries and helmet use and examines the effectiveness of legislation and injury-prevention strategies. Current studies indicate that children who wear helmets experience fewer head injuries and decreased severity of injury. Community-wide helmet-promotion campaigns combined with legislation are most successful in increasing helmet use and decreasing injury. Nurses can participate both at the institutional level and in community advocacy groups to promote bicycle safety for children.     

Head trauma in the child

Head injury, either alone or in combination with multiple injuries, is common in children. Its pattern is different in children compared to adults, with diffuse cerebral swelling rather than localized hematoma being most common. The pathophysiology of pediatric head trauma is not yet clearly elucidated, but may be closely related to changes in the regulation of cerebral blood flow. The initial management and subsequent care of the child with severe brain injury are discussed from a multisystem viewpoint. The prognosis for children with severe head injury seems brighter than for adults, but there are not yet enough data to allow prediction of outcome in any individual case. Efforts to prevent, rather than treat, head injury in childhood are more likely to be beneficial.     

Common injuries of the foot. Often more than 'just a sprain'

While most foot injuries heal without treatment, failure to recognize and treat some can have disastrous consequences. The exact mechanism of injury must be determined for accurate diagnosis. Many injuries, such as plantar fasciitis, "pump bump," sesamoiditis, and stress fractures, are the result of cumulative, repetitive stress rather than of an acute event. Others, such as injuries to tendons, may be chronic or acute. The foot is susceptible to numerous types of acute trauma, including sprains, fractures, dislocations, crushing, freezing, thermal injury, puncture wounds, and penetration by foreign bodies. Special care is required to minimize the danger of serious complications when treating foot injuries in diabetic patients.     

Pediatric injury surveillance: use of a hospital discharge data base

Mortality data traditionally have been used to describe the epidemiology of childhood injury. Fatal outcomes, however, represent less than 1% of injury events and thus provide a limited characterization of the problem. Future epidemiologic study resulting in injury prevention depends upon the development of morbidity-based injury surveillance systems. "E-coded" hospital discharge data bases (used to indicate external cause of injury) are a valuable source of information for monitoring and controlling serious, nonfatal injuries. An E-coded injury discharge data base was developed and evaluated at The Children's Hospital of Alabama in Birmingham. In addition to patient demographics, length of stay, total charge, and method of payment, E-code and "N-code" (to indicate the anatomic site of injury) data were collected. During the 2-year study period, 1077 discharges from the hospital were documented in children with serious injuries under 15 years of age for an adjusted discharge rate of 78.0 per 10,000 child-years. Injuries accounted for $5.3 million in total charges and 4899 total days of stay. Falls, unintentional poisonings, burns, and bicycle, motor vehicle-passenger, and motor vehicle-pedestrian injuries were the six most common causes of injury. Closed-head trauma accounted for 55.4% of motor vehicle-passenger injuries, 67.6% of bicycle injuries, and 51.8% of falls. Hot water scalds caused 36.4% of burns, and clonidine ingestion accounted for 22.1% of unintentional poisonings.     

When the trauma patient is elderly

Each year thousands of older adults will suffer trauma injuries. Geriatric patients who sustain serious injuries are at risk for increased morbidity and mortality. Preexisting medical conditions can dramatically impact every aspect of care in older patients. As a direct response to the stress of injury, reserve functioning can be put to the test. Vital signs may initially appear normal. However, compensatory mechanisms in older individuals may not be predictable in response to physiological needs. Perianesthesia nurses caring for older trauma patients should be familiar with the anatomical and physiological changes of aging, and have an awareness of the original mechanism of injury, coupled with the surgical procedure and anesthesia agents. Astute nursing assessments using critical thinking skills, together with effective nursing interventions, provide the framework for understanding and managing geriatric trauma patients in the perianesthesia care continuum.     

Intubation and survival in severe paediatric blunt head injury.

The majority of severe childhood injuries are due to head injuries. We studied the impact of emergency intubation in a cohort of children suffering severe blunt head trauma. A 10-year retrospective case note analysis was performed on 176 children (age < 16 years) with severe blunt head trauma (abbreviated injury scale > or =4) in Southern Finland, who required intensive care in a level 1 trauma centre, or who died despite initiation of life supporting measures at the scene. Children in whom emergency intubation was performed either at the scene, or in the emergency room (ER) were analysed. Of the 59 children who fulfilled the study criteria, 20 had an isolated head injury. Most injuries (56/59) were caused by road traffic accidents. Field-intubation was performed in 24 children, and emergency intubation in the ERs of regional hospitals or the level 1 trauma centre, in 13 and 22 children respectively. Mortality was 54.2% (32/59), and was highest in children intubated in regional hospital ERs or in the field. Children intubated at the scene or in the ER of regional hospitals, had significantly worse AIS (head/neck), injury severity score (ISS), and Glasgow coma (GCS) scores than those children intubated in the ER of the level 1 trauma centre. Survival was better in field-intubated children compared with those intubated in regional hospital ERs, despite similar trauma scores (p = 0.05). It is concluded that although children with severe (AIS > or =4) head injury who require emergency intubation have a high overall mortality, field-intubation may improve survival, compared with 'scoop and run' with BLS airway management and deferred emergency intubation.     

E-Bike–Related Trauma in Children and Adults

Background

Electric bike (e-bike) usage is growing worldwide, and so is the e-bike–related injury rate.

Perioperative anesthetic management of the pediatric trauma patient

The object of this article is to provide the anesthesiologist with an approach to the perioperative management of pediatric trauma. The initial focus is on planning and initial stabilization and transport. This is followed by the immediate management of the trauma patient in the emergency department, with a focus on the management of the airway and support of the circulation. There are some differences of opinion about the similarity of cervical spine injury in children and adults, but there is no question that children do suffer cervical spine injuries frequently following head injury. The anesthetic management of the head-injured patient is focused upon the control of intracranial pressure, and the major method for control is hyperventilation to reduce the CO2. Head trauma patients often have injuries to other body systems, which may account for both their ventilatory and their circulatory problems.     

Injury during contact with horses: recent experience with 75 patients at a level I trauma center

BACKGROUND: The objective of this study was to examine equine-related trauma at a trauma center servicing a region in which there is significant contact between horses and humans. METHODS: Data were collected on all patients admitted to the University of Kentucky Medical Center from January 1994 to December 1998 for treatment of horse-related injuries. RESULTS: Seventy-five patients were admitted to our center after injuries due to contact with horses (0.75% of all trauma admissions). There were 42 men (55%). The mean age was 37 years (range, 3 to 81 years). The majority of patients (67/75) were injured during recreational activities, and most fell or were thrown (40/75). Only 14% of patients were wearing helmets. The most common injuries were extremity fractures and head injuries, but thoracic and abdominal injuries were not rare. Of the 75 patients, 34 required surgery. Five patients (6.7%) died, all of head injury. During the study period, 11 people died in Kentucky due to contact with horses. CONCLUSIONS: Injury due to contact with horses is uncommon even at a center servicing a region with a large equine population. However, injuries are often serious and lead to significant morbidity and occasional mortality. Prevention of death from horse-related trauma is synonymous with prevention of head injury.     

Emergency care of children and adults with head injury

Head injury is common and accounts for a significant proportion of patient attendances at emergency departments and minor injury units. While most injuries will not be serious in nature, some will be severe. Therefore assessment, investigation and early management of head injury are essential to reduce the potential risk of disability or even death. This article focuses on emergency care of children and adults with head injuries. Advice about the signs and symptoms of severe head injury, the importance of computed tomography and after care following head injury are outlined.     

Carotid-cavernous sinus fistula: a case study.

Carotid-cavernous sinus fistulae are rare, but serious, vascular anomalies which may develop following traumatic injury to the skull base. Fractures or the shearing forces of severe head trauma may cause the internal carotid artery to be torn from its points of dural attachment and rupture, with resultant direct flow into the cavernous sinus. Current treatment options for carotid-cavernous sinus fistulae are surgery and coil embolization, with embolization being the most common. Clinicians and nurses treating patients with these injuries should have an understanding of this vascular entity, because prompt intervention helps to prevent permanent disability and improve patient outcomes. This case study reports the diagnosis and treatment of a carotid-cavernous sinus fistula that developed several months after a traumatic head injury.     

Soccer Injuries in Children Requiring Trauma Center Admission

Background

Soccer continues to gain popularity among youth athletes, and increased numbers of children playing soccer can be expected to result in increased injuries.

Objective

We reviewed children with soccer injuries severe enough to require trauma activation at our Level I trauma center to determine injury patterns and outcome. Our goal is to raise awareness of the potential for injury in youth soccer.

Methods

A retrospective review was performed using the trauma registry and electronic medical records at a Level I trauma center to identify children (< 18 years old) treated for soccer injury from 1999–2009. Data reviewed include age, gender, mechanism, injury, procedures, and outcome.

Results

Eighty-one children treated for soccer injury were identified; 38 (47%) were male. Of these, 20 had injury severe enough to require trauma team activation and 61 had minor injury. Mean age was 14 years old (range 5–17 years, SD 2.3). Lower extremity was the most common site of injury (57%), followed by upper extremity (17%), head (16%), and torso (10%). Mechanisms were: kicked or kneed in 27 patients (33%), collision with another player in 25 (31%), fall in 18 (22%), struck by ball in 10 (12%), and unknown in 1 (1%). Procedures included reduction of fractures, splenectomy, abdominal abscess drainage, and surgical feeding access. Long hospitalizations were recorded in some cases. There were no deaths.

Conclusion

Although less common, injury requiring prolonged hospital admission and invasive operative procedures exist in the expanding world of youth soccer. With increasing participation in the sport, we anticipate greater numbers of these child athletes presenting with serious injury.     

The digital rectal examination in pediatric trauma: a pilot study

This pilot study examined the utility of a routinely performed digital rectal examination (DRE) in pediatric trauma patients. A prospective convenience sample of patients 0 to 18 years of age presenting to the pediatric emergency department of an urban level I trauma center with a history of trauma to the spine or trunk was enrolled. An abnormal DRE was defined by the presence of gross or occult blood, decreased sphincter tone, compromised integrity of the rectal vault, or a high riding prostate. We defined DRE-identifiable injuries as spinal injury, pelvic fracture, rectal or other lower intestinal injury, and urethral injury. One hundred thirty-five patients were studied; 8 patients had DRE-identifiable injuries. The sensitivity and negative predictive value of the physical examination with and without the DRE were equivalent. Routine performance of the digital rectal examination may not improve the identification of serious injury during the secondary survey in pediatric trauma patients.     

Serious parasport injuries in Auckland, New Zealand

Objectives: ‘Parasports’ comprise parachuting, skydiving, paragliding, parapenting, parascending, parasailing and hang‐gliding, and may involve rapid deceleration on landing. The aims of this study were to determine the spectrum of parasport‐related trauma presenting to Auckland City Hospital and to make recommendations to reduce further injury. Methods: The Auckland City Hospital Trauma Registry was used to identify all patients requiring admission with serious injury as a result of parasport incidents over an 8‐year period. Demographic and injury‐related data were then analysed. Results: Parachuting/skydiving was responsible for 66% of all serious parasport injuries and 96% of patients were men. Fractures of the lower limbs and lumbar spine were the predominant injuries. Misjudgement of landing speed and attitude resulting in injurious landing forces were the usual causes of injury. Conclusions: The magnitude of serious parasport‐related trauma is greater than that indicated by previous studies in New Zealand. Appropriate use of protective clothing and close attention to safe flight planning and landing techniques may reduce the injury rate without degrading the experience of flight.     

Epidemiology and outcome of pediatric trauma treated by an emergency-physician-staffed advanced life-support unit

BACKGROUND: The aim of this study was to describe the epidemiology and outcome of pediatric trauma in the setting of an emergency-physician-staffed mobile advanced life support (ALS) unit serving a predominantly urban area in Austria. METHODS: In this retrospective chart review, all pediatric trauma patients (0-14 years of age) who were treated by a physician-staffed ALS unit in Innsbruck within a 3-year period were analyzed. In addition, hospital charts were assessed to determine the clinical course and the outcome of these patients. RESULTS: 113 injured children were treated by the physician-staffed ALS unit (1.5% of all runs) during the study period; a frequency of three pediatric trauma patients per month. On average, injuries were of moderate severity (2.6 +/- 1.3 on the NACA severity scale). Thirteen children (11.5%) sustained severe to life-threatening injuries and two of whom underwent out-of-hospital resuscitation. The majority of the injuries were caused by vehicular accidents and sports/recreation-related trauma; head trauma was the most frequent injury. Violence-related trauma including weapon-inflicted injuries was uncommon. 40% of the children were hospitalized. The overall outcome was favorable: 78% of the hospitalized children had no impairment at the time of discharge. By comparing the prehospital trauma diagnosis with the final diagnosis, we found that the vast majority of emergency-physician trauma diagnoses were accurate. CONCLUSION: Because the frequency of pediatric trauma is so low, ALS units may not gain adequate experience in the management of (severe) pediatric trauma, thus rendering regular training of paramount importance.