Outline the differences in management of multi-trauma occurring in a 6-year-old child, compared with management of multi-trauma occurring in an adult.
Many candidates missed multiple aspects of management, usually because they did not follow a systematic approach (eg. according to EMST guidelines). Basic principles of management
according to EMST guidelines are the same – ie primary survey (ABCDE), resuscitation, secondary survey, re-evaluation, definitive care. However, candidates need to recognise and accommodate the different characteristics of the 6 year old trauma patient:
Mechanism of injury: falls and assaults more likely
Patterns of injury: more likely blunt trauma with multiorgan injury and head injury common
Physiologic and anatomic differences:
• Different airway anatomy
• Large body surface area/volume ratio – implications for exposure and heat loss
• Different normal physiologic values
• Increased cardiovascular reserve – 30% blood volume may be lost before vital signs change; hypotension indicates >45% loss
• Immature skeleton – Incomplete skeletal calcification, with more flexible bones– eg pulmonary contusions without rib fractures common; ligament flexibility and increased head mass makes cervical spine injuries above C4 more likely and Spinal Cord Injury Without Obvious Radiological Abnormality (SCIWORA) may occur.
• History – may be difficult to obtain
• Examination – may need to modify for age - eg modified GCS, but a 6 year old can be scored as per an adult
• Investigations – may require modification – eg uncooperative child may require GA for CT
• Airway: uncuffed tube, size estimated from age, cervical precautions
• Circulation: IV access may be difficult, consider intraosseous needle. Fluid boluses calculated according to weight (20ml/kg) as are maintenance requirements
• Disability: modified GCS
• Exposure: care to maintain body temperature
• Drug doses calculated according to weight (average 6 year old 20kg)
• Equipment sizes (eg chest drains, urinary catheters, nasogastric) appropriate for size – Broselow tape useful
Other specific issues:
• Psychological issues – patient and parents
• Consent issues
• Potential child abuse
• Consider transfer to a specialist paediatric centre
The examiners complained that a systematic approach needed to be followed, but the college answer also fails to use such an approach. Typicaly, trauma management follows an "ABCDE" system. The summary below offers a brief systematic discussion of the differences between adult and paediatric trauma, following the ATLS system of
More detail is available in the chapter on Trauma in Children. When preparing for such a low-yield topic, one has got to keep in mind the relative value of storing this information versus the revision of more frequently examined topics.
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