Emergency Medicine

Explanation

Answer: Airway with Cervical Spine control> Breathing> Circulation with haemorrhage control> Disability or neurological status> Exposure

In trauma, like resuscitation, an ABC approach is adopted for patient assessment and management (Airway, Breathing, Circulation, Disability, Exposure). In the case of trauma however, the mnemonic is modified to:

• Airway with cervical spine protection
• Breathing
• Circulation with haemorrhage control
• Disability and neurological status
• Exposure/Environment

While in reality, assessment of these areas will run in parallel with a large team, rather than in series with one person, it is important to remember this sequence so as to identify the greatest threats to life first

Explanation

Performing a head tilt and chin lift in this context would be contraindicated, and risks worsening any underlying c-spine injury. Blindly inserting a suction catheter into the mouth risks causing trauma/bleeding, and potentially forcing a foreign body further down.

Visually inspecting the airway allows safe suctioning of any visible obstructions i.e. blood/vomit/teeth. With the patient immobilised in a collar, a jaw thrust is the only safe manoeuvre to open the airway by lifting the tongue forwards.

Explanation

This is particularly true in younger children. This makes the head a greater target in trauma and accounts for head injury being far more common. A comparatively smaller jaw, shorter airway and higher, more anterior larynx require consideration when managing the paediatric airway as the tongue has a greater tendency to obstruct and different instruments are needed for airway management.

When small children are laid flat, their larger occiputs will naturally cause the neck to flex, requiring additional attention when protecting the cervical spine and airway.

Explanation

All major trauma patients benefit from high flow oxygen via non-rebreath mask. The routine administration makes it less likely to be forgotten in those who really need it.

Explanation

Effort is best indicated by:

• Respiratory Rate,
• Chest wall expansion,
• Subcostal/Intercostal Recession,
• Tracheal Tug

Explanation

Efficacy is best indicated by:

• Air entry (Equal bilateral)
• Added sounds

Explanation

Effects is best indicated by:

• Oxygen Saturations and Skin Colour
• Heart Rate
• Conscious level

Explanation

In the assessment of breathing in the injured child, a number of the main life-threatening injuries reside in the chest. In the context of reduced air entry on one side, percussion note will help differentiate between pneumothorax (hyper resonant) and haemothorax (dull) and guide further lifesaving treatment. This can be challenging in the noisy resuscitation room. The 'Lethal Six' are:

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Cardiac tamponade

Explanation

Children do have softer ribs, but not weaker. They are much more pliable and less likely to fracture. Therefore, they more readily transfer energy to the viscera, with a much higher incidence of injuries such as pulmonary contusion in the absence of chest wall damage or rib fracture. The presence of rib fractures indicates significant force and requires a high Menu of suspicion for chest organ injury.

Explanation

These clinical features are suggestive of the presence of air in the chest, between the lung and chest wall.

Here is a radiograph of a spontaneous pneumothorax in a child.

Tap or click image for full size.

The left-hand image represents a conventional radiograph. A large right pneumothorax is demonstrated. The visceral pleural line is marked by red arrows. The lack of vascular and pulmonary markings in the periphery should be noted. The right-hand image represents the negative image of the film on the left. The pneumothorax is more clearly seen in this view.

Reference: UpToDate (www.uptodate.com)

Explanation

Answer: Hypoglycaemia.

Respiratory distress, hypoxia, tachycardia and low blood pressure, with visible distended neck veins and tracheal deviation in a trauma patient with decreased air entry and hyper-resonant percussion note, are highly suggestive of tension pneumothorax, which is rapidly life-threatening. Note tracheal deviation and distended neck veins can be difficult to spot when a child is wearing a c-spine collar and in shock.

Explanation

A true tension pneumothorax is very poorly tolerated and rapidly decompensates. Due to a ball-valve effect, air leaks between the pleura during inspiration but remains trapped. The pneumothorax enlarges, causing mass-effect on the mediastinum, ultimately impairing venous return to the heart. Hence, distended neck veins and cardiac output.

The correct emergency procedure is needle decompression by inserting the largest possible IV cannula vertically through the chest wall into the pleural space at the mid-clavicular line of the second intercostal space. This releases the tension, converting the tension pneumothorax into a simple pneumothorax. A chest x-ray would confirm the diagnosis but the child could die waiting.

Insertion of a surgical chest drain will be necessary in due course to fully treat the pneumothorax, but again, could prove too time-consuming to immediately relieve the tension. Intubation and positive-pressure ventilation will make things worse. If necessary, a chest tube is required to avoid creating a tension pneumothorax from a simple one.

Following the needle decompression, James is prepared for chest drain insertion and his circulation is assessed.