Emergency Splinting and Trauma First Aid Coburn H

Emergency Splinting and Trauma First Aid Coburn H. Allen, MD Pediatric Emergency Medicine Pediatric Infectious Diseases

Objectives • Review the most common injuries in children • Discuss what to ask, examine and do for each process • Suggest who needs further care and who can return to class

Common Injuries • Bumps and Bruises • Scrapes • Sprains • Strains • Fractures • Oral Trauma • Nose Bleeds • Lacerations • Head Injuries • Overheating

Bumps and Bruises • Bobby Bobo, a 5 y/o boy, fell down in class while chasing the teacher’s lost hamster. He hit his right thigh on the corner of a desk and now complains of pain and swelling to the leg. By the time he arrives his right thigh is tight from the swelling. He says he has “Christmas Disease. ”

Bumps and Bruises What to ask? • What happened and when? – Abuse vs. accidental • Inconsistent mechanism, frequent bruising • Abnormal locations • Abnormal patterns – No trauma? Think mass, infection, clotting d. o. • Anything else hurt? • PMHx? (Aspirin, coumadin, bleeding…)

Bumps and Bruises What to examine? • Entire body – Look for patterns – Suspicious locations • Trunk • Face • Scalp – Multiple stages of bruises? • Bone pain?

Nonaccidental Trauma Bite

Bumps and Bruises What to do? • Cold pack • Tylenol • Most need nothing • CPS? – Law is “if suspicious…report. ” – You are protected – Confidential

Texas Law • Child abuse and neglect are against the law in • • Texas, and so is failure to report it. If you suspect a child has been abused or mistreated, you are required to report it to the Texas Department of Family and Protective Services or to a law enforcement agency. You are required to make a report within 48 hours of the time you suspected the child has been or may be abused or neglected. Abuse Hotline 1 -800 -252 -5400

Bumps and Bruises Where to send them? • Back to class – Most – Not rapidly expanding – Not suspicious • Doctor – Large/deep, multiple, expanding – Uncertain of etiology (mass/infection/abuse)

Scrapes • A 9 y/o girl, Terri Tawmboi, is brought to you after she got “a huge raspberry” playing kickball at recess. Her right knee is bleeding and covered with grass and dirt.

Scrapes What to ask? • What happened? • What did you fall on? – Hard versus soft – Loose objects = foreign bodies • Able to bear weight? • Anything else hurt? • Vaccinations (Tetanus)?

Scrapes • Wound What to examine? – Deep vs. superficial – Clean vs. contaminated – If old, infected? Impetigo • Range of motion • Weight bearing

Scrapes • Gently clean What to do? – Saline and gauze – Clean wet washcloth – Running tap water • Remove debris • Antibiotic ointment • Bandage

Scrapes Where to send them? • Back to class almost always • Doctor – Retained foreign body – Restricted use of extremity – Concern for joint penetration

Sprains • Trey Studmuffin, your transfer, red- shirt, freshman, power-forward, “came down wrong” on a teammate's shoe during tryouts. He hops into the office on one foot asking you to “tape me up!”

Sprains What to ask? • What happened? – Mechanism • Twist or turn • Blunt trauma • “Something popped” or “gave way” – Could you walk on it (even with a limp)? • Old injury, ask if fever, chills, medical hx.

Sprains • What to examine? Entire involved extremity – Pain – Swelling – Bruising – Redness – Warmth – ROM, gait • Other joints

Ankle Sprain

Knee Sprain

Septic Joint

Sprains What to do? “p. RICEmmms” • Protect the joint = crutches, slings, tape… • Rest • Ice • Compression • Elevation • Medication, modality (PT), motion (keep loose) • Strength

Sprains Where to send them? • Back to class – Most – Pain under control • Doctor – Suspect fracture, infection, systemic disease – Not weight bearing – Pain poorly controlled

Strains • Coach Oldskool, your legendary, and older than he wants to admit, football coach crawls into your clinic complaining, “I popped my back showing my History Class how to chop block on a double reverse. ”

Strains What to ask? • What happened? – Sudden jerking movements? – Lifting? – Sprinting? – Jumping? • Did you feel a pop? Tear? • Numbness/tingling/weakness?

Sprain Mechanisms

Strains What to examine? • Where it hurts – Spasm – Swelling – Bruising • Joints above and below • Neuorologic function (back injuries) • Gait

Strains What to do? • Similar to strains • Massage/stretch if spasm

Strains Where to send them? • Back to class – Most – Pain controlled • Doctor – Not bearing weight – Severe pain – Any numbness/tingling/weakness

Fractures • Morgan Fleahopper, the 85 lb. head cheerleader, and the one always at the top of all those stacks of girls, fell off the infamous “Pyramid of Victory” at the 7 a. m. walk through. Her left elbow is pointing the wrong way but her make-up remains flawless.

Fractures What to ask? • Describe the injury? – Fall vs. blunt trauma vs. twist – How did you land? – Where is the worst pain (use one finger)? – Could you walk right afterward? – Anything else hurt? • Neck pain/back pain if severe fracture(s)?

Fractures What to examine? • Point tenderness/deformity • Open fracture • Joint swelling • Muscle spasms • Function/sensation below fracture • ROM/walk • Neck/back if “distracting injury”

Fractures What to do? • Stabilize = Splinting – Joint above and below fracture – Not too tight, use padding – Not too loose, shouldn’t wiggle – Don’t hide the extremity, not circumferential • Pain control – Ice – Medications

Ankle Pillow Splint

Lower Leg Splint

Long Leg Splint

Finger Splints

Wrist (Volar) Splint

Upper Arm Splint

Cervical Spine Splints

Fractures • Doctor Where to send them? – Most – EMS if severe, neurovascular changes, spine • Back to class – Broken hearts – Shattered dreams – Crushed morale

Oral Trauma • Dirk Noteeski catches an elbow during a scrimmage and comes in grinning, with his two front teeth in his hand. His mouth is full of blood.

Oral Trauma • What to ask? What happened? – Tooth/jaw/lip/tongue hurt? – What hit you? (BAD if it is another person) – How long ago? – Permanent teeth? • Where are the teeth? • Have a dentist?

Oral Trauma • Teeth What to examine? – Avulsed (knocked out, loose) – Fractured – Chipped – Intrusion • Jaw/face: feel for “crunchy” sensation • Mucosal/tongue injury

Tooth Anatomy

Avulsed Teeth

Fractured Teeth

Intrusion

Tongue/Mucosal Trauma

Oral Trauma • Teeth What to do? – Avulsion • Primary teeth – Out, leave out – Loose, straighten or is very loose remove • Permanent teeth – Out, leave out, wash gently, store in cold milk, saline, spit. – Loose, leave alone – Fracture, keep fragment, store as above

Oral Trauma • Tongue What to do? – Well approximated, nothing – Bleeding direct pressure with gauze – Gaping need repair • Mucosal – Well approximated, nothing – Gaping and vermillion border need repair

Oral Trauma Where to send them? • Dental injuries – Dentist for most injuries – Baby teeth may need nothing • Tongue/Mucosa – Most need nothing – Doctor if gaping, severe bleeding, vermillion

Nose Bleeds • Little 8 y/o Penny Piksalot is rushed to you with gushing blood from her left nare.

Nose Bleeds What to ask? • How much blood, how long? • What has been done to stop bleeding? • Trauma? – Blunt – Picking • Upper respiratory infection? Allergies? • History of Bleeding?

Nose Bleeds • Nose What to examine? – Fracture (usually at bridge) – Active bleeding • Which side? Always the same? • Throat • Neurologic • Vision

Nose Bleeds What to do? • Pinch x 10 -20 minutes (don’t peek) • Don’t put head between legs • Don’t blow nose • Afrin if available • No PICKING!

Penny’s Father

Nose Bleeds • Where to send them? Back to class – Most if stops after 20 minutes – No other injury – Not dizzy, weak, pale • Doctor – Severe bleeding – Bleeding disorder – Other injuries

Lacerations • Paris Marriott is back from the South of France for a little quality time with friends when she crashes daddy’s SLK into a parked bus in the Faculty Lot. She comes in screaming with a 1/8 th cm “gash” to her right cheek. She’s suing the bus driver and wants the school plastic surgeon called “now!”

Lacerations What to ask? • How did it happen? – Sharp vs. blunt force? – Fall, if so how high? – Foreign body, dirty? – Puncture? – How long ago? • Tetanus status

Lacerations • Wound What to examine? – How wide? – How deep? – How long? – Contaminated? – Across nerves/tendons/vessels/galea? • Head/spine injury? • Fracture?

Scalp Laceration

Forehead Laceration

Hand Laceration

Lacerations What to do? • Stop bleeding – Wear gloves – Direct pressure – 1 gauze at a time • Decide if repair needed – No wash, antibiotic ointment, bandage – Yes wash, cover with saline soaked gauze(s)

Lacerations • Doctor Where to send them? – Most – All if: • Contaminated • Persistent bleeding • Across/near vital structures • Associated with fracture • Back to class if very superficial

Head Injuries • Goofus Mc. Doofus, the class clown, thought it would be hilarious to hang upside down from the goalposts at P. E. . He fell 10 feet and stuck the landing with his noggin. You run to find him “out cold” with a few hundred people trying to wake him up.

Head Injuries What to Ask? • What happened? – – – Witnessed? Fall vs. blunt trauma? How far/hard? What surface? How landed? • Symptoms – Loss of consciousness? • Immediate/delayed? • How long? • Motor activity? – Stiff – Jerking – Limp – Vomiting? • Immediate vs. delayed? • How many times? – Weak/numb/AMS?

Head Injuries What to Ask? • Headache? – Severity – Worsening • Neck/back injury • Other pain? • H/o seizures, fainting? • Medications

Head Injuries • Head What to examine? – Contusions, feel for the bottom – Step off (depressed skull fracture) – Lacerations – Battle sign/Racoon eyes • Spine (top to bottom) • CNS/other injuries

Depressed Skull Fracture

Battle Sign

Raccoon Eyes

Intracranial Bleeding Epidural Hematoma Brain Contusion

Head Injuries • What to do? Where to go? Assume spine injury – Stabilize C-spine – Keep child still, laying down • EMS – Loss of consciousness – Persistant mental status changes • Back to class if mild, asymptomatic after

Overheating • Smoky Johnson is trying to get his weight down for his big wrestling match on Friday and is found “acting funny” after running a few laps during PE. It’s 102 degrees and he is wearing two sweat suits and a wool ski cap.

Overheating What to ask? • What’s wrong? – – – Heat rash small red bumps in hottest areas Heat cramps arms/legs/abdominal muscles Heat exhaustion Dizzy, nausea, vomiting, headaches, weakness, muscle pain, clammy. – Heat stroke Above except dry skin, confused (to coma), seizures, dry hot skin • How did it happen? • Medications/drugs?

Overheating What to examine? • Take core temperature – T 104 for Heat Stroke – May be normal for others • Mental status • Skin • Pulses

Overheating What to do? • Remove from heat • Rapidly cool

Overheating Where to send them? • Heat rash back to class • Heat cramps usually back to class • Heat exhaustion Doctor, EMS if severe • Heat stroke EMS, life threatening

Thank You! You ask me why I do not write something. . I think one's feelings waste themselves in words, they ought all to be distilled into actions and into actions which bring results. • Florence Nightengale