702 CHAPTER 15 Pediatric emergencies Foreskin problems and zip entrapment Phimosis The foreskin may normally remain non-retracti le up to age 5 years. Foreskin that remains non-retractile after this, which \200\230ballo ons \200\231 on micturition, or is associated with recurrent balanitis may bene \201 t fro m surgery (preputial stretch or circumcision). Advise the parents to see their GP to discus s referral to a pediatric surgeon. Balanitis Balanitis produces redness, swelling, and even pus. Take a swab, check for glucos e in urine and send an MSU. Treat with amoxicillin (10mg/kg PO qds) or erythromycin (10mg/k g PO qds). If redness and swelling involve the whole penis: refer for IV antibiotics. Paraphimosis Irreducible, retracted foreskin results in pain and swelling of the glans. As in the adult, cold compresses and lubricating jelly may allow reduction. If not, refer for reduction under GA. Penile zip entrapment Unfortunately, underpants do not completely protect boys (and sometim es men) from catching their foreskins in trouser zips. On many occasions the entrapment wil l be released quickly by the child or parent. On others, the child will present to the ED. The optimal method to achieve release depends upon the entrapment \200 15 % zip foreskin through the moveable part of the zip, so that it is simply caught between the teeth of the zip alone. In this case, achieve easy release by cutting transversely through the zip below the entrapment. \200 85 % of entrapments involve the foreskin being caught between the t eeth and the moveable part of the zip. Local anesthetic (either injection using plain lidoc aine or topical gel) may allow manipulation and release. If this fails, the least traumatic option is to divide the moveable part of the zip into 2 parts by dividing the central sect ion ( \200\230median bar \200\231 or \200\230bridge \200\231) using bone cutters or wire c utters (use gauze to protect against parts of the zip \202 ying off; Fig. 15.16 ). Older children and adults may tolerate this in the ED, but in younger boys referral for release u nder GA is sensible. Circumcision is rarely required. 703 FORESKIN PROBLEMS AND ZIP ENTRAPMENT Strong wire cutters Zip slider Zip bridge Zip bridge Zip bridge Top view Zip slider Zip slider Side view Fig. 15.16 Method to achieve release from zip entrapment. 704 CHAPTER 15 Pediatric emergencies The limping child This common problem can cause diagnostic dif \201 culty, particularly in the young child who cannot provide a history and is dif \201 cult to examine. It is impor tant to try to exclude some causes of a limp that will require urgent treatment. Consider the following \200 Trauma (fractures, soft tissue injury, FB in foot, NAI). \200 Speci \201 c hip problems (Perthes \200\231, slipped epiphysis, irritable hip \200 \224 b p.706). Infection (osteomyelitis, septic arthritis). \200 Arthritis (Still \200\231s disease, juv enile ankylosing spondylitis). \200 Osteochondritis ( b p.708). \200 Referred pain from in \202 ammatory process elsewhere. \200 Malignant disease (Ewing \200\231s sarcoma, le ukemia). \200 Sickle cell crisis ( b p.176). Adopt the following approach: History Ascertain whether the problem developed suddenly (eg after trauma) or gradually. En quire about recent illness and other symptoms, including joint pains elsewhere. Examination Check T * . If the child is walking, assess the gait. Carefully inspect all of the painful leg for erythema, swelling, deformity, and note the position adopted. Exclude a relatively simple problem, such as a FB embedded in the foot. Note any skin rashes. Palpat e the limb for tenderness, joint effusions, and range of movement (compare with the other s ide). If the child will not walk, but can crawl without any apparent discomfort, this local izes the problem to below the knee (thereby avoiding the need to request \200\230routine \200\231 X-rays of the hips). Investigation If the child can walk, looks well, and there is no abnormality apparent on ex amination, consider providing analgesia and arranging to review after a few days, rather th an undertaking all of the following investigations immediately. Ensure the parents are told that they should return earlier if the limp gets worse. X-ray the tender or swollen part, particularly if there is a history of injury. If there is no obvious tenderness, X-ray the pelvis to include both hips. If the X-rays do not reveal a fracture, check WCC and CRP (or plasma viscosity/ESR). If the hip is implicated, but X-ra ys are normal, request USS of the hip (some experts prefer to use USS as the initial invest igation). MRI is emerging as having a potentially useful role. Follow local ED protocols wh ere available. Management Treat according to the cause (see opposite and b pp.706 \200\2239). 705 THE LIMPING CHILD Trauma Treat according to cause, which may include a FB in the soft tissues. There may not always be a clear history of injury \200\224 this particularly applies to toddler \200\231 s fracture (see b Pediatric lower limb injuries, p.726). Osteomyelitis Acute osteomyelitis usually results from blood-borne spread of a distant path ogen (eg from the respiratory tract). Staph. aureus is usually responsible, with almost inv ariable involvement of the metaphysis of a long bone (most commonly proximal or distal femu r, or distal tibia). Features i T * , lethargy, localized tenderness (which may be misdiagn osed as trauma). Septic shock may occur (especially in infants). Investigations i WCC, i CR P, i ESR > 50mm/hr (but all may be normal initially). X-ray changes occur after 8 10days. T reatment If suspected, refer for admission, IV antibiotics 9 surgical drilling/drainage. Septic arthritis Most commonly, Staph. aureus infection in the hip or knee. Occasionally se condary to penetrating injury but usually haematogenous spread from a distant site. Constit utional symptoms, fever and joint pain occur. A joint effusion may be clinically evident. J oint movement is likely to be severely impaired. Investigations may reveal i WCC, i CRP and i ESR. Refer for urgent con \201 rmatory joint aspiration and treatment. Non-septic arthritis Multiple painful joints are more likely to be due to a juvenile arthri tic process (eg RA or ankylosing spondylitis) than septic arthritis. Pain felt in several j oints frequently accompanies a variety of infections and other diseases, eg rubella, rheuma tic fever, Henoch \200\223Sch nlein purpura. Refer to the pediatrician for further investi gation. 706 CHAPTER 15 Pediatric emergencies The painful hip The limping child may be able to localize pain to the hip, but hip pain may be referred to the knee. Hip problems causing a limp include trauma, infection and other d isorders as in b The limping child, p.704. Speci \201 c hip problems include: Perthes \200\231 disease (Legg \200\223Calv \200\223Perthes \200\231 disease) Aseptic nec rosis of the upper femoral (capital) epiphysis presents with a painful limp in children age d 3 \200\22310 years. Boys are affected more than girls (M:F = 4:1). 15 % are bilateral. Et iology is unclear, but Perthes \200\231 disease is often grouped with the osteochondritides ( b p.708). Often d range of hip movement due to pain. FBC, CRP, ESR, and blood cultures a re normal. X-ray changes re \202 ect stage of disease and are progressive (as opposite): 1 i joint space on medial aspect of capital epiphysis (compare sides) 2 i bone density in af fected epiphysis (appears sclerotic) 3 Fragmentation, distortion ( \202 attening) and late ral subluxation of upper femoral epiphysis (leaving part of the femoral head \200\230uncovered \200\231) 4 Rarefact ion of the adjacent metaphysis in which cysts may appear Treatment Refer for specialist ass essment and treatment. Most cases respond satisfactorily to conservative therapy. Slipped upper femoral (capital) epiphysis (Fig. 15.18 ) This sometimes occurs during pubert y and has been attributed to hormonal imbalance. It occurs in children (particularly boys: M:F = 3:1) who have one of 2 body types: obese with underdeveloped genitalia or tall, thin rapidly growing adolescent with normal sexual development. Presentation A child aged 10 \200\22316 years may develop a painful limp suddenly or gradually. Often there is a history of trauma. The leg may be slightly adducted, externally rotated, and shortened. Movement o f affected hip is d compared with the other side (esp. abduction and internal rotation). X- ray Obtain AP pelvis and lateral hip views \200\230frog-leg \200\231 views. Subtle slip s may only be seen on lateral view. Larger slips will be obvious on all views. Look for Tre thowan \200\231s sign: a line drawn along the superior border of the femoral neck normally cuts through the epiphysis (see Fig. 15.18 ). Treatment Refer to orthopedics for internal \201 xation manipulation. Complications Avascular necrosis, chondrolysis, and osteoarth ritis. Irritable hip ( \200\230transient synovitis \200\231) Common cause of sudden painful hip an d limp in children of all ages. Etiology is unclear, but many cases appear to follow a vira l illness. Presentation varies from a slight limp to great dif \201 culty WB. X-rays are n ormal. USS may show a hip effusion and allow aspiration for microscopy and culture. (Apply tetracaine cream over the hip before USS). Pyrexia, i WCC, i CRP (and/or i ESR/plasma visco sity) suggest infection. Treatment If signi \201 cant physical signs (signi \201 cant pai n, d movement, dif \201 culty weight-bearing) or there is evidence suggesting infection, r efer to the orthopedic team for admission for rest, traction and further investigation. If physical signs are not dramatic and X-rays and blood tests normal, discharge with NSAID, ad vise rest and review within a few days. 707 THE PAINFUL HIP Fig. 15.17 Changes in the hip in Perthes \200\231 disease. 1 P A 2 N AP view: Trethowan s sign; 1 normal, 2 abnormal hip Lateral view showing normal (left) and abnormal (right) Fig. 15.18 Slipped upper femoral epiphysis. 708 CHAPTER 15 Pediatric emergencies Osteochondritis This term is applied to a heterogeneous array of non-infectious disorders a ffecting various epiphyses. They may be divided into 3 groups, according to the proposed et iology (see Table 15.9 ). Crushing osteochondritis Apparently spontaneous necrosis of an ossi \201 cation center occ urs at a time of rapid growth. This is followed by new bone formation. Perthes \200\231 dis ease \200\224 see b The painful hip, p.706. Scheuermann \200\231s disease Fragmentation of low thoracic/upper lumbar vertebral epiphyseal plates of adolescents results in chronic ba ck pain and a \200\230round-shouldered \200\231 kyphotic appearance. X-rays show anterior wedging of vertebral bodies, with sclerotic notches (Schmorl \200\231s nodes) on inferior o r superior vertebral borders. Diagnostic criteria are > 50 * of kyphosis and wedging in 3 a djacent vertebrae. Treat symptomatically with NSAID and refer for orthopedic follow-up. Kohler \200\231s disease Avascular necrosis of the navicular affects children (particularly boys) aged 3 \200\2235 years. A painful limp develops, with tenderness on the dorsum of th e foot over the navicular. The sclerotic fragmented navicular seen on X-ray is also seen in many asymptomatic children. Treat symptoms with rest, NSAID and orthopedic follow-up. If s ymptoms are severe, consider BKPOP. Kienbock \200\231s and Freiberg \200\231s disease \200\224 usually affect young adults Traction apophysitis The pull of a strong tendon causes damage to the unfused apophysis to which it is attached. Osgood-Schlatter \200\231s disease Traction apophysitis of the tibial attachment of the pat ellar tendon is especially seen in boys aged 10 \200\22315 years. Anterior knee pain after exercise is characteristic. The tibial tuberosity is prominent and tender. The pain may be reproduced by attempted extension against resistance. X-rays are not always needed, but show an enlarged and sometimes fragmented tibial tuberosi ty. Treat symptomatically with rest, NSAID and orthopedic follow-up. Most settle with conse rvative measures. Johansson \200\223Larsen \200\231s disease (Sinding Larsen \200\231s disease) Traction apop hysitis of the lower pole of the patella in young adolescents results in local tenderness. Treat with rest, NSAID and orthopedic follow-up. Sever \200\231s disease Traction apophysitis of the calcaneal attachment of the Achilles te ndon occurs in 8 \200\22314-year-olds. The resulting limp is associated with local calcanea l tenderness. X-rays may reveal a fragmented sclerotic calcaneal apophysis. Treat with rest , NSAID, a heel raise and orthopedic follow-up. 709 OSTEOCHONDRITIS Osteochondritis dissecans A piece of articular cartilage and adjacent bone become partially or completely separated as an avascular fragment. The cause is believed to be an osteochon dral fracture from repeated minor trauma. The lateral aspect of the medial condyle of dista l femur is the most commonly affected site. Intermittent pain, swelling and joint effusion result. If the fragment becomes detached as a loose body, locking or giving way may occur. X-ray Demonstrates the fragment or defect. Treatment Refer the locked knee immediately. Treat the remainder with rest, consider crutch es, and arrange orthopedic follow-up. Table 15.9 Classi \201 cation of osteochondritis Type of osteochondritis Bone affected Eponym Perthes \200\231 disease ( b p.706) Crushing osteochondritis Femoral head Vertebrae Scheuermann \200\231s disease 2nd metatarsal head Freiberg \200\231s disease Navicular Kohler \200\231s disease Lunate Kienbock \200\231s disease Capitulum Panner \200\231s disease Osteochondritis dissecans Medial femoral condyle Talus Elbow Metatarsal Traction apophysitis Tibial tuberosity Osgood \200\223Schlatter \200\231s disease Lower pole of patella Johansson \200\223Larsen \200\231s disease Calcaneum Sever \200\231s disease 710 CHAPTER 15 Pediatric emergencies Major pediatric trauma The background Trauma is the largest single cause of death in childr en: 8 500 deaths/ year in the UK (Table 15.10 ). As in adults, blunt injury in children is far more common than penetrating injury. The number of deaths in children after trauma is d warfed by the number who sustain serious injuries. Most serious injuries result from road t raf \201 c collisions and falls. Table 15.10 Causes of trauma deaths in children Road traf \201 c collisions 48 % Fires 15 % Drowning 12 % Hanging 8 % Falls 8 % Non-accidental injury 5 % Other 4 % > 70 % of pediatric trauma deaths occur in the pre-hospital setting. Most of these children are either dead when found or have sustained overwhelming injuries. The greatest potential for reducing trauma deaths clearly lies with injury prevention. However, there is enormous potential to reduce the number of permanently disabled children by early identi \201 cati on of injuries and expert treatment. The best outcome results from involvement of senior an d experienced staff at an early stage. Prompt recognition of the seriously injured child is crucial to this. Pattern of injuries Anatomical and physiological differences mean that the pattern of injur ies in children differ considerably from those in adults. Compared with adults, children ha ve: smaller physical size, a relatively larger head, more compliant bones, a higher ratio o f surface area to body weight, epiphyses. Experience and an awareness of the patterns of pe diatric injury will assist resuscitation efforts. The smaller size and physical proximity o f internal organs frequently results in the dissipated forces causing injuries to multiple structures (multiple injuries). The compliance of the bony thoracic cage in children allows signi \201 cant underlying organ injury without rib fractures. Similarly, certain injurie s not uncommon in adults (eg rupture of thoracic aorta), rarely occur in children. 711 INJURY PREVENTION Injury prevention Terminology The term \200\230accident \200\231 implies an unforeseen uni ntentional event, one which occurs by chance. The implication is that \200\230accidents \200\231 cannot be prevented. However, there is considerable evidence to suggest that \200 \230accidents \200\231 are far from random events, but are relatively predictable and amena ble to prevention. For this reason, medical experts now prefer to avoid use of the terms \200\230accidents \200\231 and \200\230accident prevention \200\231 and refer to \200\230 injury prevention \200\231 instead. Background Injuries to children tend to occur more frequently in certain groups and at cert ain times: \200 Boys sustain more injuries than girls. \200 Injuries are associated wit h social deprivation. \200 Injuries often occur at times of family stress and change (inc luding marital disharmony, moving house and holidays). Prevention theory Prevention of injury does not simply refer to physical injuries, but pois onings also. Injuries and/or the effects of injuries may be prevented in a number of differ ent ways: Primary prevention measures stop injuries occurring. For example, the installation of fence s around domestic swimming pools may reduce drowning, locked medicine cabinets might preven t inadvertent poisoning. Secondary prevention measures reduce the extent of harm caused by an injurious event. The m ost obvious examples are helmets, seat belts, and air bags in the context of road traf \201 c collisions. Tertiary \200\230prevention \200\231 includes most forms of \201 rst aid and hospital tr eatment, and aims to limit the effect of an injury after it has already happened (eg surger y to stop intra-abdominal hemorrhage, antidotes for certain poisons). Prevention strategies and the role of ED staff The focus of hospital staff treating injured patients has understandably always been the injuries themselves ( \200\230tertiary prevent ion \200\231). In addition to any possible issues of NAI, ED staff need to consider how fut ure injuries to children might be prevented (eg by discussing with parents the bene \201 t s of bicycle helmets). In the context of an individual child, it may sometimes be appropria te to contact the GP/health visitor with a view to seeing if interventions might prevent fu ture injuries to a particular child and siblings. More general interventions include: \200 Lea \202 ets and posters in the waiting room to target a captive audience \200 Media involvement on certain issues, such as minimizing t he risks of \201 reworks and sparklers Further details of children \200\231s injuries and injury prevention are available from the Royal Society for the Prevention of Accidents ( www.rospa.org.uk ) and the Child Accident Prevention Trust ( www.capt.org.uk ). 712 CHAPTER 15 Pediatric emergencies Resuscitation of the injured child The priorities in managing major pediatric trauma (Airwa y, Breathing, Circulation) are the same as in adults ( b p.320). Staff accustomed to treati ng adults may have dif \201 culty with equipment sizes and drug doses. Estimate the child \200\231s weight ( b p.633). Call for help as soon as a seriously injured child arrives (or is expected) in the ED \200\224 senior ED doctor, ICU/ PICU doctor and surgeon (preferabl y pediatric). It is often very helpful to seek the help of a pediatrician to assist with va scular access and, calculation of drug doses, particularly for pre-school children. Airway with cervical spine control Clear and secure the airway (suction and adjuncts) and p rovide O 2 . If the airway is obstructed, use jaw thrust (not head tilt/chin lift) and call for expert help (senior ED/PICU/ICU) as intubation may be required. Ensure that manual imm obilization of the cervical spine is maintained, whilst a patient airway is being obtained. When the airway is secure, an appropriately-sized hard collar with tape and sandbags shoul d be used until injury to the cervical spine has been excluded. Breathing Quickly exclude and treat life-threatening chest injuries. Children are prone to swallow air, placing them at risk of massive gastric dilatation (can cause d BP and subsequ ent aspiration): consider an orogastric tube. Circulation with hemorrhage control As in adults, hypotension is a late sign of hypovolaemi a. Look carefully for other evidence: tachycardia, tachypnoea, agitation, lethargy, pale co ld skin with d capillary re \201 ll time (best elicited on the sternum). Obtain venous acc ess (consider the intra-osseous route) as described on b p.640. Treat hypovolaemia by stopp ing hemorrhage (splinting fractures, applying pressure to wounds, prompt surgery for intern al hemorrhage) and giving IV \202 uid/blood resuscitation. Give a 10mL/kg IV 0.9 % saline bolus rapidly and reassess. If there is no clinical improvement, give a further 10mL/kg cr ystalloid IV \202 uid bolus and repeat if necessary up to 40mL/kg. Remember that over-agg ressive \202 uid replacement may worsen the situation if the patient is suffering from in ternal hemorrhage. If further \202 uid is required, give blood products (whole blood 20mL /kg or 10mL/kg packed cells) and request fresh frozen plasma (FFP) and platelets from the l aboratory for massive transfusion. Disability Make a rapid assessment of the child \200\231s neurological status ( b p.356). Exposure Early complete inspection is mandatory, but subsequently cover the child as much a s possible in order to d anxiety and prevent excessive heat loss. 713 RESUSCITATION OF THE INJURED CHILD Analgesia ( b Analgesia in speci \201 c situations, p.280) Analgesia is often forgotten or not considered early enough, even with major injuries. Prompt and adequate analgesia given to injured children will gain their con \201 dence, enhancing assessment and treatment. G ive IV analgesia titrated according to response. Do not use IM or SC analgesia. In severe pain give morphine IV \200 Up to 100 mcg/kg over 5min if 6 \200\22312 months. \200 Up to 200 mcg/kg over 5min if > 12 months. Certain fractures are amenable to LA nerve block techniques (eg femoral nerve block for femoral shaft fractures \200\224 b p.304). N asal diamorphine ( b Analgesia in speci \201 c situations, p.280) and Entonox ( b Analg esics: Entonox and ketamine, p.278) may also be useful for analgesia before IV access is available. Parents Remember the parents \200\231 needs: allocate a member of staff to this task ( b p. 278). Children who have suffered a traumatic event are at risk of developing post-traumatic stress disorder \200\224 inform the parents or guardians about this. Brie \202 y describ e possible symptoms (sleep disturbance, night- mares, dif \201 culty concentrating, and ir ritability). Suggest to the parents/ guardians that they contact the child \200\231s GP if symptoms persist beyond one month (NICE Clinical Practice Guideline 2005 (see http://www.ni ce.org.uk/ nicemedia/pdf/CG026fullguideline.pdf ). 714 CHAPTER 15 Pediatric emergencies Considerations in pediatric trauma Spinal injury Cervical spine injury is relatively uncomm on in children, but keep the whole spine immobilized until history, examination X-rays e xclude injury. Injuries in children tend to involve upper (C1 \200\2233 level), rather than lower cervical spine. Remember that rotatory subluxation may cause signi \201 cant cervic al spine injury without fracture: the clue is combination of injury, neck pain and torticol lis. Interpretation of cervical spine X-rays in younger children is frequently complicated by pseudo-subluxation of C2 on C3 and of C3 on C4. If in doubt, continue immobilization and obtain an expert opinion. The pediatric spine is inherently more elastic so momentary inter- segmental displacement m ay endanger the cord without disrupting bones or ligaments. This can result in spinal cord injury without radiological abnormality (SCIWORA). Usually there are objective signs of inj ury, but these can be delayed. Therefore, if children present with transient neurological s ymptoms after neck injury, make sure you assess them carefully. Exclusion of signi \201 ca nt injury requires an alert child with normal spinal and neurological examination with no p ainful distracting injuries and normal radiology (rarely the case for the seriously injured child). Head injury Of those children who die from trauma, most succumb to head injuries. Anatomica l differences should be borne in mind. In infants, unfused sutures allow the intracranial v olume to i with intracranial hemorrhage, causing relatively large bleeds and even shock. Si milarly, scalp wounds in infants and young children may bleed profusely and result in signi \201 cant hypovolaemia. Assessment of children may prove dif \201 cult. An isolated epis ode of vomiting after minor head injury is a frequent occurrence. To assess level of consci ousness, use the standard GCS ( b p.361) for children aged \211 4 years; children aged <4 years require an adapted scale ( b p.717, which contains further details about head injuri es in children). Chest injury Signi \201 cant thoracic visceral injuries may occur without rib fractures. T here is a relatively high incidence of pulmonary contusion. Children have little respirator y reserve and can desaturate quickly. If a chest drain is required to treat a pneumothorax or haemothorax, use a size appropriate for the size of the child (as indicated by Broselow tape). Abdominal and pelvic injury Look for hypovolaemia. Abdominal palpation cannot yield useful infor- mation until child \200\231s cooperation and con \201 dence are gained. Restrict an y PR and PV examinations to the senior surgeon. USS and/or CT scan has replaced DPL. Gastri c tubes are useful to treat the air swallowing and gastric dilatation prevalent in injured children. Insert an appropriately-sized urinary catheter if urine cannot be passed spontane ously or if accurate output measurement is required (eg after severe burns). 715 CONSIDERATIONS IN pediatric TRAUMA Burns Burns and smoke inhalation from house \201 res still cause death in many chil- dren each year. Even more frequently, children present with scalds from hot or boiling liquids. The majority of these results from simple incidents in the home: ensure that treatment inc ludes injury prevention advice for parents ( b p.711). Remember that some (occasionally cha racteristic) burns may re \202 ect NAI. Assessment and treatment of the burned child follo ws similar lines to those in adults; urgent priorities include securing the airway (with an uncut ET tube) and adequate analgesia ( b p.320). IV \202 uid requirements in major burn s depend upon the extent of the burn (use Lund \200\223Browder charts, b p.391) and clinica l response (see b p.390). Drowning and submersion incidents Children continue to die from drowning each year despite improved swimming education. Their high surface area to body weight ratio makes them prone to hypothermia. Cardiac arrest after immersion warrants prolonged resuscitation ( b p.259). Presume cervical spine injury and immobilize the neck. Prolonged submersion ( > 8min), no respiratory effort after 40min of CPR, persistent coma, persistent pH<7.0, persistent PaO 2 <8kPa imply a poor prognosis. Hypothermia favors a better prognosis. Of those who survive after hospital CPR, 70 % make a complete recovery. Wounds in children Older children may allow wounds to be explored, cleaned, and sutured und er LA, providing they are given appropriate explanation (sometimes it is worth demonstratin g on teddy \201 rst) and a parent is allowed to stay with them. Injection of LA is least painful if a \201 ne needle is employed and the LA is warmed, buffered and injected slowl y. Some children, however, do not tolerate LA. Whilst some super \201 cial wounds may be c leaned and closed (steristrips or tissue glue) without anesthesia, often sedation or GA is needed. Anesthesia is needed to allow adequate exploration and cleaning of the wound and to d risks of infection and tattooing from embedded dirt. Never allow the lack of co-operatio n to compromise treatment, particularly with facial wounds, where wound closure under GA ma y produce the best cosmetic result. Ketamine Ketamine can be used in the ED as an alternative to GA and provides excellent anal gesia for undertaking minor procedures in children ( b p.278; http://www.collemergencymed.a c.uk/CEM/Clinical % 20Effectiveness see % 20Committee/Guidelines/Clinical % 20Guidelines/de fault.asp ). Ketamine should only be used by clinicians experienced in its use and capable of managing any airway complications. Ketamine is contraindicated if: \200 The child has had a full meal within 3hr. \200 There is a high risk of laryngospasm (active respiratory infection, active asthma, age <12 months). There are severe psychological problems (cognitive or motor delay or severe behavioral problems). Cardiovascular disease (congenital heart disease, cardiomyopathy, i BP). \200 Signi \201 cant head injury or neurological disease, porphyria, hyperthyroidism. 716 CHAPTER 15 Pediatric emergencies Head injuries in children The principles of head injury management in children are the same as in adults ( b pp.362 \200\2237), but there are some important differences (including th e assessment of conscious level in small children). Causes of head injury Most head injurie s in children are due to falls, but few of these cause serious injury. Severe head injury i s often the result of a child running out in front of a vehicle. Some deaths are caused by NAI ( b p.731), especially in babies who have been shaken violently, dropped, or thrown. As sessment of a head-injured child History Record details of the injurious event, the time it occurred and the condition of the child before and after injury. Ascertain if the child wa s previously well. In particular, elicit any history of \201 ts or bleeding disorder. An infection can render a child prone to falls and also cause subsequent symptoms: a small chi ld who vomits after a fall may be suffering from otitis media rather than the effects of a head injury. Determine the condition of the child immediately after injury: if he cried at once, he did not lose consciousness. Record if he was unconscious, confused or drowsy (and for how long) and whether he vomited or was unsteady or dizzy. Ask about headache. Remember to take into account the fact that a child might normally be asleep at the time he is exam ined. Examination Do not use the standard adult GCS ( b p.361) in children aged <4 years \200\224 instead use the adapted scale opposite. Exclude hypoglycaemia. Note whether the ch ild looks well and is behaving normally. Measure pupil size and check reactivity. Examine t he head for signs of injury, but also look for injuries elsewhere. Check T * and consider c o-existing illness, such as ear, throat, or urinary infections, or occasionally meningitis. Management of head injury in children When faced with a child with severe injuries summon senior help and follow standard resuscitation guidelines ( b p.364). If there is any suspic ion of NAI, involve the pediatrician at an early stage ( b p.734). Indications for immediat e CT scan (see www.nice.org.uk) Any 1 of: witnessed loss of consciousness for >5mins, any a mnesia lasting >5mins, abnormal drowsiness, >2 discrete episodes of vomiting, clinically su spected NAI, post-traumatic epilepsy, GCS <14/15 or for an infant <15/15 on ED assessment, suspected open or depressed skull injury or tense fontanelle, any sign of basal skull fract ure, focal neurological de \201 cit, infants with bruising, swelling or laceration >5cm, d angerous mechanism of injury. Admission or discharge Admit and observe children with contin uing symptoms or signs, skull fracture or if mechanism of injury suggests serious trauma (e g fall from upstairs window). When contemplating discharge, ensure that adequate supervisio n from a responsible adult is available. Provide the parent/guardian with a verbal explanat ion and a written advice sheet ( b p.367, or see www.sign. ac.uk or http://guidance.nice.or g.uk/index.jsp?action=download&o=36265 ). 717 HEAD INJURIES IN CHILDREN Glasgow Coma Scale (children) The \200\230Eye \200\231 and \200\230Motor \200\231 compone nts of the GCS are similar as for adults ( b p.361), but a modi \201 ed \200\230Verbal sc ore \200\231 is used in small children. The pediatric version of the GCS is shown in Table 15.11 (see www.nice.org.uk ). Assessment of the best verbal response is likely to require a ssistance from parent/guardian/carer. Table 15.11 Pediatric version of the Glasgow Coma Scale. Best eye response Score Eyes open spontaneously 4 Eye opening to verbal command Eye opening to pain No eye opening Best verbal response 3 2 1 Alert, babbles, coos, words, or sentences to usual ability Less than usual ability and/or s pontaneous irritable cry Cries inappropriately Occasionally whimpers and/or moans No vocal response Best motor response 5 4 3 2 1 Obeys commands or has normal spontaneous movements Localizes to painful stimuli or withdraw s to touch Withdrawal to painful stimuli Abnormal \202 exion to pain (decorticate) Abnorm al extension to pain (decerebrate) No motor response to pain Total 6 5 4 3 2 1 3 \200\22315 In pre-verbal or intubated patients, the \200\230best grimace response \200\231 may be use d in place of the \200\230best verbal response \200\231, as shown in Table 15.12 . Table 15.12 \200\230Best grimace response \200\231 Score Spontaneous normal facial/oro-motor activity Less than usual spontaneous ability and/or onl y responds to touch Vigorous grimace to pain Mild grimace to pain No response to pain 5 4 3 2 1 Transient cortical blindness after head injury Occasionally, children present with blindnes s immediately or soon after an apparently minor head injury. The mechanism is unclear, but in most cases blindness resolves spontaneously within a few hrs. In the meantime, arrange a CT scan to exclude intracranial haematoma. 718 CHAPTER 15 Pediatric emergencies Pediatric fractures and dislocations Many pediatric fractures are similar to those in adult s and prone to similar complications. Bones in children differ from those in adults in two important respects: they have epiphyses and are softer (hence fractures are more common tha n signi \201 cant ligament injuries). Certain types of pediatric fractures re \202 ect th ese differences: Greenstick fracture An incomplete fracture in which one cortical surface of a bone breaks, whilst the other side bends. Torus ( \200\230buckle \200\231) fracture Another form of incomplete fracture characterized by a buckling of the cortex. Plastic deformation ( \200\230bowing deformation \200\231) Traumatic bending of long bone s haft without visible fracture occasionally occurs in young children. Epiphyseal injuries Injuries to the traction epiphyses are avulsion injuries (eg peroneus b revis insertion into the base of the 5th MT). Injuries to the pressure epiphyses at the end of long bones adjacent to the articular surfa ce have been classi \201 ed into 5 types \200\224 the Salter-Harris classi \201 cation ( see Fig. 15.19 ): \200 Type I : the epiphysis separates or slips on the metaphysis. \200 Type II : a small piece of metaphysis separates with the epiphysis (commonest type). Type III : a vertical fracture through the epiphysis joins that through the epiphyseal plate. Type IV : a fracture passes from articular surface through the epiphyseal plate into metaphysis. Type V : a crush injury to the epiphyseal plate (X-rays may be normal). Note that Salter \200\223Harris types I and V may not be apparent on the initial X-ray. Undisplaced type I f ractures often affect distal tibia and \201 bula and may present with circumferential ten derness around the growth plate. Treat with POP and immobilization according to clinical \201 ndings. Epiphyseal growth plate injury A concern speci \201 c to any epiphyseal injury is that pre mature fusion of a growth plate may result, with resultant limb shortening and deformity. T he risk correlates to some extent with the mechanism of injury and amount of force involved . The different Salter \200\223Harris fractures carry a different level of risk of long-ter m growth plate problems. The risk is low for types I and II (particularly if undisplaced), moderate for type III and highest for types IV and V. Problems are usually averted if Salte r \200\223Harris type III and IV injuries are accurately reduced and held (eg by internal \201 xation). Type V fractures are notoriously dif \201 cult to diagnose and often compli cated by premature fusion: fortunately they are relatively rare. Dislocations Dislocated joints are relatively unusual in children. Most commonly involved a re the patella ( b p.726) or the radial head ( \200\230pulled elbow \200\231 \200\224 b p. 724). Similarly, due to relative strengths of bone and ligament, injuries to ligaments are much less common in children than in adults. 719 pediatric FRACTURES AND DISLOCATIONS Normal Type I Type II Type III Type IV Type V Fig. 15.19 Salter \200\223Harris classi \201 cation of epiphyseal injuries. 720 CHAPTER 15 Pediatric emergencies Approach to limb injuries in children Limb injuries are very common in children. Whilst mos t of the points outlined in the general approach to trauma in adults may be successfully ap plied, certain modi \201 cations may be required. History Carefully elicit the mechanism of injury. The history may be confused or not upcomi ng: try to establish a rapport with the child (and parents) nevertheless, in order to gain the child \200\231s con \201 dence for the examination. Examination Search for evidence of a fracture (swelling, deformity, bony tenderness) and an y associated neurovascular injury. Remember the adage that the most easily missed fracture is the second fracture: examine also for additional injuries to adjacent bones and joints. Is an X-ray required? If in doubt, obtain an X-ray. The ease with which children \200\231s bones fracture and the dif \201 culties with history and examination mean that it is sensi ble to adopt a low threshold for requesting X-rays. Ensure that two views at right angles a re taken (eg AP and lateral), including associated joints. Interpreting X-rays Many fractures are subtle and easily missed. To minimize the chance of this occurring, visually trace around the cortex of each bone, looking for any irregulariti es. Interpretation of pediatric X-rays is complicated by the presence of various ossi \201 cation centers and accessory ossicles. Both are commonly mistaken for fractures (eg the ol ecranon epiphysis, the os trigonum and bipartite patella). Ossi \201 cation centers appear and fuse in a relatively predictable fashion, although the rate at which this occurs varie s slightly from child to child (see Table 15.13 ). Knowledge of this process, combined with experience of seeing many pediatric X-rays, greatly assists interpretation. If in doubt ab out an X-ray, obtain a second opinion (there is no justi \201 cation for X-raying the unin jured side to see what \200\230normal \200\231 is). As an additional safeguard, most EDs n ow operate a policy of all X-rays being reported by a radiologist within 24hr.