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

Emergency Splinting Emergency Splinting and Trauma First Aidand Trauma First Aid

Coburn H. Allen, MDCoburn H. Allen, MD

Pediatric Emergency MedicinePediatric Emergency Medicine

Pediatric Infectious DiseasesPediatric Infectious Diseases

ObjectivesObjectives

• Review the most common injuries in Review the most common injuries in childrenchildren

• Discuss what to ask, examine and do Discuss what to ask, examine and do for each processfor each process

• Suggest who needs further care and Suggest who needs further care and who can return to classwho can return to class

Common InjuriesCommon Injuries

• Bumps and Bumps and BruisesBruises

• ScrapesScrapes

• SprainsSprains

• StrainsStrains

• FracturesFractures

• Oral TraumaOral Trauma

• Nose BleedsNose Bleeds

• LacerationsLacerations

• Head InjuriesHead Injuries

• OverheatingOverheating

Bumps and BruisesBumps and Bruises• Bobby Bobo, a 5 y/o boy, fell Bobby Bobo, a 5 y/o boy, fell

down in class while chasing down in class while chasing the teacher’s lost hamster. the teacher’s lost hamster. He hit his right thigh on the He hit his right thigh on the corner of a desk and now corner of a desk and now complains of pain and complains of pain and swelling to the leg. By the swelling to the leg. By the time he arrives his right thigh time he arrives his right thigh is tight from the swelling. He is tight from the swelling. He says he has “Christmas says he has “Christmas Disease.”Disease.”

Bumps and BruisesBumps and BruisesWhat to ask?What to ask?

• What happened and when?What happened and when?– Abuse vs. accidentalAbuse vs. accidental

• Inconsistent mechanism, frequent bruisingInconsistent mechanism, frequent bruising

•Abnormal locationsAbnormal locations

•Abnormal patternsAbnormal patterns

– No trauma? Think mass, infection, No trauma? Think mass, infection, clotting d.o. clotting d.o.

• Anything else hurt? Anything else hurt?

• PMHx? (Aspirin, coumadin, PMHx? (Aspirin, coumadin, bleeding…)bleeding…)

Bumps and BruisesBumps and Bruises

What to examine?What to examine?

• Entire bodyEntire body– Look for patternsLook for patterns– Suspicious locationsSuspicious locations

•TrunkTrunk

•FaceFace

•ScalpScalp

– Multiple stages of bruises?Multiple stages of bruises?

• Bone pain?Bone pain?

Nonaccidental TraumaNonaccidental Trauma

Bite


What to do?What to do?

• Cold packCold pack

• Tylenol Tylenol

• Most need nothingMost need nothing

• CPS?CPS?– Law is “if suspicious…report.”Law is “if suspicious…report.”– You are protectedYou are protected– ConfidentialConfidential

Texas LawTexas Law

• Child abuse and neglect are against the law in Child abuse and neglect are against the law in Texas, and so is failure to report it. Texas, and so is failure to report it.

• If you suspect a child has been abused or If you suspect a child has been abused or mistreated, you are required to report it to the mistreated, you are required to report it to the Texas Department of Family and Protective Texas Department of Family and Protective Services or to a law enforcement agency. Services or to a law enforcement agency.

• You are required to make a report within 48 You are required to make a report within 48 hours of the time you suspected the child has hours of the time you suspected the child has been or may be abused or neglected. been or may be abused or neglected.

Abuse Hotline 1-800-252-5400Abuse Hotline 1-800-252-5400


Where to send them?Where to send them?

• Back to classBack to class– MostMost– Not rapidly expandingNot rapidly expanding– Not suspiciousNot suspicious

• DoctorDoctor– Large/deep, multiple, expanding Large/deep, multiple, expanding – Uncertain of etiology Uncertain of etiology

(mass/infection/abuse) (mass/infection/abuse)

ScrapesScrapes

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

ScrapesScrapes

What to ask?What to ask?

• What happened?What happened?

• What did you fall on?What did you fall on?– Hard versus softHard versus soft– Loose objects = foreign bodiesLoose objects = foreign bodies

• Able to bear weight?Able to bear weight?

• Anything else hurt?Anything else hurt?

• Vaccinations (Tetanus)? Vaccinations (Tetanus)?

ScrapesScrapes


• WoundWound– Deep vs. superficialDeep vs. superficial– Clean vs. contaminatedClean vs. contaminated– If old, infected? Impetigo If old, infected? Impetigo

• Range of motionRange of motion

• Weight bearing Weight bearing

ScrapesScrapes


• Gently cleanGently clean– Saline and gauzeSaline and gauze– Clean wet washclothClean wet washcloth– Running tap waterRunning tap water

• Remove debris Remove debris

• Antibiotic ointmentAntibiotic ointment

• BandageBandage

ScrapesScrapes


• Back to class almost alwaysBack to class almost always

• DoctorDoctor– Retained foreign bodyRetained foreign body– Restricted use of extremityRestricted use of extremity– Concern for joint penetrationConcern for joint penetration

SprainsSprains

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

SprainsSprains


• What happened?What happened?– MechanismMechanism

•Twist or turnTwist or turn

•Blunt traumaBlunt trauma

•““Something popped” or “gave way”Something popped” or “gave way”

– Could you walk on it (even with a limp)? Could you walk on it (even with a limp)?

• Old injury, ask if fever, chills, medical Old injury, ask if fever, chills, medical hx.hx.

SprainsSprainsWhat to examine?What to examine?

• Entire involved extremityEntire involved extremity– PainPain– SwellingSwelling– BruisingBruising– RednessRedness– WarmthWarmth– ROM, gaitROM, gait

• Other jointsOther joints

Ankle SprainAnkle Sprain

Knee SprainKnee Sprain

Septic JointSeptic Joint

SprainsSprains


“ “pRICEmmms”pRICEmmms”• Protect the joint = crutches, slings, tape…Protect the joint = crutches, slings, tape…

• RestRest

• IceIce

• CompressionCompression

• ElevationElevation

• Medication, modality (PT), motion (keep Medication, modality (PT), motion (keep loose)loose)

• StrengthStrength

SprainsSprains


• Back to classBack to class– MostMost– Pain under control Pain under control

• DoctorDoctor– Suspect fracture, infection, systemic diseaseSuspect fracture, infection, systemic disease– Not weight bearingNot weight bearing– Pain poorly controlledPain poorly controlled

StrainsStrains• Coach Oldskool, your legendary, Coach Oldskool, your legendary,

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

StrainsStrains


• What happened?What happened?– Sudden jerking movements?Sudden jerking movements?– Lifting?Lifting?– Sprinting?Sprinting?– Jumping?Jumping?

• Did you feel a pop? Tear?Did you feel a pop? Tear?

• Numbness/tingling/weakness?Numbness/tingling/weakness?

Sprain MechanismsSprain Mechanisms

StrainsStrains


• Where it hurtsWhere it hurts– SpasmSpasm– SwellingSwelling– BruisingBruising

• Joints above and below Joints above and below

• Neuorologic function (back injuries) Neuorologic function (back injuries)

• GaitGait

StrainsStrains


• Similar to strainsSimilar to strains

• Massage/stretch if spasmMassage/stretch if spasm

StrainsStrains


• Back to classBack to class– MostMost– Pain controlledPain controlled

• DoctorDoctor– Not bearing weightNot bearing weight– Severe painSevere pain– Any numbness/tingling/weaknessAny numbness/tingling/weakness

FracturesFractures

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

FracturesFractures


• Describe the injury?Describe the injury?– Fall vs. blunt trauma vs. twistFall vs. blunt trauma vs. twist– How did you land?How did you land?– Where is the worst pain (use one finger)?Where is the worst pain (use one finger)?– Could you walk right afterward?Could you walk right afterward?– Anything else hurt?Anything else hurt?

• Neck pain/back pain if severe Neck pain/back pain if severe fracture(s)?fracture(s)?

FracturesFractures


• Point tenderness/deformityPoint tenderness/deformity

• Open fractureOpen fracture

• Joint swellingJoint swelling

• Muscle spasmsMuscle spasms

• Function/sensation below fractureFunction/sensation below fracture

• ROM/walkROM/walk

• Neck/back if “distracting injury”Neck/back if “distracting injury”

FracturesFractures


• Stabilize = SplintingStabilize = Splinting– Joint above Joint above andand below fracture below fracture– Not too tight, use paddingNot too tight, use padding– Not too loose, shouldn’t wiggleNot too loose, shouldn’t wiggle– Don’t hide the extremity, not Don’t hide the extremity, not

circumferentialcircumferential

• Pain controlPain control– IceIce– MedicationsMedications

Ankle Pillow SplintAnkle Pillow Splint

Lower Leg SplintLower Leg Splint

Long Leg SplintLong Leg Splint

Finger SplintsFinger Splints

Wrist (Volar) SplintWrist (Volar) Splint

Upper Arm SplintUpper Arm Splint

http://upload.wikimedia.org/wikipedia/commons/3/3a/Upper_arm_splint.jpg

Cervical Spine SplintsCervical Spine Splints

FracturesFractures


• DoctorDoctor– MostMost– EMS if severe, neurovascular changes, EMS if severe, neurovascular changes,

spinespine

• Back to classBack to class– Broken heartsBroken hearts– Shattered dreamsShattered dreams– Crushed moraleCrushed morale

Oral TraumaOral Trauma

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



• What happened?What happened?– Tooth/jaw/lip/tongue hurt?Tooth/jaw/lip/tongue hurt?– What hit you? (BAD if it is another What hit you? (BAD if it is another

person)person)– How long ago?How long ago?– Permanent teeth?Permanent teeth?

• Where are the teeth? Where are the teeth?

• Have a dentist?Have a dentist?



• TeethTeeth– Avulsed (knocked out, loose)Avulsed (knocked out, loose)– FracturedFractured– ChippedChipped– IntrusionIntrusion

• Jaw/face: feel for “crunchy” Jaw/face: feel for “crunchy” sensationsensation

• Mucosal/tongue injuryMucosal/tongue injury

Tooth AnatomyTooth Anatomy

Avulsed TeethAvulsed Teeth

Fractured TeethFractured Teeth

IntrusionIntrusion

Tongue/Mucosal TraumaTongue/Mucosal Trauma

Oral TraumaOral TraumaWhat to do?What to do?

• TeethTeeth– AvulsionAvulsion

•Primary teethPrimary teeth– Out, leave outOut, leave out– Loose, straighten or is very loose removeLoose, straighten or is very loose remove

•Permanent teethPermanent teeth– Out, leave out, wash gently, store in cold milk, saline, spit.Out, leave out, wash gently, store in cold milk, saline, spit.– Loose, leave aloneLoose, leave alone

– Fracture, keep fragment, store as aboveFracture, keep fragment, store as above



• TongueTongue– Well approximated, nothingWell approximated, nothing– Bleeding Bleeding direct pressure with gauze direct pressure with gauze– Gaping need repairGaping need repair

• MucosalMucosal– Well approximated, nothingWell approximated, nothing– Gaping and vermillion border need repairGaping and vermillion border need repair



• Dental injuriesDental injuries– Dentist for most injuriesDentist for most injuries– Baby teeth may need nothingBaby teeth may need nothing

• Tongue/MucosaTongue/Mucosa– Most need nothingMost need nothing– Doctor if gaping, severe bleeding, Doctor if gaping, severe bleeding,

vermillion vermillion

Nose BleedsNose Bleeds

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



• How much blood, how long?How much blood, how long?

• What has been done to stop bleeding?What has been done to stop bleeding?

• Trauma?Trauma?– BluntBlunt– PickingPicking

• Upper respiratory infection? Allergies?Upper respiratory infection? Allergies?

• History of Bleeding?History of Bleeding?



• NoseNose– Fracture (usually at bridge)Fracture (usually at bridge)– Active bleedingActive bleeding

•Which side? Always the same?Which side? Always the same?

•ThroatThroat

• NeurologicNeurologic

• VisionVision



• Pinch x 10-20 minutes (don’t peek)Pinch x 10-20 minutes (don’t peek)

• Don’t put head between legsDon’t put head between legs

• Don’t blow noseDon’t blow nose

• Afrin if availableAfrin if available

• No PICKING!No PICKING!

Penny’s FatherPenny’s Father



• Back to classBack to class– Most if stops after 20 minutesMost if stops after 20 minutes– No other injuryNo other injury– Not dizzy, weak, paleNot dizzy, weak, pale

• DoctorDoctor– Severe bleedingSevere bleeding– Bleeding disorderBleeding disorder– Other injuries Other injuries

LacerationsLacerations

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



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

• Tetanus statusTetanus status



• WoundWound– How wide?How wide?– How deep?How deep?– How long?How long?– Contaminated?Contaminated?– Across nerves/tendons/vessels/galea?Across nerves/tendons/vessels/galea?

• Head/spine injury?Head/spine injury?

• Fracture?Fracture?

Scalp LacerationScalp Laceration

Forehead LacerationForehead Laceration

Hand LacerationHand Laceration



• Stop bleedingStop bleeding– Wear glovesWear gloves– Direct pressureDirect pressure– 1 gauze at a time 1 gauze at a time

• Decide if repair neededDecide if repair needed– No No wash, antibiotic ointment, bandage wash, antibiotic ointment, bandage– Yes Yes wash, cover with saline soaked wash, cover with saline soaked

gauze(s)gauze(s)

http://upload.wikimedia.org/wikipedia/en/thumb/1/15/First_aid.svg/800px-First_aid.svg.png



• DoctorDoctor– MostMost– All if:All if:

•ContaminatedContaminated

•Persistent bleedingPersistent bleeding

•Across/near vital structuresAcross/near vital structures

•Associated with fractureAssociated with fracture

• Back to class if Back to class if veryvery superficial superficial

Head InjuriesHead Injuries

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

Head InjuriesHead InjuriesWhat to Ask?What to Ask?• What happened?What happened?

– Witnessed?Witnessed?– Fall vs. blunt Fall vs. blunt

trauma?trauma?– How far/hard?How far/hard?– What surface?What surface?– How landed?How landed?

• SymptomsSymptoms– Loss of consciousness?Loss of consciousness?

• Immediate/delayed?Immediate/delayed?

• How long?How long?

• Motor activity?Motor activity?– StiffStiff– JerkingJerking– LimpLimp

– Vomiting?Vomiting?• Immediate vs. delayed?Immediate vs. delayed?

• How many times?How many times?

– Weak/numb/AMS?Weak/numb/AMS?

• Headache?Headache?– SeveritySeverity– WorseningWorsening

• Neck/back injuryNeck/back injury

• Other pain?Other pain?

• H/o seizures, fainting?H/o seizures, fainting?

• MedicationsMedications

Head InjuriesHead InjuriesWhat to Ask?What to Ask?



• HeadHead– Contusions, feel for the bottomContusions, feel for the bottom– Step off (depressed skull fracture)Step off (depressed skull fracture)– LacerationsLacerations– Battle sign/Racoon eyesBattle sign/Racoon eyes

• Spine (top to bottom)Spine (top to bottom)

• CNS/other injuriesCNS/other injuries

Depressed Skull FractureDepressed Skull Fracture

Battle SignBattle Sign

Raccoon EyesRaccoon Eyes

Intracranial BleedingIntracranial Bleeding

Epidural Hematoma Brain Contusion


What to do? Where to go?What to do? Where to go?

• Assume spine injuryAssume spine injury– Stabilize C-spineStabilize C-spine– Keep child still, laying downKeep child still, laying down

• EMSEMS– Loss of consciousnessLoss of consciousness– Persistant mental status changesPersistant mental status changes

• Back to class if mild, asymptomatic after Back to class if mild, asymptomatic after

OverheatingOverheating

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

OverheatingOverheatingWhat to ask?What to ask?

• What’s wrong?What’s wrong?– Heat rashHeat rash small red bumps in hottest areas small red bumps in hottest areas– Heat crampsHeat cramps arms/legs/abdominal muscles arms/legs/abdominal muscles– Heat exhaustionHeat exhaustion Dizzy, nausea, vomiting, Dizzy, nausea, vomiting,

headaches, weakness, muscle pain, clammy.headaches, weakness, muscle pain, clammy.– Heat strokeHeat stroke Above except dry skin, confused (to Above except dry skin, confused (to

coma), seizures, dry hot skincoma), seizures, dry hot skin

• How did it happen?How did it happen?

• Medications/drugs?Medications/drugs?



• Take core temperatureTake core temperature– T 104 for Heat StrokeT 104 for Heat Stroke– May be normal for othersMay be normal for others

• Mental statusMental status

• SkinSkin

• PulsesPulses

OverheatingOverheatingWhat to do?What to do?

• Remove Remove from heatfrom heat

• Rapidly Rapidly coolcool



• Heat rash Heat rash back to class back to class

• Heat cramps Heat cramps usually back to class usually back to class

• Heat exhaustion Heat exhaustion Doctor, EMS if Doctor, EMS if severesevere

• Heat stroke Heat stroke EMS, life threatening EMS, life threatening

Thank You!Thank You!

Documents

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