emergency injuries in a school setting: head to toe€¦ · emergency injuries in a school setting:...
TRANSCRIPT
1
Emergency Injuries in a School
Setting: Head to Toe
Dee Hodge III, MD, FAAP, FACEP
Professor of Pediatrics
Washington University School of Medicine
Attending Physician, Emergency Department
St. Louis Children’s Hospital
2020
Dee Hodge III, MD, FAAP,FACEP
I have no financial relationships to disclose
2
Head Trauma
Pathophysiology
Primary injury Brain Damage
Secondary Injury
CNS Reactive Lesion
Systemic Injury
Head Trauma - EvaluationHistory
Height of fall and surface struck
Loss of consciousness, memory loss
Disorientation
Visual disturbance
Seizure
Vomiting
3
Head Trauma - EvaluationPhysical examination
Initial respiratory rate and pattern
Pulse and blood pressure
Level of consciousness
A-V-P-U
Glasgow Coma Score
Head TraumaConcussion
Trauma induced alteration in mental status
With or without LOC
4
Head TraumaConcussion
Mental status changes
Amnesia
Confusion
Disorientation
Easily distracted
Excessive drowsiness
Felling dinged, stunned, or foggy
Poor concentration and attention
Slow to answer / follow directions
Head TraumaConcussion
Physical or somatic
Ataxia or loss of balance
Blurry vision
Dizziness
Double vision
Sensitivity to light or noise
Fatigue
Headache
Nausea, vomiting
Slurred, incoherent speech
5
Head TraumaConcussion
Behavioral or psychosomatic
Emotional lability
Irritability
Low frustration tolerance
Personality changes
Nervousness, anxiety
Sadness, depressed mood
Head TraumaConcussion
Neuropsychometric Testing
Amnesia after testing
Attention span
Mental flexibility
Motor speed
Orientation
Reaction time and processing speed
Verbal memory
Visual scanning
6
Head TraumaConcussion
Neuropsychometric Tests
Automated Neuropsychological Assessment Metrics
(ANAM)
CogSport
Concussion Resolution Index (CRI)
Immediate Measurement of Peerformance and
Cognitive Testing (ImPACT)
Standardized Assessment of Concussion (SAC)
Concussion - Management
Variable time course for recovery
2 weeks to several months
Stepwise approach
No activity to light exercise
Sport specific exercise
Educational accommodation
7
Concussion - Management
MO Guideline* has three main provisions:
Education of athletes, parents/guardians and coaches
about the signs and symptoms of suspected concussion
Removal of athlete from practice/play at the time of
suspected concussion
No return to practice or play without clearance from a
licensed healthcare provider
*167.765 RS MO
MSHSAA
www.cdc.gov/Concussion
8
Eye Injuries in ChildrenU.S. Emergency Departments 1990 - 2009
Pollard KA et al Clinical Peds 2012;51:374-381
"The Red Eye"
Ciliary injection injection greatest at
limbus.
lessens as move to
palpebral conjunctiva
Conjunctival injection
palperbral conjunctiva
injected more than bulbar
9
Trauma
Chemical burns
Hyphema
Rupture of globe
Periorbital infection
Conjunctivitis (minimal)
Central retinal artery occlusion (rare)
Ophthalmologic EmergenciesConditions causing visual disturbance acutely
10
NPO
Shield
No topical medications
Immediate ED referral
Globe lacerationsTreatment
11
12
Courtesy of Robert Kennedy, M.D.
Courtesy of Robert Kennedy, M.D.
Oral / Dental InjuriesTongue Lacerations
Consider repair if:
Large flap
Active uncontrollable bleeding
Edge involvement
Completely through
13
Oral/Dental InjuriesHard dental tissue and pulp
Uncomplicated tooth
fracture
Complicated tooth
fracture
Crown root fracture
Alveolar fracture
14
15
Oral/Dental InjuriesAvulsion
Periodontal ligament healing key
Healing dependent on:
Duration of extra-alveolar period
Storage conditions/media
Root development
Patient age (> 16 yrs. healing)
Immediate re-implantation to minimize complications
Oral/Dental InjuriesAvulsion
Storage media
Saliva
Milk
Hank’s Balanced Salt Solution
Normal saline
All better than dry or tap water
16
Oral/Dental InjuriesTechnique for re-implantation
Re-implant if permanent tooth; timeliness is key
Make sure tooth socket is clean
Handle only crown of tooth as much as possible
If debris on root rinse off
Fit tooth back into socket
Immediate referral for splinting
Complications of re-implantation
root reabsorption, ankylosis
17
Wound ManagementMyth #1 – Plastic Surgeons don’t leave
scars
Wound Healing – 3 Overlapping Phases
Inflammation
Proliferation
Epithelization of edges
Remodeling
At least 1 year
Wound ManagementDefinitions
Primary Closure
Secondary
Tertiary (delayed primary closure)
18
Wound ManagementMyth #2 – Lacerations crossing the
vermilion border need Plastic Surgeons
Wound ManagementWounds Requiring Plastics Consultation
Amputation/partial amputation
Significant loss of tissue
Nerve/ Tendon/ Muscle involvement
Complex closure requiring > 45 min sedation
time
Wound ManagementFactors influencing wound closure
Location
Degree of contamination
Time from injury
19
Wound ManagementTime since wounding
Wounds > 10 hrs higher risk of infection
Face and scalp – lower risk
Up to 18 hrs
May be extended in certain situations
Wound ManagementDefinitions
Primary Closure
Tape, staples, sutures, ‘skin glue’
Clean, minimally contaminated
< 12 hrs old
Wound Management
Skin Tape
Kuo et al Dermatol Surg 2006
20
Wound ManagementClosure Options
Suture – absorbable vs. non-absorbable
Tissue adhesive
Studies w/ follow-up 9-12mos after repair
No difference in cosmetic outcomes
Wound ManagementClosure Options
Suture – absorbable vs. non-absorbable
Tissue adhesive
Studies w/ follow-up 9-12mos after repair
No difference in cosmetic outcomes
Wound ManagementDefinitions
Primary Closure
Secondary – no sutures
Non-cosmetic
Animal bites
Abscess cavities
21
Wound ManagementDefinitions
Primary Closure
Secondary
Tertiary (delayed primary closure)
> 12 hr old
Infection prone wound
Contaminated
Observe 72 – 96 hrs before suturing
Wound ManagementImmediate vs. Delayed Closure
Little consensus regarding ‘Golden Period’
Multiple factors in play
Host factors
Age
General health / nutritional state
Immunocompromised conditions
Imnmuno-suppresive medications
Wound ManagementInfection Rate Non Bite Wounds
Cochrane review (2013)
Infection rate vs. time of wound closure
No studies met inclusion criteria
Limited observational studies
Trunk and extremities higher rate after 19 hrs.
Facial low infection with adequate irrigation
22
Wound ManagementTo close or not to close?
Close full thickness wounds
Do not close if > 18 hrs. old
Do not close if bite wound on extremity or
trunk
Consider delayed primary closure
> 18 hrs. old
Infection prone wound
Wound ManagementIrrigation in Acute Wounds
Cornerstone of wound management
Reduces wound infection rate
Ideal technique still undecided
High pressure irrigation
35 – 65 ml syringe w/ 19G needle
May be different depending on:
Level of potential contamination
Foreign body / debris
Wound ManagementIrrigation in Acute Wounds
Cornerstone of wound management
Reduces wound infection rate
Ideal technique still undecided
High pressure irrigation
35 – 65 ml syringe w/ 19G needle
May be different depending on:
Level of potential contamination
Foreign body / debries
23
Wound ManagementMyth – Wounds must be irrigated with
sterile saline Cochrane review of 11 trials
In adults
Tap water more effective then saline in reduction
of infection rate
In children
No statistical significant difference in infection
rate
Limitation – no standard criteria for assessment
24
Wound Management Tissue Adhesive
Butyl-cyanoacrylates
Indermil / Quik set
Octyl cyanoacrylates
Dermabond
Octyl cyanoacrylates more
flexible and stronger
Do not use over areas of high
tension
25
Wound Management
Tip – Many hand lacerations do not
require sutures
Wound ManagementHand Lacerations
Suture vs secondary intention
Laceration < 2cm
RCT with n=91: Adults
Follow up at 3 mos.
Blinded evaluation
Similar cosmetic and functional outcome
Quinn, et al BJM 2002
Wound ManagementSuture removal
Face – 2-4 days
Upper extremity – 7-10 days
Lower extremity – 7-10 days
Extensor surface/ joint – 10-14 days
26
Wound ManagementAdditional Tips
Cyanoacrylates and staples quickest closure
methods
Small, simple hand lacerations do not require
primary closure
Sterile gloves have no advantage over nonsterile
gloves
Clean tap water as effective as sterile saline
Cyanoacrylates or absorbable sutures advantage of
no return visit
Sport InjuriesDevelopmental Causes
Too Much, Too Fast, Too Soon
Poor flexibility
Hyper-flexibility
Muscle underdevelopment
Immature apophyseal regions
Muscle weakness
Muscle inequality
Poor form / poor coordination
27
Orthopedic Injuries Strain
Injury to Muscle -Tendon Unit
Grade I - Minimal disruption and mild local
tenderness
Grade II - Partial tear with bleeding and
spasm
Grade III - Complete disruption
Orthopedic Injuries Sprain
Injury to ligamentous structure
Grade 1 - Stretching / Microscopic tearing
Grade 2 - Partial overt tearing with some
continuity
Grade 3 - Complete loss of ligamentous
continuity
28
Orthopedic Injuries Orthopedic Referral
Structurally significant fractures
Obvious deformity
Evidence of neurovascular compromise
Open fracture
Dislocation with neurovascular compromise
Open dislocation
Shoulder Dislocation
Shoulder Dislocation
Unusual prior to closure of physis
95% anterior
Fall or blow to abducted externally rotated arm
Check for axillary nerve damage
Reduction
Frequently need sedation
Post reduction films
Shoulder immobilization
29
Wrist Injuries
Wrist Injuries
Sprains unusual prior to closure of physis
Point tenderness key finding
Minimal swelling with subtle fractures
Splinting may be sufficient
ACE wraps questionable
30
Anterior Knee Pain
History
Pain is gradual, insidious onset
Associated with preceding factor
Worse at start and completion of exercise
Exacerbating factors
No history of true locking
Anterior Knee Pain
Exam
Mild swelling
Tenderness
No loss of range of motion
Hip range of motion should be normal
Anterior Knee Pain
Treatment
Rest, ice, nonsteroidal anti-inflammatory drugs
Encourage cross-training
Stretching and flexibility of quadriceps
Strengthening of quadriceps
Consider physical therapy
31
Anterior Knee Pain Reason for Orthopedic Referral
Features of structural knee pain
Persistent or recurrent knee swelling
Locking, instability or restricted joint motion
No improvement in 4 to 6 weeks
Structural Knee Pain
History
Pain of acute onset
History of audible “pop” or “crack”
Starts at time of injury
Precludes keeping knee flexed
History of true locking or unstable feeling
Knee Injuries Osgood-Schlatter Disease
Overuse apophysitis of tibial tubercle
Common in adolescents
Signs
Pain over tibial tubercle
Prominence of tibial tubercle
Treatment
Rest, NSAIDs, rehabilitation exercises
32
Knee Injuries Patellar Dislocation
Common in adolescents
Lateral displacement of patella
Rule out concomitant fractures
Reduction
Extend leg while pushing patella medially and up
Post reduction films
Non-weight bear & knee immobilizer x 4 to 6
weeks
Shin Pain / Shin Splints
Medial Tibial Stress Syndrome – MTSS
Pain worse after running
Tibial Stress Fracture
Anterior Tibial Stress Injury
Exertional Compartment Syndrome - ECS
“Tightness”
Pain worse with exercise
Lumbar radiculopathy
All treated with rest
33
Ankle Sprain
Ankle Injuries Indications for x-ray
Rapidly expanding hemarthrosis
Obvious dislocation
Eversion injuries
Point tenderness over bone
Inability to bear weight
Ankle SprainsClassification
Grade 1 Grade 2 Grade 3
Tenderness + + ++
Swelling + + ++
Ecchymosis 0 + ++
Weight Bearing
+ pain none
34
Ankle SprainManagement
Grade 1
R-I-C-E
Isometrics when comfortable
Active ROM when isometrics pain free
Grade 2
I-C-E
Splint (sugar-tong splint, Aircast)
Rehab after 2 weeks
Grade 3
Casting required
Ankle SprainManagement