Emergency Splinting and Trauma First Aid

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Emergency Splinting and Trauma First Aid

• Coburn H. Allen, MD
• Pediatric Emergency Medicine
• Pediatric Infectious Diseases

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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

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Common Injuries

• Bumps and Bruises
• Scrapes
• Sprains
• Strains
• Fractures

• Oral Trauma
• Nose Bleeds
• Lacerations
• Head Injuries
• Overheating

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Bumps and Bruises

• Bobby Bobo, a 5 y/o boy, fell down in class while
  chasing the teachers 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.

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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)

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Bumps and Bruises

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

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Nonaccidental Trauma
Bite
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Bumps and Bruises

• What to do?
• Cold pack
• Tylenol
• Most need nothing
• CPS?
• Law is if suspiciousreport.
• You are protected
• Confidential

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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 [phone]

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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)

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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.

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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)?

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Scrapes

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

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Scrapes

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

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Scrapes

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

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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!

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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.

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Sprains

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

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Ankle Sprain
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Knee Sprain
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Septic Joint
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Sprains

• What to do?
• pRICEmmms
• Protect the joint crutches, slings, tape
• Rest
• Ice
• Compression
• Elevation
• Medication, modality (PT), motion (keep loose)
• Strength

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Sprains

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

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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.

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Strains

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

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Sprain Mechanisms
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Strains

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

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Strains

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

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Strains

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

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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.

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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)?

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Fractures

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

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Fractures

• What to do?
• Stabilize Splinting
• Joint above and below fracture
• Not too tight, use padding
• Not too loose, shouldnt wiggle
• Dont hide the extremity, not circumferential
• Pain control
• Ice
• Medications

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Ankle Pillow Splint
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Lower Leg Splint
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Long Leg Splint
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Finger Splints
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Wrist (Volar) Splint
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Upper Arm Splint
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Cervical Spine Splints
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Fractures

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

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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.

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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?

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Oral Trauma

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

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Tooth Anatomy
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Avulsed Teeth
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Fractured Teeth
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Intrusion
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Tongue/Mucosal Trauma
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Oral Trauma

• What to do?
• Teeth
• 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

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Oral Trauma

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

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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

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Nose Bleeds

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

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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?

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Nose Bleeds

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

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Nose Bleeds

• What to do?
• Pinch x 10-20 minutes (dont peek)
• Dont put head between legs
• Dont blow nose
• Afrin if available
• No PICKING!

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Pennys Father
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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

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Lacerations

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

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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

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Lacerations

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

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Scalp Laceration
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Forehead Laceration
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Hand Laceration
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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)

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Lacerations

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

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Head Injuries

• Goofus McDoofus, 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.

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Head InjuriesWhat 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?

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Head InjuriesWhat to Ask?

• Headache?
• Severity
• Worsening
• Neck/back injury
• Other pain?
• H/o seizures, fainting?
• Medications

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Head Injuries

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

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Depressed Skull Fracture
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Battle Sign
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Raccoon Eyes
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Intracranial Bleeding
Epidural Hematoma Brain
Contusion
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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

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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. Its 102 degrees and he is wearing
  two sweat suits and a wool ski cap.

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Overheating

• What to ask?
• Whats 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?

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Overheating

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

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OverheatingWhat to do?

• Remove from heat
• Rapidly cool

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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

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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

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