Regarding anatomical and physiological features in children that should be considered in the management of trauma, which ONE of the following is TRUE?
Answer: D: Children are a diverse group of people and vary enormously in weight, size, shape, intellectual ability and emotional responses. The larynx is situated anteriorly and superiorly at the level of C2–C3, making intubation in children difficult. The child relies on the diaphragm for breathing with the horizontal ribs hardly contributing. The infant has a greater metabolic rate and oxygen consumption and accounts for the higher respiratory rate of infants. However, the tidal volume remains relatively constant in relation to the body weight throughout childhood. The work of breathing is also relatively unchanged at about 1% of the metabolic rate. The child’s circulating blood volume per kilogram of body weight (70–80 mL/kg) is higher than that of an adult, but the actual volume is small. This means that in severe trauma in infants and small children, relatively small absolute amounts of blood loss can be critically important.
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Regarding major trauma in children, which ONE of the following statements is TRUE?
Answer: B: Head trauma is the most common single organ system injury associated with death in injured children. The child’s head-to-body ratio is greater, the brain is less myelinated and cranial bones are thinner, resulting in more serious head injury. However, multiple injuries are common in children because the small body size allows for a greater distribution of forces.
The chest wall of children is pliable and will take a large amount of force to fracture and their mediastinum is more mobile than in adults. Children often have significant intrathoracic injuries without signs of trauma on the thoracic wall. The presence of fractured ribs is therefore an ominous sign in children. Unlike in adults, pulmonary contusions and pneumothoraces without associated rib fractures can often occur in children.
The child’s internal organs are more susceptible to injury because the abdominal wall is thin, the liver and spleen are more anteriorly placed and the diaphragm is more horizontal, causing the liver and spleen to lie lower.
In children, the bladder being mostly an intraabdominal organ, is prone to injury.
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Which ONE of the following injuries is NOT typically considered as a non-accidental injury (NAI) in a child 2 years of age?
Answer: B: Bruises in NAI are common to soft tissue areas rather than bony prominences. Additionally, certain fracture patterns have been found more characteristic of abuse than others. Metaphyseal fractures of long bones showing chip fractures at the corner of the metaphysis are due to violent torsion or traction injury and pathognomonic of NAI. Rib fractures are usually multiple and symmetrical and most occur posteriorly, resulting from maximal mechanical stress at the costovertebral junction as the child is grasped and shaken. Spiral fractures of long bones from NAI are also common, but under the age of 3 this should be differentiated from the spiral fractures of the tibia as seen in toddlers first starting to walk.
Which ONE of the following is the MOST common manifestation of abusive head trauma in children?
Answer: A: Abusive head trauma (shaken baby syndrome or shaken impact syndrome) is a form of inflicted head trauma and is the leading cause of child abuse fatalities. It is a well-recognized clinical syndrome caused by violent shaking of infants, direct blows to the head, dropping or throwing a child, and asphyxia. Retinal haemorrhages, subdural haematomas and diffuse axonal injury strongly suggest abusive head trauma (AHT), especially when they co-occur. Retinal haemorrhages are virtually pathognomonic of AHT. Although retinal haemorrhages can be found in other conditions, haemorrhages that are multiple, involve more than one layer of the retina, and extend to the periphery are very suspicious for abuse. The mechanism is likely repeated acceleration-deceleration due to shaking. Retinal haemorrhages are present in 80% of children suspected of NAI, whereas 60% of acute subdural haemorrhages in children are related to NAI. Fractures are seen in approximately 35% of children with NAI.
Which ONE of the following statements is TRUE in the assessment of motor function in a patient with a severe head injury?
Answer: C: A decerebrate or extensor posture response suggests severe midbrain injury. The arms are held extended and internally rotated and the legs are extended. Decorticate or flexor response suggests severe ANSWERS ANSWERS 251 intracranial injury above the level of midbrain. Here, the arms are held in flexion and internal rotation while the legs are in extension.
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