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A Case Study: Children and Falls

boy climbing a tree; A Case Study: Children and FallsFalls from heights are second only to automobile crashes as the leading cause of traumatic injury for children. Kids fall from trees, roofs, balconies, trampolines, windows, playground equipment, second story open foyers and many other places.
 
The chances of a successful outcome for a child who has fallen often times depends on the information from the EMT's assessment of the child and how much they share with the trauma team. One missing or inaccurate fact can make a huge difference in outcome.

Take the case of a 13-year-old boy who fell from the top of a pine tree. When the boy got to the top of the tree, a branch that he stepped on snapped. As he was in free fall, the boy hit a number of branches on the way down, which helped to slow down the fall. The 13-year-old's chest and flank received most of the injuries. But he did not suffer any head trauma when he eventually landed in a soft, grassy area.

After bystanders called 911 and an EMT basic service responded, it was not communicated to the trauma team that the boy had fallen 40 feet.

On arrival, the EMTs found the child awake but drifting in and out of consciousness. He was able to tell the EMTs that he did not hit his head. He also told them he remembered the fall. He had pain in his right wrist, chest and torso and stated that it was difficult and painful to breathe.
 
Exam revealed:
Airway: patent
Breath sounds: Labored and diminished on right side
Pulses: Thready, weak and tachycardic
Capillary refill: 3 to 4 seconds
Pain: 10/10
B/P: 102/68
HR: 128
RR: 30
Vitals:
B/P 102/68-128-30
The patient's cervical spine was maintained, non re-breather was placed and right arm splinted. Med Flight was requested to meet the EMS crew at the hospital.

Two large bore IV lines were inserted and the appropriate fluid bolus was administered (10-20ml/kg). After the bolus was infused, it was noted that the capillary refill improved to 3 seconds and pulse rate decreased to 96/minute. EMS was not completely satisfied with these results and began the second bolus of fluid. After this bolus, capillary refill increased to a brisk 2-3 seconds and his pulse was down to 96/minute.

Initally the child's blood pressure was "normal." But the EMTs were not deceived. They were aware that children can maintain a normal blood pressure even after losing 25% to 30% of their total blood volume. Prior to the two boluses, the child was in compensated shock.

After arrival to the emergency department, it was noted that the patient had a right neumothorax, pulmonary contusions and a very contaminiated right wrist fracture. A cather placed in his bladder noted a large amount of red blood in the urine. The child became very agitated and he became tachycardic. Prior to Med Flight's arrival, he received two units of O negative blood.

Further evaluation by the UW Hospital trauma team noted a fractured right kidney (noted to be "pulverized"), liver laceration, several broken ribs with increasing lung contusions and right wrist fracture.
 
He was taken to the operating room where he was stabilized and his kidney was removed.

His right wrist was cleaned and reduced prior to transferring him to the pediatric intensive care unit where he stayed for several days. During his stay in the intensive care unit, he remained intubated in order to support his respiratory system while his lung contusions healed.

After receiving extensive blood products due to the blood loss from the kidney injury, he was discharged to his home after 14 days of hospitalization.

One year later, the child is doing very well and is a member of his school's track team. When asked what prompted him to climb the tall tree, he stated, "Because it was there."