Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Tiny Bodies, Big Differences: Why Your Pediatric Trauma Approach Matters with Professor Brenda Morrow
Physiotherapists often find treating pediatric trauma patients in intensive care challenging due to limited specialized training. Professor Brenda Morrow, an internationally renowned expert in pediatric physiotherapy, brings clarity to this complex subject, explaining why children are fundamentally different from adults in trauma care. Beyond the physiological aspects, Professor Morrow emphasizes the importance of child-centered care. Children are vulnerable, dependent on adults, and often don't understand what's happening to them during medical interventions. Including caregivers in treatment planning and incorporating play-based approaches significantly improves outcomes and emotional wellbeing. Join us to gain essential insights that will transform your approach to pediatric trauma care and ensure you provide the safest, most effective interventions for these vulnerable patients.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. So welcome back and thank you for joining me for this episode. I'm sure you, as the listener, would agree that physiotherapists often find it quite stressful to treat patients in the intensive care unit, especially because of patient severity of illness.
Speaker 1:And throw into the mix traumatic injury, then our stress levels tend to go up, and even more so when patients are pediatric patients, and for that reason I have asked Professor Brenda Morrow to join me for this discussion about physiotherapy management of patients with paediatric trauma and to understand the differences in anatomy between children and paediatrics. So Professor Brenda Morrow is a very renowned physiotherapist in pediatric care and Brenda and I have known each other for many years. We are co-editors of the textbook Cardiopulmonary Physiotherapy and Trauma an evidence-based approach, and Brenda is a very well-known physiotherapy expert in pediatrics in South Africa but also internationally. Brenda, welcome to this discussion.
Speaker 2:Thanks so much, Helene. I'm glad to be here.
Speaker 1:So, brenda, would you mind telling our listeners a little bit about yourself?
Speaker 2:Yes, sure. So I qualified as a physiotherapist in 1995, and I have been based at Red Cross War Memorial Children's Hospital in Cape Town since 1996, since qualifying. So I've worked as a pediatric physiotherapist and as a clinician scientist since 1996. I am currently employed as a professor in the Department of Pediatrics and Child Health at UCT and I have both clinical and research experience in general pediatrics with experience clinically in general and trauma wards. But my focus really has been on pediatric intensive and critical care and that's my main clinical and research interest.
Speaker 2:And I think, unfortunately, the pediatric ICU is where the most severely injured children are going to be managed following trauma and we see many cases of head injuries and polytrauma from both accidental and non-accidental injuries, and that includes, unfortunately, in the South African setting, many penetrating injuries from gun violence. And just my background I think prior to the first edition of our book that we edited together, there really was very little evidence or clinical guidance for the physio management of traumatically injured children and really we were managing off the seat of our pants. We were just basing our practice on what we could extrapolate from adult data and from our own knowledge. But we really didn't have much guidance in the past until we put this book out, and I'm hoping that that helps people moving forward.
Speaker 1:Yes, indeed, me too, and I think people understand that. You are definitely well suited to discuss with us this evening the difference between pediatrics and adults, and regarding anatomical features and physiological principles, and also to give some pointers towards the end of the episode of what physiotherapists need to know and remember as they treat these patients in the unit. So am I correct in saying that the term pediatrics is an umbrella term for infants, children and adolescents up to the age of 16?
Speaker 2:So there are different definitions that people use throughout the world. Some people take a pediatric age group up to as high as 21. And generally people take it until 18 and then some until 16. So, yes, it's an umbrella term for infants, young children and adolescents. And I say that the top end of that range is a little bit variable and my experience is largely until 13, just because that's in government practice where you know, pediatric hospitals admit children until the age of 13, largely practice where pediatric hospitals admit children until the age of 13 largely. But we do include and we have to consider the special needs of adolescents as well.
Speaker 1:And in your experience, Brenda, what have you seen to be the causes of traumatic injury in children and infants?
Speaker 2:So we have to understand again that the spectrum of pediatrics is very large. So we're dealing from very small babies to adolescents who are much bigger in stature than I am, for example, and so you know we have to understand that that is a spectrum and so the spectrum of injury is also different. Children, especially young children, do have different types of injury patterns and causes of injury compared to adults because of their changing physical growth and their maturation neurodevelopmentally. So we know an infant that cannot really move independently to a child that's running and jumping and climbing, climbing. So pre-adolescent children, once they can move independently, are really at the biggest risk of injuries from falls, from accidents in the playground, at school or in parks, for example. And what we see a lot of, unfortunately, is household hazards, because they're small and they are curious, so they tend to reach up onto counters and pull things down on them. They don't really recognize dangers themselves because they don't have experience and they can't read, so they don't recognize those dangers. They don't remove themselves from dangerous situations. As I said, they tend to climb whatever they can, they squeeze into small places and injure themselves in those ways, and then when you look at older children, especially adolescents, they often get injured in more similar ways to adults. They tend to engage in more high-risk behaviors voluntarily jumping from high rocks, for example, into rivers or the sea and the older adolescents in our country as well really present a lot with motor vehicle accidents with penetrating trauma. So there are lots of risky behaviors there. When we look at South Africa specifically, unfortunately vehicle accidents are very, very common involving children. We see a lot of pedestrian accidents where children are walking in the streets where there are no pavements, or even on the pavements with an adult, and then we see motor vehicle accidents where the child is not restrained in the car. They're not in car seats. So that's a huge issue and unfortunately children are dependent on adults. We have to be caring for them, but this also makes them vulnerable to child abuse.
Speaker 2:Non-accidental injuries We've recently done an audit in our ICU and we really see that head injuries unfortunately are the most common in non-accidental cases of injury, including shaken infant syndrome, and so these are really upsetting cases.
Speaker 2:But we do need to be aware of that and we know that in the pediatric ICU context the mortality rate for children who present with injuries from non-accidental injury for abuse is significantly higher than for the general pediatric ICU population. And the other thing that's concerning is we've seen that a big proportion of survivors have long-term disabilities, and I think the other thing to say is that even where you have the same accident involving both a child and an adult, the injury patterns can differ. So if you think, for example, a pedestrian MVA motor vehicle accident, you have an adult that's hit by the bumper of a car. It's likely to cause a long bone fracture in the lower limb, whereas the child who's smaller is going to be hit on the abdominal thorax. Child who's smaller is going to be hit on the abdominal thorax and so, as a consequence, the smaller the child, the greater is the risk of multiple injuries from a single impact or a single event.
Speaker 1:Yeah, no, definitely, and I think it's important to remember that. You wrote in the textbook, the chapter in the textbook, that children move in a different sphere to adults and they're closer to the ground. Yeah, because they're smaller. Um, yeah, and therefore a single traumatic event can be more life-threatening for a child than that same traumatic event might be for an adult. Yes, exactly, yeah. So, brenda, brenda, when a physiotherapist stands by the bedside of an infant or a child with traumatic injury, what is important for them to remember about the airways, the breathing and the respiratory system of those types of patients versus adults?
Speaker 2:Thanks for that question. It's a mantra that people working in child health use is that infants and children are not just small adults, and I think it's important to emphasize that for people who aren't working with children regularly or routinely. So there are differences in all of those aspects in the airways, in breathing mechanics and in the anatomy of an infant versus an adult, and obviously this is a continuum because as the child grows and develops, the anatomy and the breathing mechanics and the physiology becomes closer and closer to adult levels or standards. So there's not an absolute cutoff in age where these things change, but we have to be aware that there is a difference. So when I try and compare the differences, I'm largely talking about infants versus older children and adults and, as I say, there's that continuum in the middle where things start to change. So if we look at the airways to start with, maybe so if you look at infants and you look at their proportions, they look different. Their heads looked relatively larger to the rest of their body. At the same time, their tongue is relatively larger. Their oral cavity is relatively smaller, which increases the risk of upper airway obstruction, and so you need to be aware of proper head and jaw positioning, so that airway opening procedure needs to be done carefully in infants. As a physio, you need to be aware of the way the child's head and neck is positioned, to try and optimize their upper airway as well. And then, for the first few months of life, babies breathe through their nose. They life babies breathe through their nose. They don't really breathe through their mouth, and the reason that that happens is it allows them to breathe and drink at the same time in order to get enough nutrition in to grow, so they're able to swallow and breathe at the same time. But they're really then required to breathe through their nose and anything that obstructs their nose is going to put them into respiratory distress and that's anything like blood. It might be mucus. If they're orbital fractures, for example, that can really affect the upper airways significantly and that changes by about six to eight months. They can breathe completely normally through their mouths and it's not as much of a problem For the other airways, the smaller airways.
Speaker 2:They're obviously much, much smaller physically and they are compliant. They obstruct easily, even on just normal dynamic breathing, on expiration we have dynamic collapse of the airways, and this is more, so much more so in a small baby. So because they've got small airways, they've got compliant airways that are not well supported and they're prone to collapse and even slight swelling can cause significant obstruction. Or a very small amount of mucus or a small amount of blood or something like a tooth can cause major obstruction to a fairly large airway, which can impact, obviously, on their respiratory system. And, related to the tooth, the teeth, foreign body aspiration is really really common in children during traumatic injury, especially if they have loose teeth, so the deciduous teeth. We know children lose their teeth up until early adolescence sometimes, and during any traumatic event, those teeth can be dislodged and can enter the airways and so, as physios, we need to be very aware that there could be a foreign body in the airways and we just need to be aware that we need to have a high index of suspicion and refer if we're concerned about potential aspiration, rather than send a child for bronchoscopy sooner rather than later, because that can obviously cause damage.
Speaker 2:Yeah, in terms of the breathing mechanics, if you think about what a baby looks like even if people have not had babies or haven't had much clinical experience you can imagine what a toddler looks like. They have this lovely round, chubby look about them with almost a barrel-shaped chest as a normal chest shape. So in an adult if we have a barrel-shaped chest it's abnormal. In small children that barrel-shaped chest is normal and that's because the infant's ribs are horizontal. They're horizontally positioned. So in adults we have a lovely bucket-handled positioned ribs and when intercostals contract that bucket handle moves up and down. In infants, because the ribs are horizontal, although they have intercostal muscles, those ribs don't have anywhere to go. They're already horizontal. So that limits the lateral movements that bucket handle movement of of the chest wall. We don't really have that and, as I say, they are intercostal muscles. They are important for stabilizing that chest chest wall but they're not actively involved as much in the breathing.
Speaker 2:But the diaphragm is the main muscle for breathing. So so babies rely on their diaphragm is the main muscle for breathing. So babies rely on their diaphragm to breathe. And that means that anything that's impacting on diaphragmatic movement is going to be impacting on how the babies are breathing. That could be distension of the abdomen, bleeding into the abdomen, for example, and so we need to think about the importance of decompression of the stomach contents, abdominal contents after trauma to try and optimize diaphragmatic function.
Speaker 2:The other problem is that the infant's diaphragm actually has a different muscle fiber content to adults.
Speaker 2:It has fewer type one muscle fibers, which are our fatigue resistant muscles, our marathon muscle fibers, which are our fatigue resistant muscles, our marathon muscle fibers.
Speaker 2:So infants that are working hard and using their diaphragm more, actually, their diaphragm gets tired and they go into respiratory failure very, very quickly, and so we need to be aware that we mustn't be overtaxing these kids and actually making their respiratory distress worse, because they can go into respiratory failure really, really quickly.
Speaker 2:So another impact that can affect diaphragmatic function is the position that the physiotherapy uses during treatment. So the optimal position for diaphragmatic function would be in the head up position, because then the diaphragm is using gravity to contract and push downwards on inspiration and it really optimizes the mechanics of the diaphragm. It makes it easier for the child. If we lie the child flat or if we put them head down which we don't advocate at all anymore inverted postural drainage that diaphragm would then have to push up against gravity and push all the abdominal contents up on inspiration and, as we said, the diaphragm is prone to fatigue easily and so increasing that work increases the work of breathing and pushes the child into respiratory failure potentially. So we need to be aware of what position we choose to actually optimize diaphragmatic function and reduce the work of breathing.
Speaker 1:And that would more readily be in an upright seated position.
Speaker 2:That's right in a head up position, not necessarily seated all the way, but 30 to 60 degrees head up is usually the position that we would choose for a child with traumatic injury, and this is a very specific reason why you wouldn't choose that position. Yes, I just want to just mention about the ribs as well. If we're talking about the mechanics of breathing, I think this is quite important is that because we have cartilaginous ribs and, as I said, we're not using our intercostals, but the cartilaginous ribs are squishy, they make a very compliant chest wall and they don't give very good support for ventilation. So we've got this combination of the position of ribs, we've got increased compliance. Actually, because we have these cartilaginous ribs, we have a mechanical disadvantage to the intercostal muscles and that all makes it very difficult for an infant to increase their tidal volume on breathing. They can't increase the depth of breathing as well as adults and, as such, they tend to increase the rate of breathing before the depth.
Speaker 2:And that's really, really important for physios to know that tachypnea is one of the first signs that a child is going into respiratory distress and they need to be aware of that, that that's a warning sign for them. But the other thing with the cartilaginous structure of the ribs from a trauma perspective is that chest trauma, even direct chest trauma, might not result in rib fractures because we don't have bone, we've got cartilage and because they're cartilaginous ribs. Basically the force of the injury is transmitted internally and so children, following chest trauma, might have very, very substantial internal injuries, with pulmonary contusions for example, but there may be no obvious external signs and again, that's something you need to have a high index of suspicion again for internal chest injury, even if you don't have any external signs.
Speaker 1:Okay, yeah, that's very important. Before we continue, I just wanted to come back to the airways. I would like to just talk about the pediatric trachea in relation to the adult and what physiotherapists need to be careful about when they suction patients, for instance, or if they want to stimulate a cough, for instance.
Speaker 2:Okay. So if you're wanting to stimulate a cough yes, there are different ways that physios would do that you might want to. In a young infant you might be suctioning and then people use tracheal pressure quite a lot, a tracheal rub, to stimulate a cough. You do need to be careful because the trachea lacks, again, firm support until the child develops. And so if you are doing a tracheal rub over the trachea, you can actually cause inflammation and swelling and you can actually occlude the trachea and cause life-threatening airway obstruction. That's one aspect.
Speaker 2:The other aspect is the stimulation of the vagus nerve, which can cause quite substantial bradycardia, and young infants often have a degree of tracheomalacia. They've got floppy airways so you don't want to obstruct those airways, and so we generally say you should not do a tracheal rub until the child is at least nine months to one year of age. We also would not do a tracheal rub soon after extubation or if the child has any other signs of airway inflammation, for example inhalation burns. You wouldn't do a tracheal rub on those children at all. Yes, definitely on those children at all. Yes, definitely yeah, and their track is also shorter. So there's an impact on intubation which is usually not within our scope of practice, but being aware of where the endotracheal tube is in relation to the carina, so that you make sure that the child isn't intubated down, for example, the right main bronchus, which does happen sometimes.
Speaker 1:One probably could see that on a chest x-ray. Yes, exactly.
Speaker 2:Exactly.
Speaker 1:And also through auscultation, if you hear less air entry into one lung versus another.
Speaker 2:Yeah, but there are obviously other reasons for that as well. There could be a pneumothorax, there could be an effusion. So again, it's looking at clinical reasoning, but being aware of what the basic anatomy and physiology is, and then looking at your clinical presentation and putting it all together.
Speaker 1:Yes, for sure, Brenda. If we think about the circulatory system and the heart function, is there anything specifically important for physiotherapists to remember? There is I don't know if you want me?
Speaker 2:sorry, helene, just go back. I don't know if you want me to just talk a little bit about. I think it's quite important to talk about the issue of compliance of the chest wall versus the lung, because that also is impactful sorry, to physiotherapists as well.
Speaker 1:Okay, let's start with that.
Speaker 2:So if we're looking at sort of anatomical and physiological differences as well, I think it's really important to highlight. I spoke about the very compliant chest wall because of the cartilaginous ribs, but actually the lungs of small children and infants are relatively stiffer and less compliant than adults. So it's like having two balloons. You've got the very cheap balloons. When you try and blow them they pop very, very easily. The balloon that just doesn't expand well, doesn't get bigger. But if you go to the expensive party shops and you get the helium balloons, they're really nice and compliant and you can blow them up really, really big.
Speaker 2:Unfortunately, the lungs of children are the cheap balloons, so if you apply a positive pressure they're very, very prone to pneumothorax. So the combination of having the relatively stiff lungs and the compliant chest wall makes them prone to pneumothoraces on the application of positive pressure. So we have to be aware in adults, where you might use manual hyperinflation almost fairly routinely in the ICU, we are very, very cautious of doing that in the pediatric context, unless you're very careful about limiting the applied pressures and the applied volumes to the lungs, because that can cause lung injury and, as I said, can cause barotrauma as well. And then I think some of the other things that we also need to consider is in terms of potential obstruction and atelectasis. So I mentioned that they're very small airways that are easily obstructed, but we add to that the problem that children only develop their collateral ventilation channels from the ages of three and up, so an infant doesn't actually have a back route. So if they develop obstruction they develop quite large segment collapse as a result.
Speaker 1:Okay, so it is a complication that can often occur.
Speaker 2:Yes, exactly, and so I think the take-home message here really is that we have the risk of children really declining very, very quickly. They also, because they're breathing much faster, they've got higher metabolic rates, they've got higher different oxygen demands they can really decompensate really, really quickly, and so, as physios, you have to be aware of the potential complications of your treatment and the fact that children are going to be responding in different ways to adults. They can improve quickly, but they can also deteriorate really quickly as well.
Speaker 1:Yes indeed, I remember several years ago when I was just qualified and on call, one night I was called out to the neonatal ICU for a child who had developed atelectasis of the whole lung and you know, the right lung and I remember looking at this child's heart rate while I was treating the chest to try and remove the excessive secretions to help with re-expansion of the lungs and I was thinking I'm sure my heart rate is very similar to this child's heart rate at that point. It was the most stressful experience ever. But I'm glad to report that the baby's lung re-expanded very quickly after the treatment, so that was good.
Speaker 2:That's great. That's great, but sometimes it does go wrong and we just need to be able to intervene and recognize it quickly. I think.
Speaker 1:Yes, definitely Brenda. So let's move on to the circulatory system and the heart. What do physios need to remember when they treat pediatric patients?
Speaker 2:So I'm thinking in terms of the general cardiovascular system and trauma. So one of the aspects that's protective in children is they've got quite elastic tissues, which means that their mediastinum is really mobile, so the heart and the great vessels are able to move around, which really protects them from direct injury. But on the other hand it increases the risk of tension pneumothoraces. So again we need to have a high index of suspicion for tension pneumothorax in children where you have deviation of the mediastinum. What's nice about children is that they generally are healthier from a cardiovascular system perspective than adults. They generally don't have pre-existing disease, unless obviously there's something like a congenital heart defect, for example. But generally speaking children are pretty healthy from a cardiovascular perspective. They have different cardiac output to adults. At birth their cardiac output is about 200 mils per kilogram per minute, I think, and that decreases by half to about 100 by adolescence and towards adulthood. But now children can't actually increase their stroke volume because their left ventricles are actually less compliant than adults and so, similar to the breathing rate, they actually rely on changing their heart rate to maintain cardiac output. So that's something to remember. So children again are different to adults.
Speaker 2:If they are going to have a cardiopulmonary arrest it's usually secondary respiratory failure, not cardiac failure.
Speaker 2:So they've usually got a good, healthy cardiovascular system to start with.
Speaker 2:What happens is, because of hypoxia, they develop a bradycardia and the bradycardia is then going to reduce cardiac output, which then leads to a drop in blood pressure and they also have an underdeveloped sympathetic nervous system.
Speaker 2:So there's quite a dramatic drop in blood pressure that follows a bradycardia and the child very rapidly decompensates and arrests. And this happens literally within seconds and you can see it in the ICU. We see the SATs drop and very quickly the heart rate drops and the response there should be to provide oxygen and breath and the response there should be to provide oxygen and breath, not to immediately start compressions, and again, that's useful to know. So in adults they've changed to a CAB approach compressions, airway breathing in CPR, in cardiopulmonary resuscitation. In children we generally stick with the ABC because of the fact that an arrest is largely respiratory and not cardiovascular. So usually in the ICU, if you start, if you bag with 100% oxygen in the face of a bradycardia and hypoxic event, usually the children respond pretty quickly and their SATs improve and their heart rates improve as soon as their SATs improve as well.
Speaker 1:All right, then. We mentioned right at the beginning that because infants and children tend to move around in a different sphere to adults, they often develop injuries to the thorax, but also to the abdomen. Is there anything about the abdomen and the musculoskeletal system that's important for physiotherapists to keep in mind?
Speaker 2:So, again with children, they're smaller and so if they're faced with an impact or an acceleration or deceleration injury, that energy from the trauma is transferred about a much smaller area than in adults. But even though it's a smaller area there's a lot of organs packed into the abdomen, and so children can have very, very severe and multiple visceral damage with a traumatic injury. They also tend to have a much thinner abdominal wall. They don't have much adipose tissue yet by and large there are some children that do, but most children have less fat and also less muscle protection than in adults. So that gives less protection to their internal organs Because their diaphragm tends to be flatter, their liver and spleen are lower, which makes them more prone to injury with different circumstances.
Speaker 2:And if you think of things like seatbelt injuries, you can get intestinal damage very easily with a lower lap belt, for example. Handlebars on bicycles can cause very, very severe pancreatic injury, which is often not recognized until there's very severe secondary effects. And the motor vehicle accidents often result in liver and spleen injuries. And the other thing to remember that in infants the blood is actually an intra-abdominal organ and so it is often damaged in infant injuries as well. So we're looking for multiple injuries. You don't, again, always see external evidence of it, but we need to be aware. Any abdomen that's distended and with a history of the trauma, you need to think that there may be severe internal injury.
Speaker 1:Yes, indeed, and the mechanism associated with the injury, exactly as you mentioned. Yeah, okay, and then let's come to head and neck. You mentioned at the beginning also that you often see patients with traumatic brain injuries in the ICU. What do physiotherapists need to think about with those types of injuries?
Speaker 2:with those types of injuries. So I think we need to look at head and neck almost together, because you have to have a high index of suspicion of cervical damage if there's a head injury as well, because they are linked and babies have a relatively bigger head, they've got a bigger occiput, they've got a weak and short neck and so they've got a much higher risk of both head and cervical trauma. You can't see a head injury and not make sure that the cervical spine has been cleared. You have to look at both, and similarly, if you have a cervical injury, you need to check that there's no head injury as well.
Speaker 2:The one thing that's particular to children which we do see, is that the combination of having a relatively large head but having very lax spinal ligaments ligaments that almost hypermobile means that you get much greater vertebral movement with an injury, and what we see in children as a result we refer to it as skewora, which is spinal cord injury without radiological anomaly, in other words, there's no fractures specifically, but there can be significant spinal cord damage even though there are no fractures visible, and so you do need to make sure that these children have a full neurological examination.
Speaker 2:Just interestingly, I remember years ago, having a child in our ICU after a motor vehicle accident where this child had a very strange breathing pattern where one side of their chest was moving much more than the other. There was no pneumothorax, and it turned out it was. I remarked on this and observed it in the ward round and actually there was a paralyzed hemidiaphragm and there was no reason for this to be except that this child in fact had an unrecognized spinal cord injury, and so it was quite exciting for me as a young physio to be able to observe this and actually help in that diagnosis. And I think you know it would have been that diagnosis would have been delayed if it hadn't been for that observation.
Speaker 1:Yeah, and I think that's a very important point that you're raising there, because physiotherapists often spend more time around the bedside and assessing patients, and I think it's really important to keep the communication open with the rest of the trauma team so that we all ensure patients get the optimal care.
Speaker 2:Exactly. And then, if you're still thinking about the neck, the fulcrum, the spinal fulcrum is actually different in young children, so it's at C2 to C3 in very young children. So cervical spine injuries tend to occur much higher in children, if there's going to be an injury, than in adults, unfortunately. So that's something to be aware of as well. And then when we look at the head so I said, they've got a bigger head, but they also have open cranial sutures and fontanelles until well. The anterior fontanelle only closes after 18 months, for example, and you've got a posterior fontanelle that's open as well until two months. So this is a bit of a balancing act. So in some ways it's protective, because the cranial bones haven't fused. It allows some leeway for increased pressure. So if pressure develops, there is space for that brain to expand with the open sutures. So that's it.
Speaker 2:If you see that a fontanelle is bulging, you need to call someone quickly, because it's likely that there's increased intracranial pressure. The other problem, though, is because you have open sutures, it makes the brain directly vulnerable to injury as well. So there's a bit of a yeah, it's a bit of a catch-22 there. It does offer some protection, but it also affords potential hazards, and they also have thinner cranial bones, so that gives less protection as well. And the intracranial pressure is actually a bit smaller in children than in adults, and so a small increase can have very significant effects. So you need to be very aware of your intracranial pressures and any change in intracranial pressure needs to be taken very seriously in kids. So you need to, you do need to handle. Any child with a head injury needs to be handled very carefully yeah, no, I think you know.
Speaker 1:you've given us much food for thought and I think it's clear to the listeners that infants and children are not just small adults. There's definite differences that we need to keep in mind as we treat these patients. Brenda, are there any other thoughts that you would like to share with the listeners?
Speaker 2:So I just think, you know, as an advocacy perspective, I think we all need to be very aware of trauma in children, protection of children and I think physios have a place in that in prevention of injury, in education and in advocacy.
Speaker 2:But I think from a practice perspective, as physios, we have to remember that we're dealing with an injured child but, more importantly, we are dealing with a child.
Speaker 2:The child is vulnerable, they're reliant on adults for everything, and traumatic injuries and hospitalization and medical interventions are frightening and they're painful and many children these children are so young they don't understand what's happening, and so treating these children gently and carefully and using child appropriate interventions is really important to help them deal with this. And I think I have to just say that we can't separate the parents if it is an appropriate loving relationship with a caregiver from the child, and so we have to be including the caregiver and the child in our treatments, in our decision making, and making sure that our practice is child friendly, that we avoiding harm and that's not just physical harm, that's also psycho-emotional harm and we're really optimizing their outcomes and their safety and improving the experience. And we've mentioned in the book some ideas that we can really use play in our treatments, which is really much better tolerated by children, and that's obviously after they are very acutely ill. But I think we just need to consider the entire time that we're dealing with a child, and what would we like for our own?
Speaker 1:child. Yes, no, I think that's very important to put yourself in the shoes of the mother, the father, the other members of the family. Brenda, as always, it's such a pleasure to chat to you. Yeah, brenda, as always, it's such a pleasure to chat to you. Thank you so much for your time and for sharing these gems of information with our listeners, and I'm sure that people will feel a little bit more confident next time they need to manage a pediatric patient with traumatic injury in the intensive care unit. Thanks so much. Thank you very much.
