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Case #45 - Trauma Kid


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#1 Mike MacKinnon

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Posted 07 November 2008 - 02:36 PM

Hi all, I have final exams coming up that are cumm for the entire program and they end dec 13th. I will not have the time to do a proper case study due to that and i dont like to do things half assed.

If you have a submission for a case study please pm me and I will add it here and you can follow through it like I would. Ill be back with a new one on dec 15th.
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It's what we know for sure that just ain't so" - Mark Twain

#2 HELOSRCOOL

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Posted 10 November 2008 - 03:21 PM

The story:
You are paged to respond to a head-on MVC (YEAH !!! scene call) on a rural highway approximately 20 min from your base. The details of the crash are sketchy, but you know the section of road and you have report of a head-on with a tractor-trailer involved. The speed limit there is 70MPH. You are told after launch that your pt is a 5 yo male that was a back seat passenger in a cab and a half small pick-up. Both of the front seat occupants are DOA. One is his mother. The local QRU is transporting to a local airfield that is closer to your location. They radio that the pt has just lost pulses and is apneic. They have started CPR and are using BVM. Three minutes later the QRU calls you back and states they have return of spontaneous respirations and a pulse. They also pass on that this is the second time the patient has arrested. You are 8 mins out.

History: No known history.

Meds: None known.

Allergies: NKDA

Discussion points:What are your differential Diagnosis for an unresponsive child in this situation?
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Bill
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#3 old school

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Posted 10 November 2008 - 06:13 PM

Discussion points:What are your differential Diagnosis for an unresponsive child in this situation?


Real quick off the top of my head:

-TBI
-SCI
-tension hemo/pneumo
-open pneumo
-pericardial tamponade
-severe cardiac contusion
-tracheal tear
-tracheobronchial disruption
-diaphragmatic rupture
-traumatic asphyxiation
-hypovolemic shock due to any number of causes

Or a combination of all of the above. Really need more info to come up with a working or differential dx.

If they got pulses back I would guess that the primary problem is most likley hypovolemia, and he will arrest again soon if he doesn't get some blood on board. Or it could be a primary respiratory problem that is being partially compensated by the BVM. Need more info. Physical exam findings?

On scene: intubate immediately, pressure dress any severely bleeding wounds, place a quick IV or IO, then load and go.

Enroute: place large bore PIV (or central line), start blood enroute to ped trauma center. Chest tubes or chest decompression prn.
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#4 HELOSRCOOL

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Posted 10 November 2008 - 06:52 PM

I understand this seems like a basic trauma situation, but my purpose is to share and introduce an injury pattern and diagnosis I was unaware of before this call. The explanation always comes at the end of these, right?

Obvious pertinent physical findings/ EMS report:
As you climb in back of the amblance you see a small male child C-spine immobilized to a LBB except for there are no head rolls or tape. The pt is being bagged with ped BVM supplementing his resps at a rate of about 14. Sats are 99%, BP 98/50, HR 150. The chest is exposed, but pants are still on. The pt is the appropriate size for a five yo. The ambulance crew is frantic and you know the scene must have been impressive. The report is that a full size cab and a half pick-up drifted left of center and hit a semi head on. Major intrusion, front of vehicle unrecognizable and both front seat occupants DOA. The child was extricated from the back seat by a bystander before EMS arrival. TheQRU arrived to find child being held by bystander in ditch next to road. Pt immediately back boarded ( minus head rolls- they were in hurry) and began transport. Pt became pulseless and apneic two minutes after that and again when they called you on the radio. No changes since then, they have just been supplementing resps.

Pt has a GCS of 7(no eye open, occasional moan, withdrew from pain)Pt airway is controlled with jaw thrust and ventilating well with BVM although you note some abdominal distention. Breath sounds equal bilat, instructed QRU to supplement to 20 B/M. HR 150 pulses in all four extremeties/ pt appears pink, warm and dry. BP 98/50. You finish exposing the pt and rapid trauma assessment reveals no other injuries except a possible right clavicle fracture and seat belt signs. You start a 20g IV RAC and with the history of two bouts of CPR you elect to RSI and manage to squeeze a 6.0 tube in and leave the balloon deflated. You confirm tube placement and secure with tape. The pt's head is secured to the back board with towel rolls and 2" tape. You elect to bag your way back to the Hospital as ETA is approx 12 min.

Now what do you think?
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Bill
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#5 BackcountryMedic

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Posted 10 November 2008 - 08:21 PM

Howdy neighbor!

Allan's list is comprehensive. If I had to choose just 3 the leading contenders are:
Hypovolumia
Tension pneumothorax
paricardial tamponade

To early to rule out any of these. Breath sounds? Heart tones? Any JVD or tracheal deviation? Pulse pressures closing?

This being Montana I would be willing to bet the child was poorly secured in his seat. Was a child seat used at all or just strapped in with the standard seatbelt arrangement? Facing forward or sideways crew cab seating? You didn't mention it, but any signs of strangulation or abdominal injury (where were those "seat belt signs" located in relation to vital structures).

EKG and blood glucose levels are worth looking at. A 12-lead may hint at tamponade or cardiac contusion, but let's get it enroute. You're baggin' so how is compliance? Anything get missed on the back? Let's get those pants off and get a good look. O2 sat and capnography?

Of course, these cases are known for their Zebra's. I look forward to hearing more.
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#6 HELOSRCOOL

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Posted 11 November 2008 - 12:42 AM

[quote]Was a child seat used at all or just strapped in with the standard seatbelt arrangement? Facing forward or sideways crew cab seating?[/quote]
Unsure of the seating arrangement and we did not get to actually visualize the crash scene. We were advised that the child had been extricated by a bystander without c-spine precautions though.

[quote](where were those "seat belt signs" located in relation to vital structures).[/quote]
The seat belt signs consisted of abrasions over the right clavicle and lateral mid abdomen bilat.
No signs of strangulation and abd is soft and non-distended.

[quote]EKG and blood glucose levels are worth looking at. A 12-lead may hint at tamponade or cardiac contusion, but let's get it enroute. You're baggin' so how is compliance?[/quote]
CBS is 89, no 12-lead and compliance is great.

[quote]Breath sounds? Heart tones? Any JVD or tracheal deviation? Pulse pressures closing?[/quote]
Clear and equal bilat, crisp S1 and S2, negative JVD or Trach dev, See BP above.

Unable to survey the back due to LSB rest of Rapid Trauma Assess(RTA) is benign.
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Bill
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#7 old school

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Posted 11 November 2008 - 04:03 AM

Sensation / movement in all 4 extremities?

Is the belly firm at all?

Does the HR decrease significantly with sedation or analgesia? With a fluid bolus? After intubation and improved oxygenation?

Spo2? Any other obvious injuries or pertinent findings?
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#8 MSDeltaFlt

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Posted 11 November 2008 - 02:46 PM

Real quick off the top of my head:

-TBI
-SCI
-tension hemo/pneumo
-open pneumo
-pericardial tamponade
-severe cardiac contusion
-tracheal tear
-tracheobronchial disruption
-diaphragmatic rupture
-traumatic asphyxiation
-hypovolemic shock due to any number of causes

Or a combination of all of the above. Really need more info to come up with a working or differential dx.


Let's not forget an aortic tear as well due to the lateral forces from being in the back seat of an extended cab pick up. I'm thinking combined speed at time of impact is at least 140mph. Consistant with both front occupants DOA and junior doing his damnedest to follow suit. My Diffs are

-TBI
-SCI
-Tension Hemo/Pneumo
-Percardial tampenade
-Severe Cardiac Contusion
-Pneumo-mediastinum
-Aortic Rupture/Tear
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Mike Hester, RRT/NRP/FP-C
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#9 fiznat

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Posted 11 November 2008 - 06:55 PM

The location of the seatbelt signs from a crash at those kinds of speeds really raises red flags about traumatic ABD vessel injury. I think aortic tear/rupturing would be at the top of my list along with cardiac tamponade and barotrauma. I doubt this state of compensated shock will last long, but I think I would keep an eye out for Beck's and/or Cushing's triads.
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#10 HELOSRCOOL

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Posted 12 November 2008 - 12:21 AM

The only movement seen prior to paralytics is on initial IV stick with right sided shoulder shrug and right hand lift that subsided immediately after gaining access.

HR decreases to 120 after RSI and 200cc bolus.

Sats are maintained at 100% the entire time.

Remember his GCS was 7 before RSI.
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Bill
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#11 old school

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Posted 13 November 2008 - 01:49 PM

OK, so here's where we are at now:

- We're bagging easily with good sats and equal breath sounds, so that minimizes the likelihood of a primary pulmonary problem. Probably not a tension pneumo, severe pulmonary contusion, or tracheobronchial injury.

- The soft, non-distended abdomen and the fact that we got pulses back without infusing blood tells us there is probably not any massive internal bleeding, especially not into the abdominal cavity. Given the MOI there likely is some bleeding from a splenic, hepatic, renal, or aortic tear, but it is probably not a massive exsanguinating injury from the great vessels or the belly organs, otherwise there would be obvious clinical signs and we would probably not have a pulse.

- Crisp heart tones and the presence of a pulse limits the likelihood of a pericardial tamponade. A pretty severe cardiac contusion is still quite possible though.

So, we've pretty much ruled out many of the things on the original list of differentials. From the info presented, I would venture this guess:

- A TBI appears evident from the GCS. A SCI is quite possible but hard to determine with such a low GCS.
- Likley has some internal bleeding from any number of potential sources, causing the shocky state. It will be impossible to determine exactly where until he goes through the CT.
- Initial arrest probably resulted from respiratory compromise secondary to TBI, or could have resulted from dysrythmias due to a cardiac contusion. Traumatic asphyxiation is possible too, though we'd probably see pulmonary s/s with that.
- Another possible cause of the initial arrest is a diaphragmatic rupture, but it seems as though that would be accompanied with more outward signs of massive internal injury.


Is there any hemoptysis? Any dysrythmias? What are VS upon loading into the AC? ETco2 and Spo2? Any movement once the sux and initial sedation wears off?


We have his airway secure. Would also provide cirulatory support with IVF (and blood, if available) as needed, including placement of at least one large line during transport, if possible.

Whats next?
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#12 LZone

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Posted 13 November 2008 - 08:32 PM

I agree with the posts so far and I like old school's synopsis.

I don't think the patient has any pulmonary issues from the assessment provided.

I am leaning toward TBI and SCI/maybe partial cord. I think the assessment point that you mentioned earlier, that the only movement noted was a shrugging motion to his right arm and movement to right hand, may be significant in this case...Although, his VS look more like he is hypovolemic.

How are his pupils? Cap refill? Is his HR still on the decline or has is leveled off @120?

We have an airway, IV access and we are transporting to an appropriate facility, so other than packaging him up a little nicer with a head immobilization device of some sort and finishing up our post intubation medication management, I think we are on track.
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#13 RoadieRN

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Posted 13 November 2008 - 10:49 PM

I like Old School's synopsis as well. There has to be some kind of respiratory component with this kid. The number 1 reason kids go into cardiac arrest is due to hypoxia. This kid is going to have multi system trauma. It didn't see anything about him being restrained, but I imagine with two doa on scene and that he wasn't says he was in almost certainty. This kid is 5yo. His head is not quite so disproportionate to the rest of his body so he probably has some kind of high c-spine fx, probably related to his arrest and then ROSC. Only a kid. We adults would have bit it by now. So I'm guessing this kid has something like a C-5 to 7ish fx. He may not have a vessel rupture, but it is not out of the question that this kid will have a liver and/or splenic lac(s) or near ruptures. Kids get liver and splenic lacs like it is their jobs d/t the fact they have poorly developed abd musculature and the way seatbelts ride on their pelvis and abd. I realize the abd may have not be rigid, but something is cooking.
This kid is liking his IVF so I would give him 20 ml/kg NS x 3, if necessary, or if I had blood 10 ml/kg x 1-2, depending on VS. With our current VS, this kid is doing OK. By now means, great or something to kick back and relax, but doable for now.
Here's what up I'm doing en route with this kid: Monitor his VS like a hawk. Any change in VS will change how aggressive I am with fluid replacement. As far as sedation/analgesia goes to help keep this kid down, I'm all about Fentanyl and would use Versed very judiciously d/t its propensity to drop BPs. Not sure if we used Suxx or Roc to induct this kid, but either way I don't see an overwhelming need to use NMBA on him. I'm thinking his injuries may take care of the need for chem paralysis. Besides, in my PICU days, unless it was a kid who would desat with movement, ie RSV, we could keep our kids down with Fent/VSD combo.
What's our ETA now? Are we up in the air or still on the ground? If we are on the ground, what are we waiting for?! Let's boogie!
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Nick Crusius RN, BSN

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#14 CEPNick

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Posted 14 November 2008 - 07:59 AM

Sounds like treatment on this kiddo has been pretty well covered and a lot of differential Dx's but I'm wondering why this kids skin signs are still normal? Yeah kids compensate but this one is post arrest with a HR of 150 and a marginal BP. with the emphesis on no initial spinal immobilization and the questionable response to the IV stick it really sounds like a cervical chord injury. It could equate for the initial arrest (loss of diaphramatic innervation caused hypoxia) and skins that don't seem to fit the pt.

Nick
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#15 HELOSRCOOL

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Posted 14 November 2008 - 08:42 PM

In the Aircraft unable to establish a second line, as you can't find anything remotely looking like a vein. Skin starting to look mottled.

Pt remains solid on the monitor-good sats, HR down to 120s, except BP starts to fall - 74/42 but responds to another fluid bolus. No blood available.

Induced with Roc, lido and versed. Atropine not needed.

Still bagging easy. Pupils 2-3mm equal and reactive.

15 min to level II trauma center.

On arrival at hospital, trauma team is waiting. ER Doc, Surgeon and pediatrician are in attendance. Pt is hypothermic and skin is motled with a temp of 92F which makes it to 90F with afterdrop during rewarming. Pupils are now fixed and dialated to 5-6mm. This resolves with one dose of mannitol. Initial chest and pelvis x-rays show only the broken clavicle. NG and Foley initiated. There are five more failed attempts at IV access, so a central line is started. After some rewarming with bear hugger and warm fluid we made it to CAT Scan which showed very slight anterolisthesis of C2-C3 without cord compression. This pt was further transported via FW to a tertiary center due to lack of pediatric intensivist.

Who has seen a SCIWORA? Any common factors if you have seen multiple?
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Bill
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#16 LWTRF14

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Posted 15 November 2008 - 10:51 AM

[

Who has seen a SCIWORA? ------ WOW, just finished PNCCT this week...thought that was just another one of the hundreds letters they trew at us.... SPINAL CORD INJURY WITHOUT RADIOLOGICAL ASSESSMENT Any common factors if you have seen multiple?
[/quote]
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Earl F Bakke III, NR-EMT-P, CC-EMT-P, PNCCT

#17 fiznat

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Posted 15 November 2008 - 02:47 PM

Does nobody have an IO or what?
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#18 HELOSRCOOL

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Posted 15 November 2008 - 06:38 PM

Spinal Cord Injury Without Radiographic Abnormality - SCIWORA

Due to the probability of a prolonged hopital stay the ER physician elected for the subclavian.

If the air enivironment (A-star) had been more conducive to IO placement I might have tried one there. However, we were also trying to keep the pt warm, even though we did a marginal job at best.

After admission to the tertiary center this pt had a MRI that showed and epidural hematoma from C2-T10!!! Xrays and CT were unconclusive for any injury. An occult mesnteric tear was also found the next day via Abd CT and DPL. The pt underwent abd surgery. Management for SCI was non-invasive, observation and vent support. Pt emerged from coma on hospital day five and had a prolonged recovery from his SCI. REhab took over a year, but he is now back in school with no sensory or motor deficits.

This was something I ran on last winter and had not had any exposure to. Basically the pediatric spine is pliable enough to allow overextension and then snap back in to place so that there is no evidence of SCI on imaging studies less sensitive than MRI. With their big heads and small necks it makes some sense. I just thought i would share my experience and ask for others insight if they have seen this type of injury.
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Bill
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#19 mjcfrn

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Posted 16 November 2008 - 04:06 PM

"Spinal Cord Injury without Radiographic ABNORMALITY."

I've seen several in PICU. Most had a concomitant head injury which interfered with clinical assessment. There is identifiable soft tissue injury on MRI. Pressure on the cord may occur from hematoma or edema, so initial assessment may be normal; then minutes to hours later (as the bleeding continues or as the inflammation progresses), neuro deficits begin to occur. Ischemia to the cord is another factor, either associated with the pressure or with the interruption of blood supply from the same leaky vessel that is creating the hematoma.

The few isolated SCIWORA's I've seen had usually been evaluated in an ED, cleared clinically, then several hours later had onset of symptoms. More than one "SCIWORA" actually had a radiographic defect identified by a pediatric neuroradiologist which had been earlier misidentified as a normal variant; for example, a true C2-C3 subluxation would have been - in the absence of SCI symptoms - read as the normal pseudosubluxation of C2-C3.
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