avoid falling objects: management of severe scalp lacerations
TRANSCRIPT
AVOID FALLING OBJECTS
Rebecca Starr DO, PEM Fellow
November 12, 2013
Objectives
Identify goals of trauma activation Review pediatric trauma alert criteria Develop an understanding of medical
errors in communication and strategies to minimize
Discuss scalp laceration morbidity and implement appropriate initial management
Analyze mass transfusion protocol and understand evidence for approach
Case
10 year old male with head trauma and scalp laceration
HPI
10 y/o M with a scalp laceration sustained from a large tree branch (est 100 lbs) that had fallen onto his head
No loss of consciousness, no vomiting, no confusion
Pt airlifted via LifeNet to MUSC ED C-collar, backboard, and pressure
dressing by LifeNet
HPI continued
PMHx: previously healthy PSHx: none Allergies: none Medications: none ROS: headache
Physical Exam Vitals: HR 75 BP 124/88 RR 22 SpO2 99% GCS 15 General: Alert and oriented Head: 15cm scalp avulsion/flap with visible galea and
active ooze Eyes: PERRLA, EOMI, Pupils ~ 3mm ENT: nares patent, o/p without lesions and 2 small
lacerations to tongue, no blood behind TM’s Neck: in c-collar, No TTP on cervical spine CV/Resp/GI: wnl Skin: left leg with small abrasions and ashes on feet Neuro: CN 2-12 GIT, no focal deficits, good tone, 5/5
UE and LE strength, full ROM, MAEW
Timeline of Events 1925- Arrival to ED awake and alert, GCS 15 1930- Primary and secondary survey by PED MD’s,
wound examined and pressure dressing reappliedDecision to not call trauma activationNeurosurgery paged
1938- Fentanyl 25mcg and 1L NS bolus given 1940- CXR and pelvis 1950- CT Head and Neck 2010- Back from CT, “active bleeding continues” 2015- Neurosurgery at bedside to address lac 2025- Dressing reapplied after neurosurgery
removed, plan to sedate for laceration repair
Timeline of Events 2045- Neurosurgery called away to adult trauma 2115- Pt complains of feeling “hot and sweaty”
BP 96/29 and HR 157MD to bedside1L NS bolus by pressure bag and placed in trendelenburg
2130- BP 80/39 and HR 1461L NS bolus repeatedI stat and repeat CBCPediatric Surgery consulted
○ Considered closing at bedside 2225- Attending to attending conversation (ED and Surg) 2300- To OR Total time in PED (1925-2300)
Imaging
CT neck- normal CT head-
No intracranial injury or fractureLarge right posterior-superior parietal
subgaleal hematoma with evidence of scalp laceration and subcutaneous emphysema
CXR- normal Pelvis xray- normal
Pertinent LabsInitial CBC (1940) Repeat CBC (2211)
WBC 10.9 Hgb 12.5 Hct 35.2 Plts 214
WBC 10.2 Hgb 8.2 Hct 24 Plts 156
Hospital course
Taken to OR 15cm right parietal scalp
laceration/avulsion repaired TLS drain placed Transferred to PACU at 0130 Admitted to floor/trauma surgery TLS drain removed Hgb: 8.2 9.4, HCT: 24 27 Discharged home the next day
Areas for Discussion Considerations for calling a trauma
activation Delay in subspecialty care/transfer Communication/chain of command
concernsBetween RN and MDBetween subspecialty physiciansBetween training levels
Scalp laceration morbidity Role of Mass Transfusion Protocol
Effect of Trauma Service in Peds ED Goals of Trauma Service
Mobilization of resources Quicker definitive care
Vernon et al -patients treated by a trauma team vs. ED staff without a peds trauma teamShorter times from arrival to CT scan (27 vs 41min)Shorter times from arrival to OR (62 vs 123min)Shorter total time in the ED (85 vs 121min)
Perno et al- implementation of a trauma service showed significant reduction in delayed diagnosis of injuryPre trauma team 4% DDI and post trauma team 0.5% DDI
Vernon et al. Pediatrics.1999
Perno et al. Pediatric Emergency Care. 2005
Delay in Transfer Affects Outcomes Mortality is significantly reduced when
early goal-directed therapy is instituted Chalfin et al “Delay in critically ill
patients > 6 hours from ED to transfer to ICU/OR increased hospital length of stay and increased mortality”Not just trauma patients, all comersResults can be extrapolated
Chalfin et al. Critical Care Medicine. 2007
MUSC Pediatric Trauma Alert CriteriaLevel A Physiologic Criteria
GCS <9 at time of EMS transportHypotensionSuspicion of respiratory compromise
Attending concern for serious injury
MUSC Pediatric Trauma Alert CriteriaLevel A Anatomic Criteria
Penetrating injury to head, neck, torsoPenetrating injury to extremity proximal to elbow or
knee with ongoing bleedingFlail chestTwo or more long bone fracturesCrushed/degloving injuryAmputation proximal to wrist or ankleOpen or depressed skull fractureSuspected Pelvic fracture2nd or 3rd degree burns >40% BSA
Level A Trauma Transfer from OSH Hemodynamically unstable Intubated Urgent need for surgical intervention Blood transfusion prior to transfer
MUSC Pediatric Trauma Alert Criteria
MUSC Pediatric Trauma Alert CriteriaLevel B Physiologic Criteria
GCS >9 and <14 at EMS transport Anatomic Criteria
Penetrating injury to extremity proximal to elbow or knee without ongoing bleeding
2nd or 3rd degree burns > 20% BSA and < 40% BSA
Attending concern for serious injury
MUSC Pediatric Trauma Alert CriteriaLevel B Mechanism of Injury Criteria
Fall >20 ft (1 story equals 10ft)Ejection from vehicleDeath in same passenger compartmentAuto/pedestrian or auto/bike with impact >20
MPHMotorcycle or ATV crash >20 MPGMVC > 25 MPH
MUSC Pediatric Trauma Alert CriteriaLevel B Trauma Transfer from OSH Accepted for transfer by trauma service Request for trauma alert by accepting
service Hemodynamically stable but possible
surgical intervention needed
Learning Point
A trauma activation for this patient may have helped mobilize more resources and facilitated quicker definitive care
Frequent Sources of Medical Error
Medication errors (weight-based dosing)Level of trainingStaffingOvercrowdingStressFatigue (Most ED errors between 4am-8am)Communication
Selbst et al. Pediatric Emergency Care. 2004
Communication
High volume and velocity of information exchangesMultiple check outs and handoffsFrequent interruptionsMultitasking
Significant source of medical errors
Coiera et al. MJA. 2002
Interdisciplinary Communication
Donchin study found ICU doctor to nurse verbal communication was only 2% of total daily communication but accounted for 37% of error reports
Hierarchy of exchange
Donchin et al. Critical Care Medicine. 1995
Communication Pitfalls for this Case Communication of urgency Chain of command
Communication Learning Point
Closed loop / confirmatory feedback Minimize hierarchy Be receptive/ approachable Remember/utilize chain of command
Scalp lacerations
May be grossly underestimatedOften ignored until patient’s work up
complete Potential for large blood loss Beware large laceration or several minor
lacerations Delay in wound management alone can
lead to hemorrhagic shock
Lemos et.al., J. Emerg. Med. 1988
The Scalp
Richest subcutaneous vascular supply in the entire body
Lemos et.al., J. Emerg. Med. 1988
Scalp lacerations
When lacerated, small arteries retract between the septa
7-10 cm laceration can cause loss of 30% blood volume
Turnage and Maull, Southern Medical Journal. 2000
Lemos et.al., J. Emerg. Med. 1988
Case Reports in the Literature
45 y/o M with large scalp lac and epidural hematoma after bike vs. carTransfer from community hospital to tertiary
care center for neurosurgery involvementScalp laceration not closed before transferArrival to hospital in shock (systolic BP 65 and
HR 156) requiring aggressive resuscitationHgb 6.3 on arrival to hospitalMultiple transfusions of PRBCs and clotting
factors given
Fitzpatrick et al, J Accid Emerg Med.1996
Case Reports in the Literature
27 y/o F with multiple scalp lacerations and depressed skull fracture with a small subdural hematoma due to knife stabbingScalp wounds stapled before transfer to tertiary care
centerEn route had a seizure and required intubationSeveral staples dislodged during event and profuse
bleeding from scalp wound occurredArrival to hospital in shock (BP 70/40 and HR 130)
requiring aggressive resuscitationHgb 7.1 on arrival to hospital4 units PRBCs given
Fitzpatrick et al, J Accid Emerg Med.1996
Bleeding Control
Direct constant pressure Dressing application Elevation Direct clamping Suture Staples
Lemos et.al., J. Emerg. Med. 1988
Initial Management Direct applied pressure Pressure dressing as a temporizing method
Frequently fails Temporary single layer closure with running stitch
Interferes with wound evaluation Surgical staples
Temporary Hemostats applied to edge of scalp
Tedious and interferes with radiographic studies Scalp clips
Requires special equipment
Fitzpatrick et al, J Accid Emerg Med.1996
Lemos et.al., J. Emerg. Med. 1988
Raney Clips
Quick, effective, and inexpensive Compresses the wound edge and
occludes the blood vessels Maintain good exposure of the wound Do not interfere with radiographic
studies
Sykes, Annals of Emergency Medicine, 1989
Raney Clips
Multiple Techniques
Definitive Closure
Likely with subspecialty service for larger lacerationsSurgeryNeurosurgeryPlastics
Sykes, Annals of Emergency Medicine, 1989
Learning Point
Quick and effective initial management is imperative in scalp lacerations
Potential for scalp lacerations to cause hemorrhagic shock
Traumatic Blood Loss Fluid resuscitation remains the cornerstone
of treatment A specific level of blood loss or anemia that
triggers transfusion has not been officially defined in pediatricsBased on clinical condition and expected further
blood lossInstitution specific
Rapid exsanguination may not be reflected in Hgb or Hct levels until fluid resuscitation catches up
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
Coagulopathy in the “Lethal Triad” Well documented part of trauma Cycle of worsening coagulopathy,
hypothermia, and acidosisHypothermia decreases platelet activation
and adhesionHemodilution decreases clotting factors and
increases hypothermiaAcidosis worsens clotting factor function
Nosanov et al., American Journal of Surgery, 2013
Pediatric Blood VolumesAge Estimated Blood Volume
(mL/kg)
Premature Infant Term infant to 3 months Children older than 3
months Obese children
90-100
80-90
70
65
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
Pediatric Blood Volume in Units Weight Blood Volume
10 kg 25 kg 50 kg (adult standard)
2 units 5 units 10 units
Fresh Whole Blood
Fresh whole blood has been used in adults in combat settingFresh whole blood transfusions have been
noted to improve 30 day survival rates FWB not widely available in civilian
settingOnly 15% of children’s hospitals stocked
FWB
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
Pediatric Mass Transfusion Defined by the volume of blood products
given to maintain hemodynamic stabilityTransfusion of blood components equaling
one or more blood volume within a 24 hour period
Definition differs per institution Pediatric MTP’s are less widely
available than adult MTP’s
Chidester et al., J Trauma Acute Care Surg.,2012
Goals of Pediatric MTP
Maintaining platelets above 50,000 Hemoglobin higher than 10mg/dL Normalization of coagulation assays
Chidester et al., J Trauma Acute Care Surg.,2012
Pediatric Mass TransfusionActivated when 1 circulating blood volume has been lost
Or
Evidence of massive hemorrhage, hemodynamically unstable and already received 40ml/kg crystalloid
Chidester et al., J Trauma Acute Care Surg.,2012
Pediatric Mass Transfusion Ratio of FFP/PRBCs/Platelets 1:1:1
Most resembles whole blood Ratios of 1:1:1 has shown to have
survival benefits in adult literatureAdult data may not be generalized to
pediatrics Controversy exists between proper
blood products ratioFurther pediatric research is needed
Chidester et al., J Trauma Acute Care Surg.,2012
Pediatric Mass Transfusion Higher FFP/PRBCs ratio has not been
statistically shown to have increased survival in childrenHwu study at Washington University in St.
Louis “Adoption of pediatric MTP in one study
led to a fourfold decrease in length of time to FFP transfusion”15 min unthaw time for FFP
Nosanov et al., American Journal of Surgery, 2013
Hendrickson et al, Transfusion, 2012
Labs to Monitor Hgb/Hct Plts PT PTT Fibrinogen Fibrin degradation products Ca+ K+ pH Lactate
Chidester et al., J Trauma Acute Care Surg.,2012
Complications of MTP
FFP transfusion associated with increased risk of respiratory distress and ARDS
Increased susceptibility to hyperkalemia secondary to blood product transfusionK+ slowly leaks out of RBC’s during storage
and can increase K+ concentrations9 case reports of pediatric hyperkalemic
cardiac arrest due to MTP in literatureCardiac patients and neonates increased riskMean K+ 9.2 mmol/L (6.3-12mmol/L)
Lee et al, Transfusion, 2013
Recombinant Factor VIIa
Useful adjunct for control of bleedingEnhances production of thrombin on the
surface of activated platelets Adult studies have documented
decreased blood product requirementsNo sufficient pediatric studies
No change in mortality in MTP Lower incidence of thromboembolic
events
Chidester et al., J Trauma Acute Care Surg.,2012
MTP and Organ Donation
MTP activation in one study showed 2 incidences where viability of organ donation was made possible1 patient with nonsurvivable injuries which
was a non MTP patient was rejected as an organ donor due to severe hemodilution
Chidester et al., J Trauma Acute Care Surg.,2012
MTP Learning Points
Activate when one circulating blood volume was lost or evidence of massive hemorrhage, hemodynamically unstable and already received 40ml/kg crystalloid
Monitor K+ and consider transfusion associated hyperkalemic cardiac arrest
Consider recombinant Factor VIIa
Summary Trauma activation helps mobilize more resources and
facilitates quicker definitive care Keys for successful communication in the ED
Closed loop / confirmatory feedback Minimize hierarchy Be receptive/ approachable Remember/utilize chain of command
Quick and effective initial management is imperative in scalp lacerations
Potential for scalp lacerations to cause hemorrhagic shock
Utilize Mass Transfusion Protocol when dealing with an actively hemorrhaging patient
References1. Dehmer, J.J., M.D, et al. Massive transfusion and blood product use in the pediatric trauma patient. Seminars in Pediatric Surgery.
2010;19:286-291. doi:10.1053/j.sempedsurg.2010.07.002.
2. Lee, A.C. et al. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion. 2013 doi:10.1111/trf.12192.
3. Hendrickson, J.E., et al. Implementation of pediatric trauma massive transfusion protocol: one institution's experience. Transfusion.2012;52:1228-1236. doi:10.1111/j.1537-2995.2011.03458.x.
4. Nosanov, L., et al. The impact of blood product ratios in massively transfused pediatric trauma patients. The American Journal of Surgery. 2013.
5. Chidester, S.J. A pediatric massive transfusion protocol. The Journal of Trauma, Acute Care, and Surgery. 12012;73 :1273-1277. doi:10.1097/TA.0b013e318265d267.
6. Turnage, B. & Maull, K. Scalp laceration: an obvious 'occult‘ cause of shock. Southern Medical Journal. 2000;93:265-266.
7. Lemos, M.J., & Clark, D.E. Scalp lacerations resulting in hemorrhagic shock: case reports and recommended management. The Journal of Emergency Medicine.1988;6:377-379.
8. Sykes, L.N. Management of hemorrhage from severe scalp lacerations with Raney clips. Annals of Emergency Medicine. 1989;18:995-996.
9. Fitzpatrick, M.O., & Seex, K. Scalp lacerations demand careful attention before interhospital transfer of head injured patients. Journal of Accidental Emergency Medicine. 1996;13:207-208. doi:10.1136/emj.13.3.207
10. Chalfin, D.B., et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine. 2007;35:1477-1483.
11. Selbst, S.M., et al. Preventing Medical Errors in Pediatric Emergency Medicine. Pediatric Emergency Care. 2004; 20:702-709.
12. Alvarez, G. & Enrico Coiera. Interdisciplinary communication: an uncharted source of medical error?. Journal of Critical Care 21. 2006:236-242.
13. Coiera, E.W., et al. Communication loads on clinical staff in the emergency department. Medical Journal of Austrailia. 2002;176:415-418.
14. Sutcliffe, K.M. et al. Communication Failures: an insidious contributor to medical mishaps. Academic Medicine. 2004; 79:186-194.
15. Vernon, D.D. et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics. 1999;103:20-24.
16. Perno, J.F., et al. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatric Emergency Care. 2005;21:367-371.
17. Donchin Y. et al., A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995;23:294-300
Special Thanks
Thank you to Dr. Rachel Tuuri, Dr. Olivia Titus, Dr. Scott Russell, Dr. Fred Tecklenburg, and Madeline Gehrig for their help.
