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PEDIATRIC EMERGENCIES3 CASE STUDIES

SALLY K. SNOW, BSN, RN, CPEN, FAEN

INDEPENDENT CONSULTANT

PEDIATRIC TRAUMA AND EMERGENCY NURSING

CHALLENGES OF THE PEDIATRIC PATIENT

UNIQUE PEDIATRIC PARAMETERSVariable Significance

Large volume of blood in head Cerebral edema develops rapidly small

bleeds are big problems

Immature musculature and poor support of

head

Flexion/extension can cause airway

compromise. Ligamentous injury common

Narrow airway diameter ↑ airway resistance, little swelling=big px

Less alveolar surface area Injury leads to rapid respiratory

compromise. Rapid rate=Insensible loss

Heart lies higher in chest cavity Prone to injury. Rib fx imply great force

Thin-walled, small abdomen Organs not well protected

Bones are soft and pliable Fractures are less common but still occur,

underlying injury a problem

Renal function not well developed Acute renal failure develops easily

Large body surface to body mass Prone to hypothermia

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Say Assessment

ENPC PRIMARY ASSESSMENT

• Airway & Alertness– vocalization; tongue obst. loose

teeth; foreign objects; liquids; edema; preferred posture,

drooling/dysphagia. Abd. sounds

• Breathing/Ventilation – spontaneous; chest rise & fall;

breath sounds; work of breathing; skin color, rate/effort.

• Circulation – central and peripheral pulses; skin temp &

color; cap refill; control external bleeding (P&E and CMT)

• Disability – AVPU, Pupils, Pedi GCS, FOUR score

• Expose & Environmental Control

GLASGOW COMA SCALE

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ENPC SECONDARY ASSESSMENT

• Full set of Vital Signs & Family Presence

• Get Adjuncts (L,M,N,O) & Give Comfort (asses for Pain)

-L-labs; M-monitors; N-NG/OG; O-oxygenation &ventilation -

pulse Ox. & Capnography Assess for pain (age appropriate scale.)

• History – CIAMPEDS, MIVT, Pt. generated

• Head to Toe – Inspect AND palpate the head AND face,

Neck, Chest (auscultate breath AND heart sounds), Abdomen,

(auscultate bowel sounds) Pelvis, Perineum, Extremities and

Inspect the Posterior surface.

THE PERILS OF RIDING LAWNMOWERS

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AUDIENCE PARTICIPATION

What are the priorities of care for this

patient?

Airway/Hemorrhage Control

Breathing

Circulation

Warming

AUDIENCE QUESTION

• Is family presence in this trauma room an

option in your ED

Yes

No

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EMS REPORT

• Found awake and alert

• RSI – Etomidate,

Succinylcholine, Atropine,

Fentanyl

• VS- HR 167, BP 132/63,

RR 14

ED ARRIVAL

• Trauma Stat paged

• Arrived Intubated – paralytics and sedation maintained

• VS – HR 183, BP 105/67, T 36.6°C (97.2°), RR 18

assisted, GCS 3P, Weight 20kg by history

• Fluid resuscitation – 2 peripheral IV’s 520 ml crystalloid in

ED

• 339 ml 0- PRBC’s in ED

AUDIENCE PARTICIPATION

What is the best indication of shock in

this patient

Heart rate

Blood pressure

Obvious signs of external hemorrhage

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INJURIES SUSTAINED

• Left leg amputation above the knee with Grade III open femur fx

• Left testicle amputation

• Degloved right testicle

• Sciatic nerve transection

• Abdominal wall complex partial thickness laceration

• Full thickness STI of right knee

• Laceration to penis including the meatus

• Abrasion to the right upper chest

• Grade 1 liver injury

OPERATIVE PROCEDURES

• Emergent I&D of amputated leg with wound vac

application. General Surgery, Orthopedic surgery and

Urology all in the OR

• Pain Team consult post op

• Multiple wound vac changes, day 2,3,7 and 10

• Extubated day 2 and transferred to the floor

• Foley dc’d, urinating well day 6

• Transferred to Neuro-rehab on day 11

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DAY OF DISCHARGE

AUDIENCE

Is it a HIPAA violation to provide feedback

on this patient to EMS?

Yes

No

THINGS ARE NOT ALWAYS AS THEY APPEAR!

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THE SITUATION

• 12 year old playing in the water at church camp

• Launched from the blob, landed flat on his back

• Swam to shore, c/o shortness of breath, grabbed

his inhaler and took two puffs

• Collapsed in respiratory arrest

AUDIENCE PARTICIPATION

Is this a trauma patient?

Yes

No

SCENE RESPONSE

• Rural camp setting

• Ground crew first responders with very little pediatric

experience

• Found the patient with GCS 3, in PEA.

• Started CPR, intubated, c-collar

• Heard no breath sounds; darted the chest bilaterally.

• Gave vasopressin, Epi x 4 and Atropine x 2 enroute to

rural hospital

• Transport time 41 minutes scene to OSH

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AUDIENCE QUESTION

What possible occult injuries could have led

to his respiratory arrest?

bilateral pneumothoraces with rib fractures

tension pneumothorax

both

something else?

AUDIENCE QUESTION

What could have caused his silent

chest?

Complete lung collapse

Bronchospasm

AUDIENCE PARTICIPATION

Was it the wrong thing to do to dart the

chest?

Yes

No

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RURAL ED

• Arrived in full arrest, CPR continued

• Fluid bolus given (total crystalloids 5000ml)

• ABG pH 6.74, pO2 373, pCO2 108, HCO3

14.1, base deficit -23.1 wt. 79kg

• Resuscitation continued with v-fib requiring

defibrillation.

• Dopamine started 5mcg/kg/hr

RURAL ED

• After 14 minutes of cont’d CPR, HR returned to 166, BP

90/53, RR 20 assisted, GCS 3, T 96°F

• Solumedrol, Bicarb and Mg sulfate given

• Right chest tube inserted with minimal drainage

• Post chest tube CXR showed right pneumothorax

• Referring facility requested transfer and called a private

fixed wing service to transport

• 50 minutes before departure (Pedi team was available

but not called)

AUDIENCE PARTICIPATION

After 55 minutes of CPR do you believe

this is a survivable injury with a

neurologically acceptable outcome?

Yes

No

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AUDIENCE QUESTION

In your ED, how long would you continue

resuscitation on this patient

None , dead on arrival

1-15 minutes

16-30 minutes

31-60 minutes

PEDIATRIC TRAUMA CENTER

• Trauma Alert activation

• Trauma Surgery, Neurosurgery, Intensive Care Consults

• VS – HR 110, BP 102/52, RR asst’d 20, T 36.4°C

(97.5°F), remained stable

• CXR – bilateral pulmonary contusions,

pneumomediastinum

• CT within 30 minutes; Head CT►diffuse cerebral

edema, all other CT’s neg

• In the ICU 40 minutes after arrival

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OUTCOME

• The prognosis was grave

• This was an only child of older parents who could

not accept the inevitable outcome. Would not

consider withdrawal. Wanted to take him home.

• Brain Death exams were started and the patient

arrested and died prior to the second exam. No

organs recovered

AUDIENCE PARTICIPATION

Was this a trauma death?

Yes

No

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KAYLA’S STORY

• 7 yr old female restrained backseat driver’s side

passenger in a no-back booster. At highway

speed their car t-boned an 18 wheeler and ran

under the frame of the truck. Her father, the

driver, was dead at the scene. She was

extricated, and flown to the nearest community

hospital.

REFERRAL FACILITY CARE

• HR 82, BP 116/77, RR 20, GCS 9 (2-2-5)

• Intubated (RSI) within 10 minutes of arrival to the ED

• Pupils 2mm on L, 3mm on R and sluggish

• 2 IV’s infusing, fluid bolus given (1700ml crystalloid total

in ED) Wt - 25 kg

• First temp 90.7°F 15 min. after arrival

• To CT 21 minutes after arrival

• Vital signs remained stable

INJURY DESCRIPTION

•Open frontal and parietal skull fractures with

grey matter present with scattered

hemorrhagic contusions and subarachnoid

bleeds

• R femur fx.

• Comminuted L clavicle fx

•Multiple complex mid-facial fractures

• Pulmonary contusions

• Liver Laceration

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CASE PROGRESSION

• Labs at the referring hospital:

• H&H 11.1/32.7

• AST 310 ALT 432

• PT 16.7, PTT 31.9, INR 1.3

• Femur splinted, c-spine precautions

• Mannitol, Phenytoin and Ancef given

• Contacted Peds Trauma Center for transfer

• Patient to OR at referring for Neurosurgery

CRANIECTOMY

• Procedure started 80 minutes after arrival to the

ED

• VS remained stable in OR, T 34.3° (93.7°)

• EBL in OR 300ml; transfused 650 ml PRBC’s, 300

ml FFP

• Skull fragments removed and saved for tissue

bank storage (decompressive craniotomy)

• Procedure ended in just over 1 hour

TRANSFER

• The patient was transferred via helicopter by a

non-pediatric team.

• Departed the referring hospital 2½ hours

post injury and within 25 minutes of the end

of the surgery

•GCS 3-6 (1-1-4), skin pale and cool

• BP 147/51, HR 96, on vent RR 20, T 94.6

• Fentanyl and Midazolam given in flight

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Acidosis

Hypothermia

Trauma Triad of Death

Coagulopathy

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OUTCOMES

•Failed extubation day 10 and re-intubated

for respiratory distress

•Flexible Bronchoscopy on day 14 revealing

swelling and eschar

•Steroids and smaller ETT helped

•Extubated and flew on day 21

•MRI of C-spine revealed ligamentous injury

•Transferred to Neuro-Rehab day 24

•Cranioplasty on Day 32

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LESSONS LEARNED

• CHILDREN ARE NOT LITTLE ADULTS- knowledge of

anatomical, physiologic AND developmental differences

put you ahead of the game!!

• No matter what it looks like, the ABC’s are always the

priority!

• Things are not always what they seem!

• No matter what you think you know about the outcome,

sometimes things change!

IS YOUR ED PREPARED TO CARE FOR KIDS?

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THE ROLE OF EMERGENCY NURSING IN PEDIATRIC READINESS IN THE EMERGENCY DEPARTMENT POSITION STATEMENT WILL BE AVAILABLE FOR PUBLIC COMMENT UNTIL MONDAY, MAY 13. I ENCOURAGE YOU TO PARTICIPATE BY PROVIDING YOUR FEEDBACK. IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO REACH OUT. DIRECT LINK: HTTPS://WWW.ENA.ORG/PRACTICE-RESOURCES/RESOURCE-LIBRARY/POSITION-STATEMENTS

Thank

You