By Santa J. Bartholomew M.D. FAAP, FCCM
See Corresponding Journal Article: Pediatric Trauma Management
Pre-Hospital:
The patient is a 2-year-old female with no previous medical history and was riding on a rural road with her parents. The parents were both wearing seatbelts and the 2-year-old was in a car seat properly belted into the back seat on the passenger’s side. Unfortunately, both parents were pronounced dead on the scene. The accident was a rollover. It was raining and perhaps due to slippery roads or poor visibility, the car was T-boned on the passenger’s side at an intersection by a car traveling at about 55 mph. The 2-year-old’s car seat was wedged into the back seat, and it took approximately 45 minutes for firefighters to extricate her from the car. It had taken them 20 minutes to arrive at the scene.
When EMS took over care, the primary survey revealed that the patient was bradycardic and without respirations. She was transported to the local healthcare facility about 20 minutes away with bag-valve-mask ventilation in progress. The team was unable to gain IV access, so an intraosseous catheter was placed in her distal tibia. The helicopter was dispatched in preparation for transfer to the pediatric trauma center which is over 2 hours from this community
In the community hospital, artificial respirations were continued. The patient was intubated and placed on a ventilator. There was placement of 2 large bore IVs, an orogastric tube, and a Foley catheter were placed which was all part of the secondary survey and treatment. The patient had a chest and abdominal x-ray. Bilateral chest tubes were placed due to bilateral pneumothoraces. Two liters of lactated ringers, followed by 2 units of blood, were given to support a blood pressure of 65/39. The patient was placed on Epinephrine and Norepinephrine drips. A head CT was deferred in order to speed transport to a trauma center.
Due to severe thunderstorms and lightning strikes in the area plus the possible formation of a tornado, the flight crew, now grounded, jumped in an ambulance and transported the patient by ground transport to the Level I Pediatric Trauma Center over two hours away. The timeframe from arrival at the community hospital to transport to ground transport was 2 hours and 46 minutes.
The patient remained critically ill receiving more lactated ringers and 2 more boluses of blood during transport. A Ketamine drip was started. The patient remained on the Epinephrine and Norepinephrine drips. She remained hypotensive throughout the 2-hour and 20-minute transport to the trauma center.
Level I Pediatric Trauma Center:
The patient arrived at the Level I Pediatric Trauma Center nearly 5 hours and 10 minutes after the injury. The patient arrived with a BP of 68/45 and a heart rate of 74. Her temperature was 84.2 rectally. She remained on the Epinephrine, Norepinephrine, and, Ketamine drips. The massive transfusion protocol was initiated. Her Glasgow Coma Scale was 3. Mannitol was given after noting that the patient had fixed and dilated pupils. The patient was sent to radiology for a CT scan of her brain. The CT brain scan shows an intracranial hemorrhage in the right parietotemporal lobe with adjacent edema. A subarachnoid hemorrhage was seen in the brain sulci. There was a midline shift of the third ventricle.
Abdominal CT showed obliteration of structures due to massive amounts of blood.
Operating Room:
The patient was emergently prepped, and the abdomen was opened. Pediatric surgeons and pediatric neurosurgeons attended the surgery. Upon opening the abdomen, the abdominal contents protruded immediately and blood pressure improved. The bowel appeared dusky yet viable. There was bleeding noted near the liver, which was packed. The rest of the abdomen was examined, without injury noted, so a damage control closure was initiated.
An ICP monitor was placed in the patient’s brain to monitor intracranial pressure for the foreseeable future. It was successfully removed one week later.
Within 2 hours, the family arrived at the hospital and the grandparents were deemed “next of kin” and decision-makers for the child.
Conclusion:
Primary survey was immediately performed and airway, breathing, and circulation continued to be addressed throughout the care of the patient. A secondary survey did not occur until primary trauma care was achieved. The patient was transferred to a level I trauma center where tertiary care as well as appropriate social care was rendered.
References:
American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of EMS Physicians, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014; Apr 133(4):e1104-16.
