CASE SIMULATION

Debriefing

Diagnosis?

Altered level of consciousness Respiratory insufficiency Acute subdural hematoma Possible inflicted traumatic brain

injury/abuse (+/-) Cardiopulmonary arrest

CASE EVALUATION

How do you think you did? What did you think you did well? What would you have done differently? How do you think your colleagues did?

As you walk into the room what do you see?

What needs to be done now!

Airway: Is the airway secure? Breathing: Is the patient’s breathing normal? Circulation: Is the patient perfusing well? Disability: What’s the GCS in this patient? Environment/Exposure: How could body temperature

change your management? IVs, O2, Monitors, full vitals and blood drawn.

Ok, we have a more stable patient, now what?

SAMPLE History: Signs/symptoms Allergies Medications Past medical

history Last Meal Events

Secondary Survey: Complete physical

examination

Order remaining labs and tests

Talk to consultants if needed

Differential for altered mental status in the pediatric population

“VITAMINS”

Vascular Infection Toxins Accidents/AbuseAccidents/Abuse

Metabolic Intussusception Neoplasms Seizure

Approach to decreased level of consciousness/comatose patient

Child abuse/Inflicted traumatic brain injury

The leading cause of death by trauma in children less than 2 years of age

The recognition of inflicted traumatic brain injury can't be overemphasized. Risks:

D/C home to dangerous environment Siblings in danger

If suspected, contact CPS or activate the resources that do this in your hospital

Child abuse/Inflicted traumatic brain injury

History: 37% of iTBI have no history of trauma Evasive and inconsistent history

Physical examination Most common presentation is non-specific. One study showed that 31% iTBI were seen

shortly after the injury and discharged home with alternative diagnosis (e.g. Viral illness)

Child abuse/Inflicted traumatic brain injury

The triad of Subdural hemorrhage, fractures, and retinal hemorrhages are the classic findings but only present in 30% of patients

Skeletal survey at presentation and in 14 days if abuse is suspected

Your report/charting: State clearly that presentation is consisted with inflicted injury

Do not try to establish a time line, Do not try to determine intent

Pediatric Head Trauma

Airway: Less

cardiopulmonary reserve in Peds.

Basic airway maneuvers

Anatomic differences

Intubation: When? RSI Atropine Blunting of intra-

cranial pressure rise

Pediatric Head Trauma

Breathing Higher baseline respiratory rate in Peds

Circulation Lower BP at baseline for Peds Blood pressure management

Goal is to maintain appropriate cerebral perfusion pressure

CPP = SABP - ICP

Pediatric Head Trauma

• Disability Glasgow Signs of herniation

Cushing reaction Mannitol/Hyperventilation

• Exposure/Environment Aggressively treat hyperthermia Induced hypothermia (+/-)

Pediatric Head Trauma

Associated with ICI: Scalp Hematoma Facial injury Abnormal

neurological exam Poor evidence for < 2 y/o Higher rates (-) sings

and symptoms at this age

Pediatric Head Trauma

CT or 6 hours Obs: Multiple episodes of

vomiting Brief LOC History of AMS that

is now resolved High force

mechanism Unwitnessed event

Pediatric Head Trauma

Disposition if positive ICI Admission to ICU with neurosurgery consult Transfer to hospital with appropriate

resources if necessary Contact CPS immediately if iTBI is

suspected

CASE REVALUATION

How do you think you did? What did you think you did well? What would you have done differently? How do you think your colleagues did?