CASE SIMULATION

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CASE SIMULATION

• Debriefing

2
Diagnosis?

• Altered level of consciousness
• Respiratory insufficiency
• Acute subdural hematoma
• Possible inflicted traumatic brain injury/abuse
• (/-) Cardiopulmonary arrest

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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?

4
As you walk into the room what do you see?
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What needs to be done now!

• Airway Is the airway secure?
• Breathing Is the patients breathing normal?
• Circulation Is the patient perfusing well?
• Disability Whats the GCS in this patient?
• Environment/Exposure How could body temperature
  change your management?
• IVs, O2, Monitors, full vitals and blood drawn.

6
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

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Differential for altered mental status in the
pediatric population

• VITAMINS
• Vascular
• Infection
• Toxins
• Accidents/Abuse

• Metabolic
• Intussusception
• Neoplasms
• Seizure

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Approach to decreased level of consciousness/comat
ose patient
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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

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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)

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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

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Pediatric Head Trauma

• Airway
• Less cardiopulmonary reserve in Peds.
• Basic airway maneuvers
• Anatomic differences

• Intubation
• When?
• RSI
• Atropine
• Blunting of intra-cranial pressure rise

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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

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Pediatric Head Trauma

• Disability
• Glasgow
• Signs of herniation
• Cushing reaction
• Mannitol/Hyperventilation
• Exposure/Environment
• Aggressively treat hyperthermia
• Induced hypothermia (/-)

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Pediatric Head Trauma

• Associated with ICI
• Scalp Hematoma
• Facial injury
• Abnormal neurological exam
• Poor evidence for lt 2 y/o
• Higher rates (-) sings and symptoms at this age

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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

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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

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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?