2. 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
4. 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
6. 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
7. 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
reapplied
Decision to not call trauma activation
Neurosurgery 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
8. Timeline of Events
2045- Neurosurgery called away to adult trauma
2115- Pt complains of feeling “hot and sweaty”
BP 96/29 and HR 157
MD to bedside
1L NS bolus by pressure bag and placed in trendelenburg
2130- BP 80/39 and HR 146
1L NS bolus repeated
I stat and repeat CBC
Pediatric Surgery consulted
○ Considered closing at bedside
2225- Attending to attending conversation (ED and Surg)
2300- To OR
Total time in PED (1925-2300)
9. Imaging
CT neck- normal
CT head
No intracranial injury or fracture
Large right posterior-superior parietal
subgaleal hematoma with evidence of scalp
laceration and subcutaneous emphysema
CXR- normal
Pelvis xray- normal
11. 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
12. Areas for Discussion
Considerations for calling a trauma
activation
Delay in subspecialty care/transfer
Communication/chain of command
concerns
Between RN and MD
Between subspecialty physicians
Between training levels
Scalp laceration morbidity
Role of Mass Transfusion Protocol
13. 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 team
Shorter 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 injury
Pre trauma team 4% DDI and post trauma team
0.5% DDI
Vernon et al. Pediatrics.1999
Perno et al. Pediatric Emergency Care. 2005
14. 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 comers
Results can be extrapolated
Chalfin et al. Critical Care Medicine. 2007
15. MUSC Pediatric Trauma Alert
Criteria
Level A
Physiologic Criteria
GCS <9 at time of EMS transport
Hypotension
Suspicion of respiratory compromise
Attending concern for serious injury
16. MUSC Pediatric Trauma Alert
Criteria
Level A
Anatomic Criteria
Penetrating injury to head, neck, torso
Penetrating injury to extremity proximal to elbow
or knee with ongoing bleeding
Flail chest
Two or more long bone fractures
Crushed/degloving injury
Amputation proximal to wrist or ankle
Open or depressed skull fracture
Suspected Pelvic fracture
2nd or 3rd degree burns >40% BSA
17. MUSC Pediatric Trauma Alert
Criteria
Level A Trauma Transfer from OSH
Hemodynamically unstable
Intubated
Urgent need for surgical intervention
Blood transfusion prior to transfer
18. MUSC Pediatric Trauma Alert
Criteria
Level 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
19. MUSC Pediatric Trauma Alert
Criteria
Level B
Mechanism of Injury Criteria
Fall >20 ft (1 story equals 10ft)
Ejection from vehicle
Death in same passenger compartment
Auto/pedestrian or auto/bike with impact >20
MPH
Motorcycle or ATV crash >20 MPG
MVC > 25 MPH
20. MUSC Pediatric Trauma Alert
Criteria
Level 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
21. Learning Point
A trauma activation for this patient may
have helped mobilize more resources and
facilitated quicker definitive care
22. Frequent Sources of Medical
Error
Medication errors (weight-based dosing)
Level of training
Staffing
Overcrowding
Stress
Fatigue (Most ED errors between 4am-8am)
Communication
Selbst et al. Pediatric Emergency Care. 2004
23. Communication
High volume and velocity of information
exchanges
Multiple check outs and handoffs
Frequent interruptions
Multitasking
Significant source of medical errors
Coiera et al. MJA. 2002
24. 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
26. Communication Learning Point
Closed loop / confirmatory feedback
Minimize hierarchy
Be receptive/ approachable
Remember/utilize chain of command
27. Scalp lacerations
May be grossly underestimated
Often 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
29. Scalp lacerations
When lacerated, small arteries retract
between the septa
7-10 cm laceration can cause loss of
30% blood volume
Lemos et.al., J. Emerg. Med. 1988
Turnage and Maull, Southern Medical Journal. 2000
30. Case Reports in the
Literature
45 y/o M with large scalp lac and
epidural hematoma after bike vs. car
Transfer from community hospital to tertiary
care center for neurosurgery involvement
Scalp laceration not closed before transfer
Arrival to hospital in shock (systolic BP 65
and HR 156) requiring aggressive
resuscitation
Hgb 6.3 on arrival to hospital
Multiple transfusions of PRBCs and clotting
factors given
Fitzpatrick et al, J Accid Emerg Med.1996
31. 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 stabbing
Scalp wounds stapled before transfer to tertiary
care center
En route had a seizure and required intubation
Several staples dislodged during event and
profuse bleeding from scalp wound occurred
Arrival to hospital in shock (BP 70/40 and HR
130) requiring aggressive resuscitation
Hgb 7.1 on arrival to hospital
4 units PRBCs given
Fitzpatrick et al, J Accid Emerg Med.1996
32. Bleeding Control
Direct constant pressure
Dressing application
Elevation
Direct clamping
Suture
Staples
Lemos et.al., J. Emerg. Med. 1988
33. 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
Lemos et.al., J. Emerg. Med. 1988
Fitzpatrick et al, J Accid Emerg Med.1996
34. 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
37. Definitive Closure
Likely with subspecialty service for
larger lacerations
Surgery
Neurosurgery
Plastics
Sykes, Annals of Emergency Medicine, 1989
38. Learning Point
Quick and effective initial management
is imperative in scalp lacerations
Potential for scalp lacerations to cause
hemorrhagic shock
39. 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 pediatrics
Based on clinical condition and expected further
blood loss
Institution 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
41. Coagulopathy in the “Lethal
Triad”
Well documented part of trauma
Cycle of worsening
coagulopathy, hypothermia, and
acidosis
Hypothermia decreases platelet activation
and adhesion
Hemodilution decreases clotting factors and
increases hypothermia
Acidosis worsens clotting factor function
Nosanov et al., American Journal of Surgery, 2013
42. Pediatric Blood Volumes
Age
Premature Infant
Term infant to 3 months
Children older than 3
months
Obese children
Estimated Blood Volume
(mL/kg)
90-100
80-90
70
65
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
43. Pediatric Blood Volume in
Units
Weight
10 kg
25 kg
50 kg (adult standard)
Blood Volume
2 units
5 units
10 units
44. Fresh Whole Blood
Fresh whole blood has been used in
adults in combat setting
Fresh whole blood transfusions have been
noted to improve 30 day survival rates
FWB not widely available in civilian
setting
Only 15% of children‟s hospitals stocked
FWB
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010
45. Pediatric Mass Transfusion
Defined by the volume of blood products
given to maintain hemodynamic stability
Transfusion 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
46. 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
47. Pediatric Mass Transfusion
Activated 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
48. 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 literature
Adult data may not be generalized to
pediatrics
Controversy exists between proper
blood products ratio
Further pediatric research is needed
Chidester et al., J Trauma Acute Care Surg.,2012
49. Pediatric Mass Transfusion
Higher FFP/PRBCs ratio has not been
statistically shown to have increased
survival in children
Hwu 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
Hendrickson et al, Transfusion, 2012
Nosanov et al., American Journal of Surgery, 2013
51. Complications of MTP
FFP transfusion associated with increased
risk of respiratory distress and ARDS
Increased susceptibility to hyperkalemia
secondary to blood product transfusion
K+ slowly leaks out of RBC‟s during storage and
can increase K+ concentrations
9 case reports of pediatric hyperkalemic cardiac
arrest due to MTP in literature
Cardiac patients and neonates increased risk
Mean K+ 9.2 mmol/L (6.3-12mmol/L)
Lee et al, Transfusion, 2013
53. Recombinant Factor VIIa
Useful adjunct for control of bleeding
Enhances production of thrombin on the
surface of activated platelets
Adult studies have documented
decreased blood product requirements
No sufficient pediatric studies
No change in mortality in MTP
Lower incidence of thromboembolic
events
Chidester et al., J Trauma Acute Care Surg.,2012
54.
55.
56.
57. MTP and Organ Donation
MTP activation in one study showed 2
incidences where viability of organ
donation was made possible
1 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
58. 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
59. 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
60. References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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.
Lee, A.C. et al. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion.
2013 doi:10.1111/trf.12192.
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.
Nosanov, L., et al. The impact of blood product ratios in massively transfused pediatric trauma patients. The American Journal of
Surgery. 2013.
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.
Turnage, B. & Maull, K. Scalp laceration: an obvious 'occult„ cause of shock. Southern Medical Journal. 2000;93:265-266.
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.
Sykes, L.N. Management of hemorrhage from severe scalp lacerations with Raney clips. Annals of Emergency Medicine. 1989;18:995996.
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
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.
Selbst, S.M., et al. Preventing Medical Errors in Pediatric Emergency Medicine. Pediatric Emergency Care. 2004; 20:702-709.
Alvarez, G. & Enrico Coiera. Interdisciplinary communication: an uncharted source of medical error?. Journal of Critical Care 21.
2006:236-242.
Coiera, E.W., et al. Communication loads on clinical staff in the emergency department. Medical Journal of Austrailia. 2002;176:415418.
Sutcliffe, K.M. et al. Communication Failures: an insidious contributor to medical mishaps. Academic Medicine. 2004; 79:186-194.
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.
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.
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
61. Special Thanks
Thank you to Dr. Rachel Tuuri, Dr. Olivia
Titus, Dr. Scott Russell, Dr. Fred
Tecklenburg, and Madeline Gehrig for their
help.
Notes de l'éditeur
I think that you can add the detail about the fact that the tree branch was burning, and the context
Pertinent positives and negatives here.
Opens up radiologic resources, More manpower
Not a trauma study
Quicker time to scanner, more man power
Particularly pertained to Peds ED. Busy night, multiple sick patients
Observation studyOBJECTIVES: The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered.DESIGN: Concurrent incident study.SETTING: Medical-surgical ICU of a university hospital.MEASUREMENTS AND MAIN RESULTS: Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-hr records taken by observers with human engineering experience on a sample of patients. During the 4 months of data collection, a total of 554 human errors were reported by the medical staff. Errors were rated for severity and classified according to the body system and type of medical activity involved. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day.CONCLUSIONS: A significant number of dangerous human errors occur in the ICU. Many of these errors could be attributed to problems of communication between the physicians and nurses. Applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors. Errors should not be considered as an incurable disease, but rather as preventable phenomena.
Is this where you are going to talk about how the nurses felt that they were communicating a higher level of urgency than the doctors heard?--Interruptions, closed loop communication--If nurses aren’t being heard, they can go up the COC.
1 neurosurgeon to cover the whole hospital, surgery has more manpower
Although not in our patient, nice jumping off point
Discuss details of Hwu study- decivf and trend for survival