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Course # 92072 • Care of the Pediatric Trauma Patient

CASE STUDY

Patient A is 20 months of age and refuses to be restrained in a car seat. The family is late for a movie, and her mother does not want to deal with a temper tantrum. So, she decides to hold Patient A on her lap while her husband drives to the theater. While sitting at a stoplight, their car is hit head-on by a car being pursued by a police officer in a high-speed chase. Immediately prior to the moment of impact, Patient A's mother had let go of her daughter to put her hands up to protect herself from the impact. Upon impact, the child is thrown to the floor and rolls under the passenger side dashboard. The front end of the car is crushed accordion-style; the parents both strike the windshield and are unconscious.

Emergency medical service (EMS) responds to the scene and identifies only two victims, the parents. Utilization of rescue tool 10, also referred to as the "Jaws of Life," is required to extricate them from the vehicle. As the car is being pulled apart to remove the mother, Patient A's body rolls down from under the dash where she was trapped. It is only at this point that the EMS personnel are aware that they have a third victim.

The child is unconscious and unresponsive at the scene. She is transported to the local pediatric hospital, where she undergoes immediate resuscitation. Upon evaluation she is noted to have a depressed skull fracture over the right temporal area and a bulging fontanelle. An emergency CT scan is performed and demonstrates an epidural bleed, an intraventricular hemorrhage, and a subdural hematoma, along with the depressed skull fracture. She is admitted to the pediatric intensive care unit, where she remains profoundly comatose.

During the next two days, efforts at supporting the patient's neurologic status are performed, including optimizing her oxygenation status and ensuring adequate circulatory volume. She is on a ventilator and is paralyzed and sedated to ensure limited increases in ICP. Pharmacologic agents administered include mannitol, dexamethasone, and narcotics for sedation. Despite these efforts, no change in her condition is noted.

The mother does not survive the automobile crash, and the father remains comatose in the trauma intensive care unit at the trauma center 30 miles away. Patient A's extended family is notified of her poor prognosis, and studies of brain function are undertaken. She is pronounced brain dead and is disconnected from the ventilator. Prior to death, her family is approached regarding organ donation. As a consensus cannot be reached and her father remains comatose, no organs are procured after her death.

Case Study Discussion

Although devastating, Patient A's injuries are not uncommon. Parents who do not restrain children in appropriate car seats run the risk of these types of devastating injuries. The EMS personnel who arrived on the scene would have been able to find and treat her had she been in her car seat. However, because she was trapped under the dashboard, no resuscitation efforts were initiated for a long period of time. This delay in resuscitation may have contributed to her death, although the extent of her injuries was severe and survival may not have been possible even with significant, aggressive resuscitation.

The issue of organ donation was initiated with the family members. Whenever a trauma victim succumbs to injuries, organ donation should be a consideration. In this case, the child's parents were unable to participate in the decision regarding donation; therefore, organs were not procured. Many adults have become designated organ donors; however, such protocols do not exist for children. The belief is that the parent will always be available to make these decisions; however, as is evident in this case study, this is not always true. Discussing organ donation for both adults and children should be initiated within family units before such decisions are required.

CASE STUDY

Patient B is a boy, 14 years of age, attending a birthday party at the local community pool. He is an excellent swimmer and has always been safe around pools. When he is swimming in the pool, another guest runs and jumps into the pool, landing on top of Patient B. The force of the impact is directed at his head and neck. Immediately, he sinks to the bottom of the pool and is rescued by the pool lifeguard. After being brought to the surface, mouth-to-mouth resuscitation is initiated. Within moments, Patient B chokes and starts to breathe on his own. However, he is unable to move his extremities and feels no sensation below his shoulders.

EMS personnel arrive on the scene, and Patient B is placed on a backboard and put in full spinal precautions prior to being removed from the water. He continues to breathe on his own after the initial period of apnea. He is transported to the local emergency department for evaluation.

Upon arrival at the emergency department, the patient continues to demonstrate flaccid paralysis of both his upper and lower extremities. Neurologic assessments are initiated and continued on an every 15-minute basis. Cervical spinal x-rays show a fracture between C5 and C6. A CT scan demonstrates diffuse swelling in this area, with severe injury to the spinal cord.

Within 30 minutes of his arrival and during his initial resuscitation, methylprednisolone is started at a 30 mg/kg bolus. Despite this infusion, no improvement in his neurologic status is noted. Supplemental oxygen is provided, a Foley catheter is placed, and the neurosurgeon on call is notified.

Subsequently, Patient B is taken to the operating room for stabilization of his cervical spine. He is placed in traction in the operating room and transferred to the intensive care unit. During his stay in the intensive care unit, neurologic assessments are continued although no change is identified. During this time, psychologic counseling is initiated, as it is felt that the injury sustained will be permanent, rendering the patient quadriplegic.

Initially, Patient B's frame of mind is good; he feels that he can overcome his injury and be able to walk again. Despite counseling to the contrary, he continues to insist that he is going to get better. Within two weeks, he is ready to transfer to a spinal cord rehabilitation center. It is at this point that he realizes the full extent of his injury and becomes profoundly depressed. At times he expresses suicidal ideology and receives intensive counseling. During the next three months, Patient B and his family learn to deal with his healthcare requirements. He is discharged to home with around-the-clock nursing care.

Case Study Discussion

Despite the fact that most spinal cord injuries occurring in swimming pools follow diving accidents, other mechanisms of injury can be the cause. In this case, the victim was within the bounds of safe swimming and was still injured due to another child's inattention to safety. Patient B was immediately given mouth-to-mouth resuscitation. Due to this prompt response, near-drowning was not a complication of this injury.

The appropriate stabilization and resuscitation measures were undertaken without improvement in his condition. The x-ray and CT scan demonstrated significant injury, and the methylprednisolone was appropriately started as soon as possible after injury. In any patient suffering a spinal cord insult, this is considered appropriate treatment. The extent of injury and long-term effects may not be easily identified at the time of injury, but the patient should be given the benefit of the doubt when considering drug administration.

The depression that Patient B demonstrated is common in all patients suffering permanent spinal cord damage. Compounding this fact is that he is 14 years of age and has his entire life ahead of him. Adolescent depression is becoming increasingly common as children face new challenges. Teenage boys have high rates of suicide, and Patient B required intensive counseling to work through the depression he developed.

CASE STUDY

Patient C is a boy, 8 years of age, who is riding his bike when hit by a car. He is knocked to the ground and a subsequent car, which was unable to stop in time, runs over his chest wall. His t-shirt shows tire marks across his anterior chest. However, immediately following being run over, he jumps up and starts yelling at the driver, who also damaged his new bicycle. Witnesses call 911, and emergency medical care personnel arrive within minutes of the accident. Upon arrival, Patient C is walking around, expressing concern regarding his new bike. He demonstrates no signs of injury other than the tire marks across his chest. Because of the mechanism of injury, the EMS personnel insist that he be transported to the local emergency department for assessment and treatment, if necessary.

Upon arrival in the emergency department, his vital signs are stable, his oxygen saturation is 96%, and a chest x-ray is normal. His parents are called, and the patient is to be discharged to home. Prior to leaving, his parents are instructed to return to the emergency department if any signs of developing respiratory distress are evident.

Case Study Discussion

Most children who are run over by an automobile will sustain multiple injuries; however, in this case, Patient C sustained no identifiable trauma immediately following the accident. As is common in children, his chest wall was very pliable, and the weight of the car crushed his chest wall without producing injury to the bony segments. The risk in this type of trauma is that underlying pulmonary injury may develop, leading to significant respiratory distress. Upon admission to the emergency department, no respiratory distress was evident, his vital signs were stable, and his oxygen saturations were within normal limits. The most common delayed development in this case would be developing respiratory distress secondary to a pulmonary contusion. Prior to his discharge, the parents were instructed in identifying signs of respiratory distress and the requirement to return to the emergency department should these signs develop.

In this case, Patient C did very well and never required follow-up care. As for his t-shirt, he never washed it, and he keeps it on his wall as a reminder of the day he was run over by a car and walked away.

CASE STUDY

Patient D is a girl, 7 years of age, who is riding in the center backseat of her automobile restrained by a lap belt. The car is in a high-speed crash, causing the patient to be thrown forward over the top of the lap belt. The lap belt keeps her in her seat, but her body is flexed over the belt, and her forehead impacts the back of the front seat.

Immediately after the crash, she is screaming and crying. She is extremely upset by the crash, and it is difficult to assess if she is merely upset or if she is indeed injured. Because of the mechanism of injury, she is placed on a backboard in full spinal precautions and transported to the nearest trauma center. Upon arrival in the emergency department, a report is given as to the type and mechanism of injury. She has quieted down by this time and is only shaking her head yes or no when questioned about her injuries. As part of the head-to-toe assessment, the nurse begins palpating her lower abdomen, which causes Patient D to scream and begin crying. Further assessment of her abdomen is deferred, as she is crying uncontrollably at this time and information is difficult to ascertain.

The head-to-toe assessment demonstrates a bump on the patient's forehead, ecchymosis over her abdomen below her umbilicus, and a bruising over her right flank. Due to the mechanism of injury, it is suspected that she has sustained abdominal trauma, possibly a ruptured bowel secondary to seatbelt compression. X-rays and lab results are obtained and all are within normal limits. Eventually, Patient D quiets down, and she is transferred to the pediatric intensive care unit for further stabilization.

During the first few hours in the pediatric intensive care unit, she remains quiet and relatively pain free. The ecchymosis over her flank area increases in size, and her urine output falls to less than 1 cc/kg/hr. A urinalysis is obtained and demonstrates microscopic hematuria. Renal trauma is suspected; however, the decision is made to treat it nonoperatively and continue to monitor the patient in the intensive care unit. Her fluid intake is increased slightly in an effort to prevent acute tubular necrosis from developing.

During the middle of the night shift, she sustains a respiratory arrest. All efforts at resuscitation are performed without success. Patient D is pronounced dead 45 minutes after the onset of resuscitative efforts.

Case Study Discussion

This case study demonstrates the type of injuries that can be sustained when children are restrained with only a simple lap belt. There is tremendous effort underway to notify parents of the dangers of lap belts and the benefits of booster seats for children younger than 8 years of age. Had this type of restraint been utilized, the injuries to Patient D may have been minimal, if occurring at all.

A number of omissions were made in her assessment and resuscitation. The bruising over the flank area is a hallmark sign of renal trauma in children, and this should have been suspected much earlier in her course of care. The assumption that she sustained seatbelt-induced injuries was correct; however, it focused the care provider's attention on her abdomen when other injuries may have been present. Another injury that may occur secondary to seatbelt injury is injury to the lumbar spine. No studies were performed to rule out this injury.

On autopsy, the cause of her respiratory arrest was determined to be secondary to a large subdural hematoma that was not identified during her care. Because the patient was verbal and crying, it was assumed that she was neurologically intact. Her quiet behavior may have been an indication of neurologic deterioration rather than that she was just "being a good girl." The bump on her forehead that was identified in the emergency department should have alerted her care providers to the risk of neurologic injury, and further studies should have been performed.

Because Patient D did not survive, the extent of her injuries will never be known. What is known is that injuries were missed, and this played a direct role in her death. This case illustrates the horrible outcome that can occur when trauma care providers focus on one specific body system that is injured and overlook other less obvious, yet life-threatening, concurrent injuries.

CASE STUDY

Patient E is a boy, 8 years of age, who is riding his skateboard in a city park. He is not wearing protective gear, including a helmet. When a friend distracts his attention, he runs head-on into a planter and is thrown over the planter box onto the concrete, landing on his left side. He immediately experiences pain in his left side, left wrist, and abdomen. His left wrist is angulated and obviously broken. His friend responds to Patient E's cries for help and calls 911. EMS personnel respond to the scene, stabilize his wrist, and transport him to the local emergency department for evaluation.

A head-to-toe assessment demonstrates small, superficial scrapes on the patient's forehead and left cheek. His facial structures appear to be intact. Neurologically, he is normal, with a GCS score of 14. He has no complaints of shortness of breath, and his chest wall shows no obvious external injury. He complains of pain when the left upper quadrant of his abdomen is palpated. His pelvis appears to be without injury. His lower extremities are bruised and have superficial contusions and abrasions, which are contaminated with dirt and rocks. An x-ray of his left wrist shows a comminuted fracture of his left radius and ulna.

Cervical spine x-ray, laboratory results, and urinalysis are all normal. At this time, the focus of treatment is on his left wrist and the pain in his abdomen. Abdominal CT scan is obtained and is normal, and liver injury is ruled out. Subsequently, Patient E is taken to the operating room for orthopedic repair of his left wrist.

After surgery, he is admitted to the orthopedic floor with orders for pain medication as needed. Repeat liver function tests are obtained on an every six-hour basis. After being settled in bed, he appears to be stable and enjoys the attention that the injury has brought him.

During the middle of the night, the patient awakens and complains of severe pain in his left wrist. He is medicated with narcotics as ordered and appears to drift off to sleep. Two hours later, he is again awake and complaining of wrist pain. As the narcotic was ordered on an every four hour basis, the nurse must obtain an order for additional narcotic, which she does. After this second dose of pain medication, the patient again drifts off to sleep.

During the next day, he has a number of visitors. He continues to complain of pain in his wrist, but when observed, he is seen to be laughing and joking with his friends. The nurse caring for Patient E asks him to rate his pain on a scale of 1 to 10 with a reply of 8. The nurse continues to observe him and has a hard time believing the pain is as severe as 8. Two hours later, the patient again calls the nurse, this time giving a pain score of 9, and he is medicated by another nurse. The nurse medicating him checks his cast and finds it to be tighter than it had been earlier in the day, and capillary refill in his left hand is slower than on this right hand. She instructs him to keep the casted arm elevated on a pillow while visiting with his friends.

Later that evening, the patient again complains of pain with a score of 9. He is again medicated and drifts off to sleep after a busy day. During the middle of the night, he is crying and says that his hand hurts more than it ever has. His cast is tight, and his left hand is cool to touch. The orthopedic surgeon is notified by telephone, and the in-house physician evaluates Patient E. The in-house physician recommends that the patient be returned to the operating room for evaluation, and the orthopedic surgeon arrives at the hospital within the hour.

In the operating room, Patient E's hand is pale, with weak pulses and a significantly reduced range of motion. A diagnosis of compartment syndrome is made, fasciotomy is performed, and the wrist is placed in another cast that is bivalved. Eventually, the patient's wrist heals, and he regains full range of motion after intensive physical therapy.

Case Study Discussion

The care Patient E received in the initial stages after his trauma was excellent. A complete assessment was performed, and all injuries, both real and potential, were identified. The complications developed post-surgery, when he was admitted to the orthopedic ward. The frequent complaints of pain were incongruous with his behavior and, therefore, not validated by the nurses caring for him. New guidelines for pain management stress the importance of including the patient in the assessment of their pain and believing the report provided by the patient. Just because the patient's outward behavior was not what the nurse expected, it must be remembered that he may have been utilizing his friends as a distraction to his pain because he was not being adequately medicated.

Patient E's complaints of pain should also have alerted the staff to the development of potential problems. After a patient's fracture has been surgically stabilized, the pain should begin to resolve, not increase in intensity. With each complaint of pain, he should have had his pulses and circulation checked and his cast evaluated. His deteriorating condition should have been noted earlier, and surgical intervention could have been undertaken earlier rather than later. Patient E was lucky in regaining full function after this complication. Children are generally more resilient than adults. Had this complication developed in an elderly individual, the results may not have been as fortunate.

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