A Severely Injured Pediatric Trauma Patient: Case Presentation and Discussion
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1 A Severely Injured Pediatric Trauma Patient: Case Presentation and Discussion Christopher Butts PhD, DO Surgical Critical Care Fellow Cooper University Hospital
2 H&P 10 year old female presents as a trauma alert after being transferred via helicopter from an Level II adult trauma center s/p motor vehicle collision. She was the restrained rear seat passenger with a lap belt. On presentation was lethargic and complaining of severe abdominal pain. No LOC. Prior to arrival the patient had Foley placed at which revealed hematuria. She also received 1U prbc at the outside hospital for splenic injury and liver injury on outside CT scan.
3
4 Physical Exam VS: 97.5, HR 173, BP 78/50, RR 40, 95% RA Airway: patent Breathing: clear bilaterally Circulation: distal pulses intact Disability: GCS14 (3/5/6) Adjuncts: FAST: positive in all 4 quadrants CXR: negative PE: lethargic, abdominal seatbelt sign CT Head/Cspine: negative
5 Pediatric Vital Signs
6 Pediatric Glasgow Coma Score (GCS)
7 CT Chest Pericardial effusion Right middle lobe/right lower lobe contusion Right 11 th rib fracture
8 CT Abdomen/Pelvis
9 CT Abdomen/Pelvis Grade V liver injury Multiple lacerations to the right kidney with likely vascular compromise and possible renal vein laceration Partial tears of the spleen Decreased attenuation in uncinate process questionable for pancreatic injury Free air Jejunal hematoma Large amount of hemorrhagic ascites
10 Operative Findings Patient taken immediately to the operating room Exploratory laparotomy Trauma and pediatric surgery
11 Operative Findings Findings: Active bleeding from Grade 4 liver laceration Active bleeding from Grade 3 splenic laceration 1cm laceration to the first portion of the duodenum Serosal injury to 1 st and 2 nd portion of the duodenum Nonexpanding right Zone 2 retroperitoneal hematoma
12 What Would You Do Procedure: Exploratory laparotomy Packing of liver hemorrhage Splenectomy Primary repair of 1 st portion of duodenum. Repair of deserosalization injury to 1 st and 2 nd portion of the duodenum Pyloric exclusion Placement of Abthera vac
13 Post-Op Day 0 Patient intubated and taken to Pediatric ICU Pediatric Critical Care Service consulted for co-management Transfused 1 unit FFP Started on Zosyn
14 Post-op Day 1 Return to OR with pediatric surgery and hepatobiliary Reopening of recent laparotomy Removal of packs Gastrojejunostomy Intraoperative cholangiogram Exploration of common bile duct Gastropexy Placement of 10 Fr T-tube
15 Pyloric Exclusion Duodenal Repair Gastrojejunostomy
16 Post-Op Day 2-3 Patient extubated to nasal cannula Child life consulted Patient would benefit from therapeutic pet visitation, caring clown visit, music therapy, and art therapy
17 Post-Op Day 4 R Femoral line removed PICC line placed TPN started Echo: Normal appearing anatomy. No effusion CT Urogram Fractured right kidney with extravasation of excreted urinary contrast into large right perinephric collection without visualization of the right ureter or evidence of vascular extravasation
18 Post-Op Day 5 Transferred to Pediatric Stepdown Unit NG-tube removed Care transitioned from Pediatric Critical Care Team to General Pediatrics Zosyn stopped
19 Post-Op Day 6-7 Foley and JP drains removed Pediatric infectious disease consulted for vaccination timing recommendations and need for prophylactic antibiotics Two weeks after her splenectomy give a dose of PCV-13 and HIB vaccines Four weeks after her PCV-13 and HIB, give a dose of conjugate Meningococcal vaccine Four weeks after receiving the conjugate Meningococcal vaccine, give pneumovax 4 weeks after pneumovax, give Meningococcal B vaccination Penicillin 250 mg BID prophylaxis
20 Post-Op Day 8-10 Regular diet started TPN stopped T-tube clamped after study showed anterograde flow Renal ultrasound: Healing renal laceration, small residual hematoma, uroma
21 Multidisciplinary Approach Trauma surgery Pediatric surgery Pediatric critical care General pediatrics Subspecialists that provide pediatric care Nursing Social work Child life
22 There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later but something has happened in your body that is irreparable. -R Adams Cowley (1975)
23 Acknowledgments
24 Questions?
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