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Pediatric Trauma Resuscitation – Pelvic fracture, Splenic laceration,

Hypovolemia

I. Pediatric trauma

II. Target Audience: Emergency Medicine Residents

III. Scenario Goals and Objectives

a. Goal – The student will lead a resuscitation team in the


evaluation and management of a pediatric patient presenting
as a multiple trauma victim after a motor vehicle accident
(MVA)
b. Learning objectives
a) Demonstrate an appropriate primary assessment of a
pediatric trauma victim
b) Complete an appropriately timed secondary survey
c) Recognize and treat hypovolemia due to internal
hemorrhage
d) Demonstrate correct sequence of steps to
diagnose/rule out potential intra-abdominal and
pelvic pathology
e) Obtain appropriate laboratory and radiology studies
f) Initiate a timely surgical consult
c. Assessment objectives/Critical actions
a) During case
1. The leader must quickly complete a primary
survey within 2 minutes of presentation
2. Two large bore IV or IO lines must be obtained
within 3 minutes of patient presentation
3. AMPLE history must be obtained
4. Leader must recognize hypotension and initiate
fluid resuscitation
5. The leader must order and interpret portable
radiographs of the pelvis
6. The leader must recognize potential need for
blood transfusion, order a type and cross, and
consider the need for emergency release blood
7. The leader must direct the team assertively and
delegate tasks appropriately
8. Patient’s clothes should be removed
9. Surgical consult must be obtained. This can
occur either early (soon after the patient
arrives) and/or after patient has been
resuscitated and injuries identified.
b) During Debriefing
1. Review quick assessment of ABCs and IV,
oxygen and monitor placement
2. List signs of hypovolemia and treatment
3. Discuss stabilization of the pelvis

IV. Environment
a. Lab set up – A PediaSim will be placed on an ED stretcher.
The scenario takes place in a tertiary care trauma pediatric-
capable emergency department
b. Manikin Set up – The PediaSim will be lying on a stretcher
with C-Collar in place and fully clothed.
c. Props - A stethoscope will be needed. A cardiac monitor
with leads, blood pressure cuff, pulse oximeter,
supplemental oxygen by nasal cannula, supplies for starting
an IV and/or intraosseous line, and simulated emergency
release blood, will be needed. In addition, medications for
resuscitation, the treatment of pain, and for rapid sequence
intubation should be readily available along with a full
spectrum of emergency airway equipment.
d. Audiovisual: A plain film X-ray of a pelvic fracture and a
CT scan showing a splenic laceration will be needed. Also a
normal chest x-ray, normal c-spine, CBC with an H/H that
shows a slightly low hemoglobin with normal WBC and
platelets, normal coags , normal LFTs, normal BMP,
normal UA.
e. Distracters – Any distracters can be used including family
members.

V. Actors
a. Roles
a) One physician leader
b) One nurse to administer medications
c) One medical technician to assist
d) Other participants can help as directed by the leader
e) One instructor to control the scenario
b. Who can play them – The leader should be played by a
resident. The instructor should be familiar with the
PediaSim. Other roles can be played by residents, students,
or other people as appropriate,
c. Action Role
a) Physician leader – The leader must coordinate and
direct the team, obtain a focused history, perform a
pertinent physical exam, order and interpret labs and
radiological studies, order treatments and
perform/direct advanced procedures.

VI. Case Narrative


a. Scenario given to participants
a) Chief Complaint – MVA
b) The physician leader will be given a triage note
stating an 8 y/o F arriving by EMS after being a
unrestrained backseat passenger involved in a MVA.
Vital signs: HR 140 BP 100/65 RR 18, Temp 98
c) History of present illness (Must be requested):
Provided by EMS- The patient was unrestrained
sitting in the back seat. Her car was hit while turning
left. The other car was going 35mph. The patient is
crying and says her left upper leg and belly hurt.
d) Past Medical history (Must be requested): None
e) Past Surgical history (Must be requested): None
f) Medication and allergies (Must be requested): None
g) Social and Family history (Must be requested):
Lives at home with her mom, dad, and 2 sisters, no
significant family history
b. Scenario initial conditions:
a) The leader will be given the triage note above. The
patient will be lying on the bed in a c-collar, still
clothed, crying. Vitals signs per triage note.
b) General appearance: Appears in mild distress,
Airway intact, Breathing spontaneously, Good
pulses bilaterally
c) HEENT: normocephalic atraumatic, PERRL, no
hemotympanum, mouth and throat normal, trachea
midline
d) Respiratory: Good breath sounds bilaterally, no
wheezes
e) Cardiac- tachycardic with no m/r/g
f) Abdomen: Soft, tender diffusely, but greater over
the LUQ with no rebound or peritoneal signs
g) Extremities: Pain to palpation over left hip, no
obvious deformity, will slightly move left leg but
says she gets a lot of pain, FROM of all other
extremities
h) Skin: No bruising, rashes or abrasions
i) Neurological: Intact, symmetric reflexes
c. Scenario branch points
a) Changes in clinical condition: The patient should
remain stable until return from the CT scanner. After
the patient returns or after 8 minutes (if the patient is
not sent to CT), the patient’s blood pressure will
drop and heart rate will increase until blood is given
to the patient. If blood products not given patient’s
blood pressure will continue to drop and patient’s
rhythm will deteriorate to Asystole.
b) Responses to therapy: The patient should be given a
20cc/kg fluid bolus and will transiently improve
blood pressure and lower heart rate. If a second
bolus is given, vials will again transiently improve.
However, blood pressure will again decrease and
only improve after packed RBCs at 10 ml/kg are
given.
c) Pain medication should be given at appropriate dose
for weight. It will decrease the patient’s pelvic pain
but not change clinical status.
d) Oxygen – will not change clinical status
e) Pelvic compression – A sheet should be wrapped
around the pelvis after fracture is identified, but the
treatment will not change clinical picture.
f) If patient’s resuscitation is delayed, the patient will
become unresponsive. The patient should be
intubated if this occurs.
g) Surgery can be initially notified that a hypotensive
trauma victim has presented. They will not be
immediately available. After the splenic laceration
and pelvic fracture are identified, surgery should be
notified for further care.

VII. Instructor notes


a. Tips to keep scenario flowing
a) Prior to scenario patient should be clothed.
b) HPI should be provided by EMS. Child will only
answer pain questions.
c) Fluids should be given in 20cc/kg, if the correct
volume is not ordered, nursing can question the
order.
d) If ABCs and primary survey not done in a timely
manner the patient should decompensate quickly. If
the decompensation is recognized and treated, the
patient should stabilize so that the work up can be
completed. If the decompensation is not treated
within 3 minutes, the patient will deteriorate to PEA.
If fluids followed by emergency release blood are
not given, then the patient deteriorates to asystole
and cannot be resuscitated. If the PEA is
aggressively treated, the patient returns to a
hypotensive state with a pulse. Surgery must be
immediately consulted for successful management at
this point.
e) Child should continue to say her abdomen hurts
until pain medication is given or she loses
consciousness.
b. Tips to direct actors
a) The leader should be informed when the child return
from the CT scanner.
b) The physician leader is expected to consult surgery.
If he/she does not initiate a consultation at the
appropriate time, the actors can prompt leader by
asking where the patient will be admitted or how the
injuries will be treated.

VIII. Debriefing plan (Attachment 1) –


a) The debriefing can occur as a group. The debriefing
should start with a discussion of the main decisions
made by the team leader during the resuscitation and
his/her thoughts leading to each decision. Team
member comments should be solicited. Feedback
should include review of the initial presentation,
findings on exam, and lab/radiology ordered.
Binding pelvis and techniques should be covered.
Early surgical consultation can also be discussed.
Grading and treatment of splenic lacerations can
also be discussed. Any learning objectives not
raised during these segments should be reviewed at
the end of the debriefing.
b) Assessment form (Attachment 2) – Completion of
critical actions will be recorded on a modification of
the standardized direct observation tool (SDOT).2

IX. Authors and affiliations


a. Benjamin D Barlow MD; Department of Emergency
Medicine- Boonshoft School of Medicine
b. Raymond P Ten Eyck MD, MPH; Simulation Center
Director; Department of Emergency Medicine- Boonshoft
School of Medicine

X. References:

1. Wegner, Stephen MD et al. Pediatric Blunt Abdominal Trauma


Pediatric Clinics of North America 53 2006 243- 256

2. Shayne P, Gallahue F, Rinnert S, et al. Reliability of a Core


Competency Checklist Assessment in the Emergency Department: The
Standardized Direct Observation Assessment Tool. Acad. Emerg. Med.
July 2006; 13(7); 727-732.
Attachment 1

Pediatric Case Debriefing Points

A. What went well and what would you do differently if you were going to repeat
the exercise? (Direct question to team leader first and then to team members)
B. What was your thought process for the key actions taken or not taken? (Direct
question modified to address specific actions to the team leader)
C. Discuss simulation events related to the specific learning objectives (Use a
group discussion format led by the instructor):

1. Perform an appropriate primary survey


a. Airway – with C-spine precautions
b. Breathing
c. Circulation
d. Disability
e. Exposure
f. Broslow tape
g. Pain control

2. Perform a timely and appropriate secondary survey


a. After the primary survey and interventions a head to toe secondary
survey should be performed to identify all injuries.

3. Recognize and treat hypovolemia secondary to internal hemorrhage


a. Tachycardia is usually the first sign of hypovolemia but vital signs
initially can be normal due to cardiovascular reserve
b. Other signs are mental status changes, delayed capillary refill, skin
pallor and hypothermia

4. Demonstrate correct sequence of steps to diagnose/rule out potential intra-


abdominal and pelvic pathology
a. Perform initial abdominal exam focusing on any bruising,
distension, tenderness and peritoneal signs.
b. Perform initial pelvic exam focusing on stability, pain, rectal tone
and blood, and genital exam.
c. Timely evaluation of a portable pelvic x-ray for fractures.
d. If patient is stable and abdominal injury is suspected from history
or exam, CT is the modality of choice.

5. Obtain appropriate laboratory and radiology studies


a. Radiographic evaluation of trauma victims includes C-spine, chest
and pelvis.
b. After these initial studies further radiological studies can be
ordered depending on mechanism of injury and physical exam
c. Laboratory work for trauma victims includes CBC, BMP, UA, and
coagulation studies.

6. Initiate a timely for surgical consult


a. Early surgical consult for decreased GCS or hypovolemia
decreases mortality in trauma victims.
Attachment 2

NI = Needs Improvement ME = Meets Expectations AE = Exceeds Expectations


Core Competency Score
Trainee:
Instructor:
During Simulation NI ME AE N/A Core
Competencies
Involved PC MK I
1. Introduces self and efficiently establishes
respectful and effective communication with
patient/EMS.
2. Gathers essential and accurate information
from patient/EMS (history of trauma, initial vital
signs in the field, symptoms, severity, duration)
3. Sequences critical actions in patient care:
vitals signs, ABCs, primary survey, establishes
IV/IO x2, AMPLE history, fluid resuscitation,
order and interpret radiographs, order blood
transfusion, attain surgical consult
4. Communicates clearly, concisely, and
professionally with staff regarding interventions,
radiology, lab orders, and consults.
5. Can handle distractions while maintaining
patient care priorities
6. Reevaluates patient after fluid bolus, when VS
start to deteriorate after initial stabilization, and
following blood transfusion.
7. Carries out appropriate admission/transfer
plan, and notifies accepting MD as indicated
During Debriefing

8. Describes indications/contraindications for


each therapy and need for early surgical consult
9. Describes an appropriate differential, plan, and
disposition
10. Explains the pathologic basis for management

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