Severe Pediatric Trauma with Michael McGonigal

I got to speak with Michael McGonigal, MD of the Trauma Professional’s Blog about severe pediatric trauma in the ED.

Pediatric Glasgow Score

Best eye response: (E)

  1. Eyes opening spontaneously
  2. Eye opening to speech
  3. Eye opening to pain
  4. No eye opening or response

Best motor responses: (M)

  1. Infant moves spontaneously or purposefully
  2. Infant withdraws from touch
  3. Infant withdraws from pain
  4. Abnormal flexion to pain for an infant (decorticate response)
  5. Extension to pain (decerebrate response)
  6. No motor response

Best verbal response: (V)

  1. Smiles, oriented to sounds, follows objects, interacts.
  2. Cries but consolable, inappropriate interactions.
  3. Inconsistently inconsolable, moaning.
  4. Inconsolable, agitated.
  5. No verbal response.

Any combined score of less than eight represents a significant risk of mortality.

Articles Mentioned in the Episode

  • Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric brain injury. J Neurotrauma 26(5):657-663, 2009.
  • CPR for bradycardia with poor perfusion vs pulseless cardiac arrest. Pediatrics 124(6): 1541-1548, 2009.
  • Osmolar therapy in pediatric  traumatic brain injury. Crit Care Med 40(1): 208-215, 2012.

The Trauma Professional’s Blog

Want to read more of Dr. McGonigal’s stuff; hell yeah you do. Go on over to the The Trauma Professional’s Blog.

Now, on to the podcast…

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Comments

  1. Minh Le Cong says:

    Scott, Michael, thanks for a brilliant discussion on paediatric trauma management. I am glad you raised the controversy of whether concepts such as haemostatic resuscitation and whether to use crystalloid are still applicable in children. the truth is still out there but Michael gave a very reasonable approach. I would raise one point of caution in regard to IO use. My opinion is that we must approach IO use for fluid resuscitation with care. True it might be the only line we can get to start with but I would be doing all I could to find another access point and minimising the fluid admin through the IO. There are numerous case reports of compartment syndrome and leg amputations as a result of overreliance upon the sole tibial IO line during a resuscitation. Sometimes you have no choice but it should not be through want of trying to find further access. I used to believe that IO lines are like central venous access. This was not correct thinking and I teach now use of IO for fluid resuscitation as short a period as possible and then removal as soon as alternative access achieved.

    • Don Diakow says:

      Minh….were the complications of the Ped IO’s due to the tibia being a small confined space and infused crystalloid under pressure leaking?
      We have had one ped IO complication here in Calgary that was reported to end in the child losing the lower leg as well.

      • Minh Le cong says:

        Don, we have had two recent cases with similar results. I cite some of the literature and case reports in this podcast I did on PHARM

        http://prehospitalmed.com/2012/06/14/pharm-podcast-20-femoral-vein-access-the-root-of-all-evil-with-dr-mathew-pirotte/

        I still advocate IO in emergency resuscitation but advise seeking alternative access ASAP and minimising volumes of fluid through the IO
        especially if its a tibial site. If its over a compartment space, be careful.

        • We are now experiencing doubts on IOs after SGAs. Very depressing. : (

          • Rebecca says:

            I’m a critical care paramedic and up until very recently I spend 95% of my time working in pediatric critical care transport.
            Tibial IO in small peds (<10kg) can be tricky if you don't do a lot of them. When everyone learned to insert EZIOs in adults, they were probably taught to drill until they felt a 'pop', then stop…then promptly forgot this direction and drilled until the hub of the catheter was resting on tissue. In adults, this usually doesn't lead to problems due to the size of the medullary space. In small pediatric patients however, sinking the IO to the hub will result in the needle passing THROUGH the tibia. If this is not recognized upon insertion or upon fluid administration it can lead to the complications mentioned by others above.

            Everything that I'm about to say is purely my opinion based on my experiences:
            – Let someone who knows what they are doing put the EZIO in. We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill. (Some of our attendings didn't even really belong on that list, that was just a politics thing.) We rarely had any issues after that. The point is, just like airway, if you don't do it a lot in small kids, you probably aren't going to be great at it.
            – If you don't put (not so) EZ-IOs into small kids a lot, consider using a manual IO. I personally think they are a lot harder to screw up. When I wasn't working primarily in peds, I would use EZ-IO for adults and manual IOs for small kids (<10kg). I really like the Jamshidis because they have an adjustable flange so you can set the maximum depth.
            – Once you get the IO in, flush vigouorously, look for an signs of infiltration, then SECURE THE HECK OUT OF IT. Any movement of the catheter increases the risk of infiltration. Be vigilant about checking for infiltration and checking distal perfusion.
            – As Minh suggested, an IO is only a temporary solution. As soon as the patient is stable enough or has enough intravascular volume get a peripheral or central line in them as their status warrants.
            – Some people have suggested that the proximal humerus might be a prefered site both for flow rates and patient comfort. I have no experience with this, but I wonder if, in peds, it might lead to a lower infiltration rate due to the larger medullary space.

            Rebecca
            NREMT-P CCP-C

  2. Hey Scott & Michael,

    Great podcast; overdue. Is it just me or does Michael sound like the greatest ER paediatrician in history … George Clooney?

    I have a few other (more constructive) queries:

    1. Putting a trauma ICC in an adult involves placing a finger in the pleural space for a sweep and then guiding the ICC into position. Tricky in a 2yo. Any tips on ensuring correct position prior to the CXR.

    2. Balancing the need for non-head OR in a patient with bad head injury -> Have either of you got experience with using a portable CT (eg Neuologica – fits an adult head or limb or a whole small child) in OR or ED?

    3. Would you ever send a paed surgeon and anaesthetist to to the regional, non-specialist centre, or always bring the child to you?

    4. Trauma + hypoBP + FAST and floor fluid negative -> in an adult, warn interventional radiology. What approach in a young paed?

    Really like the statement of “OK, we are going to break the rules for this one and here is why.” Used it myself a few times and it helps to keep everyone on the same playing field, even if they are a bit uncomfortable out of protocolville.

    Michael, easy hypertonic solution bolus for you: 3% saline 3ml/kg over 10 minutes.

    Scott, when are you going to do the difficult airway strategies in critically ill paeds podcast?

    Thanks to both of you for a high-yield, high quality podcast.

    • Matt,

      I’m going to get Michael to weigh in on most of the excellent points/questions above. I wish we had a portable CT–it would make the decision of whether or not to get a quick head before the OR so much easier. Difficult airway paeds podcast is coming. FAST neg, external bleeding neg, thorax neg, low bp: not sure automatic interventional is the way. Too many other etiologies. I would probably try really hard to get imaging at that point. Is it neurogenic shock, blunt cardiac, etc. Now if the pelvis is trashed on exam or x-ray, that is another question entirely–no?

      • Matthew Mac Partlin says:

        Hi Scott,

        That was really where I was leading to – i.e. what is the role of Int Rad in Paed trauma, for pelvic injury or otherwise? And if my centre does not provide it, at what point do I start making the telephone calls to specialist centres and retrievalists?

        Thanks

    • I think he’s a surgeon, not an ER paediatrician.

  3. Don Diakow says:

    Doctor’s Weingart and McGonigal……..any thoughts on TXA and ped hemorrhagic shock ?

  4. Tom Soeyland says:

    Scott, I think I remember an older podcast where you said paed topics would not be covered on EmCrit (I might be wrong)? I remember being disappointed at the time.

    Has this changed? Can we look forward to several more paediatric critical care topics, please? The few paeds podasts I found out there seem to have become less active.

  5. Jim Wessely says:

    Scott,
    I have recently started listening to podcasts. I believe I have listened to all of yours. I have practiced emergency medicine since 1979 and have never experienced a better teacher. You are amazing!
    Thank you,
    Jim

  6. If you want to see all of Rebecca’s IO tips, check out this post

  7. Gill Course says:

    Great podcast on Paeds trauma. I teach Emergency Nursing at Post grad level and have started sharing links to your podcasts on the Uni learning website for the students. Getting great feedback on them for ya! Creating better Emergency nurses of the future…

  8. Scott-
    Any reason or evidence to think closed chest compressions in a traumatic pediatric bradycardia (in general) would be any more effective than in a traumatic pediatric(or adult) arrest?

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