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)
- Eyes opening spontaneously
- Eye opening to speech
- Eye opening to pain
- No eye opening or response
Best motor responses: (M)
- Infant moves spontaneously or purposefully
- Infant withdraws from touch
- Infant withdraws from pain
- Abnormal flexion to pain for an infant (decorticate response)
- Extension to pain (decerebrate response)
- No motor response
Best verbal response: (V)
- Smiles, oriented to sounds, follows objects, interacts.
- Cries but consolable, inappropriate interactions.
- Inconsistently inconsolable, moaning.
- Inconsolable, agitated.
- 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.
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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… Read more »
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.
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. : (
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… Read more »
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… Read more »
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… Read more »
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.
He is a Trauma Surgeon, but the reference is to Clooney’s character on that love-it-or-hate-it show: ER
Doctor’s Weingart and McGonigal……..any thoughts on TXA and ped hemorrhagic shock ?
CRASH trial excluded <16yo
but TXA has been used in children for cardiac surgery
http://www.euroespa.org/nieuws-bericht.html?nieuws_ID=10
and dental medicine
http://www.drugs.com/dosage/tranexamic-acid.html
truth is still out there for haemorrhagic shock in kids
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.
Yes, popular demand has lead to me capitulating. A small number of peds topics will be covered.
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
thank you so much for those kind words!
If you want to see all of Rebecca’s IO tips, check out this post
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…
thanks Gill and thanks for recommending the site.
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?
again, excellent. thank you, scott