case simulation debriefing. diagnosis? altered level of consciousness respiratory insufficiency...
TRANSCRIPT
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CASE SIMULATION
Debriefing
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Diagnosis?
Altered level of consciousness Respiratory insufficiency Acute subdural hematoma Possible inflicted traumatic brain
injury/abuse (+/-) Cardiopulmonary arrest
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CASE EVALUATION
How do you think you did? What did you think you did well? What would you have done differently? How do you think your colleagues did?
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As you walk into the room what do you see?
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What needs to be done now!
Airway: Is the airway secure? Breathing: Is the patient’s breathing normal? Circulation: Is the patient perfusing well? Disability: What’s the GCS in this patient? Environment/Exposure: How could body temperature
change your management? IVs, O2, Monitors, full vitals and blood drawn.
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Ok, we have a more stable patient, now what?
SAMPLE History: Signs/symptoms Allergies Medications Past medical
history Last Meal Events
Secondary Survey: Complete physical
examination
Order remaining labs and tests
Talk to consultants if needed
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Differential for altered mental status in the pediatric population
“VITAMINS”
Vascular Infection Toxins Accidents/AbuseAccidents/Abuse
Metabolic Intussusception Neoplasms Seizure
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Approach to decreased level of consciousness/comatose patient
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Child abuse/Inflicted traumatic brain injury
The leading cause of death by trauma in children less than 2 years of age
The recognition of inflicted traumatic brain injury can't be overemphasized. Risks:
D/C home to dangerous environment Siblings in danger
If suspected, contact CPS or activate the resources that do this in your hospital
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Child abuse/Inflicted traumatic brain injury
History: 37% of iTBI have no history of trauma Evasive and inconsistent history
Physical examination Most common presentation is non-specific. One study showed that 31% iTBI were seen
shortly after the injury and discharged home with alternative diagnosis (e.g. Viral illness)
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Child abuse/Inflicted traumatic brain injury
The triad of Subdural hemorrhage, fractures, and retinal hemorrhages are the classic findings but only present in 30% of patients
Skeletal survey at presentation and in 14 days if abuse is suspected
Your report/charting: State clearly that presentation is consisted with inflicted injury
Do not try to establish a time line, Do not try to determine intent
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Pediatric Head Trauma
Airway: Less
cardiopulmonary reserve in Peds.
Basic airway maneuvers
Anatomic differences
Intubation: When? RSI Atropine Blunting of intra-
cranial pressure rise
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Pediatric Head Trauma
Breathing Higher baseline respiratory rate in Peds
Circulation Lower BP at baseline for Peds Blood pressure management
Goal is to maintain appropriate cerebral perfusion pressure
CPP = SABP - ICP
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Pediatric Head Trauma
• Disability Glasgow Signs of herniation
Cushing reaction Mannitol/Hyperventilation
• Exposure/Environment Aggressively treat hyperthermia Induced hypothermia (+/-)
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Pediatric Head Trauma
Associated with ICI: Scalp Hematoma Facial injury Abnormal
neurological exam Poor evidence for < 2 y/o Higher rates (-) sings
and symptoms at this age
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Pediatric Head Trauma
CT or 6 hours Obs: Multiple episodes of
vomiting Brief LOC History of AMS that
is now resolved High force
mechanism Unwitnessed event
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Pediatric Head Trauma
Disposition if positive ICI Admission to ICU with neurosurgery consult Transfer to hospital with appropriate
resources if necessary Contact CPS immediately if iTBI is
suspected
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CASE REVALUATION
How do you think you did? What did you think you did well? What would you have done differently? How do you think your colleagues did?