Clinical case 016: Toddler vs. TV

This is an older case that sticks in my mind.  A great example of the subtle signs and compensation kids can show despite being very sick!

3 yo boy carried into the ED of a small, peripheral metro hospital by mother – screaming.  She is crying, and between sobs says:  “I was in the kitchen when I heard a crash.  I rushed into the living room to find him lying on the floor, on a bean bag, with the new TV face down on the floor beside him.  He must have tried to climb the TV cabinet and pulled the TV down!”  [CP: this was a while back when TVs were boxy and v. heavy in the front.  Pre-plasma / baby bonus era!]

The boy is screaming unconsolably, undressed and there is not a mark on him, no graze, no haematoma, nothing.  Scalp all looks normal, no haematoma etc.

Obs: pulse 180, RR – 30 (screaming), Spo2 98% RA, BP – hard to record, not perfusing his hands or feet well, cap refill slow @ 4 -5 secs.  Belly is scaphoid, soft.  Chest looks and feels normal – no obvious fractures, HS normal, air entry equal, trachea midline.

IV access pronto x 2 and 20 ml/kg of N/saline bolus given by hand.

10 minutes later the kid is settling, sobbing quietly.  Obs have improved = pulse 160, RR = 16, cap refill now 2 – 3 secs, hands a bit pinker.

So what is going on?  We start thinking:  ?occult belly bleed eg. spleen, concealed haemothorax, maybe an intracranial bleed…

Normal CXR, no fractures, pneumothorax or effusion seen…

This was the bad old days, before bedside US in the ED was widely available.  So we were scratching our heads for a minute or two when Mum noted he had become very quiet – too quiet for a 3 yo. in an ED.  Recheck of his Obs:  responds to name and gentle prodding, seems sleepy.  Pulse now 190/min, BP done = 50/20, cap refill once again – sluggish, pale hands.  Hmmmm…. not good.   Another bolus of 20 ml/kg of N/saline given over the next 10 minutes and urgent transfer to the tertiary hospital arranged – “we need to get him to a Paeds surgeon / CT” is the thinking.

Ambulance with lights/sirens up the freeway 30 minutes.  A third 20ml/kg saline bolus en route.  Obs remain bad, peripheral pulse is weak @ 190 – 200.  On arrival the plan is to go to CT if he is stable or OT if not – ?laparotomy.

This boy had a ruptured right atrium with cardiac tamponade. Fortunately a cardiothoracic team had just completed a case and he went into their theatre. Urgent ECHO showed the tamponade, so he had a sternotomy and decompression which revealed the ruptured atrium! The surgeon suspected hat his heart was crushed between the sternum and the thoracic spine – like in zealous CPR – and pop went the atrium!

This was one tricky case.  What would you have done differently?     I think the bedside US / RUSH protocol would have made the diagnosis in quick time.

Check out these ECHO images and discussion from Ultrasound Village

OK, there has been a bit of debate about emergency thoracotomy after this post.  So I will direct you to Scott Weingart’s podcast on the topic.

Thoracotomy for trauma thanks to EmCrit

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