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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

Comments

  1. Minh Le Cong says:

    well what a trauma case and what a great outcome.

    I am an EMST/ATLS instructor and in the current manual, pericardiocentesis has been removed from our teaching if suspected tamponade. There is mention of doing ED thoracotomy but no explanation of how to do it.
    Prehospital thoracotomy borders on the definition of extreme medicine. The elite Royal London Hospital HEMS unit teaches it for penetrating thoracic trauma arrest and have published a case series of about 400 performed now in the field with a survival rate of about 18%

    IN this case of a blunt thoracic trauma leading to cardiac tamponade and atrial wall rupture, in transport if the kid arrested would anyone be prepared to do a prehospital thoracotomy? Would anyone try a needle pericardiocentesis..blind or under USS?

    The only reason I ask is that here in RFDS QLD we had a similar kind of case 2 years ago in which a a 8 yo kid fell onto a kitchen knife that was pointing up , held on a dishwasher rack that had been pulled out in the kitchen. Kid tripped and fell onto the knife. Retrieval to Brisbane cardiothoracic unit was going to take about 3 hrs. Nice knife wound just left of sternum with some lung poking out during respiration.

    Its an intriguing scenario to contemplate if the kid arrests inflight, what would you do? Indeed with your case, Casey, if the kid arrests in the back of the ambulance what would you do?

  2. Casey Parker says:

    Hmmmm. Tough one. If had the US skills then that I have now – i would have done an US e-FAST and hopefully picked he tamponade.
    Without a diagnosis I think empirical pericardiocentesis is a low-yield maneuver.

    However, if you knew the diagnosis with say >50% certainty either by commonsense or US confirmation then I think I would go for a needle under the xiphisternum.
    The alternative is…. futile resuscitation with CPR and fluids etc…very likely to have a fatal outcome I imagine!
    Casey

  3. you hear ED and pre-hospital thoracotomies talked about a lot but Minh’s point is great that there’s not much explanation of how to do it or more importantly what to do once you’ve opened the chest. Beyond sticking a finger in an atrium or a major vessel I’m not sure what I could or would do inside a chest!

  4. Casey Parker says:

    Hi Guys
    I have added a link at the bottom to a good guide / lecture from Scott at EmCrit on thoracotomy / chest trauma
    Enjoy
    Casey

    • Minh Le Cong says:

      thanks for the link to the Emcrit lecture on thoracotomy, Casey.
      Since Emcrit recently had a post on haemostatic resuscitation, damage control principles and permissive hypotensive strategy in haemorrhagic shock..my question about this case of paediatric thoracic trauma with cardiac injury is..

      would anyone have used permissive hypotensive strategy in this case? Three fluid boluses of saline were given en route to definitive care. No blood given apparently. And it seems resuscitation goals were cap refill, pulse rate and perfusion of hands/feet, correct?

      Would it have been reasonable to give no fluid boluses as long as an adequate radial pulse could be felt?

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