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Published byKenneth Harrell Modified over 9 years ago
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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/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?
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