PEST Case 2: Sink or swim?

“An 18-month-old is brought into the emergency department with a two-day history of vomiting and being off form. His mother becomes stressed and leaves the emergency department during the assessment.”

Clinical findings

A: Breathing spontaneously initially, then becomes quiet & gurgles

B: Breathing slowly initially, then becomes apnoeic

C: Tachycardic, hypertensive

D: GCS 8 – E2 (opens to pain) V2 (grunts, agitated, restless) M4 (flexion withdrawal); Pupils – Unilateral mydriasis (right pupil dilated); Tone – floppy

E: Temp 36.9°C, mottled & pale, bruising to forehead and temple

Observations

• SpO2 98%

• RR 25

• HR 91

• BP 102/70 mmHg

• CRT 1-2 sec

Diagnosis

Abusive Head Trauma – Time Critical Transfer 

Why we simulated

Abusive head trauma (AHT) is a life-threatening form of non-accidental injury often presenting in younger pre-verbal children who cannot advocate for their own wellbeing. Offending parents or caregivers can be evasive upon questioning and expertly hide signs of physical abuse. For this reason, clinicians must be familiar with signs of NAI, the management of life-threatening sequelae of AHT (↑ICP) and be comfortable navigating the hospital’s safeguarding systems put in place to protect vulnerable children presenting to the department.

Learning points

1) The management of ↑ICP

• Intubation and ventilation to ensure normocapnoea (hyercapnoea causes venous dilation further exacerbating the ↑ICP)

• Head tilt to 20° degrees

• IV Hypertonic NaCl or mannitol

• Avoid anaesthetic agents which may ↓blood pressure (impairing cerebral perfusion). For this reason, Ketamine remains a favourable option over other anaesthetics (i.e. rocuronium)

2. Time-critical transfer vs Critical-care transfer

Weighing up which is more important for the individual patient; how quickly they can arrive at their destination point vs the ability to deliver intensive care en-route. Recognising which patients are in need of a time urgent transfer to a specialist centre, in seeking a time-critical intervention (i.e. the deteriorating patient who requires urgent neurosurgical intervention). On the other hand, another group of equally sick patients may require ongoing intensive care support (i.e. ventilation and inotropic support) en-route which may be best facilitated by a specialist transport team (i.e. COMET). These decisions are logistically challenging and must be made on a case by case basis.

Our team recognised the need for urgent neurosurgical intervention making it a time-critical transfer and could not wait for a specialist transport team. Instead, an ambulance was called, two doctors (1x anaesthetic registrar, 1x paediatric registrar) and one nurse were mobilised to accompany the patient in an ambulance for an urgent transfer.

Staff feedback

“I learned working as a team in stressful situations, clear communications and clear instructions for the medications and safe prescriptions. Also, in the debrief session later I learnt about the time-critical transfer algorithm, getting the patient to the neurosurgical centre is priority”.

“The process of time-critical transfers, what help you have and who to call. The dosage and use of hypertonic saline.”

“Again, this was another well thought up scenario that allowed the team to manage the case.”