Case of Polytrauma. Case of Polytrauma and approach

Case of Polytrauma

1. Case of Polytrauma Dr Abdul Rauf KK Fellow Department of Pediatric Intensive Care Sir Ganga Ram Hospital, New Delhi

2.     History 13 year/ F 40 KG DOA: 21-12-2018 Became unconscious soon after Hit by autorickshaw at 7.30am on the way to school Brought to pediatric ER after 20 minutes No h/o seizures, ENT bleeds

3. Pediatric Assessment Triangle Initial Impression: Unstable Life threatening PAT Work of breathing : Normal Appearance: Abnormal Circulation: Abnormal

4. Primary Survey Air Way: Not maintanable Breathing: RR: 26/min Effort: Normal Air entry: Normal Auscultation: Normal Spo2: 90% Circulation: HR: 132/min BP: 96/68 mm hg CP/PP: ++/ poor CFT: 3 sec SkinTemp: Cold ECG: Normal Disability: GCS: E1M3V1 Pupils: 4mm dialated , not reacting Motor activity: Normal RBS: 90 Exposure: Temperature: 38 C Surface finding: Normal Final Physiological impression: A B D C E Primary brain/systemic dysfunction Compensated Shock

5.     What should be the initial resuscitation? What is Neuro-protective rapid sequence intubation? Criteria for intubation in Traumatic brain injury?

6. Further course Intubated Cervical hard collar applied Hyperventilation done Crystalloid bolus given Hypertonic saline bolus given Sedation and analgesia started

7. Further course Intubated Cervical hard collar applied Hyperventilation done Crystalloid bolus given Hypertonic saline bolus given Sedation and analgesia started

8. Secondary survey Head to toe examination done History includes AMPLE No facial trauma Thorax- bruises in left upper chest Abdomen- No bruises, soft Pelvis, limbs- Normal

9.     Indication of neuroimaging in Traumatic brain injury Marshall classification of cranial CT Pupils became equal and reactive to light Patient shifted for Neuroimaging (CT Brain and Cervical spine)

10.     PECARN Criteria <2 years >2 years

12.     Generalized cerebral edema with mild SAH

13.     Role of ICP monitoring in TBI… Indications Types of ICP catheters, advantages Normal ICP and CPP values Neurosurgery opinion taken Plan to insert ICP catheter

14.     In the pediatric guidelines, ICP monitoring was suggested as appropriate in children with an abnormal admission head CT scan and initial GCS score between 3 and 8. Also, ICP monitoring was suggested to be appropriate in adults with severe TBI and a normal head CT Role of ICP monitoring in TBI

15.     Normal ICP Normal ICP ranges from 5- 15 mm Hg Treatment threshold in adults 20-25mm Hg Brain trauma foundation guidelines suggests treatment of raised ICP at threshold of 20mm Hg in children Age specific CPP targets 0-5 years -- 40 mm Hg 6-17 years -- 50 mm Hg >17 years -- 60mm Hg Allen BB, Chiu YL et al. Age specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe TBI . Pediatric Crit Care Med. 2014;24:S59-64

16.     Intraparenchymal ICP Catheter inserted

17.     Identify the labels P1 P2 P3 on these ICP waveforms? Identify the abnormality in the ICP curve in monitor

18.     Hemodynamics Shock persisted after fluid bolus, HR- 130, BP- 88/68, poor peripheral pulses and cold peripheries Bedside Echo- Good cardiac function, No pericardial effusion and IVC full Epinephrine 0.1 mic/kg/min started , endpoint achieved in 1 hour, PRBC transfusion given What are the possible causes of shock after trauma ?? Most common- Hypovolemic shock due to blood loss Others- Neurogenic shock Commotio cardis , Pericardial tamponade Pneumothorax

19.     What other investigations will you do ? Index case- FAST- Normal , Skeletal survey- Normal , ?CECT chest done- fracture of left upper two ribs with b/l pulmonary contusion FAST and eFAST What do you see in this FAST – Right subcostal image

20.     Cardinal difference in between children and adults in thoracic trauma ? Ribs in children are very elastic, divert pressure to lungs; Hence, children have low incidence of rib fracture and flial chest and high chance of pulmonary contusion and vice versa in adults

21. Further course Mechanically ventilated in PRVC mode Sedation and analgesia continued Hypertonic saline infusion continued First tier anti- raised ICP measures followed Antibiotics given ICP records (8—10) Sedation stopped at 72 hours

22. What is the next step? Restart sedation, give hypertonic saline bolus Repeat neuroimaging What are the causes of secondary brain injury after TBI ?

24. Further course MRI Brain done Diffuse axonal injury Small subdural hemorrage in occipital area Occipital area hyperintensities present