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PED-EM-L  December 2017

PED-EM-L December 2017

Subject:

Re: Procedural Sedation Peds Trauma Patient

From:

Doc Holiday <[log in to unmask]>

Reply-To:

Doc Holiday <[log in to unmask]>

Date:

Sun, 17 Dec 2017 15:39:44 +0000

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (38 lines)

My view is as would suit a major trauma centre ("level 1") for all ages - I am not PEM only... In the UK, such a case will be transported to such a centre, not to any level below.

> 7yo patient previously healthy, normal habitus without dysmorphismó high speed MVC with impact passenger side, lap+shoulder belt restrained rear-passenger, brief LOC, c/o right abdominal & right lower leg pain
-GCS 15, intact neuro, Head CT neg
-Facial abrasions, no oral injury, normal phonation, no secretion handling issues
-Cspine nontender, collar in place, CT neg
-Nl SpO2, slight tachypnea, symmetric breath sounds, CXR neg
-HR settles in 110s after analgesia & fluid bolus, normotensive (never hypotensive), well perfused
-Nondistended but R abd tenderness, CT shows Grade 3 Liver lac w/o extravasation, transaminases ~300, lipase normal, no RBCs on UA
-pelvis stable w/o fracture
-R midshaft tibia deformity, tender, intact distal neurovascular status, XR reveals 20 degrees angulated tib-fib fracture
- Hemoglobin 10.2
- no other lab/imaging abnormalities

--> First, a comment on imaging, in our centre, dealing with mainly adults, such a patient would have had a full trauma CT scan, with chest and whole spine included. This would be as per guideline for a high-speed MVC. With the further info indicating there being both an abdo injury and a head injury (LOC with normal CT, thus appears to be concussion in this case), there will be a high enough yield in terms of "injuries in between" (spine/chest) to justify.

I will continue here on the assumption that any injuries you have not listed are not present.

As for your questions... The situation appears to suggest that the abdominal injuries will be managed, at least initially, in a conservative manner, or I don't expect your question will have arisen. I am no surgeon, but I expect this conservative management will include admission to an intensive care environment, with preparation for rapid transfer to O.R. should hepatic bleed make this necessary. This indication for urgent laparotomy might, of course, develop while the ortho procedure is underway - this is already not a lucky day...

With these factors in mind, I'd like the person providing sedation to be the one who will be in charge of the patient's on-going physiological care - ITU/anaesthesia. Added benefit that we will not thus be depriving the ED of a practitioner. I have many ED colleagues who are 100% capable of doing this, but, at least where I work, such skilled people will have a lot of work to do elsewhere in the ED and would not be spared. This point is further enhanced when one considers location.

Not sure how it is in your place, but we have less place in an ED trauma/resuscitation bay than is available in ITU or O.R. Also, such a procedure, when I see it done by experts, when they are not in a rush, and when they intend for it to be the only procedure, is performed with fluoroscopy. Where I work, this means O.R. (although it's possible to get it for ITU as well). In a major trauma centre we have orthopods whose speciality is to deal with such a pathology, so I certainly would not look for a way to avoid using them!

Our orthos do often ask whether they can "simply" do the procedure in the ED, with one of us sedating. We tend to decline, as it's never "simple", with our space remaining occupied for recovery, our nursing staff taken up with intensive monitoring, family having to hang about in ED crowds, etc... And we have no fluoroscopy for this case... And I'd rather patient was not in the ED when the liver thingie went off...

In this case there does not appear to be the option of speeding up discharge to happen quickly after reduction, so that's not a factor.

Sometimes there are circumstances with ITU/OR/specialists that would indicate a change in the above, but I am dealing with the general preferences.

BTW, for all major trauma patients we receive, when there is more than one speciality of interest (as in this case - general surgery & ortho & ??Neuro) we have a senior clinician on call who acts as the Major Trauma Specialist and he/she takes on all such patients and his/her job is then to coordinate care, so that patient does not suffer any speciality delays or conflict. The people who do this job may be surgeons, orthopods, intensivists, etc. They are generally not EPs, as such a person needs to have a good understanding of ITU/OR/ward procedures and status. This case would be admitted under such a person initially, until only one speciality remains which requires in-hospital stay.



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