Setup

Chief complaint: Pedestrian hit by a car
Patient age: 6 years old
Weight: 20 kg

Recommended Supplies

• Manikin: Pediatric (e.g., Laerdal SimJunior or Gaumard Pediatric HAL)
• Moulage:
  • Left parietal scalp hematoma and contusion
  • Ecchymosis in the left upper quadrant of the abdomen
  • Left shin deformity
  • Clothing with red stains/blood
• Resources: Length-based resuscitation tape (e.g., Broselow)
• Manikin set up: Two IV lines in place with drainage bag
• Equipment:
  • Pediatric airway equipment of various sizes/airway cart
    • Simple face mask
    • Non-rebreather mask
    • Nasal cannula
    • Oxygen tubing
    • Suction
    • Bag with mask
    • Endotracheal tubes
    • Colorimeter
    • Tape
    • Trauma shears
  • Warm blankets
  • IV tubing, lines, pumps, poles, and angiocatheters
  • Intraosseous needles and line kit (e.g., EZ-IO)
  • Rigid splinting materials gauze, tape, ace wrap
  • Cervical collars of various sizes
  • Ultrasound machine
• Medications: succinylcholine, rocuronium, etomidate, ketamine, midazolam, isotonic fluids, other standard code cart medications

Supporting Files

• eFAST Ultrasound (still and video images): Positive for intraperitoneal fluid, no pericardial fluid, no pneumothorax
  • Subxiphoid view
  • Right upper quadrant
  • Left flank
  • Bladder
  • Lung, M-mode
  • Lung view
• Single-view post-intubation chest x-ray: ET tube in proper position, pulmonary contusion
• Leg x-ray: Displaced fracture of the tibia and fibula (time permitting)
• Pelvis x-ray
• Point-of-care labs from venous blood sample

Imaging is unnecessary in this case, except perhaps a post-intubation CXR. However, bedside plain radiographs and ultrasound should be allowed. The patient is much too sick to leave the department for a CT scan. The instructors will have to redirect the learner if they order the patient to leave the resuscitation area. Transport to a Level 1 trauma center will be available 10 minutes into the case and transfer should not be delayed for CT scan.

Participants/Roles

• Team leader
• Airway manager
• Survey physician
• Medication preparer
• Medication giver
• Proceduralist
• Family liaison/history taker
• Standardized patient, faculty, or senior resident (actor) to play patient’s parent

* Team roles may need to be adjusted in order to suit local practices and norms

Faculty or other embedded participants can play a nurse, respiratory therapist, or tech. A nurse can play a nurse or tech, if there are not enough learners to perform the above roles. Additionally, learners may have to play multiple roles to simulate an environment with less providers.

Prerequisite Knowledge

• Faculty
  • PALS protocols
  • General knowledge of emergency medicine
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Preferably PGY-2 year or above
  • Completed ATLS
  • Splinting techniques

Case Alternatives

• As written, resuscitation with crystalloid fluid will improve the patient’s shock. One can argue that blood is a better choice. According to the most recent edition of Rosen’s, “The debate regarding the choice of colloids versus crystalloids for resuscitation is ongoing. No indisputable advantages of colloids have been demonstrated. Therefore, the less expensive and more readily available crystalloids are the mainstay of treatment.”
• For a post-scenario assignment, faculty can encourage learners to search the literature regarding fluid resuscitation guidelines in trauma

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC7. Disposition
PC10. Airway Management
PC12. Goal-Directed Focused Ultrasound
ICS2. Team Management

Resources

1. Pediatric Trauma Resources. Thunder Bay Regional Health Sciences Center. Retrieved March 6, 2023.
2. Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008; 43:72. PMID: 18053830
3. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006; 22:480. PMID: 16871106
4. Gross EA. (2018) Multiple Trauma in Walls, RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Elsevier, Inc., pp 287-300
5. Helman A, Beno S, Alnaji F. Pediatric Trauma. Emergency Medicine Cases. May, 2017. Accessed March 23, 2023
6. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013; 62:107. PMID: 23375510
7. Murray BL. (2018) Pediatric Trauma in Walls, R.M. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Elsevier, Inc., pp 2042-2057.
8. Tosounidis TH, Giannoudis PV. Paediatric trauma resuscitation: an update. Eur J Trauma Emerg Surg.2016; 42: 297–301. PMID: 26696087
9. Management of Pediatric Trauma. Committee on Pediatric Emergency Medicine, Council on Injury and Violence, and Poison Prevention, Section on Critical Care, Section on Orthopaedics, Section on Surgery, Section on Transport Medicine, Pediatric Trauma Society, and Society of Trauma Nurses Pediatric Committee Pediatrics August 2016, 138(2) e20161569. DOI: 10.1542/peds.2016-1569

Primary Survey

Primary Survey

Start to second IV fluid bolus

Critical Actions

• Team leader assigns tasks and use Broselow tape or another reference tool for weight
• Obtain history from parent
• Perform primary survey
• Perform BMV
• Place patient on continuous cardiac monitor
• Order vascular access at two sites
• Obtain point-of-care glucose
• Place cervical collar
• Give 2 intravenous (IV) fluid boluses (see notes below)
• Perform rapid sequence intubation (RSI) (see notes below)
• Discuss progress and plan of care with the parent (and involves them in decision-making)

Physical Exam

Instructor Notes: Changes and Case Branch Points

Secondary Survey

After 2 IV fluid boluses given through intubation and splinting

Critical Actions

• Perform RSI (if not performed during Stage 1)
• Arrange transfer to trauma center (hand-off communication to trauma doctor)
• Splint tibia-fibula fracture prior to transfer

Physical Exam

Instructor Notes: Changes and Case Branch Points

Increased Intracranial Pressure

After initial stabilization through ICP management

Critical Actions

• Elevate the head of the bed
• State the need to hyperventilate the patient to a pCO2 of 30-35 mmHg and order a blood gas
• Administer either mannitol or hypertonic saline

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

After management of ICP through handoff to accepting trauma center (at least 10 minutes from start of case)

Critical Actions

• Reassess patient and prepare for transfer
• Hand-off communication to trauma doc, if not already done

Unbolded items may be excluded depending on local practices and norms

Physical Exam

Instructor Notes: Changes and Case Branch Points

Demonstrate the evaluation of a pediatric patient with blunt trauma using a standard systematic approach (application)

• Evaluation of traumatic injuries follows a standardized approach taught in Advanced Trauma Life Support (ATLS)
• Evaluation begins with addressing any life-threats identified in the ABCs, followed by a systematic head to toe exam known as the secondary survey. This includes continued reassessment and a return to ABCs as the clinical condition changes.

Describe signs/symptoms of blunt multisystem trauma (comprehension)

•  There are specific injury mechanisms that should lead the practitioner to suspect the presence of intra-abdominal injury, such as a handlebar injury to the upper abdomen and a seat belt sign from a motor vehicle accident.
• It must be remembered that a negative Focused Abdominal Sonography for Trauma (FAST) exam alone does not exclude hemoperitoneum or intra-abdominal injury, and repeated assessment is warranted to ascertain a change in the patient’s clinical condition.
• The spleen is the most commonly injured organ in pediatric abdominal trauma. Non-operative management has become standard practice.

Construct and implement initial medical management plan for a child with blunt multisystem trauma (application)

• Adjuncts to the primary survey may include a chest x-ray, a pelvic x-ray, and the FAST exam. FAST is a valuable tool to evaluate abdominal trauma and identify free fluid/blood. Note that the FAST is less helpful diagnostically in children, as hemodynamically stable children with a positive FAST are much more likely to need non-operative management as opposed to adults. Hemodynamically unstable children (hypotensive, need >40 mL/kg of isotonic fluid) with a positive FAST should undergo diagnostic laparotomy.

Construct and implement initial medical management plan for a child with traumatic brain injury (application)

• Head trauma accounts for 80% or more of the traumatic injuries leading to death in US children older than 1 year. Most pediatric head trauma occurs secondary to motor vehicle accidents, falls, assaults, recreational activities, and child abuse.
• The unique anatomy of children may make them more likely to develop an intracranial lesion due to head trauma. They have a larger head-to-body size ratio, a thinner cranial bone and less myelinated neural tissue. Children with traumatic brain injury more commonly develop a pattern of diffuse axonal injury and secondary cerebral edema compared with adults.
• Severity of head trauma is classified according to GCS as follows:
  • GCS 14 to 15: Minor head trauma
  • GCS 9 to 13: Moderate head trauma
  • GCS ≤8: Severe head trauma
• A structured approach to the assessment of airway, breathing, circulation and disability (ABCD) is utilized with attention to the cervical spine. The goal of stabilization is to avoid secondary injury to the traumatized brain from hypoxia, hypotension, or raised intracranial pressure. Occasionally, early and definitive treatment of a primary intracranial injury may be required (e.g., epidural hematomas).

Demonstrate airway management of a sick child using appropriate adjuncts, BMV, and/or endotracheal intubation (application)

• Airway management is a critical component of pediatric resuscitation, especially in trauma patients. Along with ET intubation, one should also include airway adjuncts of BMV, oral airway, and nasal airway.
• The goal of ET intubation is to ensure optimal gas exchange. The most common indications in a trauma patient are coma, shock, apnea, and airway obstruction.
• The use of video laryngoscopy in trauma patients with limited neck mobility is helpful in optimal visualization of the airway.
• Common airway complications include right mainstem intubation, esophageal intubation, massive aspiration, unilateral or bilateral vocal cord paralysis, subglottic stenosis, failure to adequately preoxygenate, and extubation during transport.

Use fluids and/or blood in emergent resuscitation (application)

• Recognizing shock in the pediatric trauma patient can be more difficult as the signs of shock can be more subtle than in adult patients. A child that appears only as irritable initially may have lost as much as 30% of his or her blood volume. Children may decline rapidly, hence peripheral IV access with 2 age-appropriate IV angiocatheters should be achieved in all multisystem trauma patients. Isotonic fluid boluses of 20 mL/kg over 20 minutes are first line. Rapid infusers are used in older children and adults.
• In the resuscitation of infants, toddlers, and small children <20 kg, an efficient pump may be a 10 mL syringe, operated by a clinician, attached to traditional IV pump tubing, with a one-way valve is in place, and utilizing a pull-push technique.
• Massive transfusion is a strategy to deal with the bleeding critically ill trauma patient by administering large volume of blood products in a short period of time. It is a well-established practice in the adult population. Massive transfusion in pediatrics is based on institutional protocols.

Explain diagnosis and management to caregivers (synthesis)

• In a difficult and stressful environment, compassionate and clear communication with caregivers is critical, as they are strong partners in the treatment of their children. This should not impede lifesaving treatment, but if at all possible, a member of the treatment staff should be assigned to stay with parents and explain various interventions. Failure to provide a communication liaison may result in anxious parents that may obstruct care.
  The decision to transfer to a higher level of care and need for transport with Advanced Life Support services should be explained.

Develop a plan for transfer to a trauma center for definitive management (synthesis)

• For a multisystem trauma, care at a designated level I trauma center should be considered based on State Trauma policy and guidelines for interfacility transfer with appropriate consent and EMTALA documentation.
• When a regional pediatric referral center is available within the trauma system, the most severely injured children may be transported to a facility with a level I or II pediatric trauma designation.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

• Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
• Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
• Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
• Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
• SBAR: A framework for team members to structure information when communicating to one another.
  • S = Situation (What is going on with the patient?)
  • B = Background (What is the clinical background or context?)
  • A = Assessment (What do I think the problem is?)
  • R = Recommendation (What would I do to correct it?)
• Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
• Situation awareness: The state of “knowing what’s going on around you.”
• Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
• STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
• Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
• CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

1a: eFAST Image | Subxiphoid view

1b: eFAST Image | Right upper quadrant view

1c: eFAST Image | Left upper quadrant view

1d: eFAST Image | Suprapubic view

1e: eFAST Image | Lung view

1f: eFAST Image | Lung view M-mode view

Chest X-ray

Tibia-Fibula X-ray (AP view)

Tibia-Fibula X-ray (Lateral view)

Pelvis X-ray

Download Case 7 supporting files

Notes:

• E-FAST Interpretation: Positive for intraperitoneal fluid, no pericardial fluid, no pneumothorax. Images from Dr. Kevin Roth.
• Chest X-ray: Pulmonary contusion and endotracheal tube in proper position. Image from Dr. Manu Madhok.
• Tibia-Fibula X-ray: Tibia-fibula fracture. Image from Dr. Manu Madhok.
• Pelvis X-ray: Normal pelvis x-ray. Image from Dr. Manu Madhok.

For the embedded participant playing the patient’s parent

Case Background Information

Your daughter has just been hit by a car. You saw it happen and you immediately picked her up and took her to the nearest Emergency Department (ED). She has numerous injuries that need to be addressed.

This ED is not a Level 1 Trauma Center. Level I Trauma centers will provide the most comprehensive care of your daughter’s injuries. The learners will have to stabilize her first (give IV fluids and place a tube in her airway), and then arrange transfer for her to go to the Level 1 Trauma Center.

Who are the Learners?

Emergency medicine residents

This case is specifically aimed at residents who have fair knowledge/ experience caring for critically injured children. They should be competent regarding any emergency procedures your daughter needs. Because she has numerous injuries, they may have trouble figuring out what order they should take each action/decision.

Also, this case asks the residents to work in an environment that cannot provide definitive care for your daughter. Residents don’t typically train in this environment, so they might not know if/when they should arrange transfer to a Level 1 Trauma Center.

Standardized Patient Information

Your demeanor is concerned but relatively calm. You do not want to obstruct care but want to know what is happening. Do not interrupt them if they are thinking out loud or discussing care with one another but ask questions when possible if they don’t explain what they are doing.

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

• CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): “It happened so fast! She was playing in the front yard. The ball rolled into the street. Before I had a chance to do anything, she ran after the ball into the street and a car hit her. We live close to the hospital, so I drove her straight here.”
• AGE: 6 years old
• PAST MEDICAL HISTORY: Asthma
• SOCIAL HISTORY: No pets. No smokers. Attends school. Lives with both parents and younger brother.
• FAMILY HISTORY: Father has asthma
• PAST SURGICAL HISTORY: None
• MEDICATIONS: Albuterol every 4 hours, as needed
• ALLERGIES: Amoxicillin gives her a rash
• IMMUNIZATIONS: Up-to-date

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things you could say without being asked:

• “Is she breathing?”
• “Is she in a coma?”
• “Is she bleeding internally?”
• “Why is her leg bent like that?”
• “Is she going to be OK?”

Things you might say triggered by events in the scenario:

Learners enter the room and identify immediately that the patient is critically ill. They immediately ask for IV access and cardiac/ respiratory monitoring. A primary survey is rapidly completed.

• Airway: Learners recognize impending need for intubation. They initiate BMV and set up equipment and medications for rapid sequence intubation (RSI).
• Breathing: Assessed
• Circulation: Learners recognize shock and order some form of IV fluid resuscitation (isotonic crystalloid or blood).
• Disability: Assessed and cervical collar applied.
• Exposure: The patient is undressed and log rolled. Blankets are applied to the patient.

A secondary survey and history are then obtained. Learners complete rapid sequence intubation and, if not done concurrently with the secondary survey, obtain/interpret FAST exam, POCT labs, splint tibia/fibula fracture, obtain chest x-ray to confirm ET tube placement and pelvis/leg x-ray (time permitting). They recognize the need for transfer and arrange for immediate transfer to a Level 1 Trauma Center and provide a thorough handoff to the accepting physician.

Anticipated Management Mistakes

1. Failure to provide adequate respiratory support: Learners may not immediately recognize the need for BMV and provide oxygenation initially without assisted ventilation. The nurse may redirect by stating that the oxygen saturation is not improving despite oxygen with nasal cannula or non-rebreather mask and there is poor chest rise.
2. Difficulty with assessment of vital signs: Learners may be unfamiliar with equipment and fail to correctly place monitor leads or apply an inappropriate cuff sizing for the pediatric patient. The nurse can cue learners to use the Broselow tape/cart to select correct equipment (depending on what is available in your simulation center). If an inappropriate cuff is selected, faculty can report that the blood pressure doesn’t result and have the nurse suggest the cuff is incorrectly sized.
3. Inadequate fluid resuscitation: Learners may stop after one fluid bolus and defer blood transfusion to the trauma center. The nurse may redirect them to trauma protocol and transfer guidelines.
4. Incomplete secondary survey: Learners may not remove all clothing and not log roll the patient. The nurse may ask for missing documentation per trauma record sheet cuing them to complete the secondary survey.
5. Inappropriate imaging: Learners may order imaging (e.g., CT scan) that requires the patient to leave the Emergency Department. The nurse expresses concern that the patient is unstable to leave the department for CT scan. Also, the patient’s father may ask questions that will cast doubt on the decision to leave the department.
6. Delay in transfer: Immediately after resuscitation, learners might not initiate transfer to a Level 1 Trauma Center. Many current residents train at trauma centers and therefore, do not habitually recognize the urgent need to transfer. Again, the nurse or patient’s father can prompt the learners.
7. Ignoring family in the room: Learners may forget that family is in the room if they stay quiet. The learner may get annoyed with them if they are in the way too much and keep asking questions. They will have to balance informing the parent what is going on while asking them to not interfere in medical care. The nurse may ask for a social worker to be with the parent.