Lots of great comments about this case yesterday. So you’re looking for reasons why this 8 year old child is having blood pressure problems while undergoing craniotomy. On first pass through the ABCs, everything looks good. Looks. That’s not enough. 

The airway is definitely good. It’s been physically checked. But what about breathing? Lung sounds seem to be good, but in children they can be transmitted from the other side. There are a few solutions. If you have fluoro or quick access to a chest xray, that could be used. However, quickness is the key. If in doubt and the pressure is really becoming a problem, consider empiric needle decompression or finger thoracostomy if you want to avoid chasing with a chest tube on each side.

What about circulation? We’ve ruled out just about every source of bleeding but the abdomen. No FAST? Then why not fall back on DPL? Sure, it’s been a while since you’ve done it. And probably even longer since you’ve done one on a child.

DPL tips for kids: You’re really interested in the tap, not the lavage. If there’s enough bleeding in the abdomen to cause hypotension, you’ll find it quickly. Use open technique (not Seldinger) and insert the catheter far enough to cover all the tiny holes. One reader suggested using a suction cathether (like a Poole sucker). The only issue is one of control so the amount of blood removed can be measured. (Bonus tip: if you ever do the lavage part in a child, use 10cc saline or lactated ringers per kg).

In this case, the chest was negative, and there was no blood in the abdomen. The culprit was D (disability in ATLS jargon). And unfortunately, hypotension from CNS causes is universally an indicator of impending doom.

Yesterday, I wrote about an 8 year old bicyclist struck by a car. He had sustained a head injury with a large epidural hematoma and was taken immediately to the OR for evacuation. During the case, the vitals began to suffer. The question was, what would you do as you are called into the room to “fix” this?

There was some excellent chatter on this, and universally, people voted to stick to the ABCs. As taught in ATLS, when the vital signs go awry, the only problems that can cause this degree of sudden derangement start with A, B, C and occasionally D.

The first thing to do is recheck the adequacy of the airway. Sure, the child is intubated. But the neurosurgeon had to position the head, and anesthesia’s access to this area is more limited than in other procedures. Your anesthesiologist is able to put a fiberoptic scope into the mouth and visualize that the tube does indeed pass through the vocal cords. Oxygen saturation is 100% and ETCO2 is 33.

Next, check breathing. The numbers above are helpful, but not the complete answer. Get access to the chest, look and listen. There is good, symmetric chest rise with ventilation, and breath sounds are completely normal bilaterally. The trachea is midline.

Now, is there any circulation problem (bleeding)? There are 5 areas where you can bleed to death:

• Chest – the initial chest xray and your exam make this unlikely.
• Fractures – you examine all extremities and can’t find any gross fractures
• Pelvis – the initial portable xray did not show any fractures, and your exam is normal
• Floor – your shoes are not getting sticky and the OR table is clean (except for the neurosurgeon’s mess)
• Abdomen – ???

Hmm, the abdomen appears a bit distended, and it’s a bit tympanitic. This is a problem area! Let’s say FAST is not available to you, and the pressure is not improving with fluid and pressors.

How can you evaluate this child’s abdomen in this situation? I want the gory details, and will provide answers tomorrow.

Here’s an interesting clinical case. How would handle this difficult situation?

An 8 year old boy is struck by a car while riding his bicycle. He has obvious head trauma, and medics quickly transport him to your trauma center. He is comatose and posturing with a GCS of 5 (E1 V1 M3). RSI and intubation is carried out, and a full exam is done. Only head trauma is noted, with the right pupil a few millimeters larger than the left. The remainder of the physical exam is unremarkable, with the exception of a few extremity abrasions. FAST is negative, as are portable chest and pelvis xrays.

The child is quickly transported to CT, and this is discovered:

He is immediately transported to the OR, where your pediatric neurosurgeon immediately begins a craniotomy to evacuate the epidural hematoma. 

Thirty minutes into the case, you are summoned to the OR because the patient’s blood pressure is dropping and is not responding as expected to fluids and a touch of pressor.

What do you need to think about, and what would you do?

Please comment or tweet all the details. Answers tomorrow!

A set of guidelines for management of blunt solid organ injury in children developed by the American Pediatric Surgical Association was originally published in 1999. One of the elements of the guideline was to place the child on bedrest for a period of time after the injury. Arbitrarily, this period was defined as the injury grade plus one day. So for a grade 3 spleen injury, the child would have to stay in bed for 4 days (!).

A paper published this month looked at the impact of shortening this time interval. Over a 6 year period, all pediatric liver and spleen injuries from blunt trauma were identified and an abbreviated bedrest protocol was implemented. For low grade injuries (grade 1-2), children were kept in bed for 1 day, and for higher grade injuries this was extended to 2 days.

Here are the factoids:

• 249 patients were enrolled (about 40 per year) with an average age of 10. “Bedrest was applicable for 199 patients, 80%.” Huh? Does that mean that 50 patients were excluded due to surgeon preference?
• The organ injured was about 50:50 for spleen vs liver. Twelve children injured both.
• Mean injury grade was 2.7, which is fairly high
• Mean bedrest was 1.6 days, and mean hospital stay was 2.5
• Bedrest was the limiting factor for hospital stay in 62% of cases
• There were no delayed complications of the injury

Bottom line: Come on! Most centers don’t keep adult patients at bedrest this long, and we learned about solid organ injury management from kids! Children almost never fail nonop management, so why treat them more restrictively than adults? And have you ever tried to keep a child at bedrest? Impossible! This study is too underpowered to give real statistically valid results, but it certainly paints a good picture of what works. We’ve been keeping both adults and children at bedrest only overnight, and our average length of stay for isolated solid organs is about 1.5 days. But really, who says that staying in bed for any period of time avoids complications? There are lots of other evil things that can happen!

Related posts:

• Regions Hospital solid organ protocol and tips
• Grading spleen injuries – simplified
• Contrast blush in children
• FAST exam in children

Reference: Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Ped Surg 48(12):2437-2441, 2013.