Oct. 06, 2017
In 2016, a 14-year-old girl was driving an all-terrain vehicle (ATV) to a school practice in Minnesota. On the gravel road along the way, her vehicle flipped.
"No one knows what happened," says D. Dean Potter Jr., M.D., pediatric trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota. "She was by herself. Two guys going to football practice found her underneath this vehicle in the middle of the road. They pushed the ATV off of her and called for help."
Local emergency services arrived, and Mayo One — Mayo Clinic's emergency helicopter — was autolaunched, per Southern Minnesota Regional Trauma Advisory Committee Auto Launch protocol, due to the patient's condition and location.
From the time Mayo One personnel reached the scene to the patient's arrival in Rochester, her condition quickly went downhill.
"Initially, she was talking when the first responders got there, but she deteriorated," says Dr. Potter, explaining this was due to hemorrhagic shock. "Her respiratory status essentially was consistent with respiratory failure, which required intervention."
The Mayo One crew intubated her and decompressed her left chest with needle thoracostomy, due to potential tension pneumothorax. The team placed an intraosseous (IO) line and administered IV fluids. She was hypotensive, with her initial systolic blood pressure falling in the 80s. The patient's oxygen saturation ranged from the 60s to the 80s.
Due to the rollover, the patient suffered polytrauma: left pneumothorax, right humeral shaft fracture, left proximal humeral fracture dislocation, multiple rib fractures, grade 5 liver laceration, grade 4 splenic laceration and grade 3 renal laceration. She also developed abdominal compartment syndrome.
Mayo Clinic interventional radiologists performed an angiogram, then coil embolization to stem the bleeding from her liver and spleen. Dr. Potter performed decompressive laparotomy to drain the hemoperitoneum.
The patient spent nearly a month in the hospital, with physicians from emergency medicine, pediatric intensive care, interventional radiology, orthopedics and gastroenterology also providing care. She underwent multiple surgeries, mostly for fractures.
Shock recognition
A critical juncture in this patient's course involved recognizing and managing hemorrhagic shock, which is achieved following an orderly process. Beginning with a diagnosis by clinical examination, medical professionals need to assess whether the patient's circulation displays the following:
- Age-based tachycardia
- Hypovolemia, determined by assessing capillary refill
- Systolic blood pressure drop
"Systolic blood pressure can be a bit deceiving in kids, because kids have a tendency to be able to maintain a normal blood pressure much longer than adults," says Dr. Potter. "There's this thought out there that kids tend to 'fall off the cliff': they look OK and they're maintaining their blood pressure, and then the next minute they are hypotensive and dying."
"The concept of 'falling off a cliff,' in my opinion, is a fallacy, however, because it means the signs of compensated hemorrhagic shock were not noticed by the provider," Dr. Potter says.
Medical professionals may miss signs of early or compensated shock, especially in children, he explains, by getting distracted looking at the blood pressure or wondering if the child is scared or in pain. If the symptoms of compensated shock are not treated early enough, however, a patient can go into decompensated shock.
"At some point in time, the body cannot compensate and it's in a lot of trouble," Dr. Potter says. "It's best to recognize when someone's in compensated hemorrhagic shock."
Though not difficult to recognize a patient in decompensated shock, recognizing when a patient is in compensated shock is much more challenging. According to Dr. Potter, capillary refill is the key to early identification of compensated hemorrhagic shock in tachycardic children. Delayed capillary refill greater than two seconds indicates decreased cardiac output, and "in an injured kid, that means acute blood loss leading to shock," he says.
One other clue to compensated shock is mental status. "Patients who aren't perfusing their brains well tend to be irritable, anxious, upset," Dr. Potter says. "We need to look for these early findings and tell the difference between an agitated child and one who just wants his or her mom."
Shock management
Once shock and its type are determined, providers can proceed to patient resuscitation.
In the case of the patient with the ATV injury, this involved an IO as well as giving her IV fluids before arriving at Mayo Clinic Hospital — Saint Marys Campus. Additionally, despite the standard American College of Surgeons Advanced Trauma Life Support course's teaching to administer two crystalloid fluid boluses before moving to blood, the Mayo Clinic providers proceeded directly to blood product administration in the Emergency Department, as the child remained in shock and possibly decompensated shock.
"Moving more quickly to blood was a big advantage to her," says Dr. Potter. "If crystalloid bolus is not working, go to plasma. Particularly in a patient like this, that's very beneficial. Probably in a lot of patients it's not a big deal, but in this child who was bleeding to death, that certainly was a big advantage."
Knowing the patient's age is critical to proper resuscitation in order to recognize normal vital signs. Clinicians also may utilize the Broselow pediatric emergency tape, a color-based tape measure the care provider places at the top of a patient's head and extends to the heels. The color revealed will indicate all information needed to manage the patient's shock, providing an estimated weight and recommending equipment size, medications and dosages.
Resuscitating children follows the same pattern as adults, using the ABCs of trauma: attending to the airway, breathing and circulation. Even the use of blood and blood products is becoming more like treating adults, according to Dr. Potter. Critical differences lie in vital signs and equipment sizes, such as chest and endotracheal tubes.
For surgical hemorrhage control, physicians should carefully weigh the use of interventional radiology with coil embolization versus open laparotomy with packing. If warranted at Mayo Clinic, surgeons proceed directly to interventional radiology, which can be an improvement in management of uncontrolled bleeding in cases such as the girl in the ATV accident, for whom it helped saved her life.
For more information about managing pediatric trauma, call the Level I Pediatric Trauma Center office at 507-538-3740.
For more information
Regional practice management guideline: Auto Launch criteria. Southern Minnesota Regional Trauma Advisory Committee.
Advanced Trauma Life Support program. American College of Surgeons.