Caitlyn

4 Year old girl• Climbing on steel gates at

1015 hr • 2 gates ~100 kg fell on her• trapped - gates removed

by her father• brief loss of consciousness

Brought to Orange ED by her father

TriagePresenting Information : head injury, gate fell on child,

Additional Information ; in & out of consciousness, dad drove child , O/E child alert, blood stained hair, DCP GENERIC CODE Triage Visit Reason : head injury Triage Date/Time : 10:43 Triage Category : 2 Triage Group : Emergency OHS

Initial trauma assessment

• A - patent, crying intermittently • B – no distress, AE good bilat, no added sounds• C - well perfused, P;105/min, regular, • D – occasionally falls asleep but easily rousable by voice,

speaking in short sentences, pupils equal reactive to light, moves all 4 limbs

• E - contused lac 3x1 cm over left forehead - dirty covered with sand, lac over occipital area 1x2 cms

• small contusion over chest and thighs• Abdo soft, nad• pelvis stable

Plan

• admit under surgeon • CT head (d/w Paed )• CXR• Suturing of lacerations in OT after CT• FAST scan of abdo• IVC and analgesia• Bloods incl amylase/lipase, G&H

Progress• IVC attempts causing distress• Nasal Fentanyl (1.5 mcg/kg)• FAST normal• Medically escorted to CT for brain and C-spine

• There is presence of a small hyper dense extra axial collection noted overlying the right parietal lobe containing air and having a depth of 6.8mm.

• There is presence of an extensive fracture noted through the right and left

frontal bone extending across the coronal suture in to the right parietal bone and extending up to the occipital lambdoid suture.

• There is evidence of subarachnoid bleed noted. There is also evidence of

increased cerebral oedema noted with suggestion of loss of grey/white matter differentiation seen.

• There is no evidence of compression of the third ventricle or basilar cisterns seen. • There is extra cranial soft tissue swelling noted over the right parietal skull vault. • The cervical spine lies in alignment. There is no definite evidence of a fracture noted through

the cervical spine. Prevertebral soft tissues appear normal. • Anterior spinal line and posterior spinal line appear normal.

Change in condition ~1230hr

• Prior to scan, drowsy but rousable and combative when IVC attempted

• One episode of bradycardia 90-95 but responded to voice

• Increasingly drowsy, pulse in scan 120-130, and not moving in scanner.

• Afterwards responsive only to painful stimuli, eyes closed, withdrawal to pain. Pupils equal and reactive to light but then deviated to left. No abnormal posturing

Plan

• Arrange RSI for intubation (Thiopentone, Suxamethonium Oral uncuffed ETT)

• Normocarbia, head up, fluid optimisation• 2nd IVC, IV Abs, gastric tube, IDC, ABG

• Organise retrieval• Seek neurosurgical and PICU advice

• Conference call

Clinical discussion

• Mannitol?• Maintain paralysis?• Sedation +/- phenytoin?

• How soon can she be retrieved?• Should a neurosurgeon be flown out?

Neurosurgical management

• O.T. burrhole through R coronal sutureExternal ventricular drain inserted“moderately high pressure”

• Follow up CT day 2• Drain removed day 4• Discharge day 6

Questions

Jack

Venom detection

Bloods (2 hrs post bite)

• PT >150 sec (11 – 18)• APTT >150 sec (19 – 36)• INR >10.0• D – Dimer +ve• Fibrinogen >6.0 g/L (1.8 – 4.4)• CK 155

• Urine brown with large haem. blood on U/A

Management

• 1 vial of Brown Snake antivenom over 30 min.• Remove ‘pressure’ bandage

• NETS, PICU, Toxicology conference call

• Should he stay or should he go?

Follow up results

3 hrs post avPT 18 secAPTT 45 secINR 1.7Fibrinogen > 6.0

U/A 1 hr Small haemolysed blood

Retrieval team arrive, reconference.

Follow up results

Post antivenom 3 hrs 6 hrs 12 hrsPT 18 sec 14 sec 12 secAPTT 45 sec 42 sec 35 secINR 1.7 1.4 1.2Fibrinogen > 6.0 0.5 2.4

U/A 1 hr Small haemolysed blood

6 hrclear

Thank you