1. Rebecca Starr DO, PEM Fellow
November 12, 2013

2. Objectives





Identify goals of trauma activation
Review pediatric trauma alert criteria
Develop an understanding of medical
errors in communication and strategies to
minimize
Discuss scalp laceration morbidity and
implement appropriate initial management
Analyze mass transfusion protocol and
understand evidence for approach

3. Case
10 year old male with head trauma and
scalp laceration

4. HPI
10 y/o M with a scalp laceration
sustained from a large tree branch (est
100 lbs) that had fallen onto his head
 No loss of consciousness, no
vomiting, no confusion

Pt airlifted via LifeNet to MUSC ED
 C-collar, backboard, and pressure
dressing by LifeNet


5. HPI continued
PMHx: previously healthy
 PSHx: none
 Allergies: none
 Medications: none
 ROS: headache


6. Physical Exam









Vitals: HR 75 BP 124/88 RR 22 SpO2 99% GCS 15
General: Alert and oriented
Head: 15cm scalp avulsion/flap with visible galea
and active ooze
Eyes: PERRLA, EOMI, Pupils ~ 3mm
ENT: nares patent, o/p without lesions and 2 small
lacerations to tongue, no blood behind TM‟s
Neck: in c-collar, No TTP on cervical spine
CV/Resp/GI: wnl
Skin: left leg with small abrasions and ashes on feet
Neuro: CN 2-12 GIT, no focal deficits, good tone, 5/5
UE and LE strength, full ROM, MAEW

7. Timeline of Events


1925- Arrival to ED awake and alert, GCS 15
1930- Primary and secondary survey by PED
MD‟s, wound examined and pressure dressing
reapplied
 Decision to not call trauma activation
 Neurosurgery paged






1938- Fentanyl 25mcg and 1L NS bolus given
1940- CXR and pelvis
1950- CT Head and Neck
2010- Back from CT, “active bleeding continues”
2015- Neurosurgery at bedside to address lac
2025- Dressing reapplied after neurosurgery
removed, plan to sedate for laceration repair

8. Timeline of Events
2045- Neurosurgery called away to adult trauma
 2115- Pt complains of feeling “hot and sweaty”
 BP 96/29 and HR 157
 MD to bedside
 1L NS bolus by pressure bag and placed in trendelenburg
 2130- BP 80/39 and HR 146
 1L NS bolus repeated
 I stat and repeat CBC
 Pediatric Surgery consulted

○ Considered closing at bedside
2225- Attending to attending conversation (ED and Surg)
 2300- To OR
 Total time in PED (1925-2300)


9. Imaging
CT neck- normal
 CT head
 No intracranial injury or fracture
 Large right posterior-superior parietal
subgaleal hematoma with evidence of scalp
laceration and subcutaneous emphysema
CXR- normal
 Pelvis xray- normal


10. Pertinent Labs
Initial CBC (1940)




WBC 10.9
Hgb 12.5
Hct 35.2
Plts 214
Repeat CBC (2211)




WBC 10.2
Hgb 8.2
Hct 24
Plts 156

11. Hospital course








Taken to OR
15cm right parietal scalp
laceration/avulsion repaired
TLS drain placed
Transferred to PACU at 0130
Admitted to floor/trauma surgery
TLS drain removed
Hgb: 8.2 9.4, HCT: 24  27
Discharged home the next day

12. Areas for Discussion
Considerations for calling a trauma
activation
 Delay in subspecialty care/transfer
 Communication/chain of command
concerns

 Between RN and MD
 Between subspecialty physicians
 Between training levels
Scalp laceration morbidity
 Role of Mass Transfusion Protocol


13. Effect of Trauma Service in Peds
ED

Goals of Trauma Service
 Mobilization of resources
 Quicker definitive care

Vernon et al -patients treated by a trauma
team vs. ED staff without a peds trauma team
 Shorter times from arrival to CT scan (27 vs 41min)
 Shorter times from arrival to OR (62 vs 123min)
 Shorter total time in the ED (85 vs 121min)

Perno et al- implementation of a trauma
service showed significant reduction in
delayed diagnosis of injury
 Pre trauma team 4% DDI and post trauma team
0.5% DDI
Vernon et al. Pediatrics.1999
Perno et al. Pediatric Emergency Care. 2005

14. Delay in Transfer Affects
Outcomes
Mortality is significantly reduced when
early goal-directed therapy is instituted
 Chalfin et al “Delay in critically ill
patients > 6 hours from ED to transfer to
ICU/OR increased hospital length of
stay and increased mortality”

 Not just trauma patients, all comers
 Results can be extrapolated
Chalfin et al. Critical Care Medicine. 2007

15. MUSC Pediatric Trauma Alert
Criteria
Level A
 Physiologic Criteria
 GCS <9 at time of EMS transport
 Hypotension
 Suspicion of respiratory compromise

Attending concern for serious injury

16. MUSC Pediatric Trauma Alert
Criteria
Level A
 Anatomic Criteria
 Penetrating injury to head, neck, torso
 Penetrating injury to extremity proximal to elbow







or knee with ongoing bleeding
Flail chest
Two or more long bone fractures
Crushed/degloving injury
Amputation proximal to wrist or ankle
Open or depressed skull fracture
Suspected Pelvic fracture
2nd or 3rd degree burns >40% BSA

17. MUSC Pediatric Trauma Alert
Criteria
Level A Trauma Transfer from OSH
 Hemodynamically unstable
 Intubated
 Urgent need for surgical intervention
 Blood transfusion prior to transfer

18. MUSC Pediatric Trauma Alert
Criteria
Level B
 Physiologic Criteria
 GCS >9 and <14 at EMS transport

Anatomic Criteria
 Penetrating injury to extremity proximal to
elbow or knee without ongoing bleeding
 2nd or 3rd degree burns > 20% BSA and <
40% BSA

Attending concern for serious injury

19. MUSC Pediatric Trauma Alert
Criteria
Level B
 Mechanism of Injury Criteria
 Fall >20 ft (1 story equals 10ft)
 Ejection from vehicle
 Death in same passenger compartment
 Auto/pedestrian or auto/bike with impact >20
MPH
 Motorcycle or ATV crash >20 MPG
 MVC > 25 MPH

20. MUSC Pediatric Trauma Alert
Criteria
Level B Trauma Transfer from OSH
 Accepted for transfer by trauma service
 Request for trauma alert by accepting
service
 Hemodynamically stable but possible
surgical intervention needed

21. Learning Point
A trauma activation for this patient may
have helped mobilize more resources and
facilitated quicker definitive care

22. Frequent Sources of Medical
Error
 Medication errors (weight-based dosing)
 Level of training
 Staffing
 Overcrowding
 Stress
 Fatigue (Most ED errors between 4am-8am)
 Communication
Selbst et al. Pediatric Emergency Care. 2004

23. Communication

High volume and velocity of information
exchanges
 Multiple check outs and handoffs
 Frequent interruptions
 Multitasking

Significant source of medical errors
Coiera et al. MJA. 2002

24. Interdisciplinary Communication
Donchin study found ICU doctor to
nurse verbal communication was only
2% of total daily communication but
accounted for 37% of error reports
 Hierarchy of exchange

Donchin et al. Critical Care Medicine. 1995

25. Communication Pitfalls for this
Case
Communication of urgency
 Chain of command


26. Communication Learning Point
Closed loop / confirmatory feedback
 Minimize hierarchy
 Be receptive/ approachable
 Remember/utilize chain of command


27. Scalp lacerations

May be grossly underestimated
 Often ignored until patient‟s work up
complete
Potential for large blood loss
 Beware large laceration or several minor
lacerations
 Delay in wound management alone can
lead to hemorrhagic shock

Lemos et.al., J. Emerg. Med. 1988

28. The Scalp
Richest subcutaneous vascular supply in
the entire body
Lemos et.al., J. Emerg. Med. 1988

29. Scalp lacerations

When lacerated, small arteries retract
between the septa

7-10 cm laceration can cause loss of
30% blood volume
Lemos et.al., J. Emerg. Med. 1988
Turnage and Maull, Southern Medical Journal. 2000

30. Case Reports in the
Literature

45 y/o M with large scalp lac and
epidural hematoma after bike vs. car
 Transfer from community hospital to tertiary




care center for neurosurgery involvement
Scalp laceration not closed before transfer
Arrival to hospital in shock (systolic BP 65
and HR 156) requiring aggressive
resuscitation
Hgb 6.3 on arrival to hospital
Multiple transfusions of PRBCs and clotting
factors given
Fitzpatrick et al, J Accid Emerg Med.1996

31. Case Reports in the
Literature

27 y/o F with multiple scalp lacerations and
depressed skull fracture with a small
subdural hematoma due to knife stabbing
 Scalp wounds stapled before transfer to tertiary





care center
En route had a seizure and required intubation
Several staples dislodged during event and
profuse bleeding from scalp wound occurred
Arrival to hospital in shock (BP 70/40 and HR
130) requiring aggressive resuscitation
Hgb 7.1 on arrival to hospital
4 units PRBCs given
Fitzpatrick et al, J Accid Emerg Med.1996

32. Bleeding Control
Direct constant pressure
 Dressing application
 Elevation
 Direct clamping
 Suture
 Staples

Lemos et.al., J. Emerg. Med. 1988

33. Initial Management


Direct applied pressure
Pressure dressing as a temporizing method
 Frequently fails

Temporary single layer closure with running
stitch
 Interferes with wound evaluation

Surgical staples
 Temporary

Hemostats applied to edge of scalp
 Tedious and interferes with radiographic studies

Scalp clips
 Requires special equipment
Lemos et.al., J. Emerg. Med. 1988
Fitzpatrick et al, J Accid Emerg Med.1996

34. Raney Clips
Quick, effective, and inexpensive
 Compresses the wound edge and
occludes the blood vessels
 Maintain good exposure of the wound
 Do not interfere with radiographic
studies

Sykes, Annals of Emergency Medicine, 1989

35. Raney Clips

36. Multiple Techniques

37. Definitive Closure

Likely with subspecialty service for
larger lacerations
 Surgery
 Neurosurgery
 Plastics
Sykes, Annals of Emergency Medicine, 1989

38. Learning Point
Quick and effective initial management
is imperative in scalp lacerations
 Potential for scalp lacerations to cause
hemorrhagic shock


39. Traumatic Blood Loss
Fluid resuscitation remains the cornerstone
of treatment
 A specific level of blood loss or anemia that
triggers transfusion has not been officially
defined in pediatrics

 Based on clinical condition and expected further
blood loss
 Institution specific

Rapid exsanguination may not be reflected
in Hgb or Hct levels until fluid resuscitation
catches up
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010

40. It‟s Just a Flesh Wound

41. Coagulopathy in the “Lethal
Triad”
Well documented part of trauma
 Cycle of worsening
coagulopathy, hypothermia, and
acidosis

 Hypothermia decreases platelet activation
and adhesion
 Hemodilution decreases clotting factors and
increases hypothermia
 Acidosis worsens clotting factor function
Nosanov et al., American Journal of Surgery, 2013

42. Pediatric Blood Volumes
Age




Premature Infant
Term infant to 3 months
Children older than 3
months
Obese children
Estimated Blood Volume
(mL/kg)
90-100
80-90
70
65
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010

43. Pediatric Blood Volume in
Units
Weight



10 kg
25 kg
50 kg (adult standard)
Blood Volume



2 units
5 units
10 units

44. Fresh Whole Blood

Fresh whole blood has been used in
adults in combat setting
 Fresh whole blood transfusions have been
noted to improve 30 day survival rates

FWB not widely available in civilian
setting
 Only 15% of children‟s hospitals stocked
FWB
Dehmer and Adamson, Seminars in Pediatric Surgery, 2010

45. Pediatric Mass Transfusion

Defined by the volume of blood products
given to maintain hemodynamic stability
 Transfusion of blood components equaling
one or more blood volume within a 24 hour
period
 Definition differs per institution

Pediatric MTP‟s are less widely
available than adult MTP‟s
Chidester et al., J Trauma Acute Care Surg.,2012

46. Goals of Pediatric MTP
Maintaining platelets above 50,000
 Hemoglobin higher than 10mg/dL
 Normalization of coagulation assays

Chidester et al., J Trauma Acute Care Surg.,2012

47. Pediatric Mass Transfusion
Activated when 1 circulating blood volume
has been lost
Or
Evidence of massive
hemorrhage, hemodynamically unstable
and already received 40ml/kg crystalloid
Chidester et al., J Trauma Acute Care Surg.,2012

48. Pediatric Mass Transfusion

Ratio of FFP/PRBCs/Platelets 1:1:1
 Most resembles whole blood

Ratios of 1:1:1 has shown to have
survival benefits in adult literature
 Adult data may not be generalized to
pediatrics

Controversy exists between proper
blood products ratio
 Further pediatric research is needed
Chidester et al., J Trauma Acute Care Surg.,2012

49. Pediatric Mass Transfusion

Higher FFP/PRBCs ratio has not been
statistically shown to have increased
survival in children
 Hwu study at Washington University in St.
Louis

“Adoption of pediatric MTP in one study
led to a fourfold decrease in length of
time to FFP transfusion”
 15 min unthaw time for FFP
Hendrickson et al, Transfusion, 2012
Nosanov et al., American Journal of Surgery, 2013

50. Labs to Monitor










Hgb/Hct
Plts
PT
PTT
Fibrinogen
Fibrin degradation products
Ca+
K+
pH
Lactate
Chidester et al., J Trauma Acute Care Surg.,2012

51. Complications of MTP
FFP transfusion associated with increased
risk of respiratory distress and ARDS
 Increased susceptibility to hyperkalemia
secondary to blood product transfusion

 K+ slowly leaks out of RBC‟s during storage and
can increase K+ concentrations
 9 case reports of pediatric hyperkalemic cardiac
arrest due to MTP in literature
 Cardiac patients and neonates increased risk
 Mean K+ 9.2 mmol/L (6.3-12mmol/L)
Lee et al, Transfusion, 2013

52. Lee et al, Transfusion, 2013

53. Recombinant Factor VIIa

Useful adjunct for control of bleeding
 Enhances production of thrombin on the
surface of activated platelets

Adult studies have documented
decreased blood product requirements
 No sufficient pediatric studies
No change in mortality in MTP
 Lower incidence of thromboembolic
events

Chidester et al., J Trauma Acute Care Surg.,2012

57. MTP and Organ Donation

MTP activation in one study showed 2
incidences where viability of organ
donation was made possible
 1 patient with nonsurvivable injuries which
was a non MTP patient was rejected as an
organ donor due to severe hemodilution
Chidester et al., J Trauma Acute Care Surg.,2012

58. MTP Learning Points
Activate when one circulating blood
volume was lost or evidence of massive
hemorrhage, hemodynamically unstable
and already received 40ml/kg crystalloid
 Monitor K+ and consider transfusion
associated hyperkalemic cardiac arrest
 Consider recombinant Factor VIIa


59. Summary


Trauma activation helps mobilize more resources
and facilitates quicker definitive care
Keys for successful communication in the ED







Closed loop / confirmatory feedback
Minimize hierarchy
Be receptive/ approachable
Remember/utilize chain of command
Quick and effective initial management is imperative
in scalp lacerations
Potential for scalp lacerations to cause hemorrhagic
shock
Utilize Mass Transfusion Protocol when dealing with
an actively hemorrhaging patient

60. References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Dehmer, J.J., M.D, et al. Massive transfusion and blood product use in the pediatric trauma patient. Seminars in Pediatric Surgery.
2010;19:286-291. doi:10.1053/j.sempedsurg.2010.07.002.
Lee, A.C. et al. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion.
2013 doi:10.1111/trf.12192.
Hendrickson, J.E., et al. Implementation of pediatric trauma massive transfusion protocol: one institution's experience.
Transfusion.2012;52:1228-1236. doi:10.1111/j.1537-2995.2011.03458.x.
Nosanov, L., et al. The impact of blood product ratios in massively transfused pediatric trauma patients. The American Journal of
Surgery. 2013.
Chidester, S.J. A pediatric massive transfusion protocol. The Journal of Trauma, Acute Care, and Surgery. 12012;73 :1273-1277.
doi:10.1097/TA.0b013e318265d267.
Turnage, B. & Maull, K. Scalp laceration: an obvious 'occult„ cause of shock. Southern Medical Journal. 2000;93:265-266.
Lemos, M.J., & Clark, D.E. Scalp lacerations resulting in hemorrhagic shock: case reports and recommended management. The
Journal of Emergency Medicine.1988;6:377-379.
Sykes, L.N. Management of hemorrhage from severe scalp lacerations with Raney clips. Annals of Emergency Medicine. 1989;18:995996.
Fitzpatrick, M.O., & Seex, K. Scalp lacerations demand careful attention before interhospital transfer of head injured patients. Journal of
Accidental Emergency Medicine. 1996;13:207-208. doi:10.1136/emj.13.3.207
Chalfin, D.B., et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical
Care Medicine. 2007;35:1477-1483.
Selbst, S.M., et al. Preventing Medical Errors in Pediatric Emergency Medicine. Pediatric Emergency Care. 2004; 20:702-709.
Alvarez, G. & Enrico Coiera. Interdisciplinary communication: an uncharted source of medical error?. Journal of Critical Care 21.
2006:236-242.
Coiera, E.W., et al. Communication loads on clinical staff in the emergency department. Medical Journal of Austrailia. 2002;176:415418.
Sutcliffe, K.M. et al. Communication Failures: an insidious contributor to medical mishaps. Academic Medicine. 2004; 79:186-194.
Vernon, D.D. et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric
trauma victims. Pediatrics. 1999;103:20-24.
Perno, J.F., et al. Significant reduction in delayed diagnosis of injury with implementation of a pediatric trauma service. Pediatric
Emergency Care. 2005;21:367-371.
Donchin Y. et al., A look into the nature and causes of human errors in the intensive care unit. Critical Care Medicine. 1995;23:294-300

61. Special Thanks
Thank you to Dr. Rachel Tuuri, Dr. Olivia
Titus, Dr. Scott Russell, Dr. Fred
Tecklenburg, and Madeline Gehrig for their
help.