Trauma SurgeryShannon RosatiTori WhitlowDan CabralIsiah BrownBrandon Barnes

Cases• PGY-5• PGY-4• PGY-3• PGY-2• PGY-1

• Total

• 2• 17• 2• 3• 1

• 25

Complication• Age/Sex: 2/M• Attending/Res:

Jayaraman/Rosati• Diagnosis: self inflicted GSW to

head• Operation: placement of L EVD

and closure of scalp lac (NSG), exploration of maxillary defect with control of hemorrhage with Xeroform bolster and R lateral canthotomy, R neck exploration with ligation R common carotid artery (ENT)

• Complication: Death• Assessments:• A- PD (Patient disease)• B- V (Death)

Case Presentation• Pt presented to trauma bay on 5/25 as a DELTA TTA after

suffering a self inflicted GSW to the head • Entry through the mouth, exit R parietal scalp, where a small

exit wound was noted• Pt had been intubated in the field prior to arrival• Per EMS report, he had a gag reflex present on intubation• Was noted to be breathing over the vent in the trauma bay• Pupil exam initially was 5mm and non reactive on R, 3mm

and reactive to 2 mm on left• On arrival, initial VS were significant for HR 160s, systolic BP

30s with copious bleeding from mouth around ET tube

Hospital Course• Pt received immediate 2 units PRBC and

systolic BP improved to 60s• Taken to CT for head CT

• Coags significant for PT 73.7, INR 9.3, PTT >150• Pt’s BP dropped in CT again, so was taken back

to trauma bay, received additional 3 units PRBC and 2 units FFP (total 5 PRBC and 2 FFP) Pediatric massive transfusion protocol initiated

11.0 22216.4

5.7

Hospital Course• CT head findings: Gunshot wound trauma to the face and right

frontal temporal parietal lobe with extensive intraparenchymal hemorrhage, cerebral edema, and numerous bony and metallic fragments within the right cerebral hemisphere. There is associated subfalcine and transtentorial herniation. No definite tonsillar herniation.• CT maxillofacial findings: Entry wound is at the level of the

alveolar ridge of the right maxilla which is severely fragmented from the central incisor laterally. Severe comminution of the anterior and posterior lateral walls of the right maxilla including the inferior orbital rim and orbital floor with intraorbital displacement of the orbital floor and lateral orbital wall. There is comminution of the medial wall of the right maxillary sinus as well. The bullet trajectory is then posterior superior through the sphenoid wing into the middle cranial fossa.

Hospital Course

• Pt taken directly from trauma bay to the OR with NSG and ENT, both teams consulted immediately and were present in the trauma bay to assist in control of the hemorrhage

• NSG performed placement of a L frontal extra ventricular drain and closed the posterior parietal wound

• ENT performed an exploration of the R maxillary wound with placement of xeroform bolster for hemorrhage control and R lateral canthotomy

Hospital Course

• Post operatively in the PICU, pt began actively hemorrhaging again

• Level I Head CTA obtained transection of the R MCA just proximal to the level of expected bifurcation with a bullet fragment immediately adjacent, with increase in leftward midline shift and increase in parenchymal hematoma and subarachnoid blood

4.811.9

4.318.0

Hospital Course

• Pt taken back to OR by ENT, underwent R neck dissection and ligation of the R common carotid artery

Hospital Course

• Pt post operatively with fixed and dilated pupils, brain death testing initiated, pt found to have no gag reflex, no breathing response over the vent, no response to cold calorics, pt coagulopathic, with multisystem organ failure

• Pt made a DNR by family, had a V tach episode which progressed to asystole and he passed away at 10:12 on 5/27

Cause-and-Effect diagramMedical Knowledge-Knowledge of pediatric massive transfusion and differences in pediatric transfusion requirements

Diagnostic Reasoning Therapeutic Choices Clinical assessment

Communication-Discussion with ENT and NSG, coordination between trauma, peds surg, peds ED, and PICU

Personnel/Materials-availability of blood products

Processes EnvironmentComplication

-Patient kept in trauma bay for resuscitation rather than PICU

-Workup of head trauma- initial choice of CT scans

-Evaluation of hemorrhage source

Error in technique

Error in judgment

Error in systems

-Release of blood products by PICU and trauma teams

-Resuscitation in adult trauma bay vs peds ED vs PICU

Pediatric Massive Transfusion Protocol

Pediatric Massive Transfusion Protocol

Pediatric Massive Transfusion Protocol

Future QI

• Have pediatric MTP available in trauma bay, peds ED, peds OR (3&25) , PICU

• Educate nursing staff in ED, OR, and PICU about release of products with MTP

• Educate residents and staff about MTP and the components for each level, based on weight of pt

• Aim was to seek a data-driven MT threshold using the largest existing registry of pediatric trauma patients

• Materials and Methods: The Department of Defense Trauma Registry was queried for pediatric trauma patients (<18yrs) from 2001-2013, with evaluation of MT as a weight based volume of all blood products transfused in the first 24 hrs

• Results: 4990 combat-injured pediatric trauma patients, of whom 1113 were transfused and constituted the study cohort• Divided into MT+ (443) and MT- (670), based on threshold of 40ml/kg blood transfusion• MT + pts more likely to be in shock (68% vs 47%), hypothermic (13% vs 3.4%), coagulopathic

(45% vs 29.6%) and thrombocytopenic (10.6% vs 5%) on presentation• MT + pts had higher ISS, more mechanical ventilator days, longer ICU and overall hospital stays,

and was an independently associated with increased 24 hr mortality and in hospital mortality

• Conclusion: A threshold of 40 ml/kg of all blood products given at any time in the first 24 hrs reliably identifies critically injured children at high risk for early and in-hospital death

• Hypothesis was that a pediatric MTP would improve outcomes through a balanced blood product resuscitation

• Materials and Methods: a pediatric MTP with a fixed ratio of RBC:FFP:plts:cryo based on pts’ weight was initiated at a single institution

• Results: 53 pts enrolled over a 15 month period and compared to 49 pre-MTP pts• 72% of MTP pts had at least one coagulation value outside of normal on arrival to

the ED• Median time to FFP transfusion decreased fourfold after MTP implementation• A total of 49% of MTP pts received greater than 70ml/kg blood products and the 24-

hr median FFP:RBC transfusion ratio was twofold higher than the pre-MTP cohort• No improvement in mortality was observed after MTP initiation

• Conclusion: A pediatric MTP protocol is feasible and allows for rapid transfusion of balanced blood products to coagulopathic children

• Aim was to examine a pediatric MTP and identify factors that may prompt initiation, as well as examine M&M

• Materials and Methods: prospective cohort on all pediatric patients who received un-cross-matched blood from Jan 1, 2009 through Jan 1, 2011 (on peds MTP vs at clinician discretion)

• Results: 55 patients received un-cross-matched blood (22 pts in MTP group and 33 in non-MTP)• Mortality not significantly different b/w two groups (ISS for

MTP group 42 vs 25 for non-MTP group)• Thromboembolic complications occurred more exclusively

in the non-MTP group (p< 0.04)• Coagulopathy evidenced by PTT > 36, was associated with

the initiation of the MTP

• Conclusion: Blood transfusion via MTP was associated with fewer thromboembolic events, and with coagulopathy

Questions

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