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Caitlyn4 Year old girlClimbing on steel gates at 1015 hr 2 gates ~100 kg fell on hertrapped - gates removed by her fatherbrief loss of consciousness

Brought to Orange ED by her father

Triage

Presenting 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 assessmentA - patent, crying intermittently B no distress, AE good bilat, no added soundsC - 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 limbsE - contused lac 3x1 cm over left forehead - dirty covered with sand, lac over occipital area 1x2 cmssmall contusion over chest and thighsAbdo soft, nadpelvis stable

Planadmit under surgeon CT head (d/w Paed )CXRSuturing of lacerations in OT after CTFAST scan of abdoIVC and analgesiaBloods incl amylase/lipase, G&H

ProgressIVC attempts causing distressNasal Fentanyl (1.5 mcg/kg)FAST normalMedically 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 ~1230hrPrior to scan, drowsy but rousable and combative when IVC attemptedOne episode of bradycardia 90-95 but responded to voiceIncreasingly 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 posturingPlanArrange RSI for intubation (Thiopentone, Suxamethonium Oral uncuffed ETT)Normocarbia, head up, fluid optimisation2nd IVC, IV Abs, gastric tube, IDC, ABG

Organise retrievalSeek neurosurgical and PICU advice

Conference call

Clinical discussionMannitol?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 insertedmoderately 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 >10.0D Dimer +veFibrinogen >6.0 g/L (1.8 4.4)CK 155

Urine brown with large haem. blood on U/AManagement1 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 results3 hrs post avPT18 secAPTT45 secINR1.7Fibrinogen> 6.0U/A 1 hr Small haemolysed blood

Retrieval team arrive, reconference.Follow up resultsPost antivenom3 hrs6 hrs12 hrsPT18 sec14 sec12 secAPTT45 sec42 sec35 secINR1.71.41.2Fibrinogen> 6.00.52.4U/A 1 hr Small haemolysed blood

6 hrclearThank you