Monroe Carell Jr. Children’s Hospital at September 4, 2020 Vanderbilt Volume 1, Issue 1 Trauma Program Trauma Program Newsletter

The Trauma Service at Monroe Carell Jr. Children’s Hospital at Vanderbilt provides complete care to pediatric trauma victims of all ages. Timely access to specialized care is often a matter of life and death in trauma situations, particularly when they involve children.

Children's Hospital is the only Pediatric Level-1 within 150 miles of Nashville. We offer the highest level of service to pediatric trauma patients. Our around- the-clock service is available to all pediatric subspecialties. Our trauma center has also been verified by the American College of Surgeons.

As a token of our appreciation for all that you do as Emergency Medical Service providers, we wanted to provide you with pediatric trauma specific education in this newsletter.

2ND QUARTER MECHANIM OF STATISTICS

INSIDE THIS ISSUE

Trauma Triad of Death ...... 2 Withholding/Termination of ...... 3

ELEVATING TRAUMA PATIENT CONCERNS

For any patient quality concerns or system issues related to our trauma population, please feel free to contact Lee Blair or Jennifer Dindo with our Outreach Program so they can reach out to us, the Trauma Program.

• [email protected]

• [email protected] TRAUMA TRIAD OF DEATH

Key terms: in trauma patients is caused by a multitude of factors. Hemorrhagic shock and traumatic brain  : lower than normal pH due to increased impair the body’s ability to regulate its core hydrogen ion concentration (<7.35). temperature. Room temperature normal saline (20-25˚C) is very hypothermic relative to the desired normal body  Coagulation system: a temperature– and pH- temperature. Thus, large volume with even dependent series of complex enzymatic reactions that room temperature IV fluids can significantly contribute to result in the formation of clots to stop both this arm of the lethal triad. internal and external hemorrhage. In trauma patients, the major contributor to acidosis is  : any disorder of the blood that makes poor perfusion to the tissues. Anemia from acute blood it difficult for blood to clot. loss, peripheral vasoconstriction in response to hypothermia and blood loss, and overall decreased cardiac  Hypothermia: lowered body core temperature activity severely impair oxygen delivery to the tissues. (<35˚C) Lastly a trauma patient may also have respiratory acidosis as a result of hypoventilation due to respiratory  Lethal triad: a combination of acidosis, depression . As a trauma patient’s perfusion worsens, coagulopathy, and hypothermia that usually leads to rapidly accumulates in the tissue causing the death in a patient experiencing trauma. body’s pH to drop (metabolic acidosis). It is important to note that this process frequently occurs in the presence of In order to successfully resuscitate the critically ill trauma normal or only slightly abnormal vital signs. patient, all emergency providers must have a strong understanding of the lethal triad. This understanding The coagulopathy of trauma occurs not only because of should serve as the basis for all interventions provided to hypothermia and acidosis, but also as a result of losing the trauma patient. Left untreated, hypothermia, clotting factors through hemorrhage and hemodilution, acidosis, and coagulopathy bring about and propagate and the body’s use and subsequent depletion of both each other, eventually resulting in predictable but platelets and clotting factors. irreversible progression toward death.

2 WITHHOLDING/TERMINATION OF RESUSCITATION IN PEDIATRIC OUT OF HOSPITAL TRAUMA ARRESTS

Although there is increasing ac-  No patient who received more than 3 doses ceptance of out-of-hospital termination of epinephrine or more than 31 minutes of of resuscitation for adult traumatic resuscitation in the ED survived. (3) cardiopulmonary arrest when there is no expectation of a good outcome,  Indicators of potential for successful out- children are routinely excluded from comes in pediatric out-of-hospital arrest state termination-of-resuscitation pro- include a witnessed arrest, the occurrence tocols. of early bystander CPR, an initial shockable Trauma is the leading cause of death rhythm, and return of spontaneous circula- from 1 through 21 years of age, and tion within 20 minutes. homicide or child abuse is the leading cause of younger  Ethical concerns regarding the implemen- than 1 year; therefore, the optimal tation of a termination-of-resuscitation management of pediatric out-of- policy deserve mention. Minority popula- hospital traumatic cardiopulmonary tions experience traumatic injuries dispro- arrest deserves special attention. (2) portionately, including traumatic death. Any termination of resuscitation policy The American College of Surgeons and may, therefore, be viewed with distrust, the National Association of EMS Physi- particularly among minority populations. cians conducted a multi-organizational literature review in 2014 with the fol- lowing findings :

TREATMENT CONCLUSIONS BASED ON EVIDENCE

(A) The withholding of resuscitative efforts should be Initiation of standard resuscitation should be considered considered in pediatric victims of penetrating or blunt for a cardiopulmonary arrest patients in whom the trauma with injuries obviously incompatible with life, mechanism of injury does not correlate with a traumatic such as decapitation or hemicorporectomy (Level 2). cause of arrest unless (A) or (B) above applies (Level 2). (B) The withholding of resuscitative efforts should be Initiation of standard resuscitation should be considered considered in pediatric victims of penetrating or blunt in cardiopulmonary arrest victims of lightning strike or trauma with evidence of a significant time lapse drowning in whom there is significant hypothermia following pulselessness, including dependent lividity, unless (A) or (B) applies (Level 2). rigor mortis, and decomposition (Level 2). Following blunt and in victims in If there is any doubt as to the circumstances or timing of whom there is an unwitnessed traumatic the traumatic cardiopulmonary arrest, under the current cardiopulmonary arrest, a longer period of hypoxia may status of limiting termination of resuscitation in the field be presumed to have occurred, and an acceptable to persons older than 18 years in most states, duration of CPR (including bystander CPR) of less than resuscitation should be initiated and continued until 30 minutes may be considered with medical director arrival to the appropriate facility (Level 3). input (Level 3). Immediate transportation to an ED should be considered The inclusion of children in state termination-of- for children who exhibit witnessed signs of life before resuscitation protocols should be considered, including traumatic cardiopulmonary resuscitation and have CPR children who are victims of blunt and penetrating ongoing or initiated within 5 minutes in the field, with trauma who have or in whom there is EMS-witnessed resuscitation maneuvers including airway management cardiopulmonary arrest and at least 30 minutes of and intravenous or intraosseous line placement planned unsuccessful resuscitative efforts, including CPR (Level during transport (Level 2). 2).

3 MONROE CARELL JR. CHILDREN’S HOSPITAL AT VANDERBILT TRAUMA PROGRAM

Harold Lovvorn, MD Amber Greeno, MSN, APRN, CPNP- Brittney Aiello, BSN, RN, CPEN AC, CPN Trauma Medical Director Trauma Program Coordinator Director of Trauma, Injury [email protected] [email protected] Prevention, and Project ADAM [email protected]

Monroe Carell Jr. Children’s Hospital at Vanderbilt Trauma Website: https://www.vumc.org/pediatric-trauma-service/pediatric-trauma-program

Bibliography

1. Keane, M. (2016). Triad of death: the importance of temperature monitoring in trauma patients. Emergency Nurse, 24(5).

2. Parker, M., & Magnusson, C. (2016). Assessment of trauma patients. International journal of orthopaedic and trauma nursing, 21, 21-30.

3. Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest. (2014). Pediatrics, e1104- e1116.