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Case Report: Pediatric Blunt Trauma and Resuscitated Arrest
Heidi Altamirano, RN, MS
Program Director for Burn, Adult and Pediatric Trauma, and Telemedicine

Pre-Hospital:
The patient is a 12 year old female with no previous medical history and was snowmobiling in a rural area with her father. She was wearing a helmet and was on her own snowmobile. She was found by her father pinned between her snowmobile and a tree with her head in the snow. He estimated she had been there for 10 minutes. EMS was called and CPR was initiated as the patient was apneic without a pulse. She was transported to the local critical access facility about 20 minutes away. The helicopter was dispatched in preparation of transfer to the pediatric trauma center over 2 hours from this community.

In the community hospital, CPR was performed for nearly 60 minutes, along with placement of IVs, an endotracheal tube, orogastric tube, and Foley catheter. In addition, 2 liters of crystalloid, followed by 2 units of blood, were given. The patient was also placed on Epinephrine and Norepinephrine drips.

The flight crew called to notify the hospital that they couldn’t land at the community hospital due to a snowstorm. They recommend driving 30 minutes to another small community hospital where they were still able to land and take off from, as the weather had not impacted that area at that time. The patient left the community hospital to meet the flight crew 30 miles away.

Upon arrival at the second community hospital, the weather was now an issue, precluding a flight from there as well. The flight crew jumped in the ambulance and transported the patient by ground transport to the Level I Pediatric Trauma Center over two hours away. The timeframe from arrival at the community hospital to transport to the second community hospital to begin the ground transport was 2 hours and 46 minutes.

The patient remained critically ill. She received another liter of crystalloid, 2 more units of blood on the warmer, and a Ketamine drip was started. TXA was also given. The patient remained on the Epinephrine and Norepinephrine drips. The patient remained hypotensive throughout the 2 hour and 20 minute transport to the trauma center. The crew noted that the airway pressures were increasing en route and bilateral needle thoracostomies were performed. There was blood coming from the ETT.

Level I Trauma Center:
The patient arrived at the Level I Pediatric Trauma Center nearly 5 hours and 10 minutes after the injury. The patient arrived with a BP of 68/45 and HR of 74. Her temperature was 84.2 rectally. She remained on the Epinephrine, Norepinephrine, Ketamine, and TXA drips. The massive transfusion protocol was initiated and the FAST exam appeared positive. Mannitol was given after noting that the patient had fixed and dilated pupils. Bilateral chest tubes were also placed with serosanguinous drainage and the patient was transported to the OR for an exploratory laparotomy.

Operating Room
The patient was emergently prepped and the abdomen opened. The abdominal contents protruded immediately upon entering the abdomen and blood pressure improved. The bowel appeared dusky yet viable. There was bleeding noted near the liver, which was packed. The rest of the abdomen was examined, without injury noted, so a damage control closure was initiated. The patient became bradycardic once again and pulseless. CPR was initiated and the bleeding increased from the endotracheal tube. CPR was deemed to be futile and stopped after 15 minutes. The patient was transported out of the operating room to be with family.

Topic Review: Blunt trauma with traumatic arrest complicated by extended transport times.

The decision to stop resuscitation in a pediatric patient with blunt traumatic injury is tremendously difficult, particularly in a small rural community where EMS and hospital medical providers know the patient and family. In this complex case, ROSC was obtained in the community hospital, but not until nearly 60 minutes of CPR. In addition, the effects of the weather significantly extended the transport time to the trauma center. During this time, hypotension and hypothermia further complicated the clinical course.

There is a body of literature relating to blunt traumatic arrest both in adult and pediatric patients with recommendations and outcome predictions. The Western Trauma Association, for example, found no survivors of blunt trauma with >10 minutes of prehospital CPR and penetrating trauma within >15 minutes of prehospital CPR.(1) The patient in this case had >60 minutes of CPR initially, followed by additional rounds en route and at the pediatric trauma center.

Another study by Duron, et al. examined the National Trauma Data Bank to analyze survival of pediatric blunt trauma patients presenting with no signs of life in the field. This group determined that the survival of pediatric blunt trauma patients in the field without signs of life is dismal. In addition, resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate.(2)

Finally, the American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of EMS physicians, and American Academy of Pediatrics Committee on Pediatric Emergency Medicine collaborated on a literature review and created recommendations for out-of-hospital termination of resuscitation.(3)

The two points made were;

"If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility."

"If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis of family-centered care because the evidence suggests that either death or a poor outcome is inevitable."(3)

In this case example, the literature suggests that resuscitation efforts could have ceased at the community hospital, however as mentioned, this is extremely difficult for both the health care team as well as the family.

References:

Adler E. Defining the limits of resuscitative emergency department thoracotomy: A contemporary Western Trauma Association perspective. Journal of Emergency Medicine 2011; 41(2):231-232.

Duron V, Burke RV, Bliss D, et al. Survival of pediatric blunt trauma patients presenting with no signs of life in the field. J Trauma Acute Care Surg 2014; Sep 77(3): 422-6.

American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of EMS Physicians, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014; Apr 133(4):e1104-16.

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