If you are critically injured as a child in Victoria, Australia, the chances are that you will end up at the Royal Children’s Hospital in Melbourne. Every year, they see approximately 320 severely injured children from all over Victoria. 177 of these are brought in by helicopter. #RCHTrauma2017 was a joint educational evening put on by the trauma service and the great team from Air Ambulance Victoria. As well as a capacity crowd across two lecture theatres, it was live-streamed to 64 sites across Victoria and Tasmania.
Utilising a case-based format, the MICA (Mobile Intensive Care Ambulance) paramedics ran through a series of challenging cases.
Case 1
Ben Meadley went through some of the challenges of extrication in rural Victoria. Winch rescues are some of the most dangerous performed by paramedics (and doctors). When advanced airway management is required, there can be a trade-off between intubating a critically unwell child in a precarious position with minimal staff and a short winch to a staging area with 360° access and more staff.
Ben was followed by clinical neuropsychologist Debbie Houston, talking about the rarely mentioned sequelae of a traumatic brain injury. She spoke about the importance of cognitive rest in a low stimulus environment early in the recovery period – low light, low sound and minimal visitors. The RCH is a great resource for parents and healthcare providers alike. She reminded us that the road to recovery is a long one that is only started in the hospital. The harder work takes place later as the family and child come to terms with challenges in many cognitive domains, including:-
- Attention and concentration
- Flexible thinking
- Impulsive and inappropriate behaviour
- Problem-solving skills
- Memory and learning
Case 2
Next, Matt Shepherd presented a case of post-drowning cardiac arrest and some of the challenges experienced in the field. Even the most experienced amongst us can have challenges in obtaining intravenous access in the warm, brightly lit trauma bay. Ambulance Victoria Clinical Practice Guidelines allow MICA paramedics 90 seconds to obtain IV access before taking the intraosseous route. Unfortunately, this route can still fail despite training. We can all have bad days, and it is incumbent on all of us to be aware of our limitations. If we are having a bad day when every cannula fails, it is important not to let pride or ego take over and allow somebody else to have a go. Just ensure you have not already tried both hands, both cubital fossae and IO’s in both legs first. You need to give others a fighting chance. MICA paramedics have recently introduced ultrasound into their skill set, initially for eFAST and now, with the introduction of a linear probe, vascular access.
Trauma fellow Keith Amarakone then reminded the audience of the global, as well as the local, impact of drowning. Despite many public health appeals, there were 43 drowning deaths in Victoria last year. The basic tenets of resuscitation emphasize ventilation, but we can have just as big an impact if we focus on prevention and awareness. Instead of public pools, most of the non-fatal drownings I have been involved with have been unsupervised toddlers in the bath.
Case 3
AAV poster boy Darren Hodges presented the final challenging case. He discussed the medical details behind this case…
This case involved the first paediatric prehospital finger thoracostomy in Victoria, coupled with a prehospital blood transfusion. Even with these life-saving measures, he still showed significant signs of shock when he arrived at RCH.
Warwick Teague, the Director of Trauma, took over the microphone to discuss Jordan’s in-hospital course. The main focus of his talk was that non-operative management is the mainstay of paediatric truncal trauma and the Royal Childrens experience. Despite a high incidence of severe chest injuries, less than 2% of severe thoracic injuries (with an AIS of 3 or more) required a thoracotomy, and only 15% needed the insertion of an intercostal drain.
He also showed the latest RCH data regarding the management of solid organ injuries. Over a 10-year period, they have had a 100% splenic preservation rate (n=185). Only five laparotomies for liver lacerations (n=172) occurred in that period, and there have been just three angio-embolisations (n=499).
With so many patients arriving by helicopter, how do the paramedics deal with parents requesting to fly with their seriously injured child? Toby St Clair reinforced that it might not be in the patient or parents best interest. Even the AW-139 is not fitted out as an Uber of the sky and space in the back is limited. The seriously ill child might deteriorate in transit and require further intervention. We know that parental presence can be beneficial in resuscitation so this often causes a degree of moral distress for all involved.
The evening ended with Kat Baulch, a senior emergency social worker, discussing the response to trauma and dealing with distressed families. She highlighted the importance of performing psychological first aid.
- Promote safety
- Promote calm
- Promote connectedness
- Promote self-efficacy
- Promote hope
If you want to read more about this, then read this guide from the Australian Red Cross.
For some more great #FOAMed resources on paediatric trauma check out the following links:-
Emergency Medicine Cases: Anton Helman chats with Dr Sue Beno and Dr Faud Alnaj about all things trauma related.
Pediatric Emergency Playbook: In this two part series, Tim Horeczko talks about massive transfusion and more besides.
