Simulation Debrief 6/6/13 – Challenging paediatric RSI when everything on the right is wrong

SCENARIO – We have been tasked to a helicopter land-on primary at a motorcross event. A 12 year old male has come off their bike at high speed in a location 30 minutes flight from the nearest paediatric major trauma centre. They have been unresponsive and hypoxic on first assessment by the attending road crew.

SCENE – On our team’s arrival the patient has been removed to the back of an ambulance, where a c-spine collar and IV line have been sited and a local medical practitioner has just passed an endotracheal tube.

PATIENT – Child is actually 10 years old and projected to weigh c.35kg. They are making gasping breaths with little chest expansion on the left and absent on the right with some right-sided surgical emphysema. Monitoring when applied shows sO2 of 72% and an absent CO2 trace. GCS 4/15 with a fixed dilated right pupil. Right femur appears swollen.

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CHALLENGES – How to rapidly negotiate control of the airway from the local physician and correct the oesophageal intubation. Safer to remove tube, apply BVM and adjuncts and assist ventilation, then maneuvering stretcher back out of the vehicle whilst paramedic is setting up for RSI and definitive tracheal intubation.

Correcting the rightsided tension initially with dwellcath decompression but on multiple re-tensionings electing to perform open thoracostomy prior to intubation. Rationale of concurrent positive pressure ventilation with BVM.

Tailoring of the intitial planned drug doses to the obtunded patient who progresses to a low perfusion state.

Stabilising the pelvis with adult sling modified. Stabilising the femur with simple figure of eight splinting to expedite departure for the likely time critical neurosurgical injury apparent from the blown pupil.

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LEARNING POINTS FOR CLINICAL PRACTICE FROM DEBRIEF:

Modifications possible to the SAM Sling Pelvic Binder to adapt to the small paediatric patient

Early attention and ownership of the failing airway

Whilst dwellcath insertion for decompression of a tension pneumothorax is likely to be easier in a child the equipment is still liable to occlusion and kinking over time

The higher the skillset of the team with the patient on your arrival the harder it may be to negotiate ownership of the patient’s care from them…but the more useful they are likely to be once this is done! Diplomacy is key as you need as many skilled allies as possible.

The GSA HEMS paeds dosing guide is invaluable for clearing the mind for other time critical decisions….such as how to modify those same starting doses in response to the individual patient and their pathology!

LEARNING POINTS FROM DEBRIEF FOR SIMULATION PURPOSES:

You can never have too much lubricant in a mannequin’s airway

Option of th ‘poor perfusion’ trace for sats and ‘low output’ state for arterial line tracings gives opportunity for more dynamic interactions and interpretation of the iALS monitoring

Thanks to Toby (doc),  Lindsay (para),  Hugh, Nirosha (actors), Brian (SRC), Luke (STAR)

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