Page 726 - ACCCN's Critical Care Nursing

Paediatric Considerations in Critical Care 703

Case study
Lisa is an eight-year-old girl who was travelling home by car with ventilation para meters, dropping maintenance fluids to half daily
her family at around lunchtime on a Sunday. The car was involved requirements, commencing morphine and midazolam infusions
in a two vehicle high-speed head-on collision at 1:30 pm. Car occu- after ceasing fentanyl and propofol, and commencing transfusion,
pants were Lisa’s uncle (driver), mother (front passenger) Lisa (rear Lisa was transferred by air ambulance to a specialist children’s
driver-side seat) and 10 year old brother (rear passenger side seat). hospital. Lisa’s mother was cleared for discharge, as she had sus-
All passengers were wearing seat belts. The driver was pronounced tained only soft tissue injuries and accompanied Lisa. Lisa’s brother
dead at the scene. required admission to the paediatric ward, with his grandparents
staying with him. The duration of Lisa’s flight was approximately
On arrival in the Emergency Department (ED) of a coastal regional
hospital (located approximately 550 km from the nearest specialist one hour; total time in retrieval almost three hours. Lisa remained
children’s hospitals), the mother was conscious with no obvious stable throughout her retrieval. Her observations on arrival into
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injuries and the brother had a fractured femur. Lisa had been the PICU were: ABG pH 7.33, PaCO 2 38, PaO 2 225, HCO 3 19.8,
combative in the ambulance in transit, with a decreasing level of BE-5.6, FiO 2 0.48; HR 125, BP 123/54 (MAP 75), SpO 2 100%, T 38.1°C,
consciousness (GCS score dropping to 4), pupils mid-size and BGL 4.0, pupils 3 mm bilaterally and reactive to light; ventilator
non-reactive, possible right-sided focal seizure activity observed respiratory rate 12/min. Lisa was transferred to the operating
in the right arm and hand, a fractured right shaft of femur theatre for placement of two extra ventricular drains (EVD) and
with bruising developing over the right thorax. She was hand- Thomas splint to her right leg. Later that day, she was taken for
ventilated in 100% oxygen by an ambulance officer, with SpO 2 head, spine and abdominal MRIs. Lisa had an inter-spinous liga-
monitor reading 100%. mentous injury at C1–C2 with no cord involvement, but spinal
precautions remained in place.
Lisa was estimated to weigh 30 kg and had a large bore cannula
placed in each antecubetal fossa, was intubated, placed on While in PICU, Lisa’s ICP demonstrated a pattern of slowly increas-
the ventilator, had an orogastric tube inserted, and received two ing pressure at times, rather than sudden sharp spikes. Her cerebral
10 mL/kg intravenous fluid boluses to maintain a mean blood pres- perfusion pressure was rarely compromised at these times. ICP was
sure ≥50 mmHg. Lisa was then given a loading dose of intravenous effectively managed with muscle relaxants, increased sedation,
phenytoin, and a FAST sonography performed to identify intraperi- and infrequent 3% sodium chloride boluses. Temperature control
toneal haemorrhage or pericardial tamponade (result negative). of normothermia was the agreed endpoint for Lisa, with occasional
Once considered to be haemodynamically stable, Lisa was trans- mild rises in temperature (up to 38°C) managed successfully with
ferred for urgent head, neck and chest CT scans. On return to ED, antipyretic therapy.
Lisa had an indwelling catheter (IDC) and a radial arterial line Neurologically, Lisa began responding to painful stimulus prior to
placed. The specialist paediatric retrieval service was then con- retrieval, with pupils becoming equal in size and reacting, thought
tacted to request an urgent transfer to a paediatric trauma centre. to be non-reactive associated with initial seizures on presentation.
ED staff were able to obtain advice from a paediatric surgeon, a Seizures were never observed again, with phenytoin weaned off
paediatric intensivist, and a retrieval consultant via teleconferenc- prior to discharge from hospital. EVD placement facilitated CSF
ing. Advice given was to passively cool Lisa, maintain full spinal drainage, with drains elevated to 5 cm and kept open initially
precautions and provide analgesia. Fentanyl infusion was com- (draining blood-stained CSF for initial 48 hours) with the drain
menced. Lisa had been given stat doses of fentanyl and propofol gradually elevated and then closed, and able to be removed on day
for analgesia and sedation for imaging. 10 post-injury. During her daily sedation and muscle relaxant ‘vaca-
tions’, Lisa’s neurological status was assessed and over the initial
CT scans of Lisa’s head and chest and plain trauma series of limbs,
chest and spine X-rays reveal the following injuries: days in PICU showed responses to pain, then to voice and finally
l diffuse cerebral contusions in frontal, parietal and occipital commands prior to PICU discharge on day 11 post-injury. She had
lobes bilaterally a significant tremor of her right hand.
l diffuse ventricular blood Ventilation was anticipated to be difficult, as Lisa had right-sided
l multiple small bilateral lung contusions of all lobes, nil rib lung contusions. However her ventilation was unremarkable,
fractures though endotracheal secretions remained blood-tinged for some
l comminuted fracture of mid shaft of right femur. days. Lisa was successfully extubated on day 9 post-injury.
A paediatric neurosurgeon reviewed the emailed CT scans. The Lisa’s parents had been separated for some years with shared par-
agreed plan of care while awaiting retrieval to a children’s hospital enting of both children, enjoying an amicable and cooperative
was to transfer Lisa to ICU, maintain full spinal precautions, main- relationship. During a highly stressful time (ICU admission, death
tain serum sodium at 145–150 mmol/L with 3% sodium chloride of Lisa’s uncle), each parent allowed the other time alone with Lisa
(initial serum sodium was 136 mmol/L). The ED team asked whether as well as spending time together. Parents are generally not con-
they should use muscle relaxant agents, but were advised against sidered visitors in PICUs, and Lisa’s parents were able to spend as
this as Lisa’s ICP was not yet able to be monitored. An arterial blood much time at her bedside as they wished. Once Lisa’s brother was
gas, full blood count and electrolytes were performed on admis- discharged from hospital, he was able to rejoin his family at the
sion to adult ICU, revealing dropping haemo globin to 78, sodium paediatric hospital. The multidisciplinary PICU team provided
135, potassium of 4, blood glucose level (BGL) of 5. support for the family during their stay.
Due to bad weather, the retrieval team arrived approximately Lisa was transferred to the ward on day 11, with her management
nine hours after the accident. After reducing the taken over by the brain-injury rehabilitation team. She was fed via