1. CASE SIMULATION Debriefing

2. Diagnosis? Altered level of consciousness Respiratory insufficiency Acute subdural hematoma Possible inflicted traumatic brain injury/abuse (+/-) Cardiopulmonary arrest

3. CASE EVALUATION How do you think you did? What did you think you did well? What would you have done differently? How do you think your colleagues did?

4. As you walk into the room what do you see?

5. What needs to be done now! Airway: Is the airway secure? Breathing: Is the patient’s breathing normal? Circulation: Is the patient perfusing well? Disability: What’s the GCS in this patient? Environment/Exposure: How could body temperature change your management? IVs, O2, Monitors, full vitals and blood drawn.

6. Ok, we have a more stable patient, now what? SAMPLE History:  Signs/symptoms  Allergies  Medications  Past medical history  Last Meal  Events Secondary Survey:  Complete physical examination Order remaining labs and tests Talk to consultants if needed

7. Differential for altered mental status in the pediatric population “VITAMINS”  Vascular  Infection  Toxins  Accidents/Abuse  Metabolic  Intussusception  Neoplasms  Seizure

8. Approach to decreased level of consciousness/comatose patient

9. Child abuse/Inflicted traumatic brain injury The leading cause of death by trauma in children less than 2 years of age The recognition of inflicted traumatic brain injury can't be overemphasized. Risks:  D/C home to dangerous environment  Siblings in danger If suspected, contact CPS or activate the resources that do this in your hospital

10. Child abuse/Inflicted traumatic brain injury History:  37% of iTBI have no history of trauma  Evasive and inconsistent history Physical examination  Most common presentation is non-specific.  One study showed that 31% iTBI were seen shortly after the injury and discharged home with alternative diagnosis (e.g. Viral illness)

11. Child abuse/Inflicted traumatic brain injury The triad of Subdural hemorrhage, fractures, and retinal hemorrhages are the classic findings but only present in 30% of patients Skeletal survey at presentation and in 14 days if abuse is suspected Your report/charting: State clearly that presentation is consisted with inflicted injury  Do not try to establish a time line, Do not try to determine intent

12. Pediatric Head Trauma Airway:  Less cardiopulmonary reserve in Peds.  Basic airway maneuvers  Anatomic differences Intubation:  When?  RSI  Atropine  Blunting of intra- cranial pressure rise

13. Pediatric Head Trauma Breathing  Higher baseline respiratory rate in Peds Circulation  Lower BP at baseline for Peds  Blood pressure management Goal is to maintain appropriate cerebral perfusion pressure CPP = SABP - ICP

14. Pediatric Head Trauma Disability  Glasgow  Signs of herniation Cushing reaction Mannitol/Hyperventilation Exposure/Environment  Aggressively treat hyperthermia  Induced hypothermia (+/-)

15. Pediatric Head Trauma Associated with ICI:  Scalp Hematoma  Facial injury  Abnormal neurological exam Poor evidence for < 2 y/o Higher rates (-) sings and symptoms at this age

16. Pediatric Head Trauma CT or 6 hours Obs:  Multiple episodes of vomiting  Brief LOC  History of AMS that is now resolved  High force mechanism  Unwitnessed event

17. Pediatric Head Trauma Disposition if positive ICI  Admission to ICU with neurosurgery consult  Transfer to hospital with appropriate resources if necessary  Contact CPS immediately if iTBI is suspected

18. CASE REVALUATION How do you think you did? What did you think you did well? What would you have done differently? How do you think your colleagues did?