1. Trauma Surgery Shannon Rosati Tori Whitlow Dan Cabral Isiah Brown Brandon Barnes

2. Cases PGY-5 PGY-4 PGY-3 PGY-2 PGY-1 Total 2 17 2 3 1 25

3. Complication Age/Sex: 2/M Attending/Res: Jayaraman/Rosati Diagnosis: self inflicted GSW to head Operation: placement of L EVD and closure of scalp lac (NSG), exploration of maxillary defect with control of hemorrhage with Xeroform bolster and R lateral canthotomy, R neck exploration with ligation R common carotid artery (ENT) Complication: Death Assessments: A- PD (Patient disease) B- V (Death)

4. Case Presentation Pt presented to trauma bay on 5/25 as a DELTA TTA after suffering a self inflicted GSW to the head Entry through the mouth, exit R parietal scalp, where a small exit wound was noted Pt had been intubated in the field prior to arrival Per EMS report, he had a gag reflex present on intubation Was noted to be breathing over the vent in the trauma bay Pupil exam initially was 5mm and non reactive on R, 3mm and reactive to 2 mm on left On arrival, initial VS were significant for HR 160s, systolic BP 30s with copious bleeding from mouth around ET tube

5. Hospital Course Pt received immediate 2 units PRBC and systolic BP improved to 60s Taken to CT for head CT Coags significant for PT 73.7, INR 9.3, PTT >150 Pt’s BP dropped in CT again, so was taken back to trauma bay, received additional 3 units PRBC and 2 units FFP (total 5 PRBC and 2 FFP)  Pediatric massive transfusion protocol initiated 11.0 222 16.4 5.7

11. Hospital Course CT head findings: Gunshot wound trauma to the face and right frontal temporal parietal lobe with extensive intraparenchymal hemorrhage, cerebral edema, and numerous bony and metallic fragments within the right cerebral hemisphere. There is associated subfalcine and transtentorial herniation. No definite tonsillar herniation. CT maxillofacial findings: Entry wound is at the level of the alveolar ridge of the right maxilla which is severely fragmented from the central incisor laterally. Severe comminution of the anterior and posterior lateral walls of the right maxilla including the inferior orbital rim and orbital floor with intraorbital displacement of the orbital floor and lateral orbital wall. There is comminution of the medial wall of the right maxillary sinus as well. The bullet trajectory is then posterior superior through the sphenoid wing into the middle cranial fossa.

12. Hospital Course Pt taken directly from trauma bay to the OR with NSG and ENT, both teams consulted immediately and were present in the trauma bay to assist in control of the hemorrhage NSG performed placement of a L frontal extra ventricular drain and closed the posterior parietal wound ENT performed an exploration of the R maxillary wound with placement of xeroform bolster for hemorrhage control and R lateral canthotomy

13. Hospital Course Post operatively in the PICU, pt began actively hemorrhaging again Level I Head CTA obtained  transection of the R MCA just proximal to the level of expected bifurcation with a bullet fragment immediately adjacent, with increase in leftward midline shift and increase in parenchymal hematoma and subarachnoid blood 4.8 11.9 4.3 18.0

14. Hospital Course Pt taken back to OR by ENT, underwent R neck dissection and ligation of the R common carotid artery

15. Hospital Course Pt post operatively with fixed and dilated pupils, brain death testing initiated, pt found to have no gag reflex, no breathing response over the vent, no response to cold calorics, pt coagulopathic, with multisystem organ failure Pt made a DNR by family, had a V tach episode which progressed to asystole and he passed away at 10:12 on 5/27

16. Cause-and-Effect diagram Medical Knowledge -Knowledge of pediatric massive transfusion and differences in pediatric transfusion requirements Diagnostic ReasoningTherapeutic Choices Clinical assessment Communication -Discussion with ENT and NSG, coordination between trauma, peds surg, peds ED, and PICU Personnel/Materials -availability of blood products Processes Environment Complication -Patient kept in trauma bay for resuscitation rather than PICU -Workup of head trauma- initial choice of CT scans -Evaluation of hemorrhage source Error in technique Error in judgment Error in systems -Release of blood products by PICU and trauma teams -Resuscitation in adult trauma bay vs peds ED vs PICU

17. Pediatric Massive Transfusion Protocol

20. Future QI Have pediatric MTP available in trauma bay, peds ED, peds OR (3&25), PICU Educate nursing staff in ED, OR, and PICU about release of products with MTP Educate residents and staff about MTP and the components for each level, based on weight of pt

21. Aim was to seek a data-driven MT threshold using the largest existing registry of pediatric trauma patients Materials and Methods: The Department of Defense Trauma Registry was queried for pediatric trauma patients (<18yrs) from 2001-2013, with evaluation of MT as a weight based volume of all blood products transfused in the first 24 hrs Results: 4990 combat-injured pediatric trauma patients, of whom 1113 were transfused and constituted the study cohort Divided into MT+ (443) and MT- (670), based on threshold of 40ml/kg blood transfusion MT + pts more likely to be in shock (68% vs 47%), hypothermic (13% vs 3.4%), coagulopathic (45% vs 29.6%) and thrombocytopenic (10.6% vs 5%) on presentation MT + pts had higher ISS, more mechanical ventilator days, longer ICU and overall hospital stays, and was an independently associated with increased 24 hr mortality and in hospital mortality Conclusion: A threshold of 40 ml/kg of all blood products given at any time in the first 24 hrs reliably identifies critically injured children at high risk for early and in-hospital death

22. Hypothesis was that a pediatric MTP would improve outcomes through a balanced blood product resuscitation Materials and Methods: a pediatric MTP with a fixed ratio of RBC:FFP:plts:cryo based on pts’ weight was initiated at a single institution Results: 53 pts enrolled over a 15 month period and compared to 49 pre- MTP pts 72% of MTP pts had at least one coagulation value outside of normal on arrival to the ED Median time to FFP transfusion decreased fourfold after MTP implementation A total of 49% of MTP pts received greater than 70ml/kg blood products and the 24-hr median FFP:RBC transfusion ratio was twofold higher than the pre-MTP cohort No improvement in mortality was observed after MTP initiation Conclusion: A pediatric MTP protocol is feasible and allows for rapid transfusion of balanced blood products to coagulopathic children

26. Aim was to examine a pediatric MTP and identify factors that may prompt initiation, as well as examine M&M Materials and Methods: prospective cohort on all pediatric patients who received un-cross- matched blood from Jan 1, 2009 through Jan 1, 2011 (on peds MTP vs at clinician discretion) Results: 55 patients received un-cross- matched blood (22 pts in MTP group and 33 in non-MTP) Mortality not significantly different b/w two groups (ISS for MTP group 42 vs 25 for non-MTP group) Thromboembolic complications occurred more exclusively in the non-MTP group (p< 0.04) Coagulopathy evidenced by PTT > 36, was associated with the initiation of the MTP Conclusion: Blood transfusion via MTP was associated with fewer thromboembolic events, and with coagulopathy

27. Questions ?