At 18:08 on March 7, 2022, at the entrance of the emergency room of Zhejiang University Children’s Hospital.
A burst of ambulance sirens from far to near – Wu Xiujing, director of the Emergency Department of Zhejiang University Children’s Hospital, has long been accustomed to the siren of ambulances coming and going every day. The news from the command and dispatch center that a 3-year-old girl fell from a 14-story building still cheered her up.
Accident scene, picture source Zhejiang University Children’s Hospital
The time is pulled back to 14:50, and the fire truck arrives at the scene of the accident.
Before the video of the girl falling from a tall building went viral on the Internet, the first fire truck had rushed her to a local hospital, a three-minute drive away. However, critically ill children still need to seek follow-up treatment.
“Quick! Contact a superior hospital for referral!”
Emergency 72 Hours, Hazardous
120 Before the child was delivered, the emergency department of Zhejiang University Children’s Hospital has opened a green channel.
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At the first sight of the emergency department, the child was in a severe coma, pale and unresponsive, and there was a large amount of bloody sputum gushing out of the tracheal intubation. The situation was not optimistic.
During the transfer from the ambulance to the stretcher, our overall ambulance rhythm gradually accelerated.
The emergency team quickly assesses the child’s ABCDE (A-airway, B-breathing, C-circulation, D-disorder of consciousness, E-exposure).
Fore and hind feet, the nursing team opens arterial and deep venous access.
Basic assessment took less than 5 minutes and more than 3 hours had passed since the fall. Minutes to hours after injury is the ‘best time to treat’ for trauma emergencies, and rapid assessment and treatment can reduce mortality and improve outcomes.
So a quick assessment followed by action: address basic vital signs first.
I, together with head nurse Huang Yufen and several medical staff in the emergency department, quickly gave the child an artificial ventilator to assist breathing, and the anesthesiology department replaced the tracheal intubation.
Meanwhile, I had a colleague call the multidisciplinary team. (Multidisciplinary treatment group of Zhejiang University Children’s Hospital: consists of medical department, SICU, trauma surgery, neurosurgery, thoracic surgery, respiratory medicine, general surgery, nursing department, ultrasound department, radiology department, blood transfusion department, etc.)
The second step is anti-shock therapy.
We performed a rapid volume expansion of normal saline, emergency transfusion of red blood cells and plasma, and vasoactive drugs dopamine, epinephrine and norepinephrine to maintain blood pressure and correct coagulation disorders. and internal environment disorders; simultaneous anti-infection and other treatments.
A set of combined punches went down relatively smoothly. At 18:37, the child was transferred to SICU.
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When the child entered the SICU, we immediately put a ventilator at the tracheal tube to assist breathing.
The child has high requirements for the parameters of the ventilator. Blood is oozing continuously in the airway and around the mouth, and the clothes are stained with blood. The physical examination shows that the child’s complexion and lips are as pale as paper, and the limbs are as pale as paper. Cold, mottled skin, acute face, contusion of skin and soft tissue in cranial brain, face, chest, abdomen, limbs, etc., unconsciousness, coma, unresponsive, poor response to pain stimuli, pupillary Slow light reflex, low blood pressure, dull heart sounds, abdominal distension, life-threatening.
Obviously, there is still no relaxation phase.
SICU’s well-trained professional medical team immediately starts the standard process for the treatment of severe trauma, and in accordance with the guidelines for the diagnosis and treatment of trauma-related diseases and technical operation standards, conduct intensive, fast and orderly rescue for the children Treatment:
Active and rapid recovery and maintenance of the child’s vital signs, rapid fluid resuscitation, adjustmentVasoactive drugs, blood transfusion, maintenance of respiratory function, etc., effectively avoided the deterioration of the child’s condition, and urgently called Polygon’s team to participate in the treatment.
Within 10 minutes, the experts of the multidisciplinary collaborative treatment team responded positively, and everyone quickly assembled to the scene to further conduct a detailed physical examination of the child, combined with a quick bedside X-ray , Point-of-care ultrasound FAST (Trauma Focused Ultrasound Assessment) and other results, following CRASHPLAN (C-heart, R-breath, A-abdomen, S-spine, H-head, P-pelvis, L-extremities, A-artery The order of blood vessels, N-nerves), the child underwent a comprehensive injury assessment from head to toe, giving a more detailed judgment:
“Hemorrhagic shock, cerebral contusion, severe contusion of both lungs, massive pulmonary hemorrhage, respiratory failure, pneumomediastinum, pleural peritoneal effusion, liver, spleen, Pancreatic contusion and multiple fractures throughout the body.”
Damage control resuscitation, correction of traumatic coagulopathy, correction of acidosis and hypothermia, massive blood transfusion strategies—these treatments are gradually effective, and a combination of skillful rescue therapy can help children with The condition was initially controlled within 1 hour of the golden hour.
However, the child’s condition is extremely dangerous, and the condition still fluctuates greatly. The SICU team is not afraid of difficulties and makes concerted efforts. After 24 hours of initial rescue, the child’s heart rate and blood pressure gradually stabilized Down, the internal environment disorder is gradually corrected.
But the problem is far from solved.
Because the child had severe pulmonary contusion, poor oxygenation function, and continued decrease in hemoglobin, the critical value alarm of repeated test results appeared.
For this reason, the SICU medical team worked hard for 72 consecutive hours to rescue, repeatedly evaluated and adjusted the ventilator parameters, repeated blood transfusions many times, continuously corrected the coagulation disorder, maintained the balance of fluid intake and output, and the child’s blood pressure. And the cycle function is gradually stabilized.
After that, we stopped dopamine and epinephrine, the hemoglobin increased, and the oxygenation function was not significantly worse than before.
This is where the child has the opportunity to move on to the next stage of treatment: orthopaedic surgery.
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Multiple fractures all over the body, how to do surgery?
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Back in time on March 7th, as a member of the multidisciplinary collaborative therapy team, I participated in the consultation for the first time.
At that time, the child had multiple fractures throughout the body, requiring surgical intervention in many places: fracture of the left proximal humerus metaphysis, comminuted fracture of the left supracondylar of the humerus, fracture of the left olecranon, left Femoral fractures, etc.
But is now the right time for surgery? I don’t think so.
Whether it is the current physical examination, or the vital signs, biochemical and other indicators, they are telling me that the vital signs of the child are extremely unstable.
Therefore, after a detailed assessment of the child’s condition, I suggest that the intensive care unit should first perform life support, organ protection and other treatments, and then perform surgical treatment after the vital signs are stable.
Based on past experience, we choose to perform follow-up treatment about 3 to 5 days after trauma. By then, the child’s condition will be relatively stable, the vital signs will be stable, the swelling of the local fracture site will subside slightly, and the surgical field will be clearer if the operation is arranged.
For this child, our treatment group decided to divide it into multiple stages: first adopt a strategy of damage control surgery to convert open fractures into closed ones; after stabilization of vital signs, further treatment Orthopedic surgery.
In the next 3 days, when the SICU team was struggling to rescue, our team also joined the intensive care unit and the anesthesiology department to conduct another multidisciplinary collaborative treatment group consultation to evaluate the safety of the child’s surgery. Including the risk of anesthesia, whether other organs are suitable for surgical trauma stress, etc.
Especially the fracture of the elbow joint involves high-energy injury. Combined with the preoperative imaging data, it suggests a supracondylar comminuted fracture of the humerus, accompanied by open soft tissue on the medial side of the elbow joint. Injury, so conventional closed reduction and Kirschner wire fixation of supracondylar fractures of the humerus may have great difficulties.
Preoperative imaging data, sourced from Zhejiang University Children’s Hospital
I made a preliminary idea for the operation: Considering that the child has multiple fractures, some of which are obviously wrong, and the left humerus has fractures up and down, and the elbow joint has multiple fractures. Therefore, after repeated discussions in the department, the decision was made to “first easy and then difficult” – this is conducive to the good progress of the operation, and it is also conducive to the doctor’s confidence in the expectations of the operation.
In order to well meet the expectations of the operation, our trauma team has conducted an assessment of possible difficulties and detailed preoperative preparations, including preoperative discussion, possible intraoperative predictions such as fracture closure Failure, the fracture is severely comminuted and the internal fixation is not reliable, and multiple open reductions may cause a certain amount of bleeding. Therefore, we prepared various fixation devices including Kirschner wires, intramedullary needles, and external fixation before surgery, and contacted the blood bank to prepare two units of red blood cells.
Before the operation, we considered that if the reduction fails, we will re-enter the original open wound to assist in reduction treatment.
March 9, surgery day at 13:00, 3rd of the day.
After anesthesia, we first closed reduction of the left proximal humerus fracture, then fixed with three Kirschner wires, and then performed reduction of the left supracondylar comminuted fracture. Immediately thereafter, we attempted two closed reductions as originally planned, but both failed. Subsequently, we abandoned this method.
Children with preoperative supracondylar comminuted fracture of humerus with open injury have poor conditions for closed reduction of local fractures. In order to reduce the impact of repeated closed reduction attempts on the soft tissue of the local elbow joint and possible increased difficulty of open reduction, we performed open reduction.
Our guess was confirmed during the operation: the local elbow joint was severely injured, and the ulnar nerve was partially swollen and compressed, which was not conducive to closed reduction.
In the original open wound approach, we performed assisted reduction of supracondylar fractures of the humerus and then Kirschner wire fixation. The intraoperative C-arm machine confirmed the good effect of reduction. At the same time, the release of the ulnar nerve was also done to improve the recovery environment of the ulnar nerve.
After the successful operation of the supracondylar fracture of the humerus, we performed Kirschner wire fixation of the olecranon and elastic intramedullary fixation of the left femur fracture again according to the preoperative design.
Luckily, because both surgeries were pre-operatively predicted, the process went smoothly.
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Recurrent high fever after surgery, severe ARDS
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The surgery was generally smooth, but after a major surgery that lasted a full 5 hours, the child’s condition worsened again.
On the second day after the operation, the child developed high fever, large exudation and consolidation of both lungs, and the oxygenation function could not be maintained under the high support parameters of the artificial ventilator. Inhaled oxygen The concentration has increased to 100%, at which point the child’s airway pressure is already high.
Chest CT showed unevenly increased transparency in both lungs, diffusely distributed fuzzy patchy shadows, scattered multiple nodular high-density shadows, and multiple gas in the mediastinum and bilateral thoracic cavities A large amount of gas shadows can be seen in the maxillofacial region, bilateral neck and chest subcutaneous, and soft tissue spaces – it has progressed to severe ARDS (Acute Respiratory Distress Syndrome), and the PaO2/FiO2 ratio is as low as 70, and the child’s life is again seriously threatened .
Children’s postoperative CT image data, sourced from Zhejiang University Children’s Hospital
Deputy Director Hu Lei and I re-discussed the details of the current condition.
First of all, because the child has pneumothorax and mediastinal emphysema, it is necessary to exclude the possibility of bronchial rupture caused by trauma, and lung infection also aggravates the degree of lung disease.
Therefore, we urgently performed fiberoptic bronchoscopy, and there was no obvious abnormality or rupture of bronchial morphology.
After identifying the etiology and pathophysiological changes, the entire SICU team once again optimized a more precise treatment plan, performed sedation and analgesia, implemented prone ventilation, promoted lung recruitment, and optimized the ventilator. Support parameters, strengthen anti-infection and nutritional support, reduce phlegm and pulmonary physiotherapy, etc.
While observing the curative effect, actively take countermeasures. Once the above treatment plan is not effective, immediately adjust to the next treatment plan. In fact, we are always ready to initiate high-frequency oscillatory ventilation (HFOV) or even extracorporeal membrane oxygenation (ECMO) therapy.
Shown as ECMO machine, not relevant to this case
Image source: Figure Worm Creative
In addition to medical support, our team’s head nurse Sheng Meijun leads the SICU care team to develop individualized care for the child.
We all know that prone position ventilation is an effective treatment for severe ARDS, but airway management during prone position ventilation is difficult and risky, which poses greater challenges to clinical nursing work. Challenges: On the one hand, the airway management is inconvenient due to body position, and the tracheal intubation is easily broken and twisted or even accidentally detached, resulting in suffocation. On the other hand, due to gravity drainage in the prone position, oral and airway secretions will also increase significantly .
Considering that the patient’s awareness, cooperation level, facial skin, teeth and occlusion need to be considered when mechanical ventilation in the prone position is used, we use two 3M elastic waterproof tapes to cross the method., perform tracheal intubation fixation, and check the intubation depth every 8 hours.
At the same time, the nursing team performed oral care on the child 3 times a day, one fixed the tracheal intubation to avoid accidental detachment, the other cleaned the mouth with Kotex, and replaced the tracheal intubation. Fix the tape.
Children in intensive care unit, picture source Zhejiang University Children’s Hospital
After another thrilling 48-hour continuous rescue, the child’s severe respiratory distress and oxygenation were significantly improved, and the PaO2/FiO2 ratio gradually increased to 240. Repeat chest CT showed pneumothorax and mediastinum. The emphysema was no longer obvious, and the pneumatosis in the soft tissues of the bilateral neck and chest was obviously absorbed and improved compared with the previous one.
Everyone’s hanging hearts finally let go a little bit.
After the event, we used the Children’s Behavioral Pain Assessment Scale (FLACC) and the Comfort Behavior Scale (Comfort-B) to evaluate the patient’s analgesia and sedation, regularly wake up every day, and observe the patient’s respiratory function , the recovery of airway self-protection ability, and evaluate the possibility of weaning from the ventilator, so as to shorten the mechanical ventilation time as much as possible and reduce the occurrence of ventilator-associated pneumonia.
On postoperative day 11, the patient was successfully weaned from the ventilator and switched to mask oxygen.
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First aid, not just “rescue”
Looking back at the entire rescue relay, multidisciplinary diagnosis and treatment played an important role.
Vice President Gao Zhiqiang said that Zhejiang University Children’s Hospital not only has children’s compound trauma MDT, but also has a children’s critical and critical care center and a critical and critical transfer center. The construction of an integrated emergency rescue system for children’s health through land and air connections will escort the health of more children and benefit more families.”
Vice President of Zhejiang University Children’s Hospital Gao Zhigang, SICU Director Tan Linhua, and Deputy Director of Trauma Surgery Zhao Guoqiang came to the ward before the girl was discharged from the hospital (Photo source: Zhejiang University Children’s Hospital)
On March 31, 24 days after admission, the child was ready to be discharged.
When asked if the child could walk normally in the future, Director Zhao Guoqiang said: “At present, the child has not recovered to the level of walking on the ground, so it is difficult to say to what extent the bone function has recovered. , but judging from the nerve response of the hands and feet, the situation is still relatively good, I hope the child can gradually recover through rehabilitation treatment.”
What is certain in this case is that, for trauma first aid (especially childhood trauma first aid), “concerning The patient and the disease as an organic whole are “important in determining the order of priority treatment”.
A complete diagnosis and treatment not only includes the stabilization of vital signs, but also the recovery of behavioral function, cognitive level, and normal life ability. Communication with patients, and thinking about the humanistic care of doctors.
Revived does not mean cured.
Subsequently, the child continued to undergo hyperbaric oxygen chamber and other treatments in the rehabilitation facility.
On May 13, Lilac Garden received news from Director Zhao Guoqiang of trauma surgery that the child’s condition in the rehabilitation hospital has improved a lot. “I went to check on the child’s recovery after the operation, and found that the bones are recovering well. The child has been able to communicate with people, and will call my uncle to thank me. The recovery is worth looking forward to.”
Special thanks: Children’s Hospital Affiliated to Zhejiang University School of Medicine
Image source: provided by Zhejiang University Children’s Hospital
Poster image source: Visual China
Organization of information: Lingard
Planning and writing: carollero
Producer: gyouza