Pediatric Trauma - Hennepin County Medical Center

Dear Readers:
Pediatric trauma is a double whammy. First, the child goes through the experience of
the accident – pain, fear, strange people and places, and frantic parents all playing
major roles. Later, when the child becomes an adult, the memory of the event remains
clear, continuing as one of the defining experiences of their life. My nephew Beau was
11 when he had an ATV accident and was flown to Hennepin County Medical Center
(HCMC) from a small farming community. At 26 years old, he is still talking about it.
The same is true for the medical personnel who take care of seriously injured children.
Dr. David Plummer, an emergency department physician at HCMC for the past 27
years, made an emergency flight to Dawson, Minnesota, in 1984 that saved the life of
22-month-old Nikki Stanley. She was playing in a school lunchroom when a 300 pound
cafeteria table fell on her, leaving her with a serious head injury.
Dr. Plummer says, “Dr. Gerbig at Johnson Memorial Hospital described a child with a
serious head injury who needed immediate life-saving treatment and who required
specialized medical care during transfer to HCMC. For that reason, I agreed to fly to
Dawson to help.“
When he arrived at Johnson Memorial, she was still unconscious. Nikki was intubated
and received medication to reduce the intracranial pressure from her head injury.
Unfortunately, Nikki went into cardiac arrest. He pupils were fixed and dilated, and she
didnʼt have a pulse. Cardiopulmonary resuscitation and advanced cardiac life support
was immediately performed, and her heart started again.
“I hadnʼt been conscious of any nervousness while taking care of this child, but
somewhere in the back of my mind I was aware this was one of those cases I would
never forget.” After Dr. Plummer and Nikki arrived at HCMC and his role was essentially
over, Dr. Plummer walked away and wept. “I knew Iʼd never forget it.”
The case studies in this issue can only tell a fraction of each familyʼs story, as we
primarily address the medical problems caused by abdominal trauma, pelvic injuries
and chest trauma. In addition, we present a number of other interesting articles related
to the delivery of pediatric critical care, including a short history of pediatrics at HCMC,
the FASTR-HUG method of ICU care and a hopeful article about how one familyʼs
tragedy led to legislation that would save childrenʼs lives.
The theme for our next issue will be Immigrant Health. If you have an interesting case
study you would like to contribute, see the authorʼs guidelines on the Approaches in
Clinic Care website at www.hcmc.approaches. Weʼd love to hear from you.
Sincerely,
Michelle H. Biros, MD, MS
Approaches in Critical Care Editor-in-Chief
Department of Emergency Medicine
Hennepin County Medical Center
®
Every Life Matters

Contents Volume 6 | Approaches in Critical Care | June 2011
Approaches in Critical Care
Editor-in-Chief
Michelle Biros, MD, MS
Managing Editor
Mary Bensman
Graphic Designer
Karen Olson
Public Relations Director
Tom Hayes
Patient Care Director,
Critical Care
Kendall Hicks, RN
Patient Care Director,
Emergency Services
Kelly Spratt
Printer
Sexton Printing
Photographers
Raoul Benavides
HCMC History Museum
Karen Olson
Clinical Reviewers
Andrew Kiragu, MD
Events Calendar Editor
Susan Altmann
Case Reports
2 Unstable Pelvic Fracture Management: a Challenge in Pediatric Patients
Benjamin Orozco, MD
5 Pediatric Abdominal Trauma After an ATV Rollover
Marc Osbourne, MD and Chad Richardson, MD
8 Severe Blunt Chest Trauma in a Pediatric Patient
Richard Chang, MD and Michelle Biros, MD
10 Critical Care Profile
Andrew Kiragu, MD, medical director of Hennepin’s pediatric intensive
care unit and co-medical director of Hennepin’s pediatric traumatic brain
injury unit
12 Technology in Critical Care
Radiation Risks from Computed Tomography
Gopal Pujabi, MD
16 RN Perspectives
Give Your Patients a FAST-R HUG
Shayna Hamiel, RN, BSN, CCPN, CCRN
18 Historical Perspectives
History of Pediatrics at Hennepin County Medical Center
Sherri Murphy, RN
22 Calendar of Events
23 News Notes
To submit an article
Contact the managing editor at approaches@hcmed.org. The editors reserve the right to reject the
editorial or scientific materials for publication in Approaches in Critical Care. The views expressed in
this journal do not necessarily represent those of Hennepin County Medical Center, or its staff members.
Copyright
Copyright 2011, Hennepin County Medical Center. Approaches in Critical Care is published twice per
year by Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
Subscriptions
To subscribe, send an email to approaches@hcmed.org with your name and full mailing address.
Approaches in Critical Care | June 2011 | 1

Case Reports
Pediatric Trauma: Three Case Reports
Trauma is the most common cause of
mortality and morbidity in the US pediatric
population. Caring for the injured child
requires special knowledge, precise
management, and scrupulous attention to
details. All clinicians who are responsible
for the care of a pediatric trauma patient,
including pediatricians, emergency
clinicians, pediatric emergency clinicians,
and trauma surgeons, must be familiar with
every tenet of modern trauma care. The
special considerations, characteristics, and
unique needs of injured children must also
be recognized.
In 1962, Peter Kottmeier established the
first pediatric trauma unit at the Kings
County Hospital Center in Brooklyn. In
1976, the publication of Resources for
Optimal Care of the Injured Patient by the
American College of Surgeons established
requirements that should be met by a
dedicated pediatric trauma center. Since
1985, the National Pediatric Trauma
Registry (NPTR) has collected data
concerning pediatric accidents. According
to the American College of Surgeons, 81
accredited pediatric trauma programs are
currently in the United States.
In fall 2010, Hennepin was verified as a
Level 1 Pediatric Trauma Center by the
American College of Surgeons (ACS). This
verification-the highest possible-recognizes
Hennepinʼs distinctive expertise in caring
for critically ill and injured children.
Unstable pelvic fracture
management: a challenge in
pediatric patients
by Benjamin Orozco, MD
Department of Emergency Medicine
Hennepin County Medical Center
Case presentation
LJ is a 13-year-old male backseat
passenger involved in a high-speed motor
vehicle collision on city streets against a
telephone pole and stone wall. There was
significant vehicular intrusion and four
additional victims, with one on-scene
fatality. Emergency Medical Services
(EMS) arrived to find him pinned beneath
the driverʼs seat, unconscious. He awoke
during his two-hour extrication and
intravenous (IV) access was established
and normal saline started. He arrived at
Hennepin County Medical Center
immobilized on a back board and in a
cervical collar. His initial vitals were: BP
126/55, HR 135, RR 26 and Sp02 100%
on supplemental oxygen.
Emergency Department course
Upon arrival to the emergency department,
the patient remained alert but confused. He
was tachycardic. Additional IV access was
obtained, fluids were continued, and
trauma surgery and orthopedic surgery
were notified of his arrival. His exam was
remarkable for crepitance over the clavicle,
lower abdominal tenderness, pelvic
tenderness and ecchymosis, a deformity of
the right wrist, and a large laceration
overlying his left knee (distal pulses were
present). He was given fentanyl for pain
control and was less alert but still
protecting his airway. The extended
Focused Assessment with Sonography for
Trauma (eFAST) examination was
negative, and he was rolled from the back
board. Initial trauma radiography was
performed. His chest X-ray demonstrated a
pulmonary contusion and his pelvis X-ray
showed a diastasis of the symphysis pubis,
right pubic rami fractures, a left sacral alar
fracture with vertical displacement and a
left acetabular fracture (Figure One). X-rays
of his affected extremities revealed a right
wrist fracture and bilateral ankle fractures.
He was transferred to the computed
tomography (CT ) scanner for scans of his
head, cervical spines, chest, abdomen and
pelvis. He was somnolent but able to be
aroused with stimulation. His heart rate
was now 101, BP 111/101 and Sp02 100%.
He was transiently hypotensive while in
radiology and received an additional 500ml
bolus of normal saline. After his imaging
2 | Approaches in Critical Care | June 2011

Case Reports
transferred to the floor on hospital day nine. He was
evaluated with neuropsychological testing, which
revealed mild cognitive deficits. Given his cognitive
and physical deficits, our patient worked heavily with
physical and occupational therapy and was able to
be discharged to home on hospital day 17. He was
followed closely with outpatient therapies. Upon
follow-up in the traumatic brain injury clinic and
orthopedic clinic, he is now walking and attending
school normally.
Figure One. The plain film of the patientʼs pelvis, demonstrating a left
acetabular fracture, left sacral ala fracture, right pubic bone fractures with
pubic symphysis diastasis.
was reviewed, neurosurgery was consulted regarding
scattered areas of subarachnoid hemorrhage (SAH)
and punctate areas of intraparenchymal hemorrhage
(IPH). In addition, active extravasation of contrast,
indicating active hemorrhage, was noted from the
pelvic fracture into the retroperotineal space. At that
time, the orthopedic consultant placed a pelvic wrap
and the patient underwent procedural sedation and
femoral traction pin placement for further reduction of
the vertical shear component of his pelvic injury. His
extremity fractures were then splinted. Prior to
transfer from the stabilization room, known injuries
included the punctate areas of SAH and IPH, right
pulmonary contusion, left acetabular fracture, left
sacral ala fracture, right pubic bone fractures with
pubic symphysis diastasis, and a retroperotineal
hematoma. In addition, he had a right wrist fracture
and bilateral ankle fractures.
Hospital course
Our patient was transferred to the pediatric intensive
care unit (PICU) with a GCS 14, heart rate of 100
and normotensive, in the care of trauma surgery and
pediatrics, with neurosurgery and orthopedics in
consultation. He received two units of blood and FFP
overnight. He had a transient elevation of his hepatic
enzymes and cardiac markers. Repeat head CT
revealed a stable SAH and IPH and neurosurgery
opted for non-operative management. On hospital day
one, he was taken to the operating room with
orthopedics for open reduction and internal fixation
(ORIF) of his left acetabular fracture and sacroiliac
diastasis to stabilize his pelvic ring. A mandible
fracture was discovered upon re-institution of a solid
diet and he underwent ORIF on hospital day seven.
The other fractures were managed with closed
reduction alone. He improved steadily and was
Management of the pediatric poly-trauma patient
with an unstable pelvic fracture
Team-directed care is crucial in prioritizing the life and
limb threatening injuries in the poly-trauma patient.
Pelvic fractures are high-energy mechanism injuries
associated with significant morbidity; 60% are
associated with multi-organ system injury. Pediatric
pelvic fractures carry a mortality of approximately
3-6%. The management of pelvic fractures can
involve a combination of non-operative, operative, or
interventional radiological techniques. Our patient
was faced with injuries of nearly every organ system;
however, his pelvic fractures were responsible for
significant active hemorrhage upon presentation, and
he required blood transfusion during the night of
presentation, due to this ongoing blood loss. Our
patient illustrates the effectiveness of multidisciplinary
care in the multiple-injured pediatric trauma patient,
with an emphasis on the hemodynamically significant
pelvic fracture. His pelvis X-ray demonstrated diastasis
at the sacroiliac joint with vertical displacement,
suggesting the potential for massive hemorrhage.
Pediatric pelvic fracture management differs from
adults in that pediatric patients may have a skeletally
immature or mature pelvis. The skeletally immature
pelvis is open at the triradiate cartilage within the
acetabula, and the mature pelvis is closed with total
ossification of the triradiate cartilage. Fractures of the
immature pelvis are more often isolated iliac wing or
pubic rami fractures. Management of patients with
fractures of the immature pelvis is generally directed
at associated injuries. The mature pelvis, more
similar to adults, has a greater propensity for
acetabular fractures and sacroiliac or pubic symphysis
diastasis necessitating emergent management.
The initial management of a pelvic fracture includes
assessment for an open fracture with external
inspection, vaginal, and rectal examination. Broad
spectrum antibiotics should be given for open
fractures. Urethral injury must be considered and
when suspected, a retrograde urethrogram should be
performed prior to bladder catheterization. Pelvic
stabilization to control hemorrhage is paramount.
Approaches in Critical Care | June 2011 | 3

Case Reports
Multiple classification systems for pelvic fractures
exist, however most crucial is differentiating a stable
vs. unstable pelvic fracture. Stable pelvis fractures
include isolated iliac wing fractures and isolated
fractures of the anterior pelvic ring, such as pubic
rami fractures. Unstable fractures are those that
involve the anterior and/or posterior sacroiliac
ligaments of either or both sacroiliac joints, or vertical
sacral fractures, and may result in pubic symphysis
or sacroiliac diastasis. Significant hemorrhage
generally is seen with unstable fractures and arises
from the venous plexus immediately anterior to the
sacrum, from cancellous bone edges, and from
branches of the internal iliac artery. Measures to
tamponade this hemorrhage include minimizing
pelvic movement, pelvic wrapping, external fixation,
internal packing, angiography with embolization, and
possibly aortic balloon occlusion.
Pelvic wrapping is most effective when there is
sacroiliac or pubic symphysis diastasis without
significant vertical displacement or acetabular fractures.
Commercial pelvic binders may be utilized or a sheet
wrapped low across the pelvis compressing the
greater trochanters of the femur inward (Figure Two).
Wrapping is particularly useful for pre-hospital and
emergency providers and should be applied when
pelvic fracture is suspected. External fixation is best
applied by a skilled orthopedist in cases of significant
hemorrhage; vertical displacement or iliac wing
fractures decrease its effectiveness. Internal packing
of the pelvis and retroperitoneum with surgical
sponges is most often utilized when the patient has
concomitant hemoperitoneum or other indication for
open abdominal surgery and can be done in
conjunction with pelvic wrapping or external fixation.
Angiography with embolization is indicated in patients
with hemodynamically significant bleeding refractory
to more conservative measures and is most effective
when arterial bleeding can be identified. At times
angiography may be prioritized despite hemoperitoneum
or other active bleeding. Aortic balloon occlusion for
pelvic fractures, recently described in adults, is a
method of occluding the abdominal aorta with an
intraluminal balloon as temporizing measure in the
patient dying of hemorrhagic shock and may pose a
future role in pediatric patients.
Our patient had injuries of nearly every organ system,
but his shock was due to ongoing bleeding from a
pelvic fracture. Interventional radiology reviewed the
pelvic CT in the event that the patient should become
unstable and need angiography. In this setting,
despite an acetabula fracture, orthopedics felt the
patient would benefit from external wrapping with
reduction of the vertical displacement of the posterior
pelvis via femoral traction pin under emergency
department procedural sedation. The pediatric team
and trauma surgery managed the continuing
hemodynamic stabilization of the patient while he
was in the PICU pending the operative stabilization
of the pelvis. After a repeat head CT and serial
neurologic examination confirmed stability of his
intracranial hemorrhages, and after receiving a blood
transfusion, he was taken for ORIF of his pelvis on
hospital day one, within 24 hours of presentation. ■
Figure Two. Application of a commercially available pelvic wrap .
References
Hauschild O, Strohm PC, Culemann U, Pohlemann T, Suedkamp
NP, Koestler W, Schmal H. Mortality in patients with pelvic
fractures: results from the German pelvic injury register. J Trauma.
2008 Feb;64(2):449-55.
Junkins EP, Furnival RA, Bolte RG. The clinical presentation of
pediatric pelvic fractures. Pediatr Emerg Care. 2001 Feb;17(1):15-8.
Leonard M, Ibrahim M, McKenna P, Boran S, McCormack D.
Paediatric pelvic ring fractures and associated injuries. Injury. 2010
Aug 23.
Martinelli T, Thony F, Declety P, Sengel C, Broux C, Tonetti J, et al.
Intra-Aortic Balloon Occlusion to Salvage Patients With Life-
Threatening Hemorrhagic Shocks From Pelvic Fractures. J
Trauma. Feb 18 2010.
Silber JS, Flynn JM. Changing patterns of pediatric pelvic fractures
with skeletal maturation: implications for classification and
management. J Pediatr Orthop. 2002 Jan-Feb;22(1):22-6
Silber JS, Flynn JM, Koffler KM, Dormans JP, Drummond DS.
Analysis of the cause, classification, and associated injuries of
166 consecutive pediatric pelvic fractures. J Pediatr Orthop. 2001
Jul-Aug;21(4):446-50
Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a
marker for injury severity. Am Surg. 2006 Jun;72(6):481-4.
4 | Approaches in Critical Care | June 2011

Case Reports
Pediatric abdominal trauma after an
ATV rollover
by Marc Osbourne, MD
Chad Richardson, MD
Department of Surgery
Hennepin County Medical Center
Case report
A 10-year-old boy taken to a local hospital after an
all-terrain vehicle (ATV) rollover crash was transferred
to Hennepin County Medical Center (HCMC) by
helicopter after it was determined that he was
neurologically intact, but had sustained several other
injuries, including an occlusion of the left renal artery.
This case describes a patient with two rare injuries in
an unusual injury pattern. It highlights the complex
surgical and medical management of children with
severe abdominal trauma.
The 10-year-old patient was the passenger on an
ATV driven by his father. Neither the patient nor his
father were wearing a helmet. The ATV struck an
object, resulting in the rollover. The boy was able to
ambulate at the scene, but complained of abdominal
and back pain. Bystanders called 911 and the patient
was initially taken to a local hospital at about 2 p.m.
His airway was intact and he was breathing and
oxygenating well. He was tachycardic, but otherwise
hemodynamically stable. Secondary exam showed a
tender abdomen. Computed tomography (CT) scans
of the head, C spine, chest, abdomen, and pelvis
were obtained. The CT scans revealed several
injuries, including an occlusion of the left renal artery
without perfusion of the left kidney, a hematoma of
the third and fourth portion of the duodenum with
concern for possible perforation, free fluid within the
peritoneum, a fracture of the body of L2, and
fractures of the transverse processes of T12, L2, and
L3. Given these findings, the patient was transferred
via helicopter to HCMC.
The patient arrived at HCMC at 8:30 p.m. He was
mildly tachycardic and normotensive. On secondary
exam, he had a tender and distended abdomen, as
well as tenderness with palpation of the thoracic and
lumbar spine. He had no neurologic deficit. A
Focused Assessment with Sonography for
Trauma (FAST) exam was positive for free fluid
around the spleen. His radiographic studies arrived
via electronic transfer to HCMC, where radiologists
were also suspicious for transaction of the duodenum
in the third or fourth portion. Representative images
of his CT are shown in Figures One and Two. All
providers, including trauma and pediatric surgery, did
not feel there were any viable options for renal
salvage. Given the clinical and radiographic findings,
including a possible duodenal transaction, trauma
surgery recommended exploratory laparotomy. This
was discussed with the patientʼs mother.
In the operating room (OR), the patient was found to
have a moderate amount of intra-abdominal
hemorrhage, a small bowel perforation approximately
15 cm from the Ligament of Treitz, a small serosal
tear of the transverse colon, a perforation of the
duodenum at the junction of the third and fourth
portion of the duodenum, and a left Zone II
retroperitoneal hematoma (Figure Three). The Zone
II hematoma was slowly bleeding into the abdomen
via a defect in the posterior peritoneum. These
findings were consistent with severe blunt force
trauma within which the energy was delivered to a
very focal area of the upper abdomen just to the left
of the midline. The Zone II retroperitoneal hematoma
was explored, revealing a small amount of muscular
bleeding, as well as an ischemic left kidney. A
thrombus could be visualized transluminally in his left
renal artery, consistent with an intimal dissection.
Figure One Left. Abdominal CT
showing the ischemic left kidney
and renal artery thrombosis
Figure Two Middle. Abdominal CT
showing the site of the suspected
duodenal transection
Figure Three Right.
Retroperitoneal Zones: Zone
1–Central–bounded by the
diaphragm superiorly and pelvic
inlet inferiorly and the medial border
of the psoas muscles laterally; Zone
2–Lateral–includes the areas lateral
to zone 1 and above the pelvic inlet;
Zone 3–Pelvic–area below the
pelvic inlet
Approaches in Critical Care | June 2011 | 5

Case Reports
Grade
Injury Description
I
II
III
IV
V
Hematoma
Laceration
Hematoma
Laceration
Laceration
Laceration
Hematoma
Laceration
Contusion with microscopic hematuria, urologic studies normal
Non-expanding subcapsular hematoma without parenchymal laceration
Non-expanding peri-renal hematoma confined to renal retroperitoneum
< 1.0 cm parenchymal depth of renal cortex without urinary extravasation
Laceration > 1.0 cm parenchymal depth of renal cortex without collecting system
rupture or urinary extravasation
Parenchymal laceration extending through renal cortex, medulla, and collecting
system with urinary extravasation; injury to main renal artery or vein with
contained hemorrhage
Massive disruption of the duodenopancreatic complex
Devascularization of the duodenum
Table One.
Organ Injury
Scale American
Association for
the Surgery of
Trauma: Kidney 3
With these findings, a left nephrectomy was
performed. Given the proximity of the small bowel
and duodenal injury, a partial duodenectomy and
small bowel resection were performed to include the
distal portion of the third portion of the duodenum, the
fourth portion of the duodenum, and the involved
small bowel. This was reconstructed by mobilizing the
remaining third portion of the duodenum and then
creation of a small bowel to duodenal anastomosis
with a partially stapled, partially hand-sewn technique.
An incidental appendectomy was also performed.
The retroperitoneum continued to have a small but
steady amount of bleeding. This was packed. A
temporary abdominal closure was then performed
with a planned second-look laparotomy in 36 hours.
The patient was then transferred to the PICU.
With the assistance of the pediatric intensivists, the
patient received ongoing fluid resuscitation. Postoperatively,
he remained intubated and sedated. The
patient was taken back to the OR on post-operative
day two. The transverse colon serosal tear was
primarily repaired. The bleeding from the retroperitoneum
had stopped. The duodenal small bowel anastomosis
was inspected and found to be intact and well perfused.
His abdomen was definitively closed. His NG tube
was left in place. He was transferred back to the
PICU and was extubated later that day.
This patient did well postoperatively. His nasogastric
tube was removed on hospital day seven. On hospital
day eight, the nasogastric tube was replaced after an
episode of bilious emesis. A CT scan with PO and IV
contrast was obtained. This showed no leak, but
some edema in the third portion of the duodenum, as
well as a fluid collection within the left renal fossa.
The nasogastric tube was removed on hospital day
11. The patient was discharged to home on hospital
day 16. His peak creatinine during his hospital stay
was 0.9.
Discussion
Renal Injury
Nephrectomy for trauma in children is a rare event;
even in high grade injuries. 1 Indications for nephrectomy
include hemodynamic instability despite fluid resuscitation
from ongoing hemorrhage and uncontrolled sepsis.
Nephrectomy for an ischemic kidney from renal artery
thrombosis is recommended if a laparotomy is being
performed for another reason, i.e. hemorrhage,
suspected bowel injury, etc. Childrenʼs National
Medical Center reviewed its experience with blunt
renal injury in children. 2 This was a single center
retrospective review that included 126 children. Sixty
percent of the patients had a low-grade injury, defined
as American Association for Surgery in Trauma
(AAST) Grade 1, 2, or 3 level of injury. The remaining
40% suffered an AAST Grade 4 or 5 injuries. Only
four patients (3.2%) required nephrectomy and only
two (1.6%) required immediate surgical intervention.
Childrenʼs National Medical Center concluded that
initial non-surgical management of high-grade renal
trauma is recommended for hemodynamically stable
children. The AAST renal injury grading definitions are
given in Table One. In a 12-year retrospective series
from Baltimore of 79 patients ages 2-14 with renal
injury, 25% were Grade 4 or 5 injuries. 5 Seven (8.8%)
required nephrectomy, all of whom had Grade 5
injuries. Children who undergo conservative
management of renal injuries appear to have good
renal function in short- and long-term follow- up. 6 In a
series of 16 patients (12 of whom had high-grade
injuries) who were followed for one year post-injury,
all of the children had normal BUN, creatinine, and
blood pressure.
Current recommendations from the American
Academy of Pediatrics regarding children with an
absence of a kidney and participation in contact
sports emphasizes the need for clinical judgment and
individual assessment of both the patient and the
contact sport in question. 7 Several studies have
highlighted that the risk of renal loss from contact
sports is rare. 1
6 | Approaches in Critical Care | June 2011

Case Reports
the Surgery
Laceration Massive disruption of the duodenopancreatic complex
of Trauma:
V
Duodenum 4 Vascular
Devascularization of the duodenum
Grade Injury Description
I Hematoma Involving single portion of the duodenum
Laceration Partial thickness, non perforation
Hematoma Involving more than one portion of duodenum
Table Two.
II
Organ Injury
Laceration Disruption of 75% of D2 or involving the ampulla or distal common bile duct
Duodenal Injury
Injury to the duodenum is also rare. In the two most
recent series in the pediatric trauma literature, there
were only 52 cases in a 10-year period in the
combined experience of three pediatric Level 1 trauma
centers. 8,9 The retroperitoneal position of the duodenum
and association with other vital structures account for
several challenging features in managing duodenal
injuries. First, signs and symptoms of injury may be
vague or subtle, possibly contributing to a delay in
diagnosis. Second, these injuries are associated with
high-energy mechanisms, given the protection afforded
by the retroperitoneal location. Third, associated
injuries to adjacent structures are common. A blunt
mechanism of injury is the most common cause for
duodenal injury. This is in contrast to adults, in which
penetrating trauma is more common. Non-accidental
trauma, assault and abuse, is, unfortunately, the most
common mechanism of pediatric injury. Of the 52
patients noted above, 19 sustained their injuries from
non-accidental trauma. Motor vehicle collision was the
next most common mechanism of action, accounting
for 15 injuries. Bicycle accidents accounted for 10
injuries. These injuries are more common in boys than
girls. The duodenal organ injury scale from the AAST is
listed in Table Two. A 10-year retrospective chart
review summarizing the experience at two pediatric
Level I trauma centers identified 42 duodenal injuries. 8
A slight majority of the injuries were Grade I or II.
Overall, 25 of the 42 injuries required operative
management with 18 of the patients undergoing
primary repair. The overall average length of stay was
18 days, average length of ICU stay was seven days,
and the complication rate was 33%. Patients who
underwent operative management had an overall
longer length of stay and a longer ICU stay.
ATV Accidents
Injuries associated with all-terrain vehicles (ATVs) have
been closely monitored by the U.S. Consumer Product
Safety Commission for several years. 10 Since 1982,
there have been over 10,000 total deaths and 2,600
pediatric deaths due to ATVs. Forty percent of these
pediatric deaths were in children under the age of 12.
In 2009, there were 33,400 injuries in children related
to ATVs. Additionally in 2009, there were 61 deaths
related to ATVs in children under 16 years old, of which
29 were children under the age of 12. The yearly rate
of ATV accidents has decreased by approximately half
from four years ago. This decrease in the rate of injury
is likely multi-factorial in origin. There has recently been
a change in the definition of ATV by the U.S. Consumer
product Safety Commission, categorizing dirt bikes as
a separate category and not as an ATV. Legislative
changes, as well as public awareness and advocacy
campaigns, have also been important in highlighting
the potential dangers of ATVs. The American Academy
of Pediatrics recommends that children under the age
of 12 should not be allowed to ride an ATV. 11 Minnesota
State law prohibits anyone under the age of 11 from
operating an ATV on public lands or trails, though use
on private lands is permissible. 12
Conclusion
Serious injuries to the duodenum and kidney are
relatively rare in children. Injuries to the duodenum may
pose a diagnostic dilemma and may be associated with
other serious injuries. Recent evidence shows that
even high-grade renal injuries can be managed nonoperatively.
Management of these complex injuries
often requires a comprehensive and multi-disciplinary
approach, as described in this case. ■
References
1. Johnson B, Christensen C, Dirusso S, Choudhury M, Franco I. A
need for reevaluation of sports participation recommendations for
children with a solitary kidney. J Urol. 2005 Aug;174(2):686-9
2. Management of high grade renal trauma: 20-year experience at a
pediatric level I trauma center. J Urol. 2007 Jul;178(1):246-50
3. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling:
spleen, liver, kidney. J Trauma. 1989;29:1664-6
4. Moore E, Cogbill T, et al. Organ injury scaling II: Pancreas,
duodenum, small bowel, colon, and rectum. J Trauma. 1990;30:1427-9
5. Rogers CG, Knight V, MacUra KJ, Ziegfeld S, Paidas CN, Mathews
RI. High-grade renal injuries in children--is conservative management
possible? Urology. 2004 Sep;64(3):574-9.
6. Keller MS, Green MC. Comparison of short- and long-term functional
outcome of nonoperatively managed renal injuries in children. J Pediatr
Surg. 2009 Jan;44(1):144-7
7. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;
121/4/841
8. Clendenon JN, Meyers RL, Nance ML, Scaife ER. Management of
duodenal injuries in children. J Pediatr Surg. 2004 Jun;39(6):964-8.
9. Gaines BA, Shultz BS, Morrison K, Ford HR. Duodenal injuries in
children: beware of child abuse. J Pediatr Surg. 2004 Apr;39(4):600-2.
10. www.cpsc.gov/library/foia/foia11/os/atv2009.pdf
11. www.aap.org/advocacy/releases/ATVdeath12610.pdf
12. http://files.dnr.state.mn.us/rlp/regulations/ohv/ohv_regs.pdf
Approaches in Critical Care | June 2011 | 7

Case Reports
Severe Blunt Chest Trauma in a
Pediatric Patient
by Richard Chang, MD
Michelle Biros, MD, MS
Department of Emergency Medicine
Hennepin County Medical Center
Case report
CG is a 12-year- old, previously healthy male, who
was brought into the Emergency Department at
Hennepin County Medical Center following an
accident while playing with a slingshot. The patient
and a young friend were using a device made of
rubber tubing tied to metal posts on a playground.
They were propelling rocks far into the air when one
particularly large rock struck the patient directly in the
anterior chest and he collapsed.
His friend called for help. When first responders
arrived, the patient was apneic and pulseless.
Cardiopulmonary resuscitation (CPR) was initiated,
he was intubated, and Advanced Cardiac Life
Support (ACLS) medications were administered
through an intraossesous line. His initial rhythm was
asystole and no shocks were given. He was transferred
to the hospital with resuscitation in progress.
Emergency Department Course
The patient arrived to the stabilization room with CPR
ongoing for approximately 40 minutes. A brief exam
was notable for no external signs of chest trauma,
symmetric chest rise with bag-assisted ventilations,
and pupils that were fixed and dilated bilaterally.
Bedside cardiac ultrasound was utilized to exclude
pericardial tamponade and confirm cardiac standstill.
Pacing pads were placed on his chest and external
pacing was attempted, but unsuccessful. Multiple
rounds of intravenous epinephrine, atropine, sodium
bicarbonate, and calcium chloride were given as
CPR continued.
During the course of the resuscitation, the patientʼs
parents arrived to the hospital. His mother, a
cardiology research nurse, quickly rushed to her
sonʼs bedside along with her husband. Emergency
physicians performed internal cardiac pacing, external
defibrillation, and continued ACLS pharmacologic
therapies; however the patient had no return of
spontaneous circulation and was subsequently
pronounced dead in the Emergency Department.
Commotio Cordis
Latin for “agitation of the heart”, commotio cordis is
one of the more common causes of sudden cardiac
deaths in young athletes 1 . It occurs when blunt
trauma to the chest wall disrupts the cardiac rhythm,
resulting in ventricular fibrillation (VF) cardiac arrest.
Although initially described in the 1700s, only
recently has systematic reporting through the
National Commotio Cordis Registry helped to identify
over 200 confirmed cases.
Epidemiologically, commotio cordis occurs most
frequently in young males, usually during athletic
activities. The majority of cases have been with blunt
projectile trauma, commonly a baseball striking the
anterior chest. Cases have also been identified from
hockey pucks, lacrosse balls, and martial arts blows.
The timing of the impact within the cardiac cycle
appears to be the most important factor in the
development of VF 2 . Only impacts during a 20-40
millisecond window on the upslope of the T-wave
(ventricular repolarization) will cause VF 3 .
The diagnosis of commotio cordis is primarily clinical
(i.e. blunt chest trauma followed by collapse).
Electrocardiographic evidence of VF is rarely
obtainable at the time of injury. Further imaging
studies (i.e. echocardiogram, computed tomography)
are often unrevealing, as is autopsy. Commotio
cordis is a distinct entity from other, more severe,
traumatic injuries to the heart, such as cardiac
contusion or myocardial rupture.
The prognosis in commotio cordis is poor, with a
reported survival rate of 25% 4 . Early chest
compressions and defibrillation are critical to
resuscitation. Unfortunately, preventative measures
such as commercially available chest wall protectors
have not been shown to effectively prevent commotio
cordis 5 . Coaching techniques have encouraged young
athletes to avoid direct chest blows, such as turning
away from errant baseball pitches. Softer, less dense
balls have also been introduced in an effort to
decrease the incidence of the devastating condition.
Family Presence During Resuscitations
A death due to an acute traumatic or medical event
is a grief-provoking, unexpected experience that
changes the lives of survivors immediately and
forever. The death usually occurs in an unfamiliar
setting, such as an emergency department, attended
by strangers whose attempts to resuscitate the
patient may appear assaultive (i.e. CPR, intubation
IVs) when viewed by non-medical persons.
Emergency personnel are often reluctant to have
family members present during a resuscitation
because we believe there is insufficient time to
provide an acceptable explanation of what is
occurring, we are afraid that the family will react in
an unpredictable and possibly dangerous manner,
8 | Approaches in Critical Care | June 2011

Case Reports
that they will get in our way, that they may become
a ʻsecondʼ patient if they have a severe physical or
emotional reaction to what they see; and that they
may criticize or question our decisions. None of
these concerns are verified in the literature that
describes family presence during resuscitation.
In our attempts to interrupt the life-threatening
pathology and avert death, we often forget that our
resuscitation is being performed on someone who is
loved and will never again be available to his
survivors. Survivors relate that small details of the
day, the place and the people are remembered
forever and are replayed over and over again. The
mother of our patient recalls a call from the police
that provided no detail, and therefore, did not allow
any mental preparation for what was happening. She
recalls her distress when, arriving before her sonʼs
ambulance, no one at triage seemed aware that he
was arriving. She recalls the charge nurse stating
she could not go into the STAB room, and that, when
she insisted, the charge nurse told her that her son
was receiving CPR. This was the first hint she had of
how serious her sonʼs condition was. Death was
never on her mind.
She is a skilled clinical observer, and recalls
watching the details of the resuscitation effort and
hearing her suggestions acknowledged. She never
felt dismissed in the STAB room. She knows
everything possible was done. She felt empowered
when she was asked to participate in the decision to
discontinue resuscitation; she felt this gave her at
least a little control in this totally uncontrollable event.
She felt it was important to be present, along with her
husband, when the resuscitation was discontinued.
She felt the doctors gave great comfort when they
assured them that their son likely died immediately,
and that he likely did not feel any pain. They continue
to hang on to these few comforting words.
Afterwards, she regretted not staying with her son
jwhen the nurses cleaned him up, and in retrospect,
would have liked to have done this herself. She
appreciated the support of her extended family, who
had arrived during the resuscitation, but looking
back, wishes she had had more time with him alone.
She felt offended that she had little say in the
decision to perform an autopsy on her son.
She and her husband provided a healthy, safe life for
their son. They loved parenting him. They were with
him at his death, and he remains with them everyday.
The insights they have shared with us about their
sonʼs STAB room death can inform us in our
consideration of family presence during a resuscitation.
We, as medical providers, sometimes consider an
unsuccessful resuscitation as a personal failure or a
defeat. We reassure one another that everything that
could be done was done, and everything we did was
the right thing to do. When we think like this, we
ourselves become the center of the case, the victim
of the pathology. We must not forget that our practice
is not about us, but it is about the patient. Family
presence during resuscitations will remind us. ■
Editorʼs note: Our sincere thanks to the mother of our
patient, who met with us several weeks after the
death of her son to share her experiences on that
tragic day. His photo is displayed above with the
familyʼs permission. Without a doubt, we have
learned from her, and our discussions have helped
us understands the real priorities in our practice.
References
1. Maron BJ, Gohman, TE, Kyle SB, et al. Clinical profile and spectrum
of commotio cordis. JAMA 2002; 287: 1142.
2. Madias C, Maron BJ, Weinstock J, et al. Commotio cordis—sudden
cardiac death with chest wall impact. J Cardiovasc Electrophysiol
2007; 18:115.
3. Link MS, Maron BJ, VanderBrink BA, et al. Impact directly over the
cardiac silhouette is necessary to produce ventricular fibrillation in an
experimental model of commotio cordis. J Am Coll
Cardiol 2001; 37:649.
4. Kohl P, Nesbitt AD, Cooper PJ, Lei M. Sudden cardiac death by
Commotio cordis: role of mechano-electric feedback. Cardiovasc Res
2001; 50:280.
5. Evaluation of chest barriers for protection against sudden death due
to commotio cordis. Am J Cardiol 2007; 99:857.
Approaches in Critical Care | June 2011 | 9

Critical Care Profile
Q and A withQ and A with
Andrew Kiragu, MD, FAAP
Andrew Kiragu, MD, FAAP
Dr. Andrew Waititu Kiragu is the medical
director of the pediatric intensive care unit
and the co-medical director of the Pediatric
Traumatic Brain Injury program at
Hennepin County Medical Center. He is
also an assistant professor of pediatrics at
the University of Minnesota Medical
School. He completed his undergraduate
studies at Dalhousie University in Nova
Scotia, Canada, and subsequently
graduated from Howard University in
Washington, D.C., with an MD degree in
1994. Dr. Kiragu served his residency in
internal medicine and pediatrics at the
University of Minnesota followed by a
fellowship in pediatric critical care at the
University where he was one of the Walter
Ramsey Endowment Fellows. During his
fellowship and as a staff physician, he has
received several awards in recognition of
his commitment to resident and medical
school education. Dr. Kiragu was awarded
a Vikings Foundation grant to study the
inflammatory effects of cardiopulmonary
bypass. He was the co-primary investigator
for a grant from the Robert Wood Johnson
Foundation to establish an Injury-Free
Coalition for Kids site in Minnesota at
Hennepin, with a goal of studying and
preventing injury prevention here in the
Twin Cities. Dr. Kiragu is board-certified in
pediatrics and pediatric critical care.
Why did you choose pediatrics?
I have always enjoyed being around kids.
The kids seem to get my sometimes goofy
nature. Kids are the most “fun” patients.
When they are well, they are energetic,
curious, funny, loving human beings. Even
if they are really sick, children are quite
resilient. When they recover from their
illnesses, it makes what we do so
worthwhile. When they donʼt get better,
thatʼs the hardest. You grieve for the lost
potential and the pain that the families feel.
When you work in Pediatrics, you take
care of more than just the patient. You also
have to be aware of the needs of family
members and friends. We once had a case
of an injured teenager who had a large
group of classmates come to see him. His
family requested that we explain his
injuries to them and so we gathered all
these kids and some of their parents in a
conference room to talk about their friend.
Now that I have my own family (children
ages 9 and 11), it makes me more
cognizant of how fragile and precious life
is. I am always the one saying, “be careful”
to the kids. When we are with friends and
the kids are doing crazy stuff, everyone is
always looking at me to see my reaction.
How has your interest in the care of
critically injured and ill children shaped
your career?
As the director of the pediatric intensive
care unit, by necessity I have to interact
with a variety of people, my physician
colleagues, Hennepin staff and leadership.
This takes me beyond my usual clinical
role as a physician. There are a number of
new initiatives with regard to pediatrics we
have undertaken here at Hennepin County
Medical Center, and my colleagues know
that I am available to support these efforts.
If I identify an opportunity to advance the
care of children here at Hennepin, I can
bring people together to make it happen. I
enjoy doing that.
I am also involved in the Injury Free
Coalition for Kids (IFCK) and serve as the
principal investigator for IFCK-Minneapolis.
Through this organization, research in the
area of injury prevention is being
conducted to identify which injury
prevention measures are most effective.
Injury prevention education methods and
driving behaviors in teens are among
several topics that we have studied. The
Injury Free Coalition for Kids has worked
with other groups, including AAA-
Minnesota to provide the state legislature
with information useful in improving traffic
laws. I am currently on the boards of
10 | Approaches in Critical Care | June 2011

Critical Care Profile
directors of Safe Kids Minnesota and the Brain Injury
Association of Minnesota. These organizations are
also heavily involved in injury prevention efforts
around the state.
What does Minnesota do well when it comes to
trauma care?
There is a long tradition of dedicated Level I trauma
centers in Minnesota. In my opionion, Hennepin
County Medical Center has played a significant
leadership role in trauma care in Minnesota. We
have developed expertise in caring for patients of all
ages and developed protocols of care that are used
in the management of major trauma. The care that is
provided at Hennepin is on the cutting edge of
trauma care. An example is Dr. Gaylan Rockswoldʼs
use of hyperbaric oxygen in the management of
severe traumatic brain injury. Hennepin County
Medical Center has a strong tradition and culture of
excellent trauma and critical care, which is something
that has developed over decades. When the highway
35W bridge collapsed, this tradition was quite
evident. I remember, a young lady with a severe
head injury who was brought into the emergency
department (ED). Despite how busy the ED was at
that time, her life-threatening injury was evaluated;
she was scanned and was in the operating room in
less than 15 minutes. This kind of efficiency only
comes with years of experience and training.
What sets Hennepin County Medical Center apart
when it comes to pediatric trauma care?
Hennepin County Medical Center has the resources
available to provide surgical and critical care for
children suffering from all types of traumatic injury.
Most frequently we treat traumatic brain injuries but
we also care for a wide variety of orthopaedic trauma
and internal injuries, including trauma to the spleen,
liver and bowel.
One of the distinguishing factors is the Pediatric
Brain Injury program, which has been in existence
for the past 21 years. Through this program, multidisciplinary
care is provided to children who have
suffered from a traumatic brain injury.
Hennepin was the first acute care hospital in
Minnesota to publish return-to-school guidelines for
children who have experienced a traumatic brain
injury. The Pediatric Brain Injury program works
closely with schools to facilitate the return to school
of children with brain injuries. The program also
works closely with both the Brain Injury Association
of Minnesota and the Minnesota Department of
Health as they provide case management and
resources for these children and their families.
We are also involved in several ongoing clinical
research projects, including the use of hypertonic
saline solution in the management of increased
intracranial pressure. Researchers are also reviewing
cases where children have had an emergency
thoracotomy to examine best practices. Upcoming
clinical studies include evaluating sleep patterns in
children with traumatic brain injuries.
“The care that is provided at
Hennepin is on the cutting edge
of trauma care.”
What are some things that you anticipate will
happen in your field in the future?
I anticipate even more cooperation between the four
Level 1 trauma centers in our area – Hennepin,
Regions, North Memorial and Mayo. We have a lot to
learn from each other and can find ways to make
care better in our state. I also hope for even closer
ties between facilities that care for children. There is
a lot of pediatric care in the Twin Cities area, but it is
disjointed. Some cities have one large childrenʼs
hospital, but that isnʼt the way that things are
developing here.
I think we will see more specialization in critical care.
We can already see this with the growth of cardiac
intensive care and growing interest in the field of
neurointensive care. There will also be more
regionalization and consolidation of critical care
because there are not enough intensivists. Indeed,
many hospitals do not even have an intensivist-run
intensive care unit. There are even fewer pediatric
intensivists nationally.
Technology will improve our ability to monitor
critically ill patients. One area that is growing is in
telemedicine. Given the paucity of intensive care
physicians, technologies that allow physicians to
remotely monitor patients and aid in their management
are key. Also, the emphasis on quality improvement
and ongoing efforts towards patient and family
centered care will continue to affect the way we care
for kids. ■
Approaches in Critical Care | June 2011 | 11

Technology in Critical Care
Technology in Critical Care: Radiation risks from
computed tomography
by Gopal Punjabi, MD
Department of Radiology
Hennepin County Medical Center
Introduction
The last 40 years have seen dramatic advances in
medical imaging that have revolutionized clinical
medicine. The benefits include more effective
diagnosis, shorter hospital stays, and elimination of
exploratory surgery and rapid diagnosis of lifethreatening
conditions 1 . For example, the trauma
patient can undergo a highly accurate whole-body
computed tomography (CT) scan within a few
minutes that often replaces multiple invasive
examinations, such as angiography and exploratory
laparotomy. This has also lead to an increase in
radiation dose delivered to the patient population.
There has been considerable interest in the medical
literature and in the lay press regarding radiation
dose, often with alarming headlines. In this article,
the biological effects of low-dose ionizing radiation
and methods to reduce radiation risks in CT scanning
will be discussed.
Background
Computed tomography scan is a relatively recent
intervention, developed in the late 1960s by EMI,
Ltd., a music, electronics and leisure company based
in the United Kingdom, funded by profits from the
Beatles' recordings. Sir Godfrey Hounsfield, a British
engineer and Allan Cormack, a physicist born in
South Africa, received the Nobel Prize for this
invention in 1979 2 . The CT scanner uses ionizing
radiation to produce highly detailed images. There
has been rapid advancement in CT technology since
its invention, with current scanners using multidetector
helical technology. This involves an X-ray
beam going through the patient and detected on the
opposite side by multiple detector rows, enabling
sub-second imaging of large portions of human body.
With rapid innovations, the use of CT scans has
dramatically exploded. While in 1980 about 3 million
CT scans were performed, the projection for 2011 is
72 million CT scans. This trend is likely to increase
with an aging population, as well as multiple new
applications of CT, such as CT virtual colonoscopy,
coronary CT angiography, and CT perfusion
scanning.
Radiation dose
Radiation dose describes the amount of energy
absorbed per unit mass at a specific point, and is
expressed in Grays (1 Gy deposits 1 Joule per
kilogram). This does not reflect risk; for instance, a
100 mGy dose to an extremity would not have the
same biological effect as the same dose to the
pelvis. A more useful measurement is the effective
dose, which takes into account the biological
sensitivity of the tissue or organ being irradiated, and
is calculated by multiplying the radiation dose with
tissue and radiation weighing factors 3 . The unit of
effective dose is the Sievert (usually millisieverts
(mSv) are used in diagnostic radiology). The use of
the effective dose facilitates communication with the
patient, and understanding of the likelihood of
potential harm from the radiological exam. The
effective dose is a theoretical number that cannot be
directly measured.
The annual level of naturally occurring background
radiation in the United States is estimated at about
3.1mSv 4 . In 2006, the annual per capita effective
radiation dose from man-made sources was
estimated at about 3.1 mSv; of this, CT accounts for
about 1.47 mSv 5 . The effective dose from an
individual CT scan varies between different body
parts 6 (Table One). There is also tremendous
variation among scanners, depending on the
scanning technique used. For comparison purposes,
the average effective dose from a two-view chest X-
ray is 0.1 mSv, and that from a nuclear cardiac stress
test using technetium 99m labeled sestamibi is about
12.8 mSv.
Procedure
CT Head
CT Chest
CT Abdomen
CT Pelvis
CT Cervical Spine
CT Lumbar Spine
Average Effective Dose
2 mSv
7 mSv
8 mSv
6 mSv
6 mSv
6 mSv
Table One: Radiation doses in common CT exams 6
12 | Approaches in Critical Care | June 2011

Technology in Critical Care
Figure One: Dose report
generated by a CT
scanner, note that the total
DLP from the whole body
CT scan is estimated at
807 mGycm. The effective
dose can be calculated
(by using a conversion
factor of about 0.016)
about 12.9 mSv, or 4
years of natural
background radiation. The
dose savings refer to use
of automated dose
modulation technique.
It is important to remember that radiation doses
cannot be directly measured in a patient. Instead, the
fundamental radiation dose parameter in CT is the
CT dose index, which can be measured in simple
cylindrical phantoms. To estimate dose after
scanning a certain distance, the dose-length product
is used. CT scanners provide automated reports of
dose-length product after every CT scan. Simply put,
this estimates the radiation dose that would be
delivered to a standard phantom with the parameters
used on the scan (Figure One). Standard conversion
factors, which are regularly updated, are then used to
calculate effective dose. As shown by several authors,
there is a significant range of error in these calculations 7 .
Radiation risks
Ionizing radiation has enough energy to strip
electrons from atoms and break chemical bonds.
Radiation effects are in two broad categories: nonstochastic
and stochastic. Non-stochastic effects
appear in exposure to high levels of radiation, and
are proportionate to the level of exposure. These
include radiation burns and radiation sickness. With
CT scans, non-stochastic effects are rare, and
usually related to grossly inappropriate technique. A
recent example is numerous cases of band-like hair
loss following CT perfusion scans for stroke 8 .
With the level of radiation used in CT scans, stochastic
(probablistic) effects are of much more concern.
Increased exposure makes the effect more likely to
occur but does not influence the severity. Cancer is
the primary stochastic effect of radiation. This results
from damage to the DNA that may not have been
successfully repaired. Given the high incidence of
cancer in the general population, and the very low
risk of cancer induction from CT scans, experimentally
proving risks from CT scan would require prolonged
studies involving millions of exposures 9 .
Estimates of the risk of cancer induction by CT are
therefore used. These are based on data from
epidemiologic studies, the largest being the life span
study from survivors of the 1945 atomic bombings in
Japan. A large study of British radiation workers has
shown that the data from Japanese bomb survivors
can be expected to translate well to a Western
population. The National Academies of Science has
published reports on the biological effects of ionizing
radiation (BEIR reports) that form the foundation of
current estimates of radiation risk 10 . The FDA states
that a CT examination with an effective dose of 10
mSv may be associated with an increase in the
possibility of fatal cancer of approximately 1 chance
in 2000 11 .
The BEIR VII report endorses the linear-no-threshold
model of radiation risk, i.e., the risk from high
radiation can be extrapolated to lower radiation
exposure, there is no threshold below which radiation
effects are not observed, and the risks are spread
over the population exposed. While this is the
simplest and safest model, it is not universally
accepted, most notably by the French Academy of
Sciences 12 . It has not been definitely demonstrated
that there is any risk from radiation doses below 100
mSv. The Health Physics Society states that
"Estimation of health risk associated with radiation
doses that are of similar magnitude as those
received from natural sources should be strictly
qualitative and encompass a range of hypothetical
health outcomes, including the possibility of no
adverse health effects at such low levels." 13 .
This debate is not entirely academic, because many
publications and media reports imply that death from
CT induced cancers will significantly rise in the
future. An oft-cited article published in the Archives of
Internal Medicine states that 29,000 cancers could
be related to CT scans performed in the U.S. in
2007 14 . These reports do not adequately take into
account several factors:
Approaches in Critical Care | June 2011 | 13

Technology in Critical Care
Figure Two (a-left):
Normal dose technique
demonstrates a stone in
lower pole of right
kidney. Low dose
technique used on
follow-up scan (b-right)
demonstrated the same
stone with about 20%
the radiation dose from
standard technique.
1. Significant errors in measurement of low-level
radiation doses.
2. Significant errors in the estimation of effective
dose, which is calculated from a regularly
updated conversion factor.
3. Biological plausibility. The biological effects of
radiation decreases as dose decreases, and
DNA repair and elimination of defective cells by
death is a dynamic process.
4. Uncertainty regarding linear-no-threshold model.
5. Non-transferability of the risks and mortality from
radiation. Most medical doses are delivered to a
smaller and more elderly segment of the US
population, but the risks are extrapolated to the
general population.
Radiation risks therefore must be taken in the
appropriate context. If the estimated lifetime number
of deaths from a single CT scan with a dose of 10
mCi is indeed 0.5 per 1000, the estimated lifetime
number of deaths in the same group of individuals
from a lightning strike is 0.0 13 , and from drowning is
0.9. Similarly, the death rate from motor vehicle
accident is 11.9 15 . This does not dissuade most
Americans from driving! Similarly, while the dose
from a head CT is the same as about 20 chest
x-rays, this is still significantly less than a year of
background radiation.
Primum non Nocere
Measurement and quantification of risks from CT
radiation form a fascinating and often controversial
topic, with strong feelings on all sides. Above all, it is
our responsibility as physicians to make sure our
patients are not harmed. With this in mind, any
radiation dose should be assumed to be potentially
harmful, and careful risk-benefit analysis should be
performed. This is particularly important with children,
who are more vulnerable because of longer expected
life spans and more radiation-sensitive body tissues.
At the same time, it would be unconscionable to
deny a patient the benefits from a CT scan that is
appropriately indicated and optimally performed.
What can be done?
Justification: A CT scan should be performed only
when there is the potential of clear benefit. In other
words, the risk of not performing the examination
must exceed the potential risks. A classic situation is
following high-speed trauma, where the risk of not
performing at CT scan includes missing life-threatening
internal organ injury or aortic injury. This clearly exceeds
potential risk of inducing neoplasm later in life.
In most situations, the risk /benefit ratio is more
difficult to evaluate, and individual physician
judgment is paramount. There are many resources
available to assist physicians in making this
judgment. For example, the American College of
Radiology has provided evidence-based guidelines
for appropriate imaging tests 16 . Discussion between
radiologists and physicians, especially physicians-intraining,
clearly helps in the decision-making process
and in tailoring the exam to answer the clinical
question. Decision support systems integrated into
electronic medical systems may also be helpful. It
has been reported that 30% or more of CT scans
currently performed may be unnecessary. This
number must be reduced 17 .
Optimization: Careful attention to technique can
significantly reduce radiation dose. This includes
standardizing protocols, reducing multiple series
within each examination (avoiding "protocol creep"),
implementing dose reduction strategies, and limiting
scanning to part of interest (avoiding "scan creep").
The Society for Pediatric Radiology offers very useful
online information regarding tailoring exams in
children, as part of its "image gently" program 18 .
Of late, all CT vendors have introduced numerous
dose reduction techniques. These differ among
vendors, usually involve some form of dose
modulation tailored to the patient body habitus, and
are quite effective in reducing radiation dose while
keeping image quality adequate. In addition, there
are several situations where a low-dose exam with
noisier (grainier, less pleasing) images is appropriate.
In patients with kidney stones, the low-dose
technique takes advantage of inherent contrast
between the stone and surrounding tissues and
produces images of diagnostic quality (Figure Two).
Similarly, low-dose technique may be utilized in
patients with lung nodules for follow-up.
14 | Approaches in Critical Care | June 2011

Technology in Critical Care
practice. At the same time, every CT scan should be
assumed to involve some risks to the patient in terms
of inducing potential cancers. A basic level of
understanding radiation doses and the subsequent
risks is important for all physicians who order these
scans. With careful optimization and appropriate
justification, these risks can–and should–be minimized.
Figure Three. MRI scan shows acute appendicitis, which was surgically
proven. Note gravid uterus in cephalic presentation.
Alternate exams: Whenever feasible, alternate
exams such as ultrasound or magnetic resonance
imaging (MRI) that do not use radiation should be
considered. In children with suspected appendicitis,
ultrasound is often diagnostic. In pregnant women
with suspected appendicitis, ultrasound is often nondiagnostic
and MRI is helpful (Figure Three).
Avoiding repeated scans: Risks from repeated
scans can be assumed to be cumulative. Tracking
and collecting dose information at the patient's level
can be implemented within the electronic medical
record system. Patients who have received
excessive scans should be clearly flagged, and extra
caution should be exercised in these patients.
Communication: In all situations, clear
communication with the patient regarding the reason
for the exam being requested and the risk associated
should be discussed in simple, non-alarmist
language 19 . Statements such as, “We do not know
the exact risks, and we may never know the exact
risk associated with low doses of radiation, but in the
best interests of our patients, we assume there is
some risk” may be appropriate.
It may be useful to express radiation dose in terms of
multiples of annual background exposure, for
example, “The exposure from a chest CT may be
about that of two years of background radiation.” It
may also be useful to express the associated risk of
inducing fatal cancer in appropriate context, for
example, “The lifetime risk of fatal cancer induced by
whole body CT scan is about half that of dying from
drowning,” provided that the uncertainty about these
estimates is clearly stated.
References
1. Managing Radiation Use in Medical Imaging: A Multifaceted
Challenge. Hedvig Hricak, David J. Brenner, et al. Radiology, March
2011, 258, 889-905.
2. Sir Godfrey Hounsfield. Ian Isherwood. Radiology, March 2005,
234, 975-976.
3. Radiation Dose in CT. McNitt-Gray, MF. RadioGraphics, November
2002, 22, 1541-1553.
4. National Council on Radiation Protection and Measurements.
Ionizing radiation exposure of the population of the United States:
2006. NCRP report no. 160. Bethesda, Md: National Council on
Radiation Protection and Measurements, 2009.
5. Radiologic and nuclear medicine studies in the United States and
worldwide: Frequency, radiation dose and comparison with other
radiation sources-1950-2007. Fred A Mettler, Mythreyi Bhargavan, et
al. November 2009 Radiology, 253, 520-531.
6. Effective Doses in Radiology and Diagnostic Nuclear Medicine: A
Catalog. Fred A. Mettler Jr, Walter Huda, et al. July 2008 Radiology,
248, 254-263.
7. CT Dosimetry: Comparison of Measurement Techniques and
Devices. John A. Bauhs, Thomas J. Vrieze, et al. January 2008
RadioGraphics, 28, 245-253.
8. After Stroke Scans, Patients Face Serious Health Risks. Walt
Bogdanich, New York Times, July 31, 2010.
9. Estimating cancer risks from low doses of ionizing radiation. Land
CE. Science 12 September 1980: Vol. 209 no. 4462 pp. 1197-1203.
10. U.S. Nuclear Regulatory Commission. Health risks from exposure
to low levels of ionizing radiation: BEIR VII. Washington, DC: National
Academies Press, 2006.
11. What are the Radiation Risks from CT? FDA website, accessed
3/11/2011. http://www.fda.gov/RadiationEmittingProducts/Radiation
EmittingProductsandProcedures/MedicalImaging/Medicalx-rays/ucm
115329.htm.
12. Dose-effect relationships and estimation of the carcinogenic effects
of low doses of ionizing radiation. Aurengo A, Averback D, et al.,
French Academy of Sciences, May 2005, http://www.radscihealth.org/
rsh/Papers/FrenchAcadsFinal07_04_05.pdf, retrieved 3/11/2011.
13. Health Physics Society, 2010. Radiation Risk in Perspective
PS010-2, retrieved 3/11/2011.
14. Projected Cancer Risks From Computed Tomographic Scans
Performed in the United States in 2007. Berrington de Gonzalez A,
Mahesh M, et al. Archives of Internal Medicine, Vol. 169 No. 22, Dec
14/28, 2009.
15. In Defense of Body CT. McCollough CH, Guimaraes L, et al., AJR
2009; 193:28-39.
16. ACR Appropriateness Criteria. ACR website, http://www.acr.org/ac.
Accessed 3/11/2011.
17. Radiation Dose Associated With Common Computed Tomography
Examinations and the Associated Lifetime Attributable Risk of Cancer.
Rebecca Smith-Bindman, ; Jafi Lipson, et al. Archives of Internal
Medicine, Vol. 169 No. 22, Dec 14/28, 2009.
18. Society for Pediatric Radiology.
http://www.pedrad.org/associations/5364/ig/. Accessed 3/11/2011.
19. Quality Initiatives Radiation Risk: What You Should Know to Tell
Your Patient. Verdun FR, Bochud F, et al. RadioGraphics, November
2008, 28, 1807-1816.
Conclusions
CT scans offer dramatic advancement in patient
care, and are an essential part of modern medical
Approaches in Critical Care | June 2011 | 15

RN Perspectives
FASTR-HUG can be a
simple way to remember
the esentials of ICU care
that arenʼt always in the
forefront of our priorities
for critically ill patients with
numerous medical needs.
RN Perspectives: Give your patients a “FASTR HUG”
by Shayna Hamiel, RN, BSN, CPN, CCRN
Hennepin County Medical Center
You may have heard about the acronym
“FAST HUG”, introduced by Jean-Louis
Vincent in relation to the essential aspects
of care for all ICU patients. When patients
are being rushed into the unit in critical
condition, their medical needs are great,
with our minds shifting gear to prioritization
of stabilization and our classic ABCs.
However, there are several aspects of
intensive patient care that need to be
addressed in order to optimize stability and
improve patient outcomes. The FAST HUG
acronym helps guide us through these
important aspects of care that can have
adjunctive effects leading to overall wellbeing.
These aspects need to be addressed
on admission as well as on a daily basis as
we strive towards comprehensive care.
With skin being the largest organ in the
human body, it is becoming more of a
focus among health care workers in all
areas, but has yet to be fully given the
importance that it deserves. Wounds,
pressure ulcers, and skin breakdown of all
types, both acute and chronic, can lengthen
hospital stay and increase morbidity and
mortality. Hospital related skin issues need
to be more of a priority for hospital workers
at all levels, with an emphasis on early
detection and intervention, but more
importantly, prevention. In our practice in
the PICU, we are working on a way to
incorporate skin and prevention into our
daily care of ICU patients, and have added
the “R” to Vincentʼs acronym in order to put
skin into the forefront of our thinking with
each admission to our unit.
F-Feeding
Consider nutrition right from the start.
Malnutrition can complicate all body
systems and worsen outcomes for critically
ill patients. Good nutrition is especially
essential for wound healing and is a part of
the Braden and Braden Q risk assessment
tools for skin breakdown. If you know your
patient is not going to be able to eat
normally for any extended period of time,
don't delay feeding tube placement.
Enteral nutrition is generally preferred over
parenteral nutrition. Although the Braden
scale does not give full points for tube
feedings, many dieticians will argue that
the right formula being fed into the
stomach or jejunum can offer equal or
better nutrition than what the patient might
be getting on a regular diet.
16 | Approaches in Critical Care | June 2011

RN Perspectives
A-Analgesia
Make sure your patient has adequate pain control.
Pain can affect a patientʼs psychological and
physiological well being. Most sedatives do not
provide analgesia, so sedation and analgesia should
go hand in hand for intubated patients. Even if your
patient does not have an obvious source of pain
such as a wound or fracture, remember that all
invasive lines and tubes, as well as immobility, can
create a source of pain or discomfort. Make sure you
are an advocate for your patient's comfort.
S-Sedation
Sedative administration must be individualized. This
is especially important for pediatric patients or those
who are less tolerant of invasive lines and procedures.
Safety must be our priority, and keeping patients
comfortable helps with hemodynamic stability, keeping
lines and airways intact, and allows for adequate rest
for optimal healing.
T-Thromboembolic Prophylaxis
Mortality and morbidity rates increase with venous
thromboembolism, so prophylaxis is imperative. ICU
patients are at a high risk due to immobility and
invasive lines. Although this risk is significantly lower
in children compared to adult patients, femoral
venous lines or the use of birth control in adolescent
females can increase this risk. Make sure your
patient has pneumoboots, and unless contraindicated,
consider subcutaneous anticoagulants. Also ensure
that range of motion exercises are being performed if
tolerated and appropriate.
R-Repositioning
ICU patients have several risk factors for skin
breakdown, including immobility, sheering and friction,
moisture related to incontinence or diaphoresis, poor
tissue perfusion related to oxygenation issues and
vasopressor medications, decreased sensory
perception, and poor nutrition. These risks are
outlined by the Braden Q risk assessment scale,
adapted for pediatrics by Quigley and Curley from
the original Braden scale developed by Braden and
Bergstrom in 1987. Utilizing the tool to assess the
patientʼs level of risk can aid in implementing
appropriate interventions, and minimizing these risk
factors as well as frequent repositioning can help
prevent skin breakdown. All ICU patients need to be
repositioned regularly. If your patient isn't able to
independently make frequent full position changes,
you should be assisting them with repositioning at
least every two hours. All patients need a complete
skin assessment on admission, which would be a
great time to do your first position change. When a
patient is just arriving in the ICU, they may have
already been laying in one position for several hours
or even longer, in the ED or the OR, or even at the
scene prior to arrival at the hospital. If a patient
cannot be fully turned, use positioners for sacral offloading
or micro-turns with slight tilting from one side
to the other. If they already have a sacral or coccyx
wound, minimize the amount of time spent supine. If
your patient is difficult to reposition or has several risk
factors for breakdown, they may benefit from an
alternate surface such as a low air loss mattress or
air bed, but remember that patients on specialty beds
still need to be repositioned regularly. Also ensure that
the patientʼs heels are elevated off the bed regardless
of their position.
H-Head of bed elevation
Elevating the head of the bed decreases risk of reflux
and ventilator associated pneumonia. It also aids in
decreasing intracranial pressures. However,
increasing the head of bed also results in sheering
and friction, so unless ordered higher, keep the head
of the bed to 30 degrees. You can also use
positioners under the patientʼs legs to minimize
friction from sliding down in the bed.
U-Stress ulcer prevention
ICU patients are at high risk for GI ulcers due to
stress, respiratory failure, coagulation abnormalities,
gastric tube placement, and lack of gastric feeds.
Ensure that patients are on H2 blockers if appropriate,
or alternate therapies if gastric bleeding is suspected.
G-Glucose control
Glucose control can help reduce mortality rates in
ICU patients. The actual desired level of glucose
remains controversial, and more data is needed in
pediatrics. However, it is clear that hyperglycemia is
associated with increased morbidity and worse
outcomes. Make sure your patient's blood glucose
levels are being followed either in daily labs or more
frequent finger sticks.
Utilizing the FASTR HUG acronym on admission as
well as in daily patient care can be a simple way to
remember the essentials of ICU care that arenʼt
always in the forefront of our priorities for critically ill
patients with numerous medical needs. Remember to
include full skin inspections on all of your patient
assessments, and that prevention is easier and
faster than treatment. Please join me in giving each
of your patients a FASTR HUG today! ■
References
Vincent JL. Give your patient a fast hug at least once a day. Crit
Care Med. 2005; 33:1225-1229.
Quigley SM, Curley MAQ. Skin integrity in the pediatric population:
preventing and managing -pressure ulcers. JSPN. 1996; 1(1):7-18.
Approaches in Critical Care | June 2011 | 17

Historical Perspectives
Babies and
nurses at
Minneapolis
General Hospital,
June 26, 1930
Minneapolis
General Hospital
Annex Building,
1960ʼs
Over 100 Years of Pediatric Care
Historical Perspectives: On the Leading Edge of
Medicine for Children
The History of Pediatrics at Hennepin County Medical Center
by Sherrie Murphy, RN
Hennepin County Medical Center
During the last 100 years, advances in the
specialty of pediatrics have been astounding.
From a half-dozen pediatric practitioners
devoted to the care of children at the
beginning of the 1900s, the ranks of
pediatricians has grown to more than
60,000 in 2010, according to the American
Academy of Pediatrics. The infant mortality
rate in 1900 was 200/1000, compared with
the current 6.3/1000. (CHC data, 2010)
Physicians and nursing staff associated
with the founding hospitals of Hennepin
County Medical Center (HCMC) played
major roles in the development of specialized
care for adults and children in the region.
For example, in 1914 the Pediatric
Contagion Building was constructed for
children infected with scarlet fever and
diphtheria. In 1920, Minneapolis City
Hospital became Minneapolis General. In
1921, medical residency programs began
at Minneapolis General. In 1940 Sister
Elizabeth Kenny came to the U.S. with a
new treatment for polio. Minneapolis
General was the only hospital anywhere
that allowed her to demonstrate her hot
packing technique. In 1946 Minneapolis
General added 1000 people to the staff
during a polio epidemic. Fifty patients were
admitted daily, and 30 iron lung respirators
were in use at one time.
18 | Approaches in Critical Care | June 2011

Historical Perspectives
Top left: Milk and formula
laboratory, 1938
Top right: Lymanhurst Childrensʼ
Ward for Rheumatic Heart
Disease, 1931
Library time on the boysʼ ward
Physicians prescribe fresh air on the roof
of the hospital. 1930
Iron Lung respirator
By the mid-1960s,
Minneapolis General
Hospitalʼs pediatric unit
cared for premature
infants, sick newborns
and children to age 17. This unit also cared for
children with critical trauma and burns. The focus of
pediatrics was changing during this time. Connie
Benson, RN, head nurse of the pediatric unit at the
time, discontinued the restrictive visiting hours and
experimented with playful scrubs and other things
common to modern pediatric practice. “The day I
became head nurse, I ripped down the signs and
opened visiting hours to 24 hours a day for the whole
family. I also made space for parents to stay
overnight,” Benson recounted. “The kids were afraid
of our white uniforms, so I went out and bought polka
dot sheets to make smocks for the staff. The nurses
were afraid to walk out of the break room for fear of
looking like a lollypop until Dr. Raile (Richard Raile,
MD, chief of pediatrics) took them to the cafeteria. It
was the stamp of approval they needed.”
With a census of 60, no private rooms, and admissions
at all levels of acuity, it became clear that a Pediatric
Intensive Care Unit (PICU) was necessary. Several
local disasters in the 1960s, including the Fridley
tornado and a fire at Benilde High School, made it
painfully clear that there was not enough capacity to
care for critically injured children, especially with new
Approaches in Critical Care | June 2011 | 19

Historical Perspectives
Dr. Per Wickstrom with Peds
patient, 1969
Dr. Richard Raile, MD, Chief
of Pediatrics opens new
Pediatric Unit, 1960
treatments and technologies changing the practice.
In 1968, the first PICU in the state of Minnesota
opened with two beds, co-managed by the surgery
and burn units. A neonatology ICU was also opened
in the same area at that time.
In 1969, Minneapolis Generalʼs medical staff began
to advocate for abused children. Raile, MD, and
Robert Ten Bensel, MD, co-authored a paper
outlining the diagnosis of battered child/child abuse
that received national attention. Abused children
were being seen more frequently in the PICU. A
multidisciplinary group began to meet to discuss the
problems of abuse and the Suspected Child Abuse
and Neglect Team was created.
In 1976, Minneapolis General Hospital became
Hennepin County Medical Center moving into a new
building and sharing space with Metropolitan Medical
Center. The PICU began to admit post-surgical
cardiology patients. A new PICU consisting of a
seven-bed multidisciplinary intensive care unit was
designed to provide comprehensive care to critically
ill children, ranging in age from newborn to age 17.
Common diagnoses on admission included trauma
and respiratory distress/failure. The burn unit also
opened in 1976. The emergency department
expanded its pediatric care area and pediatric staff
became more involved in emergency cases.
20 | Approaches in Critical Care | June 2011

Historical Perspectives
Nikki Stanley, 22 months old,
recovers from a life-threatening
brain injury in 1984.
Nikki, now married, a nurse
and a mother, reunites with
Dr. David Plummer, MD, the
emergency physician who
saved her life, 2010.
Pediatric Intensive
Care Unit, 2010
Nurse examining
patient and consulting
with parent in Pediatric
Intensive Care Unit,
2010
By 1980 the PICU was meeting all the challenges of
the modern world: new technology and equipment,
an increasingly diverse patient population and the
expansion of emergency services through helicopter
service. In 1989, HCMC became the first Level I
Trauma Center for both adults and children. Family
members of different ages who were injured in an
accident could all be admitted to the same hospital
into the appropriate ICUs. The regionʼs first hospitalbased
Biomedical Ethics Committee was established
and featured on the CBS Evening News. Research
continued to be an ongoing activity. Traumatic brain
injury patients were part of a neurosurgery research
study using hyperbaric treatments. The Pediatric
Brain Injury Program was established in 1989 and
since then, more than 2,400 children have received
acute and outpatient services to help them recover
from serious or mild-to-moderate brain injuries.
In the 1990s, the Pediatric Critical Care Task Force
was established and played an important role in
quality improvement in the PICU. Coverage was
provided 24/7 by critical care specialists including
neurosurgeons, trauma surgeons and orthopaedic
surgeons, and pediatric subspecialists in surgery,
neurology, cardiology, pulmonology, and ear, nose
and throat (ENT). Nurses were certified in Pediatric
Advanced Life Support (PALS) and/or Advanced
Pediatric Life Support (APLS) and participated in
continuing education related to trauma, pediatric
resuscitation and critical care. Many HCMC nurses
presented lectures on pediatric emergency and
critical care throughout the state. Allied patient care
and support staff now included interpreters, child life
specialists, health unit coordinators, health care
assistants, social workers, respiratory care practitioners,
occupational and physical therapists, speech-language
pathologists and dietitians.
Pediatric Inpatient Unit remodel, 2010
In November 2010, HCMC was verified as a Level I
Pediatric Trauma Center by the American College of
Surgeons. This verification – the highest possiblerecognizes
Hennepinʼs distinctive expertise in caring
for critically injured children. ■
Approaches in Critical Care | June 2011 | 21

Calendar of Events
To confirm hours and location of courses
and to register, visit www.hcmc.org and click
on “Professional Education and Training.” For
questions or additional information, contact
Susan Altmann in the medical education
department at Hennepin County Medical Center
at (612) 873-5681 or susan.altmann@hcmed.org
unless another contact person is provided.
Classes are at Hennepin unless otherwise
indicated. Many courses fill quickly; please
register early to avoid being wait-listed.
First Responder Refresher
August 25-26, October 27-28
__________________________________________
Healthcare Provider Cardiopulmonary
Resuscitation
August 10, September 7, October 17, November 16
__________________________________________
Heartsaver Automated External Defibrillator and
Cardiopulmonary Resuscitation
September 12
__________________________________________
Cardiopulmonary Resuscitation Instructor
November 7
__________________________________________
Advanced Cardiac Life Support for Providers (AHA)
June 20, 21(Residents/Open), August 16 and 17,
September 20 and 21, October 10 and 11, November
1 and 2, December 6 and 7
__________________________________________
Off-Site Advanced Cardiac Life Support (ASHI)
October Open - Willmar, November Open - Marshall
__________________________________________
Advanced Cardiac Life Support Provider Renewal
(AHA)
August 17, September 21, October 11, November 2,
December 7
__________________________________________
Advanced Cardiac Life Support Provider Renewal
(ASHI) for Hennepin Staff
June 14, July 26, August 23, September 6, October 5,
November 17, December 1
__________________________________________
Advanced Cardiac Life Support for Experienced
Providers (AHA)
October 4, November 14, December 12
__________________________________________
Advanced Cardiac Life Support Instructor (AHA)
July 5 and 6
__________________________________________
Advanced Cardiac Life Support Instructor
Renewal (AHA)
July 6
__________________________________________
Emergency Medical Technician Basic
October 10-28
__________________________________________
Emergency Medical Technician Refresher
November 2-4, November 28-30 (South Lake Public
Safety, Excelsior, MN)
__________________________________________
First Responder
September 19-23
__________________________________________
Cardiopulmonary Resuscitation Instructor
Renewals
November 7
__________________________________________
Cardiopulmonary Resuscitation/Basic Life
Support for Hennepin Staff
July 27, August 9, September 7, October 12,
November 9, December 14
__________________________________________
Infant-Child Cardiopulmonary Resuscitation
June 15, July 22, August 3, September 23,
October 12, November 11, December 14
__________________________________________
MD Cardiopulmonary Resuscitation for Hennepin
Staff
June 15, July 8, August 5, August 17, September 9,
October 7, October 19, November 4, December 2,
December 7
__________________________________________
Advanced Pediatric Life Support
July 19 and 20
__________________________________________
Advanced Trauma Life Support
July 12 and 13, October 6 and 7
__________________________________________
Trauma Nursing Core Course
September 14 and 15
__________________________________________
Trauma Nursing Core Course Renewal
November 16
__________________________________________
Pediatric Advanced Life Support for Providers
(AHA)
September 27 and 28, October 18 and 19
__________________________________________
Pediatric Advanced Life Support Renewal (AHA)
September 28, October 19
__________________________________________
14 22 | Approaches in Critical Care | January June 2011 2011

News Notes
News Notes
Tragedy Moves a Family to Take
Action to Change Seatbelt Laws
by Julie Philbrook, RN, MA
Trauma Services
Hennepin County Medical Center
One year . . . 12 months . . . 365 days . . .
8,760 hours . . . 525,600 minutes. August
18th, 2008 at 10:24 a.m. - when a bright
dreamy morning turned into a dark hellish
nightmare. But God is faithful and we began
even that first day, clinging to His promise
that, “Weeping may endure for the night,
but joy comes in the morning.” (Psalm 30:5).
Little did we know how long that night
would last. (www.CaringBridge.org, 2010).
This was the 240th entry to the CaringBridge
website that was established for a sevenyear-old
girl named Brynn Duncan, whose
life was changed in an instant. She was
seriously injured during a car crash when
her ill-fitting seat belt caused permanent
spinal cord and internal organ injuries.
When I heard about her injury, I logged
onto the CaringBridge website and followed
the often hourly updates that were posted
during her 54-day hospital stay. Each time I
read the log, I could not stop thinking that if
Minnesota had been successful in passing
stronger child passenger safety legislation
during the 2008 session, perhaps Brynnʼs
outcome would have been very different. I
also wondered if this child might be the
one to put a face on the booster seat bill
that advocates in Minnesota had been
trying to pass for seven years.
As the trauma prevention specialist for
Hennepin County Medical Center (HCMC),
I was not involved in Brynnʼs day-to-day
nursing care. I had not met her mother,
Dixie, and I struggled with knowing the
best way to approach the family about the
possibility of having them speak out for the
booster seat bill. I started by first asking
her physician, Andrew Kiragu, MD, if he
would introduce me to the family. I knew it
would be difficult to approach them, as I
did not want to place blame or make them
feel guilty.
Once Brynn was stable, I met with her and
Dixie and explained about the need to
change Minnesotaʼs child passenger safety
seat law to include the need for booster
seats. Dixie told me that, even though the
current law only required children to be in a
child restraint until age four, because Brynn
was small for her age, she had her use a
booster seat. However, on the day of the
crash, Brynn she was not riding with her
mom, and was not in a booster seat. As we
talked, Brynn told us that the shoulder
harness had been rubbing on her neck,
and she had it put behind her back, leaving
only the lap belt to restrain her. In the
crash, it was the lap belt that contributed to
her L1 spinal cord transection and severe
abdominal injuries, including a complete
duodenal transection, diaphragmatic tear, and
a right kidney resulting in a nephrectomy.
This cohort of injuries is referred to as the
“seat belt syndrome.”
Dixie was more than willing to take on this
cause. She said, “If it means that another
child is not injured it will be worth it.” As
Brynn recovered physically, she and her
family found purpose and passion in trying
to make a difference in the lives of other
children. They openly shared their story
with the legislature and the media. In the
beginning of this journey, I was concerned
whether the family would want to make
themselves vulnerable to public opinion
about how they had transported their child.
I came to see how truly healing this process
was for the whole family and the community.
Letters were written, phone calls made,
and testimony was given. In the end, after
seven attempts to pass stronger child
passenger safety (CPS) legislation, the bill
did pass and became law on July 1, 2009.
Years ago when I worked in the trauma
intensive care unit at HCMC, I often found
myself standing at a bedside watching
monitors, giving meds, and changing
dressings all the while thinking, “If only….if
only they had worn a helmet, if only they
had not been talking on the phone while
driving, if only they had been correctly
restrained, how different their life would be.”
Approaches in Critical Care | June | 23

News Notes
We all play a role in preventing life changing injuries.
We can role model safe behaviors. We can also
invite patients and families to share their story in
whatever way they feel comfortable, with the press,
in the classroom, at the capitol. When we make
trauma real to people, we can make real change.
The battle to upgrade the Minnesotaʼs car seat law
began the year Brynn was born. After much lobbying,
many phone calls and countless letters from many
advocates and agencies, in the end, a little sevenyear-old
sitting before legislators and a passionate
mother, testifying with tears in her eyes, convinced
lawmakers to pass the Minnesota Car Seat Law.
__________________________________________
approaches on immigrant and homeless populations.
For information about the program, topics and
speakers visit hcmc.org/bestof hennepin and visit us
on Facebook.
The post health care reform medical model will
require many more primary care providers than are
currently in the field, or even in the pipeline. This
conference will also address the implications of this
shortage and pose some questions and challenges
for discussion.
Hennepin County Medical Center has been at the
forefront of medical change for the last 100 years.
We intend to continue to lead the medical community
in Minnesota through teaching, research and
excellent medical care.
Please join us October 20-22 at the Holiday Inn
Metrodome. Be part of the discussion.
__________________________________________
P P P
Patients • Primary Care • Partnerships
Partnerships in
Primary Care –
Continuing Medical
Education Event
for Primary
Care Providers
A focus on patient
and family centered care.
1887
October 20-22, 2011
Holiday Inn Metrodome
www.hcmc.org/bestofhennepin
Mark your calendars for the Best of Hennepin
Conference, October 20-22
by John Crossen, MD
The 2011 Best of Hennepin Conference will focus on
the relationships between primary care physicians,
specialists and patients, especially those with chronic
diseases. As we go forward into this time of radical
change and reform in health care, the patient is
replacing the disease as the focus of the medical
equation. Our conference panels will provide an
opportunity for attendees to witness Patient Centered
Care through the interplay between specialists,
primary care physicians and patients in planning and
resolving chronic health concerns–to hear their
stories and understand their flashes of insight from
all perspectives. Conference speakers will also
address the effectiveness of traditional medical
Hennepin County Medical Center Pediatric
Emergency Drug Book
2012 Revised Edition coming soon!
Designed by author Dr. Al Tsai from the department
of Emergency Medicine, as an easy-to-use
reference, this drug book offers readily accessible
dosages by age and weight for most drugs required
during the care of critically ill or injured children. It
also inclludes reference charts for coma/trauma
scales, croup, asthma, ill child assessments, and
burn resuscitation.
To receive notification when available, please e-mail
pedsdrugbook@hcmed.org.
Did you train at Hennepin?
We’re looking for you.
You are an important member of an exclusive group
of physicians who share Hennepin County Medical
Centerʼs expertise and knowledge with the people
of the Upper Midwest. Hennepin is committed to
continue a learning and sharing relationship with
our alumni and would like to stay in touch.
Please submit your contact information at
HCMC.org/alumni.html
or to R. Hoppenrath, 701 Park Ave., Mpls, MN 55415
24 | Approaches in Critical Care | June 2011

For more information
To download additional resources for
critical care physicians, please visit
the Approaches in Critical Care Web
site at www.hcmc.org/approaches.
There, youʼll find:
An electronic version of
Approaches in Critical Care that
you can email to colleagues
Protocols, educational materials,
and many other resources from
past issues.
®
Every Life Matters

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Hennepin County Medical Center is a Level I
Trauma Center and public teaching hospital
repeatedly recognized as one of Americaʼs
best hospitals by U.S. News & World Report.
As one of the largest and oldest hospitals in
Minnesota, with 469 staffed beds and more
than 102,000 emergency services visits per
year at our downtown Minneapolis campus,
we are committed to provide the best possible
care to every patient we serve today; to search
for new ways to improve the care we will
provide tomorrow; to educate health care
providers for the future; and to ensure access
to health care for all.
Approaches in Critical Care | www.hcmc.org