Publication Date: May 2019 (Volume 16, Number 5)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 5/01/2022.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Children with penetrating trauma to the torso require careful evaluation of the chest, abdomen, pelvis, and genital structures for system-specific injuries that may contribute to rapid decompensation and influence the order of emergent resuscitation. Care of the injured child and the effect on clinical outcomes starts in the prehospital setting, with hemorrhage control and IV fluid resuscitation. The evaluation and disposition of the patient in the ED will depend on the mechanism of injury and the severity of trauma. This issue reviews the diagnostic evaluation and management of pediatric patients with penetrating injuries to the torso.
Excerpt From This Issue
A 12-year-old boy is brought in to your ED via EMS after he fell onto a gatepost, impaling his abdomen. His vital signs on arrival are: temperature, 37°C (98.6°F); heart rate, 120 beats/min; blood pressure, 110/80 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 99% on room air. He arrives with part of the gatepost still intact in the right upper quadrant of his abdomen. There is no active external bleeding at the site of the injury. The primary survey is otherwise normal. Two IV catheters are placed. On secondary survey, you note that the patient has minimal tenderness, except immediately around the gatepost, no obvious signs of evisceration, and no blood in the rectum. The pediatric surgery team is concerned about this child and is pushing for him to go the operating room as quickly as possible. Which imaging test—if any—would be best for diagnosing intra-abdominal injuries in this patient? Does the child have time to go for additional testing or should he go straight to the operating room? Does he even need to go to the operating room, or can the gatepost be removed in the ED?
A 3-year-old boy with a single gunshot wound to the right upper chest is brought into the ED. There is an exit wound noted on his right upper back. His vital signs on arrival are: temperature, 37.2°C (99°F); heart rate, 120 beats/min; blood pressure, 100/70 mm Hg; respiratory rate, 26 breaths/min; and oxygen saturation, 98% on room air. He is initially alert and crying. During your primary survey, you note that his breath sounds are decreased on the right side. A resident uses a bedside ultrasound for an eFAST and notes a lack of lung sliding on the right side of the patient's chest. During the secondary survey, the patient’s heart rate begins to increase. You ask yourself: What imaging test—if any—should be performed next? Should a chest tube be placed emergently, and, if so, is there an easy way to determine the appropriate size of the chest tube?