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.
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?
A 15-year-old girl ambulates into the ED with a single stab wound to the right lower quadrant of the abdomen. She is unaccompanied. Her vital signs are: temperature, 36.9°C (98.4°F); heart rate, 96 beats/minute; blood pressure, 140/80 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 99% on room air. The primary and secondary surveys reveal no other injuries. The eFAST is negative for intra-abdominal fluid. What kind of imaging should be ordered for this patient? How do you determine whether she is a candidate for surgery versus expectant management?
Regionalized trauma centers and updates in critical and surgical care have contributed to increased survival among pediatric trauma patients; however, many emergency clinicians practice outside of trauma centers and have less experience evaluating and treating pediatric patients with a penetrating injury.1 Even trauma centers lack uniformity with highest level activation criteria,2 and outcomes data demonstrate that younger children treated at nonpediatric trauma centers have inferior outcomes.3 This issue of Pediatric Emergency Medicine Practice offers an evidence-based approach to the assessment, management, and disposition of pediatric patients who present with penetrating injuries to the torso.
A literature search was conducted in PubMed using the search terms: pediatric AND trauma, pediatric AND penetrating AND injury, and pediatric AND fluid AND trauma. The search produced 777 studies on pediatric penetrating trauma, of which, 102 were chosen for full review. A search of the Ovid MEDLINE® database returned 399 articles on pediatric trauma, 69 of which were selected for full review. The literature consists mostly of prospective observational studies, retrospective reviews, and case reports, and includes very few randomized clinical trials. The incidence of penetrating thoracoabdominal trauma in pediatric patients is not very common, and, because of this, the literature is largely observational and retrospective. Some data have been extrapolated to the pediatric population from adult trauma-related information. The 10th edition of the Advanced Trauma Life Support (ATLS®) guidelines is the most recent version and will be referred to in this text as the ATLS guidelines, unless otherwise noted.
2. “We received a 10-year-old boy who had a small abdominal stab wound from a pencil. He was admitted for observation. I was shocked when he later had worsening symptoms, which required laparotomy, during which a hollow viscus injury was noted.”
Suspicion for hollow viscus injuries requires mechanistic consideration with close ongoing examinations. Hollow viscus injuries often cannot be detected at the time of the primary and secondary surveys but become apparent on repeat serial examination.15
7. “Our trauma team cared for a 3-year-old boy who was shot by a sibling who had access to the firearms in the house. Our trauma surgeon asked that all family members be taken to the quiet room, so that the clinical team could focus and imaging could be obtained rapidly.”
Though many emergency clinicians remove family members during resuscitation, evidence supports a low occurrence of negative outcomes with family presence during pediatric trauma evaluations. Evidence shows positive reports from families, a high level of information sharing between parents and the medical team, and no operational delays.83
9. “I took care of a 12-year-old girl who had fallen from a first-floor balcony. She presented with obvious penetrating trauma to the flank. Witnesses report that she landed on a pool fence. During our resuscitation, her blood pressure remained low, despite fluid and blood resuscitation. Later, we realized the low blood pressure was secondary to neurogenic shock.”
Spinal injuries can be overlooked in the face of more obvious penetrating injuries. This patient had sustained a spinal fracture. When patients are altered and a neurologic examination is unreliable, emergency clinicians should be acutely aware of a potential spinal pathology and its relationship to hypotension.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Why to Use
Due to the heterogeneous nature of trauma patients, standardizing the severity of traumatic injuries allows for comparison of much larger sample populations in trauma research studies.
When to Use
The ISS attempts to standardize the severity of injuries sustained during trauma. This standardization allows for more accurate study and prediction of morbidity and mortality outcomes after traumatic injuries.
As the ISS is intended primarily as a research tool, the score should not affect the initial management of a patient with traumatic injuries.
Max Berger, MD
Alexandra Ortego, MD
First, the most severe injury from each of 6 body systems is assigned an AIS score on a scale of 0 (no injury) to 6 (unsurvivable injury). Next, those scores are used to determine the 3 most injured body systems. Finally, the ISS is calculated by squaring the AIS score for each of the 3 most injured body systems, then adding up the 3 squared numbers (A2 + B2 + C2 = ISS, where A, B, and C are the AIS scores of the most severe injury in each of the 3 most severely injured body systems). Patients with an AIS of 6 in any body system are automatically assigned an ISS of 75, the maximum possible score.
The ISS is used primarily in research settings, so calculation of the score should not delay initial management of patients with traumatic injuries.
The ISS was derived by Baker et al (1974) by taking the previously used AIS (American Medical Association Committee on Medical Aspects of Automotive Safety 1971) and adding the squared value of each of the 3 most severely injured body systems, in an effort to add increasing importance to the most severe injuries. The top 3 most severe injuries were used to calculate the final score because it had been shown that injuries that would not necessarily be life-threatening in isolation could have a significant effect on mortality when they occurred in combination with other severe injuries. The derivation study included only injuries sustained from motor vehicle collisions, including the occupants of the vehicles and any pedestrians involved.
Further studies have validated the ISS to include other mechanisms of injury. A study by Beverland et al (1983) of 875 patients with gunshot wounds showed that an increasing ISS was associated with increasing mortality (chi-squared = 83.31, P < .001). A study by Bull (1978) confirmed the correlation between increasing ISS and increasing mortality in road traffic accidents, and showed correlation between increasing ISS and increasing mean hospital length of stay.
In a study of 8852 trauma patients from the Illinois Trauma Program (including both vehicular and nonvehicular trauma), Semmlow et al (1976) had similar findings to Baker et al regarding the relationship between ISS and mortality. They also found that the ISS correlated with hospital length of stay.
Susan P. Baker, MPH
Why to Use
The PTS helps clinicians stratify injury severity and mortality risk in pediatric trauma patients. It can also be used to triage patients in a resource-limited environment, identifying the patients who are at high mortality risk versus patients who may not be as critically ill and will need fewer resources.
The PTS can be used for triage by first responders on the scene to help determine which patients require transfer to a pediatric trauma center.
When to Use
Patients should be monitored for any evolution of signs and symptoms, as conditions may change after the initial assessment and scoring with the PTS.
Matthew Lecuyer, MD
A low PTS correlates with high mortality risk, so a patient with a low score should be triaged for immediate medical attention at a pediatric trauma center (if nearby) or for stabilization at the nearest medical facility, at the discretion of the first responder.
Patients who have higher scores are less likely to have significant morbidity and mortality, but require reassessment as symptoms evolve. These patients should still be evaluated by a clinician, and a complete history and physical examination should be performed.
Reassessment is an essential component of patient care in all trauma cases. Patients who have a low initial PTS, which indicates high risk for morbidity and mortality, may have changes in their clinical status, so recalculation may be necessary. Patients who have a high PTS should not be advised against further medical attention, as evaluation by a clinician is still recommended.
The PTS was first described by Tepas et al (1987) in a matched cohort study comparing 2 groups of 110 and 120 pediatric trauma patients, respectively. The study found a linear relationship between the PTS and the Injury Severity Score (ISS). The authors further validated their findings in a retrospective cohort study that included data for 615 children entered into the National Pediatric Trauma Registry between April and December 1985 (Tepas 1988). This study confirmed the correlation between increasing PTS and increasing ISS. Notably, the study authors did not correlate the findings with mechanism of injury. The study found that a PTS < 0 had a 100% mortality rate and a PTS > 8 was associated with no mortality; patients with a PTS of 0 to 8 had decreasing mortality rates as the PTS increased, showing an inverse linear correlation between increasing severity of injury and decreasing PTS.
Ramenofsky et al (1988) validated these findings in a cohort of 450 injured children who were evaluated by a paramedic in the field and a physician in the emergency department. The study confirmed an inverse linear correlation of PTS with injury severity and found a 93.6% correlation between the 2 clinicians (correlation coefficient = 0.991). A later study (Saladino 1991) found the PTS to be a poor predictor of isolated blunt abdominal injuries (eg, liver and spleen).
Joseph J. Tepas, III, MD
Why to Use
The GCS is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
The GCS is designed for use in serial assessments of patients with decreased mental alterness from either medical or surgical causes and is widely applicable. It is commonly used in the prehospital and acute-care setting as well as over the course of a patient's hospitalization to evaluate for mental status in patients with either traumatic or nontraumatic presentations.
For children who are preverbal or aged ≤ 2 years, use the Pediatric Glasgow Coma Scale
Daniel Runde, MD
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
In the acute care setting, the GCS has been shown to have highly variable reproducibility and inter-rater reliability (eg, 56% among neurosurgeons in one study, 38% among emergency department physicians in another study). In its most common usage, the 3 sections of the GCS are often combined to provide a summary of severity. The authors themselves have explicitly objected to the GCS being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1E + 1V + 2M (for eye, verbal, and motor components, respectively), and a mortality rate of 27% if calculated 1E + 2V + 1M, but a mortality rate of only 19% if calculated 2E + 1V + 1M (Healey 2014).
In summary, the modified GCS provides an almost universally accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score results in information loss and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the GCS can perform as well as the GCS and is significantly less complicated. However, contracted scores may be less informative for patients with lesser injuries.
Sir Graham Teasdale, MBBS, FRCP
Elizabeth Haines, DO, FACEP; Hilary Fairbrother, MD, MPH, FACEP
Chris Newton, MD; Lara Zibners, MD, MMed
May 2, 2019
June 1, 2022
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits
Date of Original Release: May 1, 2019. Date of most recent review: April 15, 2019. Termination date: May 1, 2022.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for 48 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Haines, Dr. Fairbrother, Dr. Newton, Dr. Zibners, Dr. Mishler, Dr. Skrainka, Dr. Claudius, Dr. Horeczko, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of this article. (2) Mail or fax the CME Answer And Evaluation Form with your June and December issues to Pediatric Emergency Medicine Practice.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.