Table of Contents

 

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. This issue provides an evidence-based approach to the assessment and management of pediatric patients who present with penetrating injuries to the torso. You will learn:

Principles of firearm ballistics and how the type of weapon relates to the gunshot wound it creates

Physiologic and anatomic criteria that indicate a patient will have better survival outcomes if transported via helicopter versus ground transport

Key aspects to consider while performing the primary survey and secondary survey

Which methods for estimating a child’s weight are most accurate

A quick method for estimating the appropriate chest tube size

How tools such as the Injury Severity Score and Pediatric Trauma Score can be used to estimate the severity of injuries and associated morbidity/mortality

Evidence-based recommendations for management of pediatric patients with penetrating trauma, based on the location of the injuries, including:

When a patient with thoracic penetrating trauma should be sent emergently to the operating room

Which laboratory studies are recommended, and which have little clinical utility

Which imaging studies should be performed, and which are less sensitive/specific in patients with penetrating trauma

The benefits of laparoscopy, and when laparoscopy should be converted to laparotomy

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology and Pathophysiology
   1. Firearm Injuries
      1. Principles of Firearm Ballistics
6. Prehospital Care
   1. Transport Modality
   2. Additional Considerations in the Prehospital Care of Trauma Patients
      1. Respiratory Compromise
      2. Hemorrhagic Shock
   3. Emergency Department Preparation After EMS Notification
7. Emergency Department Evaluation
   1. Physical Examination
8. Primary Survey
   1. Airway
   2. Breathing
   3. Circulation
   4. Disability/Exposure
9. Secondary Survey
   1. Chest Examination
   2. Abdominal and Urogenital Examination
   3. Other Aspects of the Secondary Survey
10. Stabilization and Treatment
    1. Estimation of Injury Severity
       1. Injury Severity Score
       2. Pediatric Trauma Score
    2. Treatment, Based on Location of Penetrating Trauma
       1. Esophageal Penetrating Trauma
       2. Chest Penetrating Trauma
       3. Abdominal Penetrating Trauma
          • Diagnostic Testing and Procedures
            • Imaging
            • Laparotomy
            • Laparoscopy
            • Serial Physical Examinations
            • Local Wound Exploration
            • Adjunctive Testing
       4. Genitourinary Tract and Perineal Penetrating Trauma
          • Genitourinary Tract Injuries
          • Perineal Injuries
          • Female Urogenital Penetrating Trauma
          • Male Urogenital Penetrating Trauma
          • Penetrating Penile Trauma
11. Special Populations
    1. Patients With Concomitant Spinal Trauma
    2. Pregnant Patients
12. Controversies and Cutting Edge
    1. Family Presence
    2. Tranexamic Acid
    3. Damage Control Resuscitation and Transfusion Ratios
    4. Thromboelastography
    5. Thoracotomy in the Emergency Department
    6. Minimally Invasive Surgery After Penetrating Truncal Trauma
13. Disposition
14. Summary
15. Risk Management Pitfalls in the Management of Pediatric Patients With Penetrating Trauma to the Torso
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathways
    1. Clinical Pathway for Management of Pediatric Patients With Penetrating Trauma to the Torso
    2. Clinical Pathway for Management of Pediatric Patients With Penetrating Chest Trauma
    3. Clinical Pathway for Management of Pediatric Patients With Penetrating Renal/Genitourinary Trauma
    4. Clinical Pathway for Management of Pediatric Patients With Penetrating Perineal/Genital Trauma
19. Tables and Figures
    1. Table 1. Criteria for Helicopter Transport Versus Ground Transport
    2. Table 2. Chest Tube Sizes for Pediatric Trauma Patients
    3. Table 3. Abbreviated Injury Scale (AIS)
    4. Table 4. Pediatric Trauma Score
    5. Table 5. Dosing of Tranexamic Acid in Pediatric Trauma Patients
    6. Figure 1. Incidence of Trauma, by Age
20. References

Abstract

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.

Case Presentations

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?

Introduction

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.

Critical Appraisal of the Literature

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 10^th 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.

Risk Management Pitfalls in the Management of Pediatric Patients With Penetrating Trauma to the Torso

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.

Tables and Figures

References

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.

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97. Garg N, St Peter SD, Tsao K, et al. Minimally invasive management of thoracoabdominal penetrating trauma in a child. J Trauma. 2006;61(1):211-212. (Case report)
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99. American College of Surgeons. Resources for optimal care of the injured patient by the Verification Review Committee. Accessed April 15, 2019. (Industry guideline)
100. Peterson RJ, Tiwary AD, Kissoon N, et al. Pediatric penetrating thoracic trauma: a five-year experience. Pediatr Emerg Care. 1994;10(3):129-131. (Retrospective review; 13 patients)
101. Parikh K, Silver A, Patel SJ, et al. Pediatric firearm-related injuries in the United States. Hosp Pediatr. 2017;7(6):303-312. (Epidemiological review)
102. Webster DW, Starnes M. Reexamining the association between child access prevention gun laws and unintentional shooting deaths of children. Pediatrics. 2000;106(6):1466-1469. (Pooled, time-series study, national review)
103. Hobbs CJ. Abdominal injury due to child abuse. The Lancet. 366(9481):187-188. (Letter)
104. Victim Rights Law Center. Mandatory reporting of non-accidental injuries: a state-by-state guide. AccessedApril 15, 2019. (Website)
105. Centers for Disease Control and Prevention. Manual for the Surveillance of Vaccine-Preventable Diseases. Accessed April 15, 2019. (National organization manual)
106. American College of Surgeons. Advanced Trauma Life Support course manual. 9^th ed. American College of Surgeons; 2012. (National course manual)
107. Maull KI, Rozycki GS, Vinsant GO, et al. Retroperitoneal injuries: pitfalls in diagnosis and management. South Med J. 1987;80(9):1111-1115. (Retrospective review; 177 patients)
108. Houry D, Sachs CJ, Feldhaus KM, et al. Violence-inflicted injuries: reporting laws in the fifty states. Ann Emerg Med. 2002;39(1):56-60. (Review)

Points and Pearls Excerpt

• 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.
• Knowing the weight of the child (or at least having an initial estimate) is critical. Obtain an estimate of the patient’s weight by asking the parent(s) for an estimation of their child’s weight or by using length-based formulas that include general body habitus.
• Children can bleed 50% of their blood volume into their chest, and may not show signs of decreased blood pressure until the loss of up to 30% of their blood volume.
• Estimations for total-body blood volume are as follows: infants, 80 mL/kg; children aged 1 to 3 years, 75 mL/kg; children aged > 3 years, 70 mL/kg.

Most Important References

• Brand M, Grieve A. Prophylactic antibiotics for penetrating abdominal trauma. Cochrane Database Syst Rev. 2013(11):CD007370. (Literature review)
• Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68(3):721-733. (Practice management guideline)
• Quinn AC, Sinert R. What is the utility of the focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? Injury. 2011;42(5):482-487. (Literature review)
• CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. (Randomized controlled trial; 20,211 adults) 
• Pearson EG, Clifton MS. The role of minimally invasive surgery in pediatric trauma.. Surg Clin North Am. 2017;97(1):75- 84. (Review)