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
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Abstract
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Case Presentations
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Introduction
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Critical Appraisal of the Literature
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Epidemiology and Pathophysiology
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Firearm Injuries
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Principles of Firearm Ballistics
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Prehospital Care
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Transport Modality
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Additional Considerations in the Prehospital Care of Trauma Patients
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Respiratory Compromise
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Hemorrhagic Shock
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Emergency Department Preparation After EMS Notification
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Emergency Department Evaluation
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Physical Examination
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Primary Survey
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Airway
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Breathing
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Circulation
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Disability/Exposure
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Secondary Survey
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Chest Examination
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Abdominal and Urogenital Examination
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Other Aspects of the Secondary Survey
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Stabilization and Treatment
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Estimation of Injury Severity
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Injury Severity Score
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Pediatric Trauma Score
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Treatment, Based on Location of Penetrating Trauma
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Esophageal Penetrating Trauma
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Chest Penetrating Trauma
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Abdominal Penetrating Trauma
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Diagnostic Testing and Procedures
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Imaging
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Laparotomy
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Laparoscopy
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Serial Physical Examinations
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Local Wound Exploration
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Adjunctive Testing
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Genitourinary Tract and Perineal Penetrating Trauma
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Genitourinary Tract Injuries
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Perineal Injuries
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Female Urogenital Penetrating Trauma
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Male Urogenital Penetrating Trauma
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Penetrating Penile Trauma
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Special Populations
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Patients With Concomitant Spinal Trauma
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Pregnant Patients
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Controversies and Cutting Edge
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Family Presence
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Tranexamic Acid
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Damage Control Resuscitation and Transfusion Ratios
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Thromboelastography
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Thoracotomy in the Emergency Department
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Minimally Invasive Surgery After Penetrating Truncal Trauma
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Disposition
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Summary
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Risk Management Pitfalls in the Management of Pediatric Patients With Penetrating Trauma to the Torso
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Time- and Cost-Effective Strategies
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Case Conclusions
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Clinical Pathways
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Clinical Pathway for Management of Pediatric Patients With Penetrating Trauma to the Torso
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Clinical Pathway for Management of Pediatric Patients With Penetrating Chest Trauma
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Clinical Pathway for Management of Pediatric Patients With Penetrating Renal/Genitourinary Trauma
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Clinical Pathway for Management of Pediatric Patients With Penetrating Perineal/Genital Trauma
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Tables and Figures
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Table 1. Criteria for Helicopter Transport Versus Ground Transport
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Table 2. Chest Tube Sizes for Pediatric Trauma Patients
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Table 3. Abbreviated Injury Scale (AIS)
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Table 4. Pediatric Trauma Score
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Table 5. Dosing of Tranexamic Acid in Pediatric Trauma Patients
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Figure 1. Incidence of Trauma, by Age
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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 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.
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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Miyata S, Cho J, Lebedevskiy O, et al. Trauma experts versus pediatric experts: comparison of outcomes in pediatric penetrating injuries. J Surg Res. 2017;208:173-179. (Retrospective study; 3737 patients)
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American College of Surgeons. The National Trauma Data Bank Annual Report 2016. Accessed April 15, 2019. (Annual report, ACS website)
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Tracy ET, Englum BR, Barbas AS, et al. Pediatric injury patterns by year of age. J Pediatr Surg. 2013;48(6):1384-1388. (Retrospective database review of pediatric trauma, all mechanisms; 354,196 patients)
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Adorisio O, Elia A, Pinzauti E, et al. The importance of a multidisciplinary approach in a child with major abdominal penetrating trauma. Pediatr Emerg Care. 2008;24(1):34-36. (Case report)
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Schecter SC, Betts J, Schecter WP, et al. Pediatric penetrating trauma: the epidemic continues. J Trauma Acute Care Surg. 2012;73(3):721-725. (Retrospective study, prognostic study, level II evidence; 598 patients)
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Brown JB, Forsythe RM, Stassen NA, et al. The National Trauma Triage Protocol: can this tool predict which patients with trauma will benefit from helicopter transport? J Trauma Acute Care Surg. 2012;73(2):319-325. (Retrospective review of the National Trauma Data Bank; 258,387 patients)
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Hansen M, Meckler G, O’Brien K, et al. Pediatric airway management and prehospital patient safety: results of a National Delphi Survey by the Children’s Safety Initiative-Emergency Medical Services for Children. PediatrEmerg Care. 2016;32(9):603-607. (National survey; 492 patients)
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Jones N, Ee M, Fenton E. Permissive hypotension in paediatric trauma. ANZ J Surg. 2012;82(7-8):567-568. (Expert opinion)
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Tosounidis TH, Giannoudis PV. Paediatric trauma resuscitation: an update. Eur J Trauma Emerg Surg. 2016;42(3):297-301. (Narrative review)
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Yoo Y, Mun S. The advantages of early trauma team activation in the management of major trauma patients who underwent exploratory laparotomy. Ann Surg Treat Res. 2014;87(6):319-324. (Retrospective review; 27,626 patients)
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Sasser SM, Hunt, RC, Faul M, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep. 2012;61(RR-1):1-20. (Expert guidelines)
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Lee TH, Ouellet JF, Cook M, et al. Pericardiocentesis in trauma: a systematic review. J Trauma Acute Care Surg. 2013;75(4):543-549. (Systematic review; 2094 patients)
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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-controlledtrial. Lancet. 2010;376(9734):23-32. (Randomized controlled trial; 20,211 adults)
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Harvey V, Perrone J, Kim P. Does the use of tranexamic acid improve trauma mortality? Ann Emerg Med. 2014;63(4):460-462. (Literature review)
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Beno S, Ackery AD, Callum J, et al. Tranexamic acid in pediatric trauma: why not? Crit Care. 2014;18(4):313. (Comparative study, review)
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Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858. (Retrospective review; 766 patients)
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Nosanov L, Inaba K, Okoye O, et al. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013;206(5):655-660. (Retrospective review; 105 patients)
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Vogel AM, Radwan ZA, Cox CS Jr, et al. Admission rapid thrombelastography delivers real-time “actionable” data in pediatric trauma. J Pediatr Surg. 2013;48(6):1371-1376. (Retrospective review; 86 patients)
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Nicolson NG, Schwulst S, Esposito TA, et al. Resuscitative thoracotomy for pediatric trauma in Illinois, 1999 to 2009. Am J Surg. 2015;210(4):720-723. (Retrospective review; 25 patients)
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Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: a 40-year review. J Pediatr Surg. 2016;51(2):315-318. (Prospective observational study; 179 patients)
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Allen CJ, Valle EJ, Thorson CM, et al. Pediatric emergency department thoracotomy: a large case series and systematic review. J Pediatr Surg. 2015;50(1):177-181. (Retrospective review; 252 patients)
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Easter JS, Vinton DT, Haukoos JS. Emergent pediatric thoracotomy following traumatic arrest. Resuscitation. 2012;83(12):1521-1524. (Retrospective cohort study; 29 patients)
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Hofbauer M, Hupfl M, Figl M, et al. Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation. 2011;82(2):185-189. (Retrospective cohort review; 11 patients)
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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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Pearson EG, Clifton MS. The role of minimally invasive surgery in pediatric trauma. Surg Clin North Am. 2017;97(1):75-84. (Review)
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American College of Surgeons. Resources for optimal care of the injured patient by the Verification Review Committee. Accessed April 15, 2019. (Industry guideline)
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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)
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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)
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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)
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Hobbs CJ. Abdominal injury due to child abuse. The Lancet. 366(9481):187-188. (Letter)
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Victim Rights Law Center. Mandatory reporting of non-accidental injuries: a state-by-state guide. AccessedApril 15, 2019. (Website)
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Centers for Disease Control and Prevention. Manual for the Surveillance of Vaccine-Preventable Diseases. Accessed April 15, 2019. (National organization manual)
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American College of Surgeons. Advanced Trauma Life Support course manual. 9th ed. American College of Surgeons; 2012. (National course manual)
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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)
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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
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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.
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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.
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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.
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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
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Brand M, Grieve A. Prophylactic antibiotics for penetrating abdominal trauma. Cochrane Database Syst Rev. 2013(11):CD007370. (Literature review)
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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)
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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)
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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)
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Pearson EG, Clifton MS. The role of minimally invasive surgery in pediatric trauma.. Surg Clin North Am. 2017;97(1):75- 84. (Review)
To Read The Companion Article:
To Read The Companion Article:
To Read The Companion Article:
The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems, The Pediatric Trauma Score (PTS) stratifies the severity of injury and mortality risk in pediatric trauma patients, and The Glasgow Coma Scale (GCS) assesses impairment in a patient's level of consciousness using eye, verbal, and motor criteria.
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Injury Severity Score (ISS)
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Pediatric Trauma Score (PTS)
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Glasgow Coma Scale
Injury Severity Score (ISS)
Introduction
The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems.
Points & Pearls
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The Injury Severity Score (ISS) was initially derived in patients with blunt traumatic injury from motor vehicle accidents.
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The ISS is not intended to be used for bedside decision-making for a single patient in the emergency department setting, but rather as a tool to standardize the study of trauma patients.
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Due to the nature of the score, multiple combinations of Abbreviated Injury Scale (AIS) scores may result in the same ISS, each of which may indicate a different mortality rate. For example, an ISS of 17 can be calculated from patients with a combination of points based on the 3 most se-vere injuries, such as (4, 1, 0) or (3, 2, 2). The ISS assigns equal value to each body region.
Why and When to Use and Next Steps
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.
Next Steps
As the ISS is intended primarily as a research tool, the score should not affect the initial management of a patient with traumatic injuries.
Calculator Review Authors
Max Berger, MD
Ronald O. Perelman Department of Emergency
Medicine, NYU Langone Health, New York, NY
Alexandra Ortego, MD
Ronald O. Perelman Department of Emergency
Medicine, NYU Langone Health, New York, NY
Instructions
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.
Critical Actions
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In all trauma patients, the initial treatment strategy should focus on the primary and secondary survey, and assessing and stabilizing the patient.
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Although the ISS score is intended primarily for research purposes, it may have broader clinical use in the intensive care unit for prognostication following the initial stabilization of traumatic injuries.
Evidence Appraisal
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.
Calculator Creator
Susan P. Baker, MPH
References
Original/Primary Reference
Validation References
Pediatric Trauma Score (PTS)
Introduction
The Pediatric Trauma Score (PTS) stratifies the severity of injury and mortality risk in pediatric trauma patients.
Points & Pearls
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The Pediatric Trauma Score (PTS) is best used as a general predictor for stratifying traumatic injury severity.
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The PTS is poorly validated in blunt abdominal trauma and has not been shown to reliably predict isolated injuries to the liver or spleen (Saladino 1991).
Why and When to Use and Next Steps
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
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The PTS should be used for pediatric patients (aged < 18 years) who present with trauma.
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The score is poorly validated in patients with blunt abdominal trauma, so it should be used with caution in this population.
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The PTS should not be used to predict the presence of isolated injuries.
Next Steps
Patients should be monitored for any evolution of signs and symptoms, as conditions may change after the initial assessment and scoring with the PTS.
Calculator Review Author
Matthew Lecuyer, MD
Department of Emergency Medicine (Pediatrics), Warren
Alpert Medical School of Brown University, Providence, RI
Advice
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.
Critical Actions
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.
Evidence Appraisal
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).
Calculator Creator
Joseph J. Tepas, III, MD
References
Original/Primary Reference
Validation References
Other Reference
Glasgow Coma Scale
Introduction
The Glasgow Coma Scale (GCS) assesses impairment in a patient's level of consciousness using eye, verbal, and motor criteria.
Points & Pearls
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The Glasgow Coma Scale (GCS) allows clinicians in multiple settings and with varying levels of training to communicate succinctly about a patient’s mental status.
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The GCS has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality.
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The GCS score has been incorporated into numerous guidelines and assessment scores.
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The correlation of the GCS score with outcome and severity is most accurate when applied to an individual patient over time; the trend in the patient's GCS score is important.
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A GCS score of 8 should not be the only factor used to determine whether or not to intubate a patient, but it does suggest a level of obtundation that should be evaluated carefully.
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The reproducibility of GCS scores can be low; the GCS creators provide training and education to help improve scoring agreement between providers at www.glasgowcomascale.org.
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There are simpler scores that have been shown to perform as well as the GCS in the prehospital and emergency department setting (for initial evaluation); these are often contracted versions of the GCS itself. For example, the Simplified Motor Score uses only the motor portion of the GCS. These contracted scores are less well-studied than the GCS for trending over time and for outcomes such as long-term mortality.
Why and When to Use, Next Steps, and Advice
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.
Next Steps
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The GCS score can indicate the level of critical illness.
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Trauma patients presenting with a GCS score < 15 warrant close attention and reassessment.
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A declining GCS score is concerning in any setting, and should prompt airway assessment and possible intervention.
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A GCS score of 15 should not be taken as an indication that a patient is not critically ill.
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Decisions about management and treatment plans should be made based on clinical presentation and context, and should not be overridden by the GCS score.
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If a trauma patient has a GCS score < 8 and there is clinical concern that the patient is unable to protect the airway or there is an expected worsening clinical course based on examination or imaging findings, then intubation can be considered.
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In any patient, a rapidly declining or waxing and waning GCS score is concerning, and intubation should be considered.
Advice
For children who are preverbal or aged ≤ 2 years, use the Pediatric Glasgow Coma Scale
Calculator Review Author
Daniel Runde, MD
Department of Emergency Medicine, University of Iowa
Hospitals and Clinics, Iowa City, IA
Critical Actions
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.
Evidence Appraisal
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.
Calculator Creator
Sir Graham Teasdale, MBBS, FRCP
References
Original/Primary Reference
Validation Reference
Other References
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Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology. 1978;49(3):225-226.
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Teasdale G, Jennett B, Murray L, et al. Glasgow coma scale: to sum or not to sum. Lancet. 1983;2(8351):678.
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Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003;54(4):671-678; discussion 678-680.
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Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011;58(5):427-430.
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Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012;15(3):170-183.
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Yeh DD. Glasgow Coma Scale 40 years later: in need of recalibration? JAMA Surg. 2014;149(7):734.
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Teasdale G. Forty years on: updating the Glasgow Coma Scale. Nurs Times. 2014;110(42):12-16.
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Gill M, Windemuth R, Steele R, et al. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005;45(1):37-42.
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Haukoos JS, Gill MR, Rabon RE, et al. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med. 2007;50(1):18-24.
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Thompson DO, Hurtado TR, Liao MM, et al. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58(5):417-425.
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