Evaluation and Management of Pediatric Patients With Penetrating Trauma to the Torso (Trauma CME)

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.

1. Petrosyan M, Guner YS, Emami CN, et al. Disparities in the delivery of pediatric trauma care. J Trauma. 2009;67(2 Suppl):S114-S119. (Literature review; 60 studies)
2. Zagory JA, Wieck MM, Lerner BE, et al. Evaluation of highest level pediatric trauma activation criteria. Pediatr Emerg Care. 2017. (Retrospective review of all ACS Level I pediatric trauma centers)
3. 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)
4. American College of Surgeons. The National Trauma Data Bank Annual Report 2016. Accessed April 15, 2019. (Annual report, ACS website)
5. 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)
6. 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)
7. 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)
8. Centers for Disease Control and Prevention, Injury Prevention Control. Injury prevention and control: data and statistics (WISQARS) National Center for Health Statistics, National Vital Statistics system. Accessed April 15, 2019. (CDC website)
9. Lichte P, Oberbeck R, Binnebosel M, et al. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med. 2010;18:35. (Literature review)
10. Gonzalez RP, Cummings GR, Phelan HA, et al. Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis. Am J Surg. 2009;197(1):30-34. (Statewide analysis/survey; 45,763 patients)
11. 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)
12. 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)
13. Cooper A, DiScala C, Foltin G, et al. Prehospital endotracheal intubation for severe head injury in children: a reappraisal. Semin Pediatr Surg. 2001;10(1):3-6. (National review; 31,464 patients)
14. Simons T, Soderlund T, Handolin L. Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study. Eur J Trauma Emerg Surg. 2017;43(6):797-804. (Retrospective review; 34 patients)
15. American College of Surgeons. Advanced Trauma Life Support Student Course Manual, 10^th ed. Chicago: American College of Surgeons; 2018:186-212. (Industry standard guidelines)
16. Spinella PC, Cap AP. Prehospital hemostatic resuscitation to achieve zero preventable deaths after traumatic injury. Curr Opin Hematol. 2017;24(6):529-535. (Review)
17. Johnson M, Inaba K, Byerly S, et al. Intraosseous infusion as a bridge to definitive access. Am Surg. 2016;82(10):876-880. (Retrospective study; 68 patients)
18. Haskell GH, Gausche-Hill M. Pediatric Advanced Life Support Review: Pearls of Wisdom. 3^rd ed. New York: McGraw Hill Medical; 2007. (Book)
19. Vrettos T, Poimenidi E, Athanasopoulos P, et al. The effect of permissive hypotension in combined traumatic brain injury and blunt abdominal trauma: an experimental study in swines. Eur Rev Med Pharmacol Sci. 2016;20(4):620-630. (Animal study; 12 pigs)
20. Jones N, Ee M, Fenton E. Permissive hypotension in paediatric trauma. ANZ J Surg. 2012;82(7-8):567-568. (Expert opinion)
21. Tosounidis TH, Giannoudis PV. Paediatric trauma resuscitation: an update. Eur J Trauma Emerg Surg. 2016;42(3):297-301. (Narrative review)
22. Fischer PE, Bulger EM, Perina DG, et al. Guidance document for the prehospital use of tranexamic acid in injured patients. Prehosp Emerg Care. 2016;20(5):557-559. (Guidelines)
23. 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)
24. Dowd MD, McAneney C, Lacher M, et al. Maximizing the sensitivity and specificity of pediatric trauma team activation criteria. Acad Emerg Med. 2000;7(10):1119-1125. (Observational study; 492 patients)
25. Vernon DD, Furnival RA, Hansen KW, et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics. 1999;103(1):20-24. (Prospective case-controlled study; 49 patients)
26. 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)
27. Lloyd-Thomas AR. ABC of major trauma. Paediatric trauma: primary survey and resuscitation--I. BMJ. 1990;301(6747):334-336. (Review)
28. Wells M, Goldstein LN, Bentley A. The accuracy of emergency weight estimation systems in children-a systematic review and meta-analysis. Int J Emerg Med. 2017;10(1):29. (Systematic review and meta-analysis)
29. Wells M, Goldstein LN, Bentley A, et al. The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide - a systematic review and meta-analysis. Resuscitation. 2017;121:9-33. (Systematic review and meta-analysis)
30. Young KD, Korotzer NC. Weight estimation methods in children: a systematic review. Ann Emerg Med. 2016;68(4):441-451. (Literature review)
31. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl3):S862-S875. (Industry standard guidelines)
32. Lloyd-Thomas AR. ABC of major trauma. Paediatric trauma: primary survey and resuscitation--II. BMJ. 1990;301(6748):380-382. (Review)
33. Acker SN, Hall B, Hill L, et al. Adult-based massive transfusion protocol activation criteria do not work in children. Eur J Pediatr Surg. 2017;27(1):32-35. (Retrospective review; 50 patients)
34. 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)
35. Matsushima K, Khor D, Berona K, et al. Double jeopardy in penetrating trauma: get FAST, get it right. World J Surg. 2018;42(1):99-106. (Retrospective study; 2851 adults)
36. Borgialli DA, Mahajan P, Hoyle JD Jr, et al. Performance of the pediatric Glasgow Coma Scale score in the evaluation of children with blunt head trauma. Acad Emerg Med. 2016;23(8):878-884. (Prospective observational study, secondary analysis; 10,499 patients)
37. Cotton BA, Nance ML. Penetrating trauma in children. Semin Pediatr Surg. 2004;13(2):87-97. (Review)
38. Yadav K, Jalili M, Zehtabchi S. Management of traumatic occult pneumothorax. Resuscitation. 2010;81(9):1063-1068. (Review)
39. Lee LK, Rogers AJ, Ehrlich PF, et al. Occult pneumothoraces in children with blunt torso trauma. Acad Emerg Med. 2014;21(4):440-448. (Prospective observational cohort study, substudy; 8020 patients)
40. Hazinski MF, Cummins RO, Field JM, et al. 2000 Handbook of Emergency Cardiovascular Care for Healthcare Providers. 2000 ed. Dallas. American Heart Association; 2000. (Clinical guidelines)
41. Okur MH, Uygun I, Arslan MS, et al. Traumatic diaphragmatic rupture in children. J Pediatr Surg. 2014;49(3):420-423. (Retrospective review; 22 patients)
42. Uhlich R, Kerby JD, Bosarge P, et al. Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration. Trauma Surg Acute Care Open. 2018;3(1):e000251. (Retrospective review;1068 patients)
43. Robicsek F, Daugherty HK, Stansfield AV. Massive chest trauma due to impalement. J Thorac Cardiovasc Surg. 1984;87(4):634-636. (Case report)
44. Edwin F, Tettey M, Sereboe L, et al. Impalement injuries of the chest. Ghana Med J. 2009;43(2):86-89. (Case report)
45. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59(6):1314-1319. (Prospective trial; 512 patients)
46. Niemi TA, Norton LW. Vaginal injuries in patients with pelvic fractures. J Trauma. 1985;25(6):547-551. (Retrospective review; 114 patients)
47. Reece RM, Hanson RF, Sargent J. Treatment of Child Abuse: Common Ground for Mental Health, Medical, and Legal Practitioners. 2^nd ed. Baltimore: The Johns Hopkins University Press; 2014. (Textbook)
48. Fleisher GR, Ludwig, S. Textbook of Pediatric Emergency Medicine. 6^th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. (Textbook)
49. Brand M, Grieve A. Prophylactic antibiotics for penetrating abdominal trauma. Cochrane Database Syst Rev. 2013(11):CD007370. (Literature review)
50. Goldberg SR, Anand RJ, Como JJ, et al. Prophylactic antibiotic use in penetrating abdominal trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S321-S325. (Literature review)
51. Ozturk H, Dokucu AI, Otcu S, et al. The prognostic importance of trauma scoring systems for morbidity in children with penetrating abdominal wounds: 17 years of experience. J Pediatr Surg. 2002;37(1):93-98. (Retrospective review; 119 patients)
52. Gennarelli TA, Wodzin E. The Abbreviated Injury Scale 2005. Update 2008. Chicago: Association for the Advancement of Automotive Medicine; 2008. (Book)
53. Baker SP, O’Neill B, Haddon W Jr, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-196. (Retrospective cohort study)
54. Reinhorn M, Kaufman HL, Hirsch EF, et al. Penetrating thoracic trauma in a pediatric population. Ann Thorac Surg. 1996;61(5):1501-1505. (Retrospective review; 65 patients)
55. Tepas JJ 3rd, Ramenofsky ML, Mollitt DL, et al. The pediatric trauma score as a predictor of injury severity: an objective assessment. J Trauma. 1988;28(4):425-429. (Retrospective case series)
56. Tepas JJ 3rd, Mollitt DL, Talbert JL, et al. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg. 1987;22(1):14-18. (Retrospective review; 615 patients)
57. Biffl WL, Moore EE, Feliciano DV, et al. Western Trauma Association critical decisions in trauma: diagnosis and management of esophageal injuries. J Trauma Acute Care Surg. 2015;79(6):1089-1095. (Industry standard guidelines)
58. Kharasch SJ, Millham F, Vinci RJ. The use of autotransfusion in pediatric chest trauma. Pediatr Emerg Care. 1994;10(2):109-112. (Case review)
59. Lustenberger T, Talving P, Lam L, et al. Penetrating cardiac trauma in adolescents: a rare injury with excessive mortality. J Pediatr Surg. 2013;48(4):745-749. (Retrospective review; 32 patients)
60. 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)
61. Sakamoto R, Matsushima K, de Roulet A, et al. Nonoperative management of penetrating abdominal solid organ injuries in children. J Surg Res. 2018;228:188-193. (Retrospective cohort analysis; 3005 patients)
62. Sanei B, Mahmoudieh M, Talebzadeh H, et al. Do patients with penetrating abdominal stab wounds require laparotomy? Arch Trauma Res. 2013;2(1):21-25. (Retrospective cross-sectional study; 1100 patients)
63. Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol. 1998;159(3):956-959. (Retrospective study; 20 patients)
64. Hinrichsen C, Lisowski, F.P. Anatomy Workbook - Volume 2: Thorax And Abdomen. Singapore: World Scientific Publishing Co Pte Ltd; 2007. (Textbook)
65. Lander A, Newman J. Paediatric anatomy. Surgery. 2010;28(1):11-15. (Review)
66. Eichelberger MR, Randolph JG. Thoracic trauma in children. Surg Clin North Am. 1981;61(5):1181-1197. (Review)
67. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002;39(5):500-509. (Prospective observational series; 1095 patients)
68. 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)
69. Ross SE, Dragon GM, O’Malley KF, et al. Morbidity of negative coeliotomy in trauma. Injury. 1995;26(6):393-394. (Retrospective consecutive study; 50 patients)
70. Feliz A, Shultz B, McKenna C, et al. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg. 2006;41(1):72-77. (Retrospective review; 113 patients)
71. Marwan A, Harmon CM, Georgeson KE, et al. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma. 2010;69(4):761-764. (Retrospective review; 92 patients)
72. Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg. 1996;31(8):1178-1181. (Retrospective review; 48 patients)
73. Arslan MS, Zeytun H, Arslan S, et al. Operative and non-operative management of children with abdominal gunshot injuries. Ulus Travma Acil Cerrahi Derg. 2018;24(1):61-65. (Retrospective review; 30 patients)
74. Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol. 2007;178(1):246-250. (Retrospective review; 164 patients)
75. Petrone P, Inaba K, Wasserberg N, et al. Perineal injuries at a large urban trauma center: injury patterns and outcomes. Am Surg. 2009;75(4):317-320. (Retrospective review; 69 patients)
76. Antonis MS, Phillips CA, Blaivas M. Genitourinary imaging in the emergency department. Emerg Med Clin North Am. 2011;29(3):553-567. (Review)
77. Yoshida GM, Garland D, Waters RL. Gunshot wounds to the spine. Orthop Clin North Am. 1995;26(1):109-116. (Review)
78. Mirza FG, Devine PC, Gaddipati S. Trauma in pregnancy: a systematic approach. Am J Perinatol. 2010;27(7):579-586. (Review article)
79. Awwad JT, Azar GB, Seoud MA, et al. High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war. Obstet Gynecol. 1994;83(2):259-264. (Review article)
80. Stone IK. Trauma in the obstetric patient. Obstet Gynecol Clin North Am. 1999;26(3):459-467. (Review)
81. Lavin JP Jr, Polsky SS. Abdominal trauma during pregnancy. Clin Perinatol. 1983;10(2):423-438. (Review)
82. Awwad JT, Azar GB, Haddad FF, et al. Abdominal penetrating trauma in pregnancy. J Med Liban. 1993;41(2):70-72. (Review)
83. O’Connell K, Fritzeen J, Guzzetta CE, et al. Family presence during trauma resuscitation: family members’ attitudes, behaviors, and experiences. Am J Crit Care. 2017;26(3):229-239. (Observational, mixed-methods study; 126 patients)
84. 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)
85. 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)
86. Beno S, Ackery AD, Callum J, et al. Tranexamic acid in pediatric trauma: why not? Crit Care. 2014;18(4):313. (Comparative study, review)
87. 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)
88. Royal College of Paediatrics and Child Health. Evidence statement - major trauma and the use of tranexamic acid in children. November 2012. Accessed: April 15, 2019 (Evidence statement)
89. 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)
90. 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)
91. Chan KL, Summerhayes RG, Ignjatovic V, et al. Reference values for kaolin-activated thromboelastography in healthy children. Anesth Analg. 2007;105(6):1610-1613. (Prospective observational study; 100 patients)
92. 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)
93. 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)
94. 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)
95. Easter JS, Vinton DT, Haukoos JS. Emergent pediatric thoracotomy following traumatic arrest. Resuscitation. 2012;83(12):1521-1524. (Retrospective cohort study; 29 patients)
96. 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)
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)
98. Pearson EG, Clifton MS. The role of minimally invasive surgery in pediatric trauma. Surg Clin North Am. 2017;97(1):75-84. (Review)
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)