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Trauma Overview: Penetrating Injuries

Trauma

Trauma Overview: Penetrating Injuries

Background

  1. Trauma causes 50% of all pediatric mortality
    • > 830,000 persons < 18 yo are killed by trauma annually worldwide (WHO)
    • Head injury is the most common cause of death
  2. For every pediatric death:
    • 40 others are hospitalized
    • 1140 need emergency treatment
  3. MVCs (50%) > falls (25%) > burns (5%)
  4. In pediatrics, blunt trauma accounts for 90%, whereas penetrating trauma is 10%
  5. Males > females (2:1)
  6. Obese patients with penetrating chest trauma are less likely to require surgery

Know normal vital signs for Pediatric Patients

  • Table 1. Vitals by Age
    Age Heart Rate (HR) Respiratory Rate SBP (mmHg) DBP (mmHg)
    Newborn 90-180 30-50 60 +/- 10 37 +/- 10
    1-5 Months 100-180 30-40 80 +/- 10 45 +/- 15
    6-11 Months 100-150 25-35 90 +/- 30 60 +/- 10
    1 Year 100-150 20-30 95 +/- 30 65 +/- 25
    2-3 Years 65-150 15-25 100+/- 25 65 +/- 25
    4-5 Years 65-140 15-25 100 +/- 20 65 +/- 15
    6-9 Years 65-120 12-20 100 +/- 20 65 +/- 15
    10-12 Years 65-120 12-20 110 +/- 20 70 +/- 15
    13+ Years 55-110 12-18 120 +/- 20 75 +/- 15

Periorbital Penetration

  1. Diagnostics
    • Evaluate orbit: ocular trauma, or globe rupture
    • Evaluate GCS
  2. Treatment
    • Protect eye
    • Ophthalmology consult
    • Prophylactic antibiotics

Intracranial Penetration

  1. Background
    • Common and treatable source of morbidity/mortality
  2. Diagnostics
    • History/Physical Exam
      • Signs and symptoms of expanding intracranial mass
      • Epidural hematoma: lucid interval following the injury
        • Patient is stunned by the blow, recovers consciousness, and lapses into unconsciousness as the clot expands
      • Diffuse axonal injury or shearing
        • Immediate prolonged unconsciousness from the moment of injury and remain impaired
    • Labs/Tests
      • CBC +Diff, BUN/Cr, BMP
      • Electrolytes
      • Coagulation profile
      • Type and crossmatch
      • Obtain toxicology screen
    • Imaging
      • CT scan of the head should be obtained as soon as the patient is stable
  3. Treatment
    • Neurosurgical evaluation and often surgery if penetration is significant

Carotid Cavernous Sinus Fistula

  1. Background
    • Abnormal communication between the internal or external carotid arteries and the cavernous sinus
  2. Diagnostics
    • History/Physical Exam
      • Red eye, diplopia, decreased vision, bulging eye
      • Facial pain in the distribution of the first division of the trigeminal nerve
      • Proptosis
      • Eyelid edema
      • Ocular pulsations
      • Pulsating exophthalmos
      • Ocular bruit
      • Conjunctival arterialization and chemosis
      • Exposure keratopathy
      • Dilation of retinal veins
      • Optic disc swelling
      • Intraretinal hemorrhage
      • Vitreous hemorrhage
      • Proliferative retinopathy
      • Central retinal vein occlusion
      • Elevated intraocular pressure
      • Neovascular glaucoma
      • Angle-closure glaucoma
    • Imaging
      • CT of the orbits
  3. Treatment
    • Neurosurgical consultation
    • Exposure keratopathy
      • Ocular lubricants
    • Glaucoma
      • Aqueous suppressants and hyperosmotic agents
    • Closure of carotid-cavernous sinus fistula

Anterior Neck Penetration

  1. Background
    • Estimated 5-10% of all trauma that present to the ED
    • Standard of care is immediate surgical exploration
      • For patients who present with signs and symptoms of shock and continuous hemorrhage from the neck wound
    • Anatomical zones
      • Zone I
        • Horizontal area between the clavicle/suprasternal notch and cricoid cartilage
      • Zone II
        • Between cricoid cartilage and angle of the mandible
      • Zone III
        • Angle of the mandible and the base of the skull
  2. Diagnostics
    • History/Physical Exam
      • Dysphagia: tracheal and/or esophageal injury
      • Hoarseness: tracheal and/or esophageal injury
      • Oro-nasopharyngeal bleeding: vascular tracheal or esophageal
      • Neurologic deficit: vascular and/or spinal cord injury
      • Hypotension
      • ATLS
      • Neurological evaluation
      • Retropharyngeal hematoma
        • Potential airway compromise
        • Subcutaneous emphysema
        • Air bubbling through wound
        • Stridor or respiratory distress
        • Potential esophageal injury
        • Evaluate with esophagography
        • Prophylactic antibiotics
      • Vascular injuries
        • Hematoma
        • Active external hemorrhage from the wound site
        • Bruit/thrill
        • Pulselessness/pulse deficit
        • Distal ischemia
    • Labs/Tests
      • CBC +Diff
      • Type and crossmatch
      • Toxicology screen
    • Imaging
      • Cervical x-ray (AP, lateral)
        • Vertebral bony injury
        • Retained foreign bodies
      • Four-vessel cerebral angiography
        • To assess for vascular injury
      • CT neck
        • Evaluate many structures and may define and diagnose laryngeal injury
      • CT angiography
        • Adjunctive screening tool
  3. Treatment
    • Secure definitive airway
    • Adequate ventilation and oxygenation
    • Resuscitation fluid
    • Surgery evaluation

Central Chest Penetration

  1. Cardiac Injury
    • Background
      • Highly lethal
        • Case fatality rates: 70-80%
      • Ventricular injuries > atrial injuries; right > left
    • Diagnostics
      • Beck triad (only 10-30% of patients with tamponade)
        • High venous pressure
        • Low arterial pressure
        • Muffled heart sounds
      • Evaluation with echocardiography
    • Treatment
      • Patients arriving lifeless: resuscitative thoracotomy
      • Bleeding: rapidly controlled using finger occlusion, sutures or staples
      • Pericardiocentesis
        • Diagnostic and therapeutic
  2. Pneumothorax
    • Background
      • Common in children with blunt trauma
    • Diagnostics
      • Decreased/absent breath sounds
      • Hypotension usually with tension pneumothorax
    • Treatment (Immediate/Emergent)
      • Needle decompression
        • Through the second intercostal space at midclavicular line
      • Tube decompression
  3. Hemothorax
    • Background
      • Common in children with blunt trauma
      • Potential for large intrathoracic blood loss
    • Diagnostics
      • Decreased/absent breath sounds
      • Hypotension with massive hemothorax
    • Treatment (Immediate/Emergent)
      • Needs evacuation with tube decompression
  4. Great Vessel Injury
    • Background
      • Surgical/trauma consult/evaluation will be required
      • > 90% of thoracic great vessel injuries are caused by penetrating trauma
        • High morbidity rate
        • Aorta, major branches, and major pulmonary arteries
        • Primary venous conduits
          • Superior and inferior vena cava and main tributaries and pulmonary veins
      • Hemodynamic stability evaluation determines management
    • Diagnostics
      • If patient is stable:
        • Helical CT
          • Assess mediastinal hematomas
          • Assess aortic wall and intraluminal abnormalities
        • CT-Angiography
          • Determines vascular injuries
        • Transesophageal echocardiography
          • Relatively new
    • Treatment
      • Blunt injuries
        • Conservative treatment
      • Patients in extremis or rapid deterioration
        • Emergent thoracotomy

Buttocks Penetration

  1. Background
    • Prompt multisystem work-up is necessary
    • Rare, comprising 2-3% of all penetrating injuries
    • Bleeding
      • Most serious complication from internal injury
      • Leads to shock in 10%
      • Mortality: 2.9%
    • Major injury pattern in shot wounds:
      • Small bowel, colon, or rectum injuries
    • Major injury pattern in penetrating wounds:
      • Vascular
  2. Diagnostics
    • History/Physical Exam
      • General Signs/Symptoms
        • Hemorrhagic shock
        • Peritoneal irritation
        • Gross rectal blood
        • Gross hematuria
        • Massive external bleeding
        • False aneurysm formation
        • Absent distal pulses
        • Cold painful leg
        • Groin hematoma
        • Severe bone pain
      • Rectal Injury
        • Least likely area of trauma
        • Digital rectal examination important
        • Rigid sigmoidoscopy/proctoscopy to determine injury to the rectal wall
        • Assess for pelvic injury
      • Peritoneal Penetration
        • Most injuries are identified at laparotomy
        • Assess for peritoneal signs with abdominal examination
    • Imaging
      • Diagnostic proctosigmoidoscopy
      • Angiography
      • Cystography
      • Intravenous pyelography
      • Urethrography
      • CT scan of abdomen/pelvis
  3. Treatment
    • Surgical intervention for all injuries
      • Laparotomy and extended gluteal surgery

Related Topics

References

  1. Guice KS, Cassidy LD, Oldham KT. Traumatic injury and children: a national assessment. J Trauma. Dec 2007;63(6 Suppl):S68-80
  2. Steenburg SD, Sliker CW, Shanmuganathan K, Siegel EL. Imaging evaluation of penetrating neck injuries. Radiographics. Jul-Aug 2010;30(4):869-886
  3. Lunevicius R, Schulte K-M. Analytical review of 664 cases of penetrating buttock trauma. World J of Emerg Surg. 2011;6:33
  4. Castle SL, Barthel ER, Tamura DY. Obesity Protects Against Operation in Pediatric Penetrating Trauma to the Torso. J Surg Res. 2021 Jul;263:57-62.

Contributor(s)

  1. Hughes, Michelle, DO
  2. Ballarin, Daniel, MD

Updated/Reviewed: July 2024