penetrating trauma in pediatric patients(1) [read-only] · penetrating trauma in pediatric patients...
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Penetrating Traumain Pediatric Patients
Heidi P. Cordi, MD, MPH, MS, EMTP, FACEP, FAADMEMS WEEK 2017
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Introduction
Trauma is the leading cause of death between ages of 1-18 years
Penetrating injury accounts for 10% -20% of all trauma in pediatric patients
Firearms account for the majority of penetrating wounds
Penetrating wounds are more lethal than blunt trauma
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Introduction
Mortality is even higher for younger children (compared to adolescents)
Major physiologic consequence of penetrating trauma outside of the brain = Hemorrhage
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Gun Shot Wounds
Lethality related to:
• Projectile dispersion
• Higher kinetic injury
• Impulse
• Yaw
• Deformation
• Fragmentation
Shot-gun wounds
• Multiple pellet incursions
• Spread out over a large area
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Ballistics
Yaw – rotation of the nose of the bullet away from the line of its flight
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AmmunitionComplete cartridges containing the projectile of a firearm aka ”the bullet”
The bullet = actual projectile = primarily lead with a rounded or pointed tip; various sizes and calibers
Caliber = width of the bullet in proportion of an inch or millimeter
Range of designs that affect their energy transference:
• Pointed tips Full metal jackets
• Round tips Partial metal jackets
• Hollow points Scored bullets
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Bullets
Expanding:
• Designed to maximize tissue damage
Nonexpanding:
• Greater penetration
• Pointed tip
• Coated with a thin metal covering/jacket of copper
• Limits lead residue (dangerous mechanical malfunctions)
• Bullet maintains its shape
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Ammunition
Birdshot
• Spherical
• Small, soft lead or similar metal
Buckshot
• Spherical
• Shells contain only a few tightly packed balls – larger diameter
• Lead or steel
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Ammunition
Slugs
• Single, large solid projectile
• May or may not have rifling built into the lead – gives it a spiral path which increase accuracy
• Low velocity, limited range
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Damage Caused by Bullets
Lacerate or crush tissue or bone
Fluid-filled organs (heart, lungs, bowel) can burst by the pressure
Fragments of bone shards can further cause damage
Cavitation
• Temporary
• Formed by continuous acceleration of the medium (air or tissue)
• Permanent
• Caused by the pathway
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Zones of Injury of Ballistic Wounding
Primary wound tract
• Permanent cavity, dead crushed tissue
Contusion zone
• Tissue adjacent to primary wound tract
• Inflammatory with cellular debris
Concussion zone
• Temporary cavity
• Tissue damage by stretching, shearing and compression
• Inelastic tissue (bone, brain, liver, spleen) susceptibleBruner, 2011
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Air-Rifle Injuries
More fatal if:
• Suicide attempt
• Close range
• Projectile entered the cranium through the orbit or cranium
• 30% mortality
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Non-firearm Related Injuries
More difficult to predict which wounds would be fatal
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Head 3 times more likely to die
GCS < 8, unilateral dilated pupil, transventricular or bi-hemispheric trajectories = High mortality!
https://neupsykey.com/management-of-penetrating-brain-injury/
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Thorax
Most common non-intracranial lethal wound
Most likely noted in adolescent males
Anterior mediastinum penetration: tamponade
Lung = Pneumothorax
Hemothorax
Major vascular structures
Fatal immediately if object removed by victim or bystander
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Penetrating Chest Wound
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Tension Pneumothorax
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Needle Decompression
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Thorax
Each hemithorax can hold up to hold of a patient’s total blood volume
Lung tissue is low density and high elasticity
Children have:
• diminished functional residual capacity
• Higher oxygen consumption
• Prone to rapid evolution of hypoxia
• Remain compensated with blood loss up to 40%
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Thorax
Low-velocity GSWs
• Limited minimal chest trauma to the bullet entry and exit sites
• Minimal injuries, lacerations and contusions to the lungs
High-velocity GSWs
• More extensive damage at the exit of the bullet
• Severe tissue damage beyond the initial tract of penetration
• More intense cavitation, laceration and contusion
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Thorax
Dyspnea
Anxiety
Tachycardia
Pleural pain
Asymmetric chest wall expansion
Decreased breath sounds
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Spinal Injuries
Direct path and concussive effects of the missile contribute to the destruction of both spine and cord
GSW to spine have potential for instability if missile fractures pedicles and facets as it traverses the spinal canal
Incomplete injury or partial motor function should remain immobilized – children have the greatest likelihood of regaining ambulatory function
Cotton, 2004
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Neck Injuries
Uncommon in children
Protected by:
• spine posteriorly
• Mandible anteriorly and superiorly
• Large head
• Short neck
~ 25 % will require urgent intubation
Vascular injury is the most common complication
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Neck Injuries
Multiple structures within the neck and cervical spine are at risk
Identify and manage injuries
Prevent progression of injuries
Injuries to blood vessels can be dramatic or subtle
Cervical injuries and physical findings may not be straight forward
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Neck Trauma
https://aneskey.com/neck-trauma/
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Neck Trauma
Rapidly expanding neck hematoma
Laryngotracheal injury
Pulsatile bleeding
Bruit
Lateralizing neurological signs
Hoarseness
Hemoptysis
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Rapid First Impression
Gather much information by quickly assessing:
• Position found
• Obvious injuries
• Breathing effort
• Skin color
• Mental status
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Abdominal Injuries
Distension from hemorrhage or hollow visceral injury –free air
Tenderness – secondary to
• peritoneal irritation – blood and/or enteric content
• Local tissue destruction
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Frequency of Intraabdominal Organs Injury
Cotton, 2012
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Extremity Injuries
Bony defects
Joint involvement
Peripheral nerve damage
Vascular injuries
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References
Brunner, D, et al Ballistic Injuries in the Emergency Department. Emergency Medicine Practice, Vol 13 No 12 Dec 2011
Cotton, BA et al. Penetrating Trauma in Children.Seminars in Pediatric Surgery, Vol 13, No 2 (May), 2004: pp 87-97
Martin RS, Siqueria MG, Santos MT, et al: Prognostic factors and treatment of gunshot wounds to the head. Surg Neurol 60:98-104, 2003