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Approach to the initially stable child with blunt or penetrating injury

Approach to the initially stable child with blunt or penetrating injury
Literature review current through: Jan 2024.
This topic last updated: Jun 28, 2022.

INTRODUCTION — The initial approach to the management of the stable child who has sustained traumatic injury is reviewed here. Initial trauma management in the unstable child is discussed separately. (See "Trauma management: Approach to the unstable child".)

TERMINOLOGY AND INJURY CLASSIFICATION — For this review, the stable pediatric trauma patient refers to an injured child who initially has normal or near normal vital signs, normal vital functions (airway, breathing, circulation, mental status), and no readily apparent critical injury. It is imperative for the trauma provider to use normative values for children as opposed to adults when assessing vital signs. Normal vital signs change with age in children. In general, heart and respiratory rates are higher than in adults (table 1), and blood pressure is lower. The 5th percentile systolic blood pressure for age can be approximated by the following formula for children 1 to 10 years of age:

Systolic pressure (5th percentile) = 70 mmHg + 2 X (age in years)

Many seriously injured children, who ultimately require hospitalization and/or surgical intervention, initially appear stable. It is incumbent on the emergency provider to thoroughly evaluate initially stable appearing traumatized children and to identify those at high risk for serious injury based on mechanism and physical findings (table 2 and table 3).

Injury classification — Traumatic injuries can range from minor to life-threatening. Several methods for measuring severity of injury exist. In order to appropriately triage the management of the trauma patient, one useful method to categorize injuries uses the following parameters (see "Classification of trauma in children"):

Injury extent – Multiple trauma is defined by apparent injury to two or more body areas. Localized trauma involves only one anatomic region (eg, head and neck, chest and back, abdomen, extremities) of the body. Sometimes the extent of injury may be obvious; at other times this may not be readily apparent, and the clinical picture may evolve over time.

Injury type – The expected injuries differ based on whether they occur as a result of blunt trauma (eg, fall, motor vehicle collision [MVC]) or penetrating trauma (eg, gunshot, stabbing, or shrapnel from explosion).

Injury severity – The mechanism of injury and physical examination findings are useful in the determination of severity. Assessment of severity will dictate the initial management and disposition of the injured child [1]. High-risk trauma mechanisms predict patients who are more likely to be unstable or become unstable and, along with vital signs and physical findings, are often used to guide prehospital transport decisions and to initiate evaluation by a trauma team in hospital trauma centers (table 2 and table 3 and table 4). (See "Classification of trauma in children".)

BLUNT TRAUMA — Blunt injury accounts for approximately 90 percent of all pediatric trauma. When blunt force is applied to a child's small body, multisystem trauma occurs frequently. However, the majority of injuries are mild to moderate in severity.

Initial evaluation — The initial evaluation of the pediatric patient with a history of mild or moderate blunt trauma begins with the primary and secondary surveys according to the principles of Advanced Trauma Life Support (ATLS) (table 5 and table 6) [2]. The stable pediatric trauma patient should have a normal primary survey with the possible exception of tachycardia caused by age-appropriate anxiety and crying or mild lethargy (Glasgow coma scale ≥14) (table 7).

During the secondary survey, the emergency provider determines the injury extent (multiple trauma or isolated trauma), injury type (blunt or penetrating), and injury severity based on all physical findings.

The primary and secondary surveys may be truncated in the setting of trivial trauma or obviously isolated trauma (eg, struck on the knee by a baseball, twisted ankle, or fall on an outstretched arm). All other children should undergo a complete physical examination to ensure that subtle findings of significant injury are not missed.

Based on the initial brief history and physical assessment, injuries in each anatomic region in children with blunt trauma can be classified as mild (eg, isolated bruise), moderate (eg, head trauma with loss of consciousness), or severe (eg, liver laceration after blunt trauma) (table 4). The severity of injuries may be estimated as a guide to management. This preliminary estimate is based upon the amount of force and mechanism of injury, the physical examination findings, including the vital signs, and evidence of superficial versus internal injuries. Further diagnostic evaluation depends upon the clinical assessment.

Approach by injury location

Head trauma — Most children evaluated in the emergency department (ED) for blunt head trauma have sustained a minor injury and require no further intervention. (See "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'Pathophysiology'.)

A clinical decision rule identifying those at low risk of clinically important traumatic brain injury has been derived and validated in a large, multicenter cohort and is shown in the table (table 8). Low-risk patients who do not undergo neuroimaging should meet all of these criteria. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Clinical decision rules'.)

The approach to neuroimaging for stable infants and children with minor head trauma who do not meet low-risk criteria for significant traumatic brain injury and further discussion of clinical decision rules are provided separately. (See "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Approach' and "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'Clinical decision rules'.)

For the large majority of infants and children with minor head trauma, management is based upon clinical findings rather than results of neuroimaging. For the few patients with clinically important traumatic brain injury, specific management is determined by the type of injury. Prompt neurosurgical consultation should be obtained in the patients with the following clinically important traumatic brain injuries (ciTBI) or skull fractures:

Parenchymal brain injury or intracranial hemorrhage detected by computed tomography (CT) (see "Intracranial subdural hematoma in children: Clinical features, evaluation, and management" and "Intracranial epidural hematoma in children")

Depressed, basilar, or widely diastatic skull fracture (see "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures' and "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Depressed skull fractures')

Deteriorating clinical condition (eg, Glasgow coma scale ≤13 or rapidly decreasing) regardless of neuroimaging results (see "Severe traumatic brain injury (TBI) in children: Initial evaluation and management")

Otherwise, almost all infants and children who have had isolated minor head trauma can be safely discharged following evaluation. Observation is still important even in discharged patients because signs and symptoms of traumatic brain injury may arise and warrant prompt return to the ED for reevaluation. Thus, clear instructions should be provided and the presence of responsible caretakers who can return in a timely manner, if necessary, should be assured. The clinician should also determine, based upon the clinical scenario (eg, age and symptoms of child, time since injury, time of day, home distance from hospital, and perceived quality of caregiver observation), whether emergency department or hospital observation is necessary and, if it is necessary, how long observation should last. (See "Minor head trauma in infants and children: Management", section on 'Discharge instructions' and "Minor head trauma in infants and children: Management", section on 'Minor head trauma'.)

The assessment and management of concussion in children and adolescents is discussed separately. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis" and "Concussion in children and adolescents: Management" and "Acute mild traumatic brain injury (concussion) in adults" and "Sideline evaluation of concussion".)

Neck trauma — Patients who have not experienced a high risk injury and who are alert with no distracting injuries, no cervical spine symptoms or signs, and no anatomical predisposition to cervical spine injury may be cleared clinically (algorithm 1). Otherwise, the patient should undergo cervical spine motion restriction and evaluation and treatment for cervical spine injury as shown in the algorithm (algorithm 2). (See "Pediatric cervical spinal motion restriction" and "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Clinically cleared and previously healthy patients with mild injury mechanisms (eg, nine-year-old seat-belted passenger in a low speed motor vehicle collision [MVC]) and normal physical examination findings warrant no further specific management.

If the patient has a predisposition to cervical spine injury (eg, Down syndrome, Klippel Feil syndrome, Morquio syndrome, Larsen syndrome) or an underlying illness (eg, hemophilia) that may result in delayed complications, any clinical or radiographic findings suggestive of cervical spine or cord injury warrant further evaluation and early consultation with the appropriate specialist (eg, orthopedic surgeon, neurosurgeon, or hematologist) is encouraged.

Thoracic trauma — The approach to chest trauma in the hemodynamically stable patient is provided in the algorithm (algorithm 3). A patient with a history of minimal trauma to the chest (eg, a six-year-old punched by a classmate) with normal vital signs, breathing, and only superficial chest wall/skin injuries is unlikely to require radiologic imaging and may be discharged home.

The presence of abnormal vital signs (including oxygen saturation), a history of moderate thoracic trauma as defined by the amount of force involved (eg, a 15-year-old struck by a "fastball"), significant bony tenderness, or abnormal breath or cardiac sounds suggest potential intrathoracic injury. Patients with these findings warrant additional evaluation for potential life-threatening thoracic injury (eg, pulmonary contusion, cardiac contusion, and pneumothorax) (algorithm 3). (See "Thoracic trauma in children: Initial stabilization and evaluation" and "Chest wall injuries after blunt trauma in children" and "Overview of intrathoracic injuries in children".)

Abdominal trauma — Unlike penetrating trauma, which usually results in wounds that are apparent upon inspection, injuries caused by blunt abdominal trauma must be suspected from historical information, particularly the mechanism of injury, and careful physical examination. Repeated assessments are helpful to identify developing intraabdominal injuries over time when the mechanism of injury is concerning, particularly with perforations of the bowel as seen in lap belt injuries.

Mechanism of injury – Mechanisms of trauma that are associated with intraabdominal injury include high speed motor vehicle collision (MVC), especially without restraint or with seat belt but not shoulder strap usage, and falls from a height greater than 20 feet (table 3). However, serious intraabdominal injury, especially splenic laceration or hematoma, can occur with seemingly trivial abdominal trauma to the left upper quadrant. For this reason, even abdominal trauma sustained as a result of minimal force (eg, a two-year-old struck by a ball) requires a thorough physical examination.

Additional findings – A clinical decision rule for the identification of children at very low risk for intra-abdominal (IAI) blunt injuries requiring acute intervention, defined as intra-abdominal injury associated with death, therapeutic intervention at laparotomy, angiographic embolization, blood transfusion for anemia, or intravenous fluids for >2 nights has identified the following predictors of those at low risk (see "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Low-risk rule for intra-abdominal injury'):

Glasgow coma scale ≥14

No evidence of abdominal wall trauma or seat belt sign

No abdominal tenderness

No complaints of abdominal pain

No vomiting

No thoracic wall trauma

No decreased breath sounds

Patients who meet all criteria have an approximately 0.1 percent risk of an IAI and typically do not warrant extensive laboratory testing or abdominal CT. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Low-risk rule for intra-abdominal injury'.)

Potential indications for laboratory evaluation and abdominal CT in children who do not meet these criteria or have other concerning findings after sustaining blunt abdominal trauma are discussed in greater detail separately. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Approach' and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Abdominal and pelvic CT'.)

Focused assessment with sonography for trauma (FAST) is a rapid ultrasound examination of four abdominal locations (right upper quadrant, left upper quadrant, subxiphoid region, and pelvis). Use of FAST in children with a clinical impression of low risk for IAI after initial evaluation does not appear to improve clinical outcomes and has low sensitivity for IAI when compared with abdominal CT [3,4]. In the stable patient, the presence of intraperitoneal fluid on FAST typically indicates hemorrhage secondary to an intra-abdominal organ injury that should be examined further by an abdominal CT with intravenous contrast. (See "Trauma management: Approach to the unstable child", section on 'e-FAST (extended focused assessment with sonography for trauma)'.)

Pelvic radiographs add little to the evaluation and are not recommended in alert and hemodynamically stable patients unless the physical examination reveals pelvic tenderness and/or instability or the urinalysis shows hematuria [5].

Abdominal CT with intravenous contrast is the preferred imaging modality for the definitive evaluation of blunt abdominal trauma in hemodynamically stable children. CT is sensitive and specific in diagnosing liver, spleen, and retroperitoneal injuries. CT is less sensitive in detecting injuries of the pancreas, intestinal tract, bladder, and lumbar spine. Based upon a systematic review of observational studies that reported outcomes on over 9000 children, asymptomatic children with a negative abdominal CT are very unlikely to have intraabdominal injuries [6]. Caregivers of children with a normal abdominal CT who are being discharged home should be instructed to seek medical care if the child develops worsening abdominal pain or vomiting, which has the potential to occur subacutely with intestinal tract injury [7]. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Radiologic evaluation'.)

Extremity trauma — Low energy trauma to the extremities (eg, a 12-year-old trips and falls and now has pain of the wrist) often requires radiographic examination for possible fracture, especially physeal fractures in children. A normal radiograph does not exclude a Salter-Harris type I fracture of the growth plate, which may be diagnosed based upon focal tenderness at the physis (figure 1). (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal (growth plate)'.)

Extremity injuries that pose a significant risk of loss of limb function include the following:

Fractures or dislocations with neurovascular compromise – Obvious dislocations and fractures with neurovascular compromise should be reduced and immobilized as expeditiously as possible. Dislocations of the large joints (knee, hip, and elbow) may lead to vascular compromise if not reduced.

Compartment syndrome – Patients with crush injuries and high-risk fractures (eg, tibial fractures) should be carefully evaluated for acute compartment syndrome (ACS), which typically manifest with the following findings (see "Acute compartment syndrome of the extremities", section on 'Clinical features'):

Symptoms of ACS such as:

-Pain out of proportion to apparent injury (early and common finding)

-Persistent deep ache or burning pain

-Paresthesias (onset within approximately 30 minutes to two hours of ACS; suggests ischemic nerve dysfunction)

Examination findings suggestive of ACS including:

-Pain with passive stretch of muscles in the affected compartment (early finding)

-Tense compartment with a firm "wood-like" feeling

-Pallor from vascular insufficiency (uncommon)

-Diminished sensation

-Muscle weakness (onset within approximately two to four hours of ACS)

-Paralysis (late finding)

The classic findings associated with arterial insufficiency are often described as signs useful for the diagnosis of ACS, but this approach is inaccurate because these findings occur only late in the course. Of the five classic signs of arterial insufficiency (five Ps: pain, pallor, pulselessness, paresthesias, paralysis), only pain is commonly associated with compartment syndrome in its early stages. Paresthesias may also occur. (See "Acute compartment syndrome of the extremities", section on 'Clinical features'.)

Open fracture – Open fractures create a communication between the external environment and the bone. These injuries have significant infectious risk and are often complicated by delayed wound healing. They require urgent orthopedic consultation. Additionally, immobilization, analgesia, antibiotic administration (eg, cefazolin or, in children allergic to penicillin or cephalosporins, clindamycin) and tetanus prophylaxis, if indicated (table 9), should occur promptly. (See "General principles of fracture management: Early and late complications", section on 'Open fractures'.)

PENETRATING TRAUMA — The approach to penetrating trauma is similar to blunt trauma, although significant injury and the need for operative intervention are more likely. The emergency provider should have a low threshold for obtaining surgical consultation, especially in patients injured by gunshot wounds to the head, neck, thorax, or abdomen.

Initial evaluation — Patients with penetrating injuries should undergo primary and secondary surveys according to the principles of Advanced Trauma Life Support (ATLS) (table 5 and table 6).

The severity of injury can often be predicted by the characteristics of the weapon and the location of the wound or wounds as follows:

Gunshot wounds – Gunshot wounds are divided into low, medium, and high velocity and shotgun injuries as follows (see "Initial evaluation and management of abdominal gunshot wounds in adults", section on 'Mechanisms of injury'):

Low velocity – Low velocity weapons (eg, .22-caliber guns, other handguns, or air guns) do not typically penetrate bone, they tend to produce a more erratic path through soft tissue, following tissue planes.

Medium or high velocity – Medium and high velocity weapons (such as AK 47s) also cause injury by opening and closing tissue with force. Clinicians may underestimate tissue damage from this effect. Military weapons and hunting rifles can fire at speeds over 2000 to 3000 feet per second (610 to 910 m per second). Thus, they produce wounds with a more direct, predictable course through bone and soft tissue.

Shot gun – Shotgun wounds have different characteristic patterns of injury given their use of pellets, rather than single bullets, and longer barrels. Typically, initial pellet velocity decreases quickly and spread increases with distance from the target.

Stab wounds – The severity of stab wounds can be assessed by determining the size of the object (length and width), the location of the wounds, and whether multiple stab wounds are present. (See "Initial evaluation and management of abdominal stab wounds in adults", section on 'Mechanism of injury' and "Initial evaluation and management of abdominal stab wounds in adults", section on 'History'.)

Location of injury – Penetrating injuries to the head, neck, torso, and extremities proximal to the elbow or knees have the highest potential for abrupt decompensation in the stable child and have high priority for triage to a trauma center (algorithm 4).

Approach by injury location

Head trauma — The first step in managing these wounds is to reasonably exclude penetration of the calvarium. In some cases, the clinical finding will suffice. Examples would include a history of an injury from a BB gun in which the pellet is palpable subcutaneously or a stab wound with no evidence of bony involvement upon exploration of the resulting laceration.

However, if there is any concern for penetration into the cranial vault (eg, moderate to high velocity gunshot wound to the head or deep dog bite), neuroimaging and neurosurgical consultation is warranted. Unenhanced CT of the head provides the most detailed information in a timely fashion [8].

Any protruding object that appears to traverse the skull should be left in place until imaging and definitive management can be performed by a neurosurgeon [1].

Once an intact calvarium has been confirmed clinically and/or by neuroimaging, the physician should consider whether a foreign body is present. As for wounds in other regions of the body, retained organic material (eg, wood splinters) generally warrant removal due to the high likelihood of infection. Most substantial inorganic foreign bodies (eg, BB pellet or shards of glass) should be removed as well, but tiny, deeply embedded objects that are not easily retrieved (eg, sliver of glass) may at times be left in place, especially if attempted removal will require extension of the wound or a prolonged exploration. (See "Minor wound evaluation and preparation for closure", section on 'Foreign body'.)

Those wounds that do not penetrate the calvarium and involve no foreign bodies are divided into punctures and lacerations. Punctures are generally allowed to heal by secondary intentions, whereas lacerations require primary repair, unless highly contaminated (eg, pitchfork tong contaminated by manure).

The assessment and management of puncture wounds and lacerations of the head are discussed separately. (See "Infectious complications of puncture wounds" and "Assessment and management of scalp lacerations" and "Assessment and management of facial lacerations" and "Assessment and management of lip lacerations" and "Assessment and management of auricle (ear) lacerations".)

Neck trauma — Patients with injuries penetrating the platysma on exploration of the wound require stabilization and emergency surgical consultation. Penetrating neck injury may cause vascular injury with significant hemorrhage, damage to the spinal cord, larynx, or trachea. Disruption of the larynx or trachea may result in displacement and obstruction of the airway or bleeding into the tracheobronchial tree. Any signs of airway compromise or findings of airway injury warrant endotracheal intubation. Further evaluation and management of penetrating injuries through the platysma are provided in the algorithm (algorithm 5) and discussed separately. (See "Penetrating neck injuries: Initial evaluation and management", section on 'Emergency management'.)

Surgical consultation for neck exploration is recommended for the following indications:

Continued bleeding, pulsatile bleeding, and/or expanding hematoma from the wound or shock

Bruit

Unilateral extremity pulse deficit

Signs of stroke/ischemia

Blood in the aerodigestive tract

Subcutaneous emphysema

Hoarseness

Stridor

Aphonia

Wound bubbling

Airway compromise

Neurologic deficits at or below the level of the cervical cord

Inability to observe or study the child prior to operation for other injuries

Asymptomatic patients may be evaluated with diagnostic testing and if negative may be observed, without mandatory surgical exploration [8,9]. Wounds superficial to the platysma muscle may be repaired in the emergency department (ED). (See "Penetrating neck injuries: Initial evaluation and management", section on 'Emergency management'.)

Thoracic trauma — Gunshot wounds and stab wounds are the major causes of penetrating thoracic trauma. A stable child with a penetrating wound to the thorax is still at high risk for major traumatic injury, including open, closed, or tension pneumothorax, hemothorax, cardiac tamponade, and/or exsanguinating hemorrhage and requires emergency surgical consultation.

Key clinical findings, approach to diagnostic imaging, and management of stable children with penetrating thoracic trauma are similar to adults as follows [8]:

Key clinical findings (see "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Initial evaluation and management'):

Any vital sign abnormality, not explained by anxiety, particularly persistent tachycardia or hypoxia.

Persistent difficulty breathing or pleuritic chest pain.

Foreign body sensation in the throat or change in voice.

Abnormal breath sounds.

Subcutaneous air (crepitus).

Jugular venous distension suggests pericardial effusion. However, jugular veins may appear prominent in supine patients without an effusion. Conversely, distended veins may not be present in hypovolemic patients with tamponade.

Diagnostic imaging – In general, a plain chest radiograph is rapidly obtained for all patients who present with penetrating chest trauma, whether or not they are experiencing signs or symptoms of intrathoracic injury. Bedside thoracic ultrasound by experienced clinicians is also indicated to evaluate for hemopericardium or free intraabdominal fluid in the event that the bullet has penetrated the abdominal cavity and for rapidly detecting a small or medium sized pneumothorax. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Diagnostic testing in Stable/Stabilized Patient'.)

CT scans in stable patients with normal examinations and chest radiographs do not significantly increase diagnostic yield [10]. Indications for obtaining a CT of the chest in a hemodynamically stable child with penetrating thoracic trauma include the following (see "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Candidates for chest CT'):

Trajectory of a penetrating object crosses the mediastinum or middle of the chest.

Symptoms or signs (eg, crepitus, expanding hematoma of the neck, absent upper extremity pulses) concerning for esophageal or tracheobronchial or vascular injury are present.

Chest pain, shortness of breath, or other symptoms consistent with injury are present that are not explained adequately by a plain chest radiograph.

These indications are not exhaustive and if there is clinical suspicion for a thoracic injury on other grounds it is reasonable to obtain a CT. CT of the chest demonstrates the greatest sensitivity and specificity for detecting pneumothorax and hemothorax, and most studies of ultrasound and chest radiographs use CT as the gold standard. However, CT exposes the patient to higher levels of radiation and may not be necessary if initial and follow-up plain chest radiographs are normal and there is no clinical suspicion for aortic or other major thoracic injury. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Candidates for chest CT'.)

Management – Further management is determined by clinical findings and the results of imaging (see "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Disposition'):

Asymptomatic patients – Asymptomatic children with penetrating thoracic injuries and a normal chest radiograph on presentation are observed for development of a delayed pneumothorax or hemothorax. A repeat examination and chest radiograph are performed six hours after injury.

Isolated pneumothorax – Pneumothorax is the most common serious injury associated with penetrating thoracic trauma and tube thoracostomy (ie, chest tube) is the most common intervention needed for treatment. Among asymptomatic patients, a chest tube is needed for any pneumothorax that occupies over 15 percent of the lung's total volume, as these are not likely to resolve spontaneously.

Hemothorax – Hemothoraces visible on chest radiograph warrant chest tube thoracostomy. Immediate bloody drainage of ≥20 mL/kg is generally considered an indication for surgical thoracotomy. Shock and persistent, substantial bleeding (generally >3 mL/kg/hour) are additional indications.

Disposition should be determined in consultation with a surgeon with pediatric expertise whenever possible, for patients requiring admission and/or operative care. Patients requiring tube thoracostomy warrant inpatient admission. Asymptomatic patients, who are suspected of having very superficial injuries that do not violate the pleural cavity (eg, a superficial wound from a pellet gun with the pellet identified in the subcutaneous tissue) and who remain asymptomatic and do not have signs of pneumo- or hemothorax on repeat chest radiograph may be discharged home to a reliable caretaker and as long as close follow-up is assured.

The evaluation and management of unstable children with thoracic trauma is discussed separately. (See "Trauma management: Approach to the unstable child" and "Thoracic trauma in children: Initial stabilization and evaluation".)

Abdominal trauma — Gunshot wounds frequently lead to significant intraperitoneal injury and often require laparotomy for evaluation and management. Thus, emergency surgical consultation is warranted for these patients to determine if the patients will require operative or nonoperative care. (See "Initial evaluation and management of abdominal gunshot wounds in adults" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management", section on 'Primary evaluation and management'.)

Stab wounds may be superficial or deep to the peritoneum. Superficial wounds may be explored and repaired in the ED if penetration of the peritoneum can be excluded clinically with a high degree of certainty. Deeper wounds through the peritoneum require surgical consultation and may necessitate imaging and a laparoscopy or laparotomy. Any protruding foreign body should be left in place until definitive management can be performed. (See "Initial evaluation and management of abdominal stab wounds in adults".)

Penetrating wounds to the abdomen may also be associated with intrathoracic injury. (See 'Thoracic trauma' above.)

Spine trauma — In penetrating trauma caused by gunshot wounds, the direct path and the concussive effects of the missile can lead to injury of the spinal cord and spine. Prior to imaging, patients with possible spinal injury warrant spinal motion restriction and emergency surgical consultation should be obtained [8]. CT of the involved area of the spine is recommended to determine the missile trajectory, extent of bony involvement, stability of the injury, and the presence of a spinal epidural hematoma. (See "Acute traumatic spinal cord injury".)

Extremity trauma — The initial evaluation and management of penetrating extremity injury in the pediatric patient requires control of hemorrhage, detailed peripheral nerve and vascular assessment, extremity radiography based upon findings, and consideration of antibiotic and tetanus prophylaxis. These injuries can be associated with complications including infection, compartment syndrome, and fractures that require additional operative procedures [11,12]. The approach in children is similar to adults and is provided separately. (See "Severe lower extremity injury in the adult patient", section on 'Initial evaluation and management'.)

Nerve deficits or evidence of arterial injury warrants emergency consultation with the appropriate surgical specialist. Findings of neurovascular involvement include:

Serious nerve deficits typically have both a sensory and motor component. (See "Severe lower extremity injury in the adult patient", section on 'Peripheral nerve assessment'.)

Hard signs of arterial injury in the extremity include (see "Severe lower extremity injury in the adult patient", section on 'Hard signs of arterial injury'):

Brisk hemorrhage on arrival to the ED

Expanding or pulsatile hematoma

Bruit or thrill over wound

Absent distal pulses

Extremity ischemia (pain, pallor, paralysis, cool to touch)

Superficial penetrating trauma in the stable patient should receive appropriate wound care and tetanus prophylaxis, if indicated (table 9). Radiographs should be obtained when the presence of an open fracture, joint penetration, or any radio-opaque foreign body (eg, glass, bullet, or BB) is suspected. (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures".)

DEFINITIVE CARE — After physical examination, most stable pediatric trauma patients are able to go home, including those who have sustained superficial penetrating trauma. Patients that warrant additional studies and possible admission include patients with abdominal tenderness or hematuria after blunt trauma or those with significant penetrating injury. (See 'Abdominal trauma' above and 'Penetrating trauma' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma".)

SUMMARY AND RECOMMENDATIONS

In any child with a history of trauma, determination of the extent (multiple or single), nature (blunt or penetrating), and severity (mild, moderate, or severe) is important in the assessment and management of the patient. (See 'Terminology and injury classification' above.)

The stable pediatric trauma patient refers to an injured child who initially has normal or near normal vital signs, vital functions (airway, breathing, circulation, mental status), and no readily apparent critical injury after primary and secondary survey for injuries (table 5 and table 6 and table 2). It is imperative for the trauma provider to use normative values for children as opposed to adults when assessing vital signs (table 1). (See 'Terminology and injury classification' above and 'Blunt trauma' above and 'Penetrating trauma' above.)

During the secondary survey, the emergency provider determines the injury extent (multiple trauma or isolated trauma), injury type (blunt or penetrating), and injury severity based on all physical findings (table 5 and table 6). (See 'Blunt trauma' above and 'Penetrating trauma' above.)

After the initial history and physical assessment, injuries in each anatomic region in children with blunt trauma can be classified as mild, moderate, and severe (table 4). This estimate of severity guides further management. (See 'Approach by injury location' above.)

Additional considerations for blunt trauma by specific anatomic sites include:

Children who have not experienced a high risk injury and who are alert with no distracting injuries and no cervical spine symptoms or signs may be cleared clinically (algorithm 1). Otherwise, the patient should undergo cervical spine immobilization and evaluation and treatment for cervical spine injury as shown in the algorithm (algorithm 2). (See 'Neck trauma' above.)

Most children evaluated in the emergency department (ED) for blunt head trauma have sustained a minor injury and require no further intervention. Clinical decision rules that indicate a low risk of significant traumatic brain injury have been described (table 8). (See 'Head trauma' above.)

The approach to chest trauma in the hemodynamically stable patient is provided in the algorithm (algorithm 3). A history of a trivial mechanism of chest trauma with normal vital signs, breathing, and only superficial chest wall or skin injuries is unlikely to require radiologic imaging. (See 'Thoracic trauma' above.)

Intraabdominal injuries caused by blunt abdominal trauma must be suspected from historical information, particularly the mechanism of injury (table 3), and careful physical examination. (See 'Abdominal trauma' above.)

Low energy trauma to the extremities often requires radiographic examination for possible fracture, especially physeal fractures in children. A normal radiograph does not exclude a Salter-Harris type I fracture of the growth plate, which may be diagnosed based upon focal tenderness at the physis (figure 1). (See 'Extremity trauma' above.)

The approach to penetrating trauma is similar to blunt trauma although trauma requiring operative care is more likely. In the stable patient, the severity of the injury is primarily determined by the characteristics of the weapon and the location of the wound or wounds. (See 'Initial evaluation' above and 'Approach by injury location' above.)

If there is any concern for penetration into the cranial vault (eg, moderate to high velocity gunshot wound to the head or deep dog bite), imaging is required and wounds more likely to penetrate the calvarium, such as gunshots, warrant neurosurgical consultation. Unenhanced computed tomography of the head provides the most detailed information. (See 'Head trauma' above.)

Patients with injuries penetrating the platysma, pleura, peritoneum, or spinal canal or causing neurovascular deficit in an extremity require stabilization and emergency surgical consultation. Evaluation and management of penetrating injuries of the neck through the platysma are provided in the algorithm (algorithm 5). (See 'Neck trauma' above and 'Thoracic trauma' above and 'Abdominal trauma' above and 'Spine trauma' above and 'Extremity trauma' above.)

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Topic 6572 Version 29.0

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