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19 Penetrating injury

  • Introduction

    • Are uncommon in the paediatric age group
    • Over a 3-year period the Royal Children's Hospital treated 22 patients with penetrating injuries to the neck, chest, or abdomen (neck 6, thoracic 7, abdominal 10)
    • The injuries are usually the result of accidents. - A fall on to sharp objects - Playing with dangerous objects - guns, nails, sticks etc -Being in the path of projectiles - eg from lawn mower.
    • A number arise from injuries inflicted by a family member (often involving mental illness).

    In all aspects of trauma management, the primary survey is the first priority

    Primary survey

    Airway with c-spine stabilisation (see chapter 1.3) Breathing (see chapter 1.4) Circulation assessment and management (see chapter 1.5)
    The most common penetrating injuries are:

    1. Abdominal
    2. Thoracic
    3. Neck

    Abdominal trauma

    Basic principle: all penetrating wounds require exploration.

    • With penetrating abdominal trauma, there is significant risk of compromise to circulation due to major vessel injury.
    • Do not remove impaled foreign bodies in the emergency room.
    • Remember stab wounds through the lower rib spaces can penetrate into the abdominal cavity.
    • Where there are clear signs of penetration through the peritoneum (peritonism, abdominal distension, free air on X-ray), urgent laparotomy should be performed. In an environment not experienced with paediatric patients, consultation with a paediatric hospital is necessary to determine suitability for transfer.
    • If there is doubt about a breach in the peritoneum, exploration of the wound is still advisable. In the paediatric group, this is rarely achieved satisfactorily using local anaesthesia and the patient therefore requires transfer to an operating theatre and use of general anesthesia. When this is undertaken, the surgeon must have the skills to proceed and deal with a breach, if found.
    • Some large American trauma centers consider conservative management. We currently do not, because of concern about missed injuries (especially bowel perforation) and the infrequency with which we see these injuries.
    • Laparoscopy has recently become more popular in paediatrics. It may be useful to determine if there has been a peritoneal breach, but it has a significant missed injury rate if used to explore for associated injury. Laparotomy remains the gold standard if there is clear penetration into the peritoneum.

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    Thoracic trauma

    1. As with all trauma, initial management is governed by ABC
    2. There is major risk of airway, vessel or cardiac injury, depending on the site of the trauma.
    3. Patients with penetrating wounds tend to be classified as either Stable or Unstable.

    Stable

    1. ABC - ascultate for blood or air in chest.
    2. CXR.
    3. Chest-drain placement, if appropriate.
    4. Consultation with Thoracic Surgeon - ? Exploration.

    Unstable

    • ABC ascultate for blood or air.
    • Urgent chest tube placement, bilateral if necessary.
    • Urgent CXR.
    • Urgent consultation with Thoracic Surgeon
    • Ongoing major blood loss or major air loss requires thoracotomy?
    • Emergency room thoracotomy may be appropriate to control haemorrhage or relieve cardiac tamponade in the moribund or arrested patient. But this is only likely to be successful in centers experienced in penetrating trauma.
    • Stable patients with penetrating wounds may be managed conservatively with close observation, but only in institutions with 24-hour access to thoracic surgeons.
    • Watch out for potential injury to the diaphragm and associated intraperitoneal injury. This may occur in injuries to the lower chest.
    • There may be a role for thoracoscopy, to assess wound and potential injury.

    Penetrating chest wound

    Neck trauma

    • As with all trauma, initial management is governed by ABC
    • These injuries require great respect and are difficult to manage because of the density of major structures in the region.
    • The particular structure at risk in neck injury depends on the site of the wound in the neck.
    • Do not pull out retained foreign bodies in the emergency department.
    • Do not explore wounds deep to platysma in the emergency department
    • Do not blindly clamp structures in the face of ongoing haemorrhage. Apply direct pressure and get advice from a consultant surgeon.
    • Control of airway is a major priority. Intubation is often needed, and should always be considered prior to transfer.
    • Patients tend to be either stable or unstable.

    Stable

    1. Neck exploration may be appropriate, where the wound extends beyond platysma. This is the safest approach in an institution that sees very few of these cases.
    2. The conservative approach. This requires thorough investigation including CT of the Neck, tracheobronchoscopy, oesophagoscopy +/- barium swallow and consideration of arteriography. Patients being managed conservatively also require very close observation.

    Unstable

    1. Symptoms - shock, bleeding, haematoma, dyspnoea, stridor, subcutaneous emphysema, hoarseness, dysphonia.
    2. If there is a wound through the platysma, exploration is required.
    3. A Vascular surgeon needs to be immediately available.
    • Oesophageal injury is easily missed at both exploration and investigation. Need a high index of suspicion.
    • These are difficult procedures that require suitable surgical expertise
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