Paediatric Penetrating Trauma
Danny Cass
Outline
Paediatric Trauma
-Penetrating Injuries
Daniel T Cass
Professor, Director of Trauma
Children’s Hospital, Westmead, Sydney
AIMS
1. Detail the dimension of the problem
2. Describe injuries and treatment
3. Discuss the mental approach
PENETRATING TRAUMA (Paediatric)
Definition: to pierce – sharp
– Not motor mowers or machinery
– Not dog bites
Data
– Jan 1988 to Dec 2000 (13 years)
34 cases {2.6 per year} Paed. Child Health 38: 487 (2002)
– Jan 2001 to June 2005 (5.5 years)
125 cases {22.7 per year}
– More complete data collection
– Increased services (eye)
– Peripheral Hospitals refer increasing numbers of minor cases
Trauma care
Model of Philosophical approach
When you enter the ED department to assess and then provide definitive care to a trauma patient do you feel like:
1. an Airline pilot: walking to plane with protocol checklist
2. a Cricketer strolling to the batting crease
It’s not airlines it’s cricket
Penetrating injury - CHW data
Jan 2001- June 2006 (5.5 years)
125 patients (1.2% of admission)
4 ISS>15 (2.63% of serious injuries)
1 death
65% male
Even distribution throughout childhood
– 0-4y: 46; 5-10y: 44; 11-16y: 35
Location
– Home 83%, Park 4%, School 3%
Assailant
– Self 80%, Known 12%, Stranger 7%
Penetrating injury - CHW data
Jan 2001- June 2006 (5.5 years)
Penetrating Objects
– Needles/Pins 38
– Wood/Stick 16
– Sharp Metal 15
– Knife 10
Stab 5
Accidental 5
– Glass/ceramic 7
– Gun 5
Firearm 1
Air/slug gun 2
Nail gun 1
Spear gun 1
– Pencil/pen 4
– Umbrella 3
Penetrating injury - CHW data
Jan 2001- June 2006 (5.5 years)
Injury type (n = 114)
– Foot 38
– Eye 34
– Hand 9
– Leg 8
– Mouth 6
– Thorax 5
– Perineal 3
A: Airway
Case 1
Boy riding farm bike and hits wire fence
Hoarse voice
At ease when sitting up and forward
B: Breathing
18 yo boy BIBA after stabbing – set upon by gang, stabbed with ? Scissors (pts own)
Stable at scene, some dyspnoea
Management
C: Circulation
DM – penetrating neck injury
After 70 minutes pronounced deceased
Postmortem:
– No airway breach
– No pneumothorax laceration
– Internal carotid artery partially transected with massive haematoma compressing trachea
Review:
– development of “code crimson” where such patients taken straight to anaesthetic bay in theatre and full ED resuscitation trolley set up
– trial of 2 trauma surgeons taking 6am-10pm “trauma attend” calls
Subtle Cases - 1
4 year old girl
Did not walk following injury
GP noticed wound over right chest wall
CXR normal
Presented to RHSH 3/7 following injury.
Wetting herself more frequently since accident
Examination
Alert and appropriate. Entry wound over right chest wall. No CSF leak.
LL flaccid. No spontaneous movement. MRC grade 3/5 power in all LL muscle groups to tickle. LL reflexes absent, but anal tone normal. Sensation appeared reduced R > L LL. Reduced temperature and proprioception R LL. Plantars extensor.
Subtle Case - 2
12 year old boy
Examination
Alert, orientated, GCS 15.
Puncture wound at L3 without CSF leak
LL – grade 0/5 power L LL, 4-5/5 RLL
- L KJ and AJ absent, tone flaccid
- dysaesthesia L L5 dermatome
- PR normal tone
- Plantars equivocal
Conclusions
Stab injury to the paediatric spinal cord is rare
ABC approach
MRI of spine
Indications for operation remain controversial
Spinal injury care starts at time of injury
A hopeful outlook is appropriate as a degree of recovery will occur in most patients
Perineal injury
• 9 year old girl presented 2 hrs post injury at 1630
• History of straddle injury
Initial Management
• Had small vomit following clear fluids, kept fasted and admitted for observation
• Passed urine
• Overnight became febrile, ongoing small fresh blood losses PV
• Abdominal pain slightly improved, slept
• Review on ward in morning: persistent vaginal ooze and abdominal tenderness
• Decision made for formal EUA
EUA
• Vaginoscopy and Proctoscopy performed
• Findings:
• Anterior anal fissure
• Large full thickness laceration of rectovaginal wall
• Discussion with both parents who confirmed likely history
• Decision for laparotomy
Laparotomy
• Laceration from anterior anal verge through rectovaginal wall
• Anterior vaginal wall also lacerated with intraperitoneal extension
• Diverting colostomy performed with primary repair of the laceration
Perineal Trauma: lessons
• Perineal trauma is uncommon in children but can cause a wide spectrum of serious injuries
• Most common symptom is bleeding from the perineum
• May be minimal signs/symptoms
• Children <10years (especially females) with a history of perineal trauma must undergo EUA to exclude injury
• Grading anorectal injuries may assist in determining treatment
SUMMARY
PENETRATING TRAUMA (Paediatric)
Most are single system and simple
– Feet/eye: needles/sticks
Occasionally life threatening
– Need a rapid response gear – code crimson
Small subset of penetrating trauma are very tricky
– Few signs: anatomy means thin external tissues
– History, History, Examination; History in notes, Re-examination
SUMMARY
Documented history and examination
Tests
– MRI for spinal
Explore any penetrating injury unless the consultant has personally managed 10 similar cases
– Glass, knives: the internal injury is always much greater than appears from the surface lesion
|
Ministry
of Health
