Firearm Injuries to the Extremity Pediatric

Action

Patient presents with a firearm injury to the extremity

Perform primary survey with focus on hemorrhage control

How to use a tourniquet
Given their fixed-stroke volume, infants increase their heart rate to raise their cardiac output, thus tachycardia is the most common presenting examination finding for shock.
Both tachycardia and delayed capillary refill time (≥3 seconds) are seen prior to the onset of hypotension with blood volume losses of 15% to 30%, thus an abnormality of either can help the clinician identify compensated shock in a timely manner.
For infants and children, hypotension is a late finding, often not notable until large intravascular volumes (30%-40%) have been lost.
For a child with suspected hemorrhagic shock, the latest ATLS® guidelines recommend the administration of an IV bolus of 20 mL/kg crystalloid fluids followed by blood product transfusion

Perform secondary survey

Based on the evidence thus far, for children with impending or current hemorrhagic shock, we recommend 10 mL/kg of packed red blood cells or 20 mL/kg of whole blood after 20 mL/kg of crystalloids have been provided

Administer tetanus shot (if indicated)
+/- Antibiotics

Despite commonly held beliefs, bullets are not sterilized by ballistic processes, and wounds may be further contaminated by clothing, debris, and in the case of blast injuries, even soil carried in the projectile’s wake. Therefore, antibiotic coverage for most firearm injuries is still prudent.

Consider TXA in children

Extrapolation from available adult data indicates that tranexamic acid should be considered within 3 hours of injury when overt signs of hemorrhagic shock are present.
Children aged ≥12 years: loading dose of 1 g IV over 10 minutes given within the first 3 hours post injury, followed by an infusion of 1 g IV over 8 hours.
Children aged <12 years, the loading dose is 15 mg/kg IV over 10 minutes (maximum dose 1 g) followed by an infusion of 2 mg/kg/hour over 8 hours or until the bleeding stops.

Reduce fracture/splint (if indicated)

Decision

What clinical signs are present?

Open/unstable fracture, joint involvement, or compartment syndrome

Obtain surgical intervention (Class I)

Persistent hard signs of vascular injury Class II)

Obtain surgical intervention (Class I)

Soft signs of vascular injury

Calculate Arterial Pressure Index

Background

Hard signs of vascular injury

Pulsatile bleeding
Expanding hematoma
Thrill
Bruit
Pulselessness
Pallor
Neurologic deficit

Soft signs of vascular injury:

History of prehospital arterial bleed
Wound in proximity to major vessels
Small non-pulsatile hematoma

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Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department (Trauma CME and Pharmacology CME) | EB Medicine

Firearm injuries are a leading cause of pediatric mortality in the United States. The frequency of pediatric extremity firearm injuries and the high repeat incidence in high-risk patients make it important for emergency clinicians to understand how to manage these injuries.