What's Your Diagnosis? Pediatric Firearm Injuries to the Extremity: Management in the ED

Welcome to this month’s What’s Your Diagnosis Challenge! But before we begin, check to see if you got last month’s case on Pediatric Spinal Epidural Abscess: Recognition and Management in the Emergency Department right.

Case Presentation: Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department

An 8-year-old previously healthy boy presents with a penetrating wound to his left upper extremity…

Several children were playing with BB guns when the boy sustained the wound.

Upon arrival, EMS reports an estimated 100 mL of blood loss on scene before a family member placed a makeshift dressing and applied pressure. EMS is unsure about pulsatile bleeding since the dressing was placed prior to their arrival. After noting the dressing soaked in blood, a tourniquet was placed in the field.

While you are completing your examination, the boy is crying in pain. IV access is obtained, and he is placed on a cardiac monitor. The boy’s vital signs are notable for a heart rate of 110 beats/min; blood pressure of 107/60 mm Hg, measured on the right arm; respiratory rate of 20 breaths/min; and oxygen saturation of 100%.

The primary survey reveals an absent left radial pulse but no other immediate concer ns. The secondary survey demonstrates an appropriately placed left upper extremity tourniquet, and a 0.75-cm linear transverse laceration to the medial left upper arm overlying a small hematoma without active bleeding. No other wounds are appreciated.

What precautions should you take prior to releasing a tourniquet in the ED? What physical examination findings can help deter mine the next steps in management? Is advanced imaging indicated? Is emergent surgery required?

Case Conclusion

After confirming with EMS that the tourniquet had been in place <120 minutes and noting no other life-threatening injuries, you released the tourniquet, without signs of rebleeding. Upon reassessment of the left upper extremity, you noted a nonpulsatile hematoma with a faint but present radial pulse. There were only soft signs of an arterial injury, so you calculated an API. You noted a left upper extremity SBP of 96 mm Hg, and a right upper extremity SBP of 107 mm Hg, leading to an API <0.9. Given that the API was nonreassuring, you ordered a CTA to decide whether operative intervention would be required. The CTA was negative for arterial injury, though a superficial, circular 5 mm foreign body was noted in the left arm, without an acute fracture.

The wound was explored at bedside, and the pellet was safely removed. The child’s immunization status was up-to-date. He was treated with simple wound dressing and discharged home to his parents after a period of observation did not reveal rebleeding and serial neurovascular examinations remained unremarkable. Prior to discharge, the parents denied having other firearms and were informed about safe-storage practices as well as the risks of airguns. They agreed to remove the airgun from the child’s environment.