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? 

Make your best guess, and check back next month to find out the correct answer!

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