Stab W o u n d s in Chi ldren

By Barbara Barlow, Maria Niemirska, and Rajinder P. Gandhi N e w York

�9 The Pediatric Surgical Service of Harlem Hospi- tal Center admitted 75 children, 16-years-old and younger, with stab wounds since 1969. Rapid resus- citation and triage of children with major injuries directly to the operating room achieved 100% surviv- al. Review of the circumstance of injury revealed that 75% of the stab wounds were inflicted by children and 66% were known to have been inten- tional. Social service and psychiatric intervention for troubled children and their families is essential and may decrease the risk of subsequent traumatic injury.

INDEX WORDS: Stab wounds in children; penetrat- ing injury.

V r lOLENT INJURY to children has in- creased in Central Harlem in the last

decade. Since 1969 75 children, 16 years of age and younger, were admitted to the Pediatric Surgical Service of Harlem Hospital Center for stab wounds. Only three children were admitted for stab wounds in the 10 years preceding this review.

Available medical and social data were reviewed for the children admitted for stab wounds. Social data were compared to a control group admitted for simple fractures and to the previously reported group admitted for gunshot wounds during the same period, t

MATERIALS AND METHODS

Patient Group

The age and sex distribution of the 75 children admitted for stab wounds are shown in Fig. 1: 84% were adolescents and 81% were boys.

From the Division of Pediatric Surgery, Harlem Hospital Center, College of Physicians & Surgeons, Columbia Uni- versity, New York.

Presented before the 14th Annual Meeting of the Ameri- can Pediatric Surgical Association, Hilton Head Island, South Carolina, May 4-7, 1983.

Address reprint requests to Barbara Barlow, MD, Chief of Pediatric Surgery, Harlem Hospital Center, 506 Lenox Avenue, KP-17103, New York, N Y 10037.

�9 1983 by Grune & Stratton, Inc. 0022/3468/83/1806~057501.00/0

Injuries Sixty children had a single stab wound and 15 had multiple

stab wounds caused by a knife (88%), a glass bottle (8%), scissors (3%), or a compass (1%).

Stab wound sites are depicted in Fig. 2. Chest wounds were the most common injury followed by extremity and abdomi- nal wounds. The major internal injuries resulting from the stab wounds are shown in Fig. 3. Operative intervention was required in 34% of the children: 11 abdominal, 5 thoracoab- dominal, 1 thoracic, 1 neck, and 7 extremity stab wounds.

Management

The majority of children reached the emergency room within 30 minutes of the stabbing via taxi, private car, police car, or on foot. The Emergency Medical Service brought 18% of the children with an average arrival time of 1 hour and 22 minutes following injury.

After evaluation and resuscitation in the emergency room children requiring immediate surgery were triaged directly to the operating room. Radiologic evaluation was undertaken only in stable patients.

Stab wounds of the head and neck were explored only for injury to a major vessel, the trachea, or esophagus diagnosed by examination, angiography, or endoscopy.

Stab wounds of the chest were treated with tube thoraeos- tomy. Thoracotomy indications were cardiac tamponade, major or continuing rapid blood loss, uncontrolled air leak, and food contamination of the thoracic cavity secondary to thoracoabdominal stab wounds through a full stomach.

Children with abdominal stab wounds presenting in shock or with evisceration, blood in the stomach or rectum, or signs of acute peritonitis had immediate laparotomy. Patients without indication for immediate operative intervention were admitted to the Pediatric Intensive Care Unit for monitoring of the vital signs and hematocrit and for serial physical examinations. Dye studies and peritoneal lavage were not used for evaluation. Signs which led to laparotomy in the children under observation were absent or decreasing bowel sounds, diffuse abdominal or rebound tenderness, or omental protrusion through the wound.

Stable children with major vessel injury or stab wounds close to major vessels were evaluated by angiography. Patients with nerve and tendon injuries were prepared for sugery since these injuries were not acute emergencies.

Stable children with gross or microscopic hematuria had an IVP and/or cystogram prior to surgery.

Selective management, as advocated by Shaftan, 2 rather than exploration of all penetrating injuries, reduces but does not eliminate negative explorations. Using this approach one of the five patients diagnosed as having a thoracoabdominal stab wound had a negative laparotomy and five of the eleven children explored for an abdominal stab wounds had insignif-

926 Journal of Pediatric Surgery, Vol. 18, No. 6 (December), 1983

STAB WOUNDS IN CHILDREN 927

z5 ~

2O

t~ 15

I0

Z

0 ~ I 2 3 4 5 6 7 8 9 I0 II 12 13 14 15 16

Age in Years

Fig. 1. Age and sex distribution of 7 5 children admit ted for stab wounds.

icant internal injuries which would not have required opera- tive treatment.

The decision for operative intervention was made in the emergency room in all but four of the children who had surgery. Two children with decreasing bowel sounds and increasing abdominal tenderness were explored after three hours observation: one exploration was negative and the other showed only a seromuscular laceration of the jejunum. Two children had protrusion of the omentum through the wound after six hours of observation: both explorations revealed nonbleeding laceration of the liver as the only internal injury.

Stab wound sites, unless they were large, were not sutured. Chest wounds were covered with vaseline gauze and an airtight dressing. Other wounds were cleaned and dressed.

head

neck

upr

bower extremity

Fig. 2. Stab wound sites in 7 5 children.

duod

Fig. 3. Major injuries in 7 5 children with stab wounds.

Thoracostomy sites and laparotomy incisions were kept sepa- rate from the stab wound site since inclusion is known to produce a high incidence of infectionfl

RESULTS

Complications and Sequelae

All of the children admit ted for stab wounds survived. Compl ica t ions of t r e a t m e n t were uncommon: one child had a broken catheter tip removed from the right a t r ium by the cardiac catheter izat ion team; one child, s tabbed through a full stomach, developed left subphrenic, right subhepatic, and lesser sac abscesses requir ing operative dra inage in spite of meticulous removal of food particles dur ing the initial laparotomy.

Sequelae were all neurologic. One child has paresis and shortening of the left leg secondary to spinal injury. Five children have motor and sen- sory deficits secondary to peripheral nerve t ran- section: four were repaired at the t ime of injury.

Circumstances

The circumstances of the s tabbing are known for 83% of the children, Fig. 4: 66% were s tabbed intentionally; 17% were stabbed accidental ly dur ing a fight or while playing with a knife,

928 BARLOW, NIEMIRSKA, AND GANDHI

~ ental 17% Unknown 17%

~ % Gang Attack

1% Rapist

5% Street Assailant

Intentional 66%

Fig. 4. Circumstance of injury in 75 children with stab wounds.

including nine children whose wounds were self- inflicted. The injured child knew his assailant in 88% of the cases: 75% were children; 26% were relatives.

Social Data

Social data for the stab wound group were compared to social data of the fracture group and the previously reported gunshot wound group, ~ Table 1. Both stab wound and gunshot wound patients came from larger families who were more frequently self-supporting and had a higher incidence of violent death in their nuclear fami- lies than the children admitted for fractures.

Children admitted for stab wounds had a higher incidence of troubled nuclear families than children admitted for fractures or gunshot

Table 1. Social Data of 75 Children With Stab Wounds

Compared to 75 Children Wi th Fractures and 75 Children With Gunshot Wounds

Gunshot Stab Fracture Wound (75) (75) (75)

Family composition Two parents 28% 39% 37% One parent 55% 53% 54% Relative 17% 8% 9% Siblings (average) 4 2 4.5

Family economics Welfare 52% 61% 41% Employed 48% 3 9 % 57%

Drug abuse Parent 17% 8% 9% Child 5% 3% 20%

Family deaths Mother 7% 5% 8% Father/stepfather 21% 5% 19% Sibling 3% 1% 4% % Violent 61% 11% 65%

Table 2. History of Prior and Subsequent Major Injury in Children Admitted for Stab Wound, Fractures, and

Gunshot Wounds

Stab Fracture Gunshot Wound

Prior major trauma 33% 24% 37% Major trauma in follow-up 14% 24% 10%

wounds. This is reflected in the large number of children with stab wounds who were living with relatives other than their parents. The placement of these children with relatives occurred because of drug abuse of their parents, or because of parental death.

Trauma History

Children from the three groups (stab wounds, fractures, and gunshot wounds) were evaluated for prior major t rauma and major t rauma during follow-up. Burns, fractures, gunshot wounds, severe concussion, car accidents, drowning, falls from a height; severe beatings, and violent rape were tabulated as major traumatic injury. Table 2 demonstrates that all three groups had a high incidence of major t rauma preceding their index admission. In follow-up the fracture group had a higher incidence of major t rauma than the stab and gunshot wound groups.

Patients admitted to our service with stab and gunshot wounds receive intensive social service and psychiatric assistance for both the child and the family. This service has not been provided for the children admitted for a fracture. We now feel that the circumstances of injury and the social background should be thoroughly evaluated for all children presenting with major t raumatic injury in order to identify those children where timely intervention and assistance for troubled families and children may well prevent further traumatic injury.

ACKNOWLEDGMENT

The authors gratefully acknowledge G Mabry and C Dalencour for their help with data collection and D Campbell for her assistance in the preparation of this manuscript.

REFERENCES

1. Barlow B, Niemirska M, Gandhi R: Ten years experi- ence with pediatric gunshot wounds. J Pediatr Surg 17:927- 932, 1982

2. Shaftan GW: Indications for operation in abdominal trauma. Am J Surg 99:657-664, 1960

3. Steichen FM: Penetrating wounds of the chest and abdomen. Current problems in surgery. Chicago: Yearbook Med Publ, 1967, pg 20

STAB WOUNDS IN CHILDREN 929

Discuss ion

Max Ramenofsky (Mobile, Alabama): It would be foolish to discuss any improvement in survival for this particular series since survival was 100%. However, several aspects require comment. Regarding your EMS system, you state that there was a 1 hour 22 minute delay when your EMS system transported the patient. We've been interested in the prehospital phase as a means for decreasing the morbity and mortal- ity associated with pediatric trauma. Was there a problem in notification and dispatch of your EMTs or was there an overly long time spent in-the-field by your EMTs treating the patients, or was there a very long transport time as I imagine could happen in New York, particularly around rush-hour.

Another comment focuses on the number of negative laparotomies in this particular series. When considering abdominal and thoracoab- dominal trauma, I noted that there were 6 of 16 negative laparotomies or a negative laparotomy rate of 37%. Although complications were rare in this series, longterm complications such as bowel obstruction may occur over the next 50 or so years. Selective management as described by Jerry Shaftan would appear to offer the possibil- ity of decreasing the number of negative lapa- rotomies. In our own series of 50 patients suffer- ing stab wounds, using the modalities of local wound exploration to identify peritoneal penetra- tion, peritoneal lavage to identify intraperitoneal injury, and various radiographic techniques to localize specific organ injury, 18% of our chil- dren were saved hospital admission. Thirty-seven percent, the same percentage as yours, were saved by laparotomy. However, 45% of our chil- dren had significant intraabdominal injury requiring surgical intervention. The question is, therefore, have you considered more selective methods of management for stab wounds of the abdomen?

Finally, you have identified the patients who are prone to accidental traumatic injury. I believe this is a valid and very important concept if we are to intervene and thus prevent the recurrence of this sad state of affairs.

Robert Touloukian (New Haven): Since there is a significant risk of serious injury to so many vital structures in the neck and since diagnostic testing, including angiography in children, is difficult, we are now exploring ways to rule these out.

Barbara Barlow (Closing): Emergency Medi- cal Technicians record the time of dispatch, arrival, and departure from the scene and emer- gency room arrival. The delay between injury and hospital arrival in children brought by ambulance seems due to excessive time between injury and notification of the ambulance team.

Children in the series with negative laparot- omy had penetrating wounds with hemoperito- neum so that dye study or lavage would also have led to operative intervention. The internal inju- ries in the children with negative explorations were insignificant and would have resolved with- out intervention. Selective management doesn't eliminate negative laparotomy but it reduces them in comparison to routine exploration of all penetrating injuries. We have been likewise satis- fied with our policy of selective management of neck wounds.

The Adolescent Medicine Department and the Adolescent Social S6rvice at our hospital have been key to providing assistance to these children although we value the opinion of the Pediatric Psychiatrists. The Adolescent Social Worker and the Adolescent Clinic provide the children and their families with concrete solutions to their problems when possible and serve as an ongoing support group for crisis ridden families.