From the Guidelines
Postoperative management for a 14-year-old gunshot victim undergoing surgery should prioritize a comprehensive approach addressing pain control, wound care, infection prevention, and psychological support, with a focus on multimodal analgesia, early enteral feeding, and trauma-informed care.
Key Considerations
- Pain management should include multimodal analgesia with age-appropriate dosing, such as acetaminophen 15 mg/kg every 6 hours (maximum 4g/day), combined with NSAIDs like ibuprofen 10 mg/kg every 6 hours if not contraindicated 1.
- For moderate to severe pain, opioids may be necessary, with careful monitoring for respiratory depression and constipation, considering morphine 0.05-0.1 mg/kg IV every 2-4 hours or patient-controlled analgesia 1.
- Wound care involves regular dressing changes using sterile technique, monitoring for signs of infection, and removing sutures or staples as directed by the surgeon, typically 7-14 days postoperatively.
- Prophylactic antibiotics should be continued for 24-48 hours postoperatively, with extended coverage if there was significant contamination or hollow viscus injury, following local and national guidelines for choice of antibiotic, dosing, and administration 1.
- Physical therapy should begin early to prevent complications and maintain function.
- Nutritional support is crucial, with early enteral feeding when feasible.
- Psychological support through trauma-informed care and mental health referrals is essential, as pediatric gunshot victims often experience PTSD and other psychological sequelae.
- Close follow-up with the surgical team, pediatrician, and appropriate specialists should be arranged before discharge to ensure proper healing and address any complications promptly.
Additional Considerations
- The use of intraoperative cell salvage (ICS) during traumatic haemorrhage may be considered, as it can reduce the need for allogeneic blood transfusion, although the evidence is limited and the procedure may have potential drawbacks, such as worsening coagulopathy and immunomodulation 1.
- Transfusion of red blood cells should be restrictive, with a trigger hemoglobin level of 70-90 g/l, and individualized based on the patient's clinical status and comorbidities 1.
- A multidisciplinary discussion at the end of surgery should assess the patient's suitability for endotracheal extubation, considering the risk of postoperative pulmonary complications and reintubation 1.
From the Research
Postoperative Management for a 14-year-old Gunshot Victim
Overview of Postoperative Care
The postoperative management of a 14-year-old gunshot victim undergoing surgery involves several key considerations, including:
- Correction of coagulopathy, as seen in patients with severe head injuries due to gunshot wounds 2
- Management of potential hollow viscus injuries (HVI) and solid organ damage, which may require surgical intervention or non-operative management (NOM) 3
- Monitoring for signs of peritonitis, hemodynamic instability, and other complications that may arise from the injury or surgery
Coagulopathy Management
Coagulopathy is a significant concern in patients with gunshot injuries, particularly those with head trauma 2, 4. The use of recombinant activated factor VII (FVIIa) has been shown to be effective in correcting coagulopathy and achieving hemostasis in patients with severe head injuries 2. Additionally, the SPIN score, which includes INR as a major component, has been found to be a better predictor of mortality than other available prediction models for patients with gunshot traumatic brain injury 4.
Non-Operative Management (NOM)
NOM may be considered for patients with solid organ damage who are hemodynamically stable and exhibit no signs of peritonitis upon serial abdominal exam 3. However, the major drawback of NOM is the difficulty in diagnosing HVI, which may delay treatment.
Intensive Care Unit (ICU) Management
In the ICU, the physician should identify all physiological alterations to establish resuscitation management goals, including correction of hypothermia, acidosis, coagulopathy, and hypocalcemia 5. Damage control surgery has transformed the management of severely injured trauma patients, and the ICU physician plays a critical role in the resuscitation and management of these patients.
Antibiotic Prophylaxis
The use of long-half life antibiotics, such as ceftriaxone, may be effective in reducing the length of hospitalization and potential for morbidity from infection in patients with low-velocity gunshot wounds 6.