What is the immediate management for a pediatric patient with a gunshot wound to the chest who has lost pulses during transport?

Immediate Management of Pediatric Gunshot Wound to Chest with Loss of Pulses During Transport

Immediately initiate high-quality CPR with chest compressions at 100-120 per minute to at least one-third of the chest's anterior-posterior diameter (approximately 5 cm), using a 15:2 compression-to-ventilation ratio with two rescuers, while simultaneously preparing for emergency resuscitative thoracotomy if the child remains pulseless despite optimal resuscitation. 1, 2

Initial Resuscitation Protocol

Immediate CPR Initiation

• Start chest compressions immediately without delay for detailed assessment—the child has lost pulses and requires immediate restoration of cardiac output 1
• Compress at least one-third of the anterior-posterior chest diameter (approximately 5 cm in children) at a rate of 100-120 compressions per minute 1, 2
• Use 15:2 compression-to-ventilation ratio when two or more rescuers are available (which should be the case during transport) 1
• Allow complete chest recoil between compressions—incomplete recoil prevents adequate cardiac refilling and is a critical error 1
• Minimize interruptions in compressions to less than 10 seconds 1

Airway and Breathing Management

• Begin bag-mask ventilation with 100% oxygen immediately while compressions continue 1
• Maintain cervical spine immobilization throughout resuscitation given the traumatic mechanism 2
• Use jaw thrust without head tilt to open the airway while protecting the cervical spine 2
• If jaw thrust fails to open the airway, use head tilt-chin lift—a patent airway takes priority over potential spinal injury 2
• Anticipate airway obstruction from blood or debris and have suction immediately available 2
• Proceed to endotracheal intubation or supraglottic advanced airway as soon as feasible 1
• Use waveform capnography to confirm and monitor endotracheal tube placement 1

Trauma-Specific Interventions

Hemorrhage Control and Circulation

• Stop all external bleeding with direct pressure immediately—this is the most reversible cause of cardiac arrest in penetrating trauma 2
• Establish vascular access (IV or intraosseous) rapidly for medication administration and fluid resuscitation 1
• Administer epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration), maximum dose 1 mg, repeated every 3-5 minutes 1
• If no IV/IO access is available, give endotracheal epinephrine 0.1 mg/kg (0.1 mL/kg of 1 mg/mL concentration) 1

Cardiac Rhythm Assessment

• Attach monitor/defibrillator as soon as available without interrupting CPR 1
• Check rhythm every 2 minutes during CPR cycles 1
• If ventricular fibrillation or pulseless ventricular tachycardia is present (occurs in up to 25% of pediatric in-hospital arrests): deliver 1 shock and immediately resume CPR for 2 minutes 1, 3
• For refractory VF/pulseless VT, administer amiodarone 5 mg/kg IV/IO bolus (may repeat up to 3 total doses) or lidocaine 1 mg/kg IV/IO 1

Critical Decision Point: Resuscitative Thoracotomy

Indications for Emergency Thoracotomy

• Penetrating thoracic trauma with witnessed cardiac arrest or loss of pulses during transport is a classic indication for resuscitative thoracotomy 4, 5, 6
• This child likely has cardiac tamponade, direct cardiac injury, or massive intrathoracic hemorrhage causing the arrest 5, 6
• Resuscitative thoracotomy should be performed immediately upon arrival at a facility with surgical capability if the child remains pulseless despite optimal CPR 4, 5
• The procedure allows for: relief of pericardial tamponade, direct cardiac compression, control of intrathoracic hemorrhage, and cross-clamping of the descending aorta 5

Transport Considerations

• Transport immediately to the nearest trauma center with pediatric surgical capability—do not delay for prolonged field resuscitation 2, 4
• Continue high-quality CPR throughout transport 1
• Secure the child to an immobilization board at minimum the thighs, pelvis, and shoulders 2
• Account for the disproportionately large head in young children—may require recessing the occiput or elevating the torso to avoid cervical flexion 2

Critical Pitfalls to Avoid

• Do not delay CPR for prolonged pulse checks—if uncertain after 10 seconds, start compressions 1, 7
• Do not provide inadequate compression depth—must be at least one-third of chest diameter, not superficial compressions 1, 2
• Do not lean on the chest between compressions—this prevents adequate cardiac refilling 1, 7
• Do not sacrifice airway patency for spinal precautions—if jaw thrust fails, use head tilt-chin lift 2
• Do not transport to a non-trauma center if a pediatric trauma center is accessible—survival depends on rapid surgical intervention for penetrating cardiac injuries 4, 5
• Do not perform blind finger sweeps of the pharynx—this can impact foreign bodies or blood clots into the larynx 2

Prognosis Considerations

While penetrating cardiac injuries carry significantly increased mortality rates, early recognition and rapid surgical intervention within the "Golden Hour" can be lifesaving 5. Survival following cardiac tamponade and arrest in pediatric penetrating trauma has been documented when timely diagnosis and emergency thoracotomy are performed 5. The key determinants of survival are: short duration of arrest, early initiation of high-quality CPR, and rapid transport to definitive surgical care 8, 3.