What is the immediate management of a 17‑day‑old neonate with a gun‑shot wound and visible chest retractions?

Immediate Management of Gunshot Wound in a 17-Day-Old Neonate with Chest Retractions

This neonate requires immediate airway stabilization with positive-pressure ventilation as the absolute priority, followed by rapid assessment for life-threatening thoracic injuries, hemorrhage control, and urgent surgical consultation.

Immediate Airway and Breathing Management

Establish effective positive-pressure ventilation immediately because chest retractions in a neonate with trauma indicate respiratory failure, and ventilation is the most effective action in neonatal resuscitation 1, 2.

• Use a T-piece resuscitator over a self-inflating bag for delivering positive-pressure ventilation, as this is the preferred method 3.
• Initiate ventilation with 100% oxygen for any neonate requiring assisted ventilation 2.
• If the neonate becomes unresponsive with heart rate <60 bpm despite adequate ventilation for 30 seconds, begin chest compressions using the 2-thumb encircling hands technique on the lower third of the sternum, compressing approximately one-third of the anterior-posterior chest diameter 1, 2.
• Maintain a 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths per minute) because gas exchange compromise is the primary cause of neonatal cardiovascular collapse 1.

Endotracheal Intubation Considerations

• Intubate if bag-mask ventilation is ineffective or if chest compressions are required 1.
• Confirm tube placement with exhaled CO₂ detection as the most reliable method, though poor pulmonary blood flow during arrest may prevent CO₂ detection despite correct placement 1, 2.
• Clinical indicators include chest movement, equal bilateral breath sounds, and condensation in the tube 1.

Circulation and Hemorrhage Control

Immediately assess for external hemorrhage and apply direct pressure or tourniquets because circulation interventions are the most common and effective prehospital intervention in severely injured pediatric patients 4.

• Apply tourniquets to any bleeding extremity wounds as they significantly reduce blood product and fluid requirements 4.
• Use hemostatic dressings for truncal or junctional hemorrhage that cannot be controlled with tourniquets 4.
• Establish intravenous or intraosseous access urgently for volume resuscitation and medication administration 2.
• Administer isotonic crystalloid or O-negative red blood cells for volume expansion if signs of shock are present; albumin is no longer first-line 2.

Medication Administration

• Give epinephrine 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) intravenously if heart rate remains <60 bpm after 30 seconds of adequate ventilation and chest compressions 2.
• Intravenous route is preferred over endotracheal because endotracheal administration requires higher doses (0.05-0.1 mg/kg) and produces lower blood concentrations 1.

Thoracic Injury Assessment

Perform immediate clinical assessment for pneumothorax or hemothorax because chest retractions with penetrating trauma suggest intrathoracic injury 5.

• Look for subcutaneous emphysema, asymmetric breath sounds, and tracheal deviation as these indicate airway or pleural injury 5.
• Needle thoracostomy or chest tube placement should be performed if tension pneumothorax is suspected, though these interventions are uncommon in neonates and should be performed by experienced providers 4.
• Be aware that three patients in one trauma series experienced sudden respiratory arrest during evaluation, emphasizing the need for continuous monitoring and preparedness 5.

Wound Management

Cover the gunshot wound with a sterile non-adherent dressing immediately to prevent further contamination and reduce pain 6, 3.

• Use warm sterile saline irrigation if time permits, but do not delay resuscitation 6.
• Avoid aggressive wound manipulation until the neonate is stabilized 6.
• Document wound characteristics including location, size, exudate, and surrounding tissue condition 6.

Pain Management

Administer appropriate neonatal analgesia once hemodynamically stable because gunshot wounds cause severe pain 1.

• First-line medications include paracetamol/acetaminophen and oral morphine or oxycodone for severe wounds 1, 3.
• Monitor pain using validated neonatal scales (NIPS or FLACC) 1, 3.
• Ensure resuscitation equipment is available when administering opioids 1.

Temperature Management

Prevent hypothermia by keeping the neonate warm during resuscitation, but avoid hyperthermia 2.

• Minimize exposure time during assessment and procedures.
• Use radiant warmers or warming blankets as available.

Urgent Surgical Consultation

Immediately activate pediatric surgery and trauma teams because penetrating thoracic injuries in neonates require operative management 5.

• Transfer to a pediatric trauma center with neonatal intensive care capabilities if not already at one 5.
• Airway injuries require meticulous surgical repair after initial stabilization 5.

Critical Pitfalls to Avoid

• Do not delay positive-pressure ventilation to perform other interventions; ventilation is the absolute priority in neonatal resuscitation 1, 2.
• Do not assume adequate ventilation without visible chest rise and improvement in heart rate 1.
• Do not perform chest compressions without first ensuring optimal ventilation because compressions compete with effective ventilation 1.
• Do not use endotracheal epinephrine as first-line when intravenous or intraosseous access can be rapidly obtained 1, 2.
• Do not overlook hemorrhage control while focusing on airway; tourniquets and hemostatic dressings are highly effective and should be applied immediately 4.
• Do not transport without securing the airway if respiratory distress is present, as sudden decompensation can occur 5.