Bonnie L. Beaver

Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma

BACKGROUND Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Small Bowel Injury in Children after Blunt Abdominal Trauma: Is Diagnostic Delay Important?

OBJECTIVE To assess the incidence and consequences of small bowel injury (SBI) in children suffering blunt abdominal trauma managed with the intent to treat nonoperatively. DESIGN Retrospective chart review. MATERIALS AND METHODS A total of 168 consecutive hemodynamically stable children admitted to a Level I pediatric trauma center during a 24-month period. RESULTS Nine of 168 children (5%) sustained SBI: three underwent early (< 4 hours) operation for recognized SBI (identified on computed tomographic scan); and six had delayed (36 +/- 16 hours) operation for missed SBI (not identified on computed tomographic scan). Increased temperature and heart rate, or decreased urine output at 24 hours suggested occult SBI. The hospital course was unaltered by delayed diagnosis. Fifty-seven percent of the children (95) suffered intra-abdominal injury; 10% required laparotomy for SBI (9) or solid organ injury (7); 90% (152) were discharged without laparotomy. CONCLUSIONS SBI is uncommon in children suffering blunt abdominal trauma. The diagnosis can be made using clinical and radiographic findings. Limited diagnostic delay does not seem to affect outcome. We conclude that clinical diagnosis of SBI is safe, permits the nonoperative treatment of most blunt abdominal injuries, and reduces the risk of unnecessary laparotomy associated with alternate approaches.

Efficacy of emergency room thoracotomy in pediatric trauma

With improved rapid transportation systems, an increasing number of children may arrive at the emergency room (ER) without detectable vital signs and may undergo vigorous resuscitation, including emergency room thoracotomy, aortic cross clamping, and open cardiac massage. Of 1,287 pediatric trauma admissions between 1980 and 1985, 101 deaths were recorded. Fifty (50%) of the deaths occurred in the ER. Thirty-three of the patients were pronounced dead with obvious irreversible injuries, while 17 (34%) with suspected thoracoabdominal injuries underwent ER thoracotomy during resuscitation. None of the 17 patients had detectable vital signs upon arrival to the ER. Fifteen patients had multisystem injuries associated with blunt trauma and two with isolated penetrating injuries. Despite maximal conventional resuscitation and ER thoracotomy, none of the 17 patients survived. In this group of pediatric blunt trauma victims who appear initially salvageable, and present in the ER with no detectable vital signs, ER resuscitative thoracotomy did not influence survival. ER thoracotomy in children, therefore, should be reserved for patients presenting with penetrating thoracic injuries or blunt injuries associated with detectable vital signs and deterioration despite maximal conventional therapy.

Characteristics of pediatric firearm fatalities

An increase in the awareness of the problem of gunshot fatalities in children has occurred nationwide over the last year. Unintentional firearm deaths are more common among children and young adults. These deaths may be addressed by preventive measures beyond those available for pediatric firearm suicide and homicide. This study focuses on the incidence of fatal gunshot injuries in children under 16 years of age during the years 1979 through 1987 in our state. Over the past 9 years 132 children (0 to 16 years) were shot and killed as a result of firearm injuries (M:F ratio, 3:1). No difference in absolute number in racial distribution existed. Deaths were classified as homicide, 61 (46%); accidental, 33 (25%); suicide, 29 (22%); undetermined, 7 (5%); and other, 2 (1.5%). Over 70% of these fatal injuries occurred in the home environment. Types of weapons involved included handguns (48%), shotguns (22%), rifles (17%), unspecified weapon (12%), and air rifle (1%). In a large number of cases, guns were found in the home unsecured. The perpetrator was known by the victim in 64 instances, while unknown in 27. Thirty-nine self-inflicted wounds and two shotgun blasts in the line of fire accounted for the remaining deaths. The most common anatomical injury and ultimate cause of death was cranial central nervous system (CNS) (62%), followed by chest/mediastinum (20%), abdomen (10%), and other (8%). A child who has sustained a firearm injury is more likely to know the perpetrator, be killed in the home by a readily available unsecured firearm, and die from severe head injury.

The Efficacy of Computed Tomography in Evaluating Abdominal Injuries in Children With Major Head Trauma

Physical examination may be unreliable in the evaluation of children with blunt abdominal trauma particularly in those with associated major head injuries. In the absence of obvious clinical signs or physical findings of intraabdominal injury, the usefulness of abdominal computed tomography in children is controversial. To test the efficacy of CT scans, a 12-month prospective study of computed tomography for the initial assessment of children with blunt abdominal trauma and major head injuries was carried out. Of 320 pediatric trauma admissions to our regional trauma center, 65 consecutive patients with Glasgow Coma Scores less than ten were managed with sequential head and abdominal computed tomography in the emergency room for (1) closed head injury and (2) suspected abdominal trauma. Fifteen patients (23%) were found to have significant intraabdominal injury. Only two required operative intervention. No patients died as a result of the abdominal injuries. In children with significant head trauma and suspected abdominal trauma, combined head and abdominal CT proved to be reliable.

Neonatal diagnosis of a presacral mass in the presence of congenital anal stenosis and partial sacral agenesis

The simultaneous presentation of clinically symptomatic anal anomalies and roentgenographically demonstrated sacral dysgenesis should alert the pediatric surgeon to investigate for the presence of a presacral malformation. We report on such a case to illustrate a new radiographic technique that facilitates diagnosis and management of complex congenital malformations. A 1-day-old white boy presented with anal stenosis, a scimitar-shaped sacrum, and large anterior and posterior meningoceles. In addition, a distinct presacral tumor--a teratoma--was identified. These malformations were identified utilizing metrizamide myelography and three-dimensional reconstruction computed tomography (CT) scanning. The meningoceles and a tethered cord were successfully corrected utilizing a posterior approach. A diverting colostomy was performed and subsequently taken down. Two years postoperatively, the patient continues to do well. This case demonstrates that this triad of anomalies (presacral mass, sacral dysgenesis, and anorectal malformation), once considered, can be safely detected with modern radiologic techniques and can be expeditiously corrected during infancy before further deterioration occurs.

Deer stand-related trauma in West Virginia: 1994 through 1999.

BACKGROUND Deer hunting is a popular activity in much of the United States. In West Virginia, over 350,000 people each year actively hunt deer. Although injuries and deaths caused by shooting-related incidents have declined, hunting injuries caused by falls from deer stands have not. We present a retrospective study from January 1994 through December 1999 to determine the number of and trauma resulting from deer stand-related incidents in West Virginia. METHODS Data have been compiled from individual hospital and state trauma registries, patient charts, and Department of Natural Resources logs. RESULTS A total of 90 individuals have been identified with injuries related to deer stand falls over the 6-year period. There were seven deaths. Most patients had multiple injuries that included extremity fracture (47%), spine fracture (36%), head injury (20%), pelvic fracture (10%), rib/clavicle fracture (11%), solid organ injury (6%), pneumothorax (3%), and other minor injuries (21%). The majority of accidents were associated with home-built as opposed to commercial stands, and most hunters were not using safety straps. Blood alcohol was elevated in only 7% of injured victims. CONCLUSION Injuries from deer stand falls are a significant cause of morbidity and mortality in this state. This is the largest series of hunting-related deer stand injuries reported in the current literature. Other states have successfully implemented prevention programs that have resulted in a reduction of these types of injuries. Our data emphasize the need to establish and promote preventative education programs for hunters using tree stands.

Surgical intervention in children with human immunodeficiency virus infection

Twenty-one children with human immunodeficiency virus (HIV) infection required surgical intervention during the course of their disease. There were 11 females and 10 males (age range, 3 months to 6 years). The children underwent 54 operative procedures after diagnosis of their disease. These included placement of central venous catheter (23 patients), open lung biopsy (11), incision and drainage of perirectal abscess (4), incision and drainage of soft tissue abscess (5), myringotomy (2), diverting colostomy (3), Nissen fundoplication (1), and other (5). All 21 patients had clinical AIDS by the Centers for Disease Control CDC classification. To date, there have been 12 deaths in the 21 patients (57%) due to progressive deterioration with the patients disease. Most procedures were adjuncts for diagnostic and therapeutic intervention in a population of children with a uniformly fatal disease. The knowledge of various high risk groups for AIDS must heighten the surgeons awareness to the growing and significant pediatric segment of the HIV population, the complications of their disease, and the surgeons limited role in treating these problems.

Ectopic calcitonin in adrenocortical carcinoma: A new tumor marker

Ectopic calcitonin has never before been described in association with pediatric malignancy. This is the first report of ectopic calcitonin in a child with adrenocortical carcinoma. It may prove to be a useful tumor marker in this, as well as other childhood malignancies.