Dale G. Johnson

The modified injury severity scale in pediatric multiple trauma patients

A Modified Injury Severity Scale (MISS) was devised to classify 110 pediatric patients with multiple trauma. Each of five body areas (neurologic, face and neck, chest, abdomen and pelvic contents, and extremities and pelvic girdle) were ranked by severity according to the carefully-defined categories of the AMA Abbreviated Injury Scale (AIS), with minor modifications. The AIS grades of injury are: 1—mild; 2—moderate; 3—severe, not life-threatening; 4—severe, life-threatening, survival probable, and; 5—critical, survival uncertain. The MISS score is defined as the sum of the squares of the three most-severely injured body areas. Final patient outcomes were ranked as: normal; disabled (some limitation not previously present); dependent (for some activity of daily living), and death. Overall mortality was 14.5% with 9% disability and 0.9% dependency. Both mortality and morbidity correlated linearly with increasing MISS score. Of patients with MISS scores >25, 60% died and 16.7% were either disabled or dependent, while no mortalities and 2.5% disabilities were seen with scores

Patterns of gastroesophageal reflux in children following repair of esophageal atresia and distal tracheoesophageal fistula.

We studied gastroesophageal reflux (GER) in 25 children between 3 and 83 mo post-repair of esophageal atresia and distal tracheoesophageal fistula (EATEF). The incidence of GER was determined by 18-24 hr pH monitoring of the distal esophagus and gastroesophageal scintiscan following the ingestion of 99mTc sulfur colloid in apple juice. Gastric emptying was also assessed in 20 children. Only 17 of 25 (68%) children had significant GER by esophageal pH monitoring, and 13 of 20 (65%) had significant GER by gastroesophageal scintiscan. Significant GER was found in 10 of 12 (83%) patients wih recurrent vomiting, respiratory symptoms or severe esophagitis. Three of these 10 patients required an operation to control GER. Significant GER occurred in continuous, discontinuous and mixed patterns. The discontinuous pattern was seen in 11 of 17 (65%) children, and was associated with slow gastric emptying. The only factor during the repair of EATEF that subsequently was associated with a higher incidence of significant GER (88% vs. 59%) and slow gastric emptying (11.2 +/- 4.2% vs. 25.9 +/- 3.7% gastric emptying at 30 min, p less than 0.05) was excessive tension at the esophageal anastomosis. Many children with EATEF do not have significant GER, but in those with significant GER slow gastric emptying seems to be important.

Pulmonary sequestration in infants and children: a 20-year experience and review of the literature.

Abstract Pulmonary sequestration is a relatively rare condition in which a portion of lung tissue develops without communication with the tracheobronchial tree or the pulmonary artery. Blood supply is derived from one or more branches of the aorta. Its embryogenesis is uncertain, but it occurs in two forms, extralobar (ELS) and intralobar (ILS). In ELS the abnormal lung tissue is completely separate from the normal lung. It occurs in males four times as frequently as in females and is usually discovered in infancy. It is associated with an ipsilateral diphragmatic hernia in the majority of cases, and occasionally bronchial connections from the ELS to the esophagus or stomach have been described. ELS almost always occurs on the left side and, rarely, may be found below the diaphragm. Venous drainage is to the systemic veins or to the portal system. The ELS itself usually does not become diseased; symptoms are produced either by cystic degeneration and resultant compression of adjacent lung or by an associated diaphragmatic hernia. On the other hand, ILS typically occurs in the posterior basal segment of one of the lower lobes, most often the left. It occurs in males and females with equal frequency, and usually it makes its appearance later in childhood. Only very occasionally are associated anomalies present. Venous drainage is to the inferior pulmonary vein together with the rest of the lower lobe. The sequestered segment very frequently becomes infected and gives rise to symptoms of pneumonia. Arteriography is useful in diagnosis, and segmental resection or lobectomy is the indicated treatment.

Bronchoscopic removal of aspirated foreign bodies in children

Foreign body aspiration is the cause of death in over 500 children per year in the United States. Tracheobronchial inhalation of foreign bodies may result in acute respiratory distress, chronic pulmonary infections, atelectasis, or death. A review of 262 children ranging from 4 months to 13 years of age was undertaken to identify factors important in diagnosis to illustrate the effectiveness of newer endoscopic techniques and equipment, and to evaluate results and complications. Coughing, choking, and wheezing were the presenting symptoms seen in 91 percent of the patients. Inspiratory and expiratory chest radiographs were positive in 81 percent of the 224 children with foreign bodies removed. Fluoroscopy was positive in 41 patients, 88 percent of whom had foreign bodies removed. Bronchoscopy is required for treatment, and with experience, this procedure can be simple and safe. Ninety-nine percent of foreign bodies identified at bronchoscopy were removed successfully. Minor complications occurred in 8 percent of the patients, and there were no deaths.

Insertion of a small central venous catheter in neonates and young infants.

Total parenteral nutrition (TPN) administered through a central venous catheter in low-birthweight neonates and infants has been complicated by mechanical catheter malfunctions and catheter-associated infections. A retrospective survey of catheter complications 66 infants with 90 pediatric Broviac (1.3 mm o.d.) and large-diameter (French size 3, 4, and 5) Silastic catheters revealed 17 mechanical malfunctions (27%) and 16 cases (26%) of catheter infections. The current study presents our experience using 58 small-diameter (0.635 mm o.d.) Silastic catheters for TPN in 53 neonates and infants. There were 13 episodes (22%) of mechanical problems such as accidental dislodgement, occlusion of the catheter, and perforation of the tubing. Only four cases (7%) of catheter-associated sepsis occurred, a significant reduction (p = 0.008) in this serious problem compared to the previous large catheter study. We have compared clinical features of both large- and small-diameter catheters and suggest specific guidelines for their use. The small-diameter Silastic catheter is safe, easily inserted, and effective in the critically ill, low-birthweight neonate and in young infants weighing less than 6 kg. The pediatric Broviac catheter is recommended for administration of long-term or home TPN to infants and children greater than 6 kg. These catheters are useful for multiple purposes such as blood drawing, chemotherapy, and nutritional support while the small catheter is not as versatile.

Gastroschisis and omphalocele. An eight-year review.

Until recently confusion has existed concerning the clinical features and surgical treatment of gastroschisis and omphalocele. Since 1971 75 infants with these abdominal wall defects have been treated at our institution. Significant differences (p < 0.001 in all instances) were noted between the two diseases. Gastroschisis occurred twice as often as omphalocele and is increasing in frequency. Prematurity was commonly seen with gastroschisis (65%). While the overall incidence of malformations associated with gastroschisis was low (23%), the vast majority of the additional malformations were jejunoileal or colonic atresias. The mortality rate was 12.7% among gastroschisis patients, with only one death attributable to prematurity. All other deaths were preventable, indicating that even lower mortality rates are feasible. Omphalocele was associated with a 23% incidence of premature birth but associated anomalies were present in 66% of the patients. Major cardiac (52%) and chromosomal defects (40%) predominated. In addition, 17% of omphalocele patients had either Cantrells pentalogy or cloacal/bladder exstrophy. The mortality rate in omphalocele (34%) was nearly three times that of gastroschisis. Nine of ten patients who died from omphalocele died either from major cardiac or chromosomal disease. However, in patients without cardiac or chromosomal defects the survival rate was 94%.

Value of tests for evaluation of gastroesophageal reflux in children.

The accuracy of five tests for the diagnosis of gastroesophageal reflux in children was performed in 93 symptomatic children with gastroesophageal reflux and 16 nonreflux patients. These tests include the barium esophagram, the Tuttle test, extended esophageal pH monitoring, esophagoscopy, and esophageal biopsy. Esophagoscopy was less sensitive in detecting reflux in patients than any other test (P = less than 0.001), and biopsy was more likely to identify reflux patients than the barium swallow (P = less than 0.02), but there was no test superior to others. The severity of esophagitis noted at endoscopy or the presence of eosinophils or neutrophils in the mucosa was not associated with a decreased possibility that one other test would be normal or that surgical repair of the reflux would be performed. Patients with extended esophageal pH test scores markedly elevated were less likely to have another negative test (P = less than 0.01) and more likely to have surgical repair of gastroesophageal reflux (P = less than 0.001). Obtaining two tests of esophageal function that agree increases the certainty of diagnosis, and use of several tests are indicated if the results of a single test do not support the clinical impression.

Neuroblastoma: An assessment of therapy in reference to staging

Abstract A total of 134 patients with neuroblastoma have been treated in one clinic with a relatively consistent method of management. When these patients are staged according to the system of Evans et al., the results in reference to survival would seem to validate the staging system and warrant its use by others. If the stage of the tumor is accurately assessed, patients with Stage I and II tumors require no radiation therapy whereas those with Stage III tumors benefit from postoperative irradiation.

Special report. Air transport of pediatric emergency cases.

Prompt delivery of appropriate care is of great importance in the management of medical emergencies. The necessity for adequate, efficient resuscitation and rapid transportation of patients has bee...

Cystic and solid heterotopic brain in the face and neck: A review and report of an unusual case*

An unusual case of heterotopic brain tissue was confused as a lymphangioma in the neck. Although these lesions are rare, they should be included in the differential diagnosis of congenital head and neck masses. They can compress and deform surrounding structures and cause airway obstruction in the newborn. Excision is curative, but the possibility of encephalocele should be eliminated by prior computed tomography scan.