David P. Meagher

Vascular trauma in infants and children.

A 20-year retrospective evaluation of vascular trauma in infants and children was undertaken. The study included 53 cases of blunt and penetrating vascular injuries in pediatric patients. There were 36 males and 17 females ranging in age from 24 days to 14 years (average, 10 years). The most frequently encountered sites of arterial trauma were the brachial or superficial femoral artery, and of venous trauma the inferior vena cava. Any patient presenting to the Emergency Center with an injury in proximity to a major vessel, hematoma formation, audible bruit, or palpable thrill underwent prompt arteriography or immediate operative exploration of the injury sit. All patients in the series were managed operatively. There were 41 major arterial and 32 major venous injuries. No patient required a major amputation. Most injuries were repaired by primary closure or segmental resection and end-to-end anastomosis; interposition vein grafts and substitute conduits were used in four patients with more extensive injuries. A 13% operative mortality was encountered: the most frequent cause of death was intraoperative exsanguinating hemorrhage. The triad for successful management of vascular trauma in pediatric patients is: 1) a high index of suspicion, 2) performance of aggressive diagnostic studies when indicated, and 3) prompt surgical intervention.

Recurrent appendicitis after initial conservative management of appendiceal abscess

Therapy for children with appendiceal abscess remains controversial. The authors present two such cases initially treated conservatively, without interval appendectomy, that later had recurrent appendicitis. An 8-year-old boy presented with fever, abdominal pain, and a right-lower-quadrant abscess (noted by ultrasonography). During laparotomy, the abscess was drained and the appendix was not found. He was lost to follow-up but returned 2 1/2 years later with perforated appendicitis. An appendectomy was performed, and image-guided drainage of a postoperative abscess was required. A 10-year-old girl presented with fever and right-lower-quadrant pain. Computed tomography showed a multiloculated mass. During laparotomy, the cecum was found to be densely adherent to the pelvic organs and bowel, so the surrounding abscess was drained. Interval appendectomy was refused. The patient returned 8 months later with recurrent acute appendicitis and an appendiceal abscess requiring appendectomy and drainage. Although initial drainage alone of appendiceal abscess is efficacious, the authors strongly advocate interval appendectomy as a critical component of the complete management of this entity.

Tracheal agenesis: A clinical approach

Tracheal agenesis, though seemingly rare and fatal to date, has been reported from multiple institutions with increasing frequency. Establishment of the diagnosis necessitates a high index of suspicion in an infant in respiratory distress at birth, without a cry and in whom intubation is difficult. Following definitive diagnosis by endoscopy, infants have been given a chance at survival on four occasions by prompt surgical intervention. The procedure proposed by Altman is adequate for initial stabilization. Postoperative management is aided by the use of continuous positive airway pressure (CPAP) and rigorous pulmonary toilet. Definitive correction should be considered at an early stage in order to prevent fatal complications.

Intussusception in Henoch-Schonlein Purpura: Diagnosis with Ultrasound

This report describes the successful use of abdominal ultrasound to diagnose intussusception in a patient with Henoch-Schonlein purpura.

A multicenter prospective analysis of pediatric trauma activation criteria routinely used in addition to the six criteria of the American College of Surgeons

BACKGROUND The American College of Surgeons has defined six minimum activation criteria (ACS-6) for the highest level of trauma activations at trauma centers. The verification criteria also allow for the inclusion of additional criteria at the institution’s discretion. The purpose of this prospective multicenter study was to evaluate the ACS-6 as well as commonly used activation criteria to evaluate overtriage and undertriage rates for pediatric trauma team activation. METHODS Data were prospectively collected at nine pediatric trauma centers to examine 29 commonly used activation criteria. Patients meeting any of these criteria were evaluated for the use of high-level trauma resuscitation resources according to an expert consensus list. Patients requiring a resource but not meeting any activation criteria were included to evaluate undertriage rates. RESULTS During the 1-year study, a total of 656 patients were enrolled with a mean age of 8 years, a median Injury Severity Score of 14, and mortality of 11%. Using all criteria, 55% of patients would have been overtriaged and 9% would have been undertriaged. If only the ACS-6 were used, 24% of patients would have been overtriaged and 16% would have been undertriaged. Among activation criteria with more than 10 patients, those most predictive of using a high-level resource were a gunshot wound to the abdomen (92%), blood given before arrival (83%), traumatic arrest (83%), tachycardia/poor perfusion (83%), and age-appropriate hypotension (77%). The addition of tachycardia/poor perfusion and pretrauma center resuscitation with greater than 40 mL/kg results in eight criteria with an overtriage of 39% and an undertriage of 10.5%. CONCLUSION The ACS-6 provides a reliable overtriage or undertriage rate for pediatric patients. The inclusion of two additional criteria can further improve these rates while maintianing a simplified triage list for children. LEVEL OF EVIDENCE Therapeutic study, level III.

“Bucket Handle” Avulsion of Intestine in Gastroschisis

Two infants with gastroschisis had most of the midgut avulsed during cesarean section. There was only 12 and 20 cm of small bowel remaining, with an intact ileocecal valve in each case. Cutaneous enterostomy followed by anastomosis was done in both patients. The first child is 4 years old and is now on total enteral feedings after prolonged intravenous support. The second infant is still on partial parenteral nutrition. The cases illustrate the vulnerability of the fetus with gastroschisis during extraction by cesarean section.

The Importance of Acid Reflux Patterns in Neurologically Damaged Children Detected by Four-Channel Esophageal pH Monitoring

Multiple level esophageal pH studies were performed in 23 neurologically damaged infants and children for evaluation of gastroesophageal reflux (GER) and feeding difficulties. The patients were placed in one of three anatomic groups based on the extent of their neurologic injury. Seven children had an acute cerebral injury due to closed head trauma or infections. Six patients with perinatal asphyxia or progressive encephalopathy had a global CNS insult. Eight children with CNS malformations or intraventricular hemorrhage had subacute cerebral damage. Two patients with generalized seizure disorders could not be anatomically classified. In all groups, abnormalities detected at the distal esophagus were also noted at more proximal levels. The middle esophageal probe demonstrated a significant difference (P less than .02) for the longest reflux episode between patients with subacute cerebral injury and those with a global insult. The difference (P less than .02) for the longest reflux episode detected by the distal pH sensor in globally damaged children compared with those with acute cerebral injury also persisted at the middle and proximal esophageal levels. Comparing these same groups, a difference (P less than .02) in acid clearance time and percentage of time pH less than 4 was noted only at the proximal esophageal level. Only the middle and proximal pH probes detected differences (P less than .02) for acid clearance time between patients with both types of cerebral damage and those with a global injury. In infants and children with CNS damage and suspected GER, monitoring the proximal and middle esophageal pH provides important information not detected by the distal esophageal sensor.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital anomalies of the diaphragm. Personal experience with thirty-five consecutive cases.

A personal experience of thirty-five consecutive patients with congenital anomalies of the diaphragm is reported. The anomalies included twenty-five Bochdalek hernias, seven diaphragmatic eventrations, and three esophageal hiatal hernias. Except for the patients with esophageal hiatal hernias, virtually all patients presented with respiratory embarrassment, twenty-seven of the thirty-five within 24 hours of birth. An especially high mortality is associated with this early onset of symptoms. The treatment was surgical with a thoracic approach used for right Bochdalek defects and eventrations, and an abdominal approach used for left Bochdalek hernias. The importance of proper preoperative and postoperative management in a well equipped neonatal intensive care unit is emphasized.

Colon Esophagoplasty in the Orthotopic Position

Three cases of long-gap esophageal atresia were repaired using a technique that included a right extrapleural thoracotomy, preservation of the entire esophagus available, both anastomoses in the mediastinum, use of a short segment of colon, and preservation of the ileocecal valve. This approach, not previously described, combines multiple features aimed at decreasing complications related to traditional techniques. Successful early results are promising.