James L. Talbert

The pediatric trauma score as a predictor of injury severity in the injured child

The ability of the Pediatric Trauma Score (PTS) to accurately predict the degree of injury severity of the injured child was assessed by comparing two separate groups of pediatric trauma victims. The first group consisted of 110 patients evaluated at a regional pediatric trauma center whose data was collected and assessed by a single investigator. The second group consisted of a similar matched cohort of 120 patients from the National Pediatric Trauma Registry whose data was collated from multiple participating institutions. In both cases, a linear relationship between PTS and Injury Severity Score (ISS) was documented that was statistically significant to P less than .001. The linear regression coefficients of each group were similar as was the distribution of PTS and ISS. This study documents the validity of the PTS as an initial assessment tool and confirms its reliability as a predictor of injury severity.

Detrimental Effects of Standard Medical Therapy in Congenital Diaphragmatic Hernia

OBJECTIVE To evaluate the impact of a nonstandard ventilation strategy on survival in congenital diaphragmatic hernia (CDH). BACKGROUND Despite recent advances, including nitric oxide, CDH remains an unsolved problem with a mortality rate of 35% to 50%. Hyperventilation and alkalization remain common therapies. METHODS In 1992, the authors prospectively abandoned hyperventilation and alkalization. Patients are lightly sedated and ventilated with the lowest pressure providing adequate chest movement, and the rate is set to patient comfort. Nitric oxide and extracorporeal membrane oxygenation (ECMO) are reserved for life-threatening instability. Surgical repair is delayed 1 to 5 days. Sixty consecutive patients are compared with 29 previous patients treated with hyperventilation and alkalization, 13 before and 16 after the availability of ECMO. RESULTS Overall, 47 of 60 patients (78%) in study era 3 survived compared with 2 of 13 (15%) in the hyperventilation era and 7 of 16 (44%) in the hyperventilation/ECMO era (p < 0.0001). The disease severity and the incidence of associated anomalies did not differ between groups. To compare management strategies, patients who had treatment withheld because of lethal associated conditions were then removed from analysis. Peak inspiratory pressure and arterial pH were lower (p < 0.0001) and Paco2 was higher (p < 0.05) in era 3 than in the previous eras. The rate of pneumothorax (1.9%) decreased (p < 0.0001). In era 3, survival was 47 of 53 (89%) treated patients, and 23 of 25 inborn patients with isolated CDH survived (92%). CONCLUSIONS Nonstandard ventilatory support of patients with CDH has led to significantly improved survival rates. This study sets a survival benchmark and strongly suggests the negative effects of hyperventilation and alkalization.

Nonsurgical test for the diagnosis of Hirschsprung's disease.

Abstract A manometric technic is described for the diagnosis of Hirschsprungs disease without the necessity of deep-muscle rectal biopsy. Separate pressure recordings were obtained from the internal and external anal sphincters by a double balloon device and from the rectum by a third balloon. Simultaneous electromyographic activity was recorded from the external sphincter by a concentric needle electrode. In 34 normal subjects transient distention of the rectal balloon produced reflex relaxation of the internal sphincter (smooth muscle) and contraction of the external sphincter (striated muscle), with a simultaneous increase of electrical activity in the external sphincter. In 10 patients with Hirschsprungs disease, there was contraction of the internal sphincter instead of relaxation. External sphincter responses were normal. In 31 patients with idiopathic megacolon, both internal and external sphincter responses were normal, indicating that the abnormal contractile response found in Hirschsprungs di...

Intrahepatic cholestasis with parenteral alimentation

Abstract From July 1971 to March 1975, eleven infants receiving total or partial parenteral alimentation at the University of Florida showed histologie evidence of intrahepatic cholestasis. The clinical records of these patients have been examined. These infants were critically ill and had protracted hospital courses, with only two survivors. Liver biopsies demonstrated marked cholestasis with some fibrosis and thickening of the limiting membrane of the hepatocyte. In those patients in whom serial liver biopsies were obtained, hepatic histology returned toward normal, paralleling improvement in liver function studies, as intravenous alimentation was discontinued. Careful monitoring of the liver function tests is essential to detect this progressive abnormality as early as possible and discontinue intravenous alimentation. Follow-up as long as two and a half years in the two surviving patients has demonstrated no chronic hepatic dysfunction.

Differential sphincteric studies in the diagnosis of ano-rectal disorders of childhood

Summary A reliable method for evaluating recto-sphincteric reflexes using differential manometric recordings of internal and external sphincter responses, combined with electromyographic recordings of the external sphincter, was used in 34 normal subjects, 31 patients with psychogenic constipation, 10 patients with Hirschsprungs disease and 20 patients with imperforate anus. Internal sphincter relaxation was found in all normal subjects and in those with constipation while internal sphincter contraction was found in all patients with Hirschsprungs disease, suggesting this technique in the diagnosis of Hirschsprungs disease. Preoperative electromyographic localization of the external sphincter could avoid improper placement of the bowel in surgery for imperforate anus. The external anal sphincter has an important role in the maintenance of continence.

Thoracoscopy in children.

In the past four and one-half years we have used thoracoscopy as the primary technique for pulmonary biopsy in children. During that interval, over 80 thoracoscopic procedures have been performed with no mortality and minimal morbidity. The ages of the patients have ranged between 2 weeks and 20 years. The procedure is carried out in the general operating room under regional and intravenous anesthesia, avoiding the need for endotracheal intubation. Fourty-two of the procedures have been performed in immunosuppressed patients, attempting to determine the presence of Pneumocystis carinii pneumonia. Twenty-four of the procedures have been performed for the diagnosis of intrathoracic tumors while 15 procedures have been performed for the diagnosis of localized pulmonary infiltrates. The diagnostic accuracy in immunosuppressed patients has been 100 persons and in the tumor patients has been 92 percent. The complications of this technique have been minimal. Four patients developed pneumothoraces which responded to manipulation of the chest tube and 3 patients have had sufficient postoperatoire bleeding to require transfusion, while none have required re-exploration. The technique of thoracoscopy has provided a safe and rapid method of pulmonary diagnosis in this aged patient.

Thoracoscopy for diagnosis of intrathoracic lesions in children

Disenchantment with available techniques for specific diagnosis of intrathoracic pulmonary lesions in children has led us to explore the usefulness of thoracoscopy. We have performed this technique in nine patients ranging in age from 17 mo to 16 yr. The procedure is performed under intravenous anesthesia with the patient spontaneously breathing oxygen. A fiberoptic rod lens system is employed for the direct observation and biopsy of pulmonary parenchymal or chest wall lesions. Adequate tissue has been obtained in each case to allow a specific diagnosis. There has been no mortality from this procedure and only minor morbidity. We believe that this technique offers a rapid and simple method for the diagnosis of diffuse or localized disease of pulmonary parenchyma or chest wall in children.

The use of preserved human dura for closure of abdominal wall and diaphragmatic defects.

The surgical management of large body wall defects presents special challenges. The prosthetic materials employed for these defects, although readily available, have the disadvantage of susceptibility to infection. Autologous tissue is frequently not available in sufficient quantity. The long-term functional and histologic results of the use of preserved human dura for closure of abdominal wall and diaphragmatic defects have been evaluated. Dural patches were sutured into abdominal wall and diaphragmatic defects of six dogs, using interrupted sutures of Dexon and Prolene. The animals were killed eight, 16 and 24 weeks after patch placement. The strength of the material was tested with a pneumoperitoneum prior to death and in all animals it appeared firmly incorporated into the host tissue. Histologically there was a mononuclear inflammatory response seen at eight weeks, with resolution by 24 weeks. Ingrowth of surrounding collagen and muscular tissue produced a firm union between the homologous material and the host tissue. The results of this study indicate that preserved human dura is an excellent material for closure of body wall defects. It appears to be well tolerated by host tissue and maintains its strength over prolonged periods of time.

Balloon dilatation of long-segment tracheal stenoses

Although a rare anomaly, congenital tracheal stenosis is associated with a high mortality. Surgical approaches proposed for this life-threatening lesion have included resection of localized stenoses; tracheoplasty involving interposition of cartilage, periosteum, or pericardium via an anterior tracheal split; or esophageal anastomosis to a posterior tracheal split. None of these techniques have provided uniformly satisfactory results, and all entail significant morbidity associated with the tracheal anastomosis. We have used endoscopic balloon dilatation in four children with critical airway obstruction from long-segment tracheal stenoses. In each of these patients, symptoms began early in life (from 2 weeks to 6 months of age) and consisted of respiratory distress from upper airway obstruction or recurrent episodes of stridor and chest retractions requiring hospitalization. The location of the tracheal stenoses varied, involving the upper third, middle third, middle half, and distal half of the trachea in the patients encountered. At bronchoscopy, the lumen was judged to be less than or equal to 1 mm in three of these patients. Dilatation was accomplished using Gruentzig balloon catheters in sizes ranging from 3 mm to (eventually) 8 mm, and produced a posterior split in the complete tracheal rings responsible for the stenosis in all patients, resulting in great increases in airway lumen. All children were improved following balloon dilatation, and three are currently doing well at 2.5, 3.0, and 3.0+ years postdilatation. One infant eventually died of airway obstruction incurred by severe bronchomalacia distal to the tip of an endotracheal tube that had been passed to the carina after sequential balloon dilatations.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of gastroschisis and omphalocele with biological dressings.

Porcine skin grafts and human amniotic membranes have been used as biological dressings for the treatment of gastroschisis or omphalocele in 16 newborn infants. Eleven infants with gastroschisis were managed initially by the Silastic pouch technique but delayed healing resulted in separation of the Silastic sheeting from the wound margins and required use of biologic dressings to achieve complete closure. Biological dressings were used in five patients with intact omphaloceles for all or part of their course. Average time to achieve complete closure was 55 days. Three patients died of associated anomalies. One patient developed an enteric fistula. Biologic dressings appear to be useful adjuncts in the management of some patients with gastroschisis or omphalocele.