James M. Lynch

Management of blunt splenic trauma: significant differences between adults and children.

BACKGROUND Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age). METHODS Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%). RESULTS Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention. CONCLUSIONS Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.

Laryngotracheal disruption from blunt pediatric neck injuries: Impact of early recognition and intervention on outcome

Blunt and penetrating neck injuries are an infrequent cause of morbidity and mortality in the pediatric population. Although less common than penetrating injuries, blunt pediatric neck injuries are more often life-threatening because of associated laryngotracheal disruption. The authors reviewed their experience with pediatric neck injuries over the past 5 years. There were nine blunt and 14 penetrating injuries, representing 0.5% of the trauma admissions. There was no significant difference in age or gender distribution between the two groups. Blunt pediatric neck injuries were more often associated with frank respiratory distress at the time of presentation. Massive subcutaneous emphysema and hoarseness were the most common symptoms encountered. All patients with blunt injury underwent direct laryngoscopy and bronchoscopy (DL & B) and esophagoscopy. DL & B results were positive for eight patients; seven patients underwent neck exploration and successful repair of the laryngotracheal injuries. There were two deaths; one of these patients had laryngeal transection, which was not recognized at the time of DL & B. The other death resulted from associated tracheobronchial disruption secondary to massive blunt chest trauma. The patients with penetrating neck injuries were more likely to be treated nonoperatively, to have a shorter stay in the hospital and intensive care unit, and to have a lower injury severity score. There were no deaths in this group. The authors conclude that all patients with blunt neck trauma should undergo emergent and meticulous DL & B. Visualization of laryngotracheal disruption mandates immediate neck exploration and primary repair.

Management of Blunt Pancreatic Injury in Children

BACKGROUND AND METHODS Controversy persists regarding the management of pancreatic transection. Over the past 10 years, 51 patients admitted to the Childrens Hospital of Pittsburgh sustained blunt pancreatic injuries. We reviewed their medical records to clarify the optimal management strategy and to define distinguishing characteristics, if any, of patients with pancreatic transection. RESULTS Patients who sustained pancreatic transection had a significantly higher Injury Severity Score, length of stay, serum amylase, and serum lipase, than those patients who sustained pancreatic contusion. Patients who underwent laparotomy within 48 hours of injury for pancreatic transection had a significantly shorter length of stay than those who underwent laparotomy more than 48 hours after injury. CONCLUSION Serum amylase greater than 200 and serum lipase greater than 1,800 may be useful clinical markers for major pancreatic ductal injury when combined with physical examination. Early operative intervention for pancreatic transection results in shorter length of stay and fewer complications.

The use of drugs in emergency airway management in pediatric trauma

Most patients who require emergency airway control receive drugs to induce rapidly sufficient anesthesia for direct laryngoscopy and endotracheal intubation, but there are no protocols that outline the use of specific drugs in general use. Drugs should safely and rapidly produce (1) unconsciousness; (2) paralysis; and (3) blunt intracranial pressure (ICP) responses to airway procedures. Consequences to be considered include increased ICP, hemorrhagic shock, and a full stomach. To refine the use of drugs used for airway procedures in pediatric trauma patients, the authors reviewed all cases of emergency endotracheal intubation over a recent 12-month period (1) to see whether medications used met the goals of producing unconsciousness and paralysis and blunting ICP responses were met safely; and (2) to identify potential drug-related complications. From July 1, 1990, to June 30, 1991, 60 of 791 children (7.6%) required endotracheal intubation at the scene of injury, at the referring hospital, or in our emergency department (15; 25%). Ten patients died (16.7%). Three fourths were younger than 9 years of age. All except one suffered blunt injuries. Nearly all (95%) suffered head injuries, isolated in 39 of 57 (68.4%) and combined with injuries in other regions in 18 (31.6%). Fifteen patients were in apnea (25%); seven were both apneic and pulseless. Three fourths (45 of 60) had diminished levels of consciousness; one fourth (15 of 60) were awake. Immediate endotracheal intubation proceeded appropriately without drugs in all seven patients in cardiopulmonary arrest. Only eight of the remaining 53 patients (15.1%) received an optimal medication regimen. Many patients with head injury were inadequately protected against increases in ICP. Thiopental, an effective anesthetic agent that effectively lowers intracranial pressure, was not used in 25 of 35 stable patients with isolated head injury (71.4%). Intravenous lidocaine was not used in 38 of 50 head-injured patients in whom it would have been an appropriate adjunct to control increases in ICP (76%). Eight patients received paralyzing agents alone, without sedatives or narcotics. Medications were thought inadequate to relieve the pain and discomfort of laryngoscopy and endotracheal intubation in 32 of the 53 patients who should have received them (60.4%). No paralyzing agents were used in 36 of the 53 instances where it would have been appropriate (67.9%). In two of 11 instances (18.3%) where succinylcholine was administered, no prior nondepolarizing agent was used. Complications of a full stomach at the time of emergency endotracheal intubation became evident in 10 patients (16.7%) who vomited during procedures to control the airway. Two patients (3.3%) aspirated.(ABSTRACT TRUNCATED AT 400 WORDS)

Is early discharge following isolated splenic injury in the hemodynamically stable child possible

Nonoperative treatment of splenic injury is well accepted. Two questions have not been answered. (1) What is the intensity of monitoring required in the hemodynamically stable patient? (2) How long do patients need to be hospitalized? Ninety-one patients having computed tomography (CT) or surgically proven splenic injury were treated between September 1986 and September 1991. Excluded from the study were 16 patients requiring operation and 22 patients having multiple system injuries. All operations occurred within 24 hours of admission. No transfusions were required later than 48 hours following admission. The remaining 53 patients (58%) constitute the study group. CT classification of Buntain indicated 6 class I, 21 class II, 24 class III, and 2 class IV injuries. The mean Injury Severity Score (ISS) for the group was 6.98 +/- 3.43. Serial hematocrits for the patients treated without transfusions were followed until three consecutive determinations showed no change. The lowest average hematocrit for the nontransfused group was 30.96% +/- 4.47% and occurred on day 2.06 +/- 0.76. Eleven patients (23%) had left-sided pleural effusions that resolved without intervention. One patient had an ileus for 3 days. CT or ultrasound examination was obtained on day 5 to 7 to document healing before the patient was allowed out of bed and discharged. The average hospital stay was 7.06 +/- 2.24 days. Twenty-two patients were initially observed in the intensive care unit (ICU). Clearly the interval between hematocrit stability (average, 2.06 days) and discharge (average, 7.06 days) constitutes a time of minimal nursing care while utilizing bed space and health care dollars.(ABSTRACT TRUNCATED AT 250 WORDS)

The Influence of Down's Syndrome on the Management and Outcome of Children With Hirschsprung's Disease

BACKGROUND Children with Downs syndrome (DS) have a reportedly poorer outcome after treatment of Hirschsprungs disease (HD) compared with control children. Because of overall improvements in their management, the authors hypothesized that the diagnosis of DS would not influence outcome after the management of HD. METHODS Consecutive children with HD (1995 through 2002) were collected prospectively then divided retrospectively into those with DS and controls (C). Patients who underwent surgery at another institution and those with total colonic aganglionosis were excluded. RESULTS Of 66 patients, 9 had DS. Mean age at diagnosis, gender, racial distribution, gestational age, and proximity to our center were similar between groups. Presenting symptoms, location of the transition zone, and type of initial operation were similar. Patients with DS had significantly more comorbidities than controls, which generated significantly greater treatment costs and a higher mortality rate. However, with an average of 22 months of follow-up, the overall outcome including postoperative complications, enterocolitis, and constipation was similar. CONCLUSIONS These data suggest that in contrast to earlier reports, DS has minimal influence on surgical outcome of patients with HD. Although the overall cost of treating patients with DS is greater, this mainly reflects the impact of managing comorbidities.

Computed tomography grade of splenic injury is predictive of the time required for radiographic healing

It is largely unknown when a child who has suffered a splenic laceration can return to full unrestricted activity. The purpose of this prospective study is to establish whether the grade of splenic injury is predictive of the length of time required for radiographic healing, and to determine whether there are any adverse long-term sequelae after resumption of unlimited activity. Sixty-nine patients underwent successful nonoperative management (NOM) of computed tomography (CT)-documented splenic injury over a 4-year period. Fifty-eight patients completed follow-up. Mean age was 9.8 years (range, 1 to 17) and mean injury severity score (ISS) was 14.4 (range, 4 to 38). Mechanisms of injury were motor vehicle accident (n = 11), motor vehicle pedestrian (n = 5), falls (n = 13), bike crashes (n = 12), sports (n = 8), all-terrain vehicle (n = 4), and horse (n = 5). The CT-documented injury was identified by discharge ultrasound scan (US) in all cases. There were no long-term complications. Mean time to US healing in grade I (n = 9), II (n = 26), III (n = 19), IV (n = 4) injuries was 3.1, 8.2, 12.1, and 20.7 weeks, respectively. P values were significant (P < .01) in all cases when compared with the next lower injury grade. The time to radiographic healing is directly proportional to the severity of the splenic injury. There was excellent correlation between the initial CT scan and identification of the injury on the discharge US. No long-term complications leg, delayed splenic rupture, splenic pseudocyst) were seen in this study. Pediatric patients who have suffered splenic injury can safely return to full unrestricted activity when the US documents healing.

Hemodynamic Significance of Pediatric Femur Fractures

PURPOSE To determine whether hemodynamically significant bleeding occurs after pediatric femur fractures. METHOD A retrospective chart review was performed; demographic and injury data were collected for all patients with the diagnosis of femur fracture over a 30-month period at a level/ pediatric trauma center. Included were patients with multisystem injury and patients with femur fractures as the only injury. The incidence of hemodynamic insufficiency, the reasons for and timing of transfusions, and the changes in hematocrit levels over time were evaluated. RESULTS One hundred seventy-eight children were identified (182 femur fractures). There were 116 boys and 62 girls, and the mean age was 6.04 +/- 4.5 years (range, 1 month to 19 years). The mechanisms of injury included falls (46), pedestrian/ motor vehicle accidents (43), motor vehicle crashes (19), sports accidents (22), abuse (10), and miscellaneous (38). The mean Injury Severity Score (ISS) was 5.88 +/- 3.93 (range, 4 to 29). There were no deaths. The length of hospital stay was 8.13 +/- 9.37 days (range, 1 to 43 days). Prehospital treatment included early immobilization. Fracture treatment was according to recognized orthopedic techniques based on age, size, and fracture configuration. The mean hematocrit in the emergency department was 34% +/- 3.5% (range, 27.8% to 44.4%) and 32% +/- 6.6% (range, 16.9% to 47.8%) at 24 hours. 67 patients (38%) suffered multiple injuries. Mean ISS for this group was 9.4 +/- 5.0 (range, 5 to 29). Four patients had hemodynamic insufficiency at the time of admission. All were in the multiple-injury group Seven of these 67 patients (10%) required transfusion-three in the first 24 hours (two in the emergency department [associated with severe facial/scalp bleeding] and one in the operating room [associated with severe liver injury]) and four after the first 24 hours (three associated with intraoperative orthopedic procedures and one with a hemothorax). The mean age of those who underwent transfusion was 8.29 +/- 4.79 years, and their mean ISS was 13.71 +/- 4.61. All patients who required transfusion had been injured in motor vehicle crashes or in pedestrian/motor vehicle accidents. One hundred eleven children had isolated closed femur fractures. No patient in this group had evidence of hemodynamic insufficiency or required transfusion. The initial mean hematocrit was 34.5% +/- 2.7%, and the mean 24-hour hematocrit was 34.6% +/- 3.2%. We found that (1) no child with an isolated closed femur fracture had evidence of hemodynamic instability, or showed significant blood loss as evidenced by a decreasing hematocrit at 24 hours, and (2) in this series, evidence of hemodynamic insufficiency and/or the need for transfusion was found only in multiply injured children. CONCLUSION Hemodynamic instability or evidence of a declining hematocrit in the child should not be attributed to a closed femur fracture and that other sources of blood loss must be found.

Blunt urogenital trauma in prepubescent female patients: more than meets the eye!

Blunt traumatic injury to the urogenital region in the prepubescent girl is commonly evaluated in pediatric emergency departments (ED). The purpose of this study is: 1) to establish recommendations for an accurate, painless (both physically and psychologically), and timely diagnosis, and 2) to determine whether the ED examination can accurately determine the extent of the injury. Over a 24-month period (January 1991 through December 1992), 22 girls with blunt trauma to the urogenital region (mean age 5.7 years, range 2-9 years) were retrospectively evaluated. Initial ED evaluations were by both an emergency physician and a pediatric surgeon. All 22 patients underwent an examination under anesthesia (EUA) in the operating room to evaluate the extent of the injury and to repair the injury as needed. Follow-up was obtained in all patients and averaged 18 months. The findings at EUA demonstrated a significant disagreement with the preoperative ED evaluation. In only five patients was there agreement between the preoperative ED assessment and the findings during the EUA (24% concurrence). Thus, 16 patients (76%) had injuries of greater extent than was appreciated during the preoperative examination in the ED. Partial or complete disruption of the perianal sphincters occurred in six patients (27%) and was unrecognized preoperatively in each. Twenty-one of the 22 patients required suture repair of lacerations, the remaining patient did not require surgical therapy. Three patients had contusions or lacerations to the urethral area requiring repair and/or prolonged bladder catheter drainage for two to 14 days (average seven days). The average hospital stay was 19.3 hours. There were three minor wound complications following surgery: two required repeat EUA with suturing or cauterization, and one required no further therapy. This study clearly demonstrates that the ED examination, by both emergency physicians and pediatric surgeons, of young girls who have suffered blunt urogenital trauma grossly underestimates the severity of injuries when compared to the EUA in the operating room. EUA is safe and allows early discharge with minimal psychologic sequelae. Recommendations for mandatory EUA are made.

Intestinal stricture following seat belt injury in children

The most commonly reported intestinal injury from seat belts in children is perforation. A rarely reported late sequela following this type of injury is posttraumatic intestinal stricture (PTIS). A review of the literature reveals a common clinical pattern of presentation in children and adults but an apparent difference in the pathophysiologic mechanism between the pediatric and adult patient. Recently, we treated two children with PTIS. Each case is discussed, and a pathophysiological mechanism for this injury in children is proposed. Recommendations are made for the evaluation and treatment of these uncommon complications of seat belt-related blunt intestinal injury.