James R. Pierce

Massive subcutaneous emphysema, pneumomediastinum, and pneumopericardium in children

Massive subcutaneous emphysema (SE), pneumomediastinum (PM), and pneumopericardium (PP) are rare conditions in the pediatric population. Air leak syndrome is a constellation of disorders that include SE, PM, PP, and pulmonary interstitial emphysema. In children, SE, PM, and PP are associated with obstructive airway disease most often in the case of asthma. Management may be conservative or involve invasive procedures that require surgical intervention. Here, we describe a case of massive SE, PM, and PP in a 10-year-old child after placement of a peripherally inserted central line and review the literature.

Can a pediatric trauma center improve the response to a mass casualty incident

ABSTRACT Recent events including the 2001 terrorist attacks on New York; Hurricane Katrina; the 2010 Haitian and Chilean earthquakes; and the 2011 earthquake, tsunami, and nuclear disaster in Japan have reminded disaster planners and responders of the tremendous scale of mass casualty disasters and their resulting human devastation. Although adult disaster medicine is a well-developed field with roots in wartime medicine, we are increasingly recognizing that children may comprise up to 50% of disaster victims, and response mechanisms are often designed without adequate preparation for the number of pediatric victims that can result. In this short educational review, we explore the differences between the pediatric and adult disaster and trauma populations, the requirements for designation of a site as a pediatric trauma center (PTC), and the magnitude of the problem of pediatric disaster patients as described in the literature, specifically as it pertains to the availability and use of designated PTCs as opposed to trauma centers in general. We also review our own experience in planning and simulating pediatric mass casualty events and suggest strategies for preparedness when there is no PTC available. We aim to demonstrate from this brief survey that the availability of a designated PTC in the setting of a mass casualty disaster event is likely to significantly improve the outcome for the pediatric demographic of the affected population. We conclude that the relative scarcity of disaster data specific to children limits epidemiologic study of the pediatric disaster population and offer suggestions for strategies for future study of our hypothesis. LEVEL OF EVIDENCE Systematic review, level III.

Perirectal arteriovenous malformation treated by angioembolization and low anterior resection.

We present a case of a child with ongoing lower gastrointestinal bleeding caused by a rectosigmoid arteriovenous malformation. To reduce perioperative bleeding, we performed preoperative angioembolization followed by subsequent resection by low anterior resection. Here we present the case and review the literature regarding neoadjuvent embolization for gastrointestinal and pelvic arteriovenous malformations.

Sigmoid perforation and bucket-handle tear of the mesocolon after bicycle handlebar injury: a case report and review of the literature

We describe an unusual case of sigmoid colon perforation secondary to a bicycle handlebar injury. Because the patient presented 2 days after the initial injury, we suspected that the colon perforation was not the immediate result of the bicycle accident but, rather, was secondary to devascularization. At operation, we found a bucket-handle tear of the colonic mesentery, which was the patients primary injury and cause of the perforated colon.

Pneumatosis intestinalis after laparoscopic appendectomy: case report and review of the literature

Pneumatosis intestinalis (PI) is the presence of intraluminal gas within the wall of the intestine. As a marker for bowel injury owing to mucosal injury, PI may herald a severe underlying disease process in patients without a significant medical history. In other cases, PI is a benign process, and expectant management is appropriate. Here, we present the first reported case of pneumatosis associated with postoperative abscess after appendectomy and its successful management. Then, we describe the pathophysiology of pneumatosis and review the literature regarding its origin and management.

Intraoperative hypercyanosis in a patient with pulmonary artery band: case report and review of the literature

A case of intraoperative cyanosis in a patient with a common atrioventricular canal palliated with a pulmonary artery (PA) band is presented. The patients physiology was consistent with cyanosis due to inadequate pulmonary blood flow, and responded quickly to typical interventions used for a hypercyanotic episode in a patient with unrepaired Tetralogy of Fallot. Differences and similarities in the physiology of PA banding compared with Tetralogy of Fallot are presented, including a rationale for treatment options for hemodynamic decompensation occurring in the setting of anesthesia and surgery.

Calcified gallstone in a 3 year-old boy: a case report

BackgroundGallstones are relatively rare in children. At-risk populations include patients suffering from hemolysis syndromes. Regardless of etiology, these patients usually will present with postprandial abdominal pain, and ultrasonography is the mainstay of diagnosis. However, some gallstones are radiopaque and can be visualized on plain abdominal radiography.Case presentationWe present the uncommon but classic plain x-ray finding of a calcified gallstone in a 3 year-old Hispanic boy. He was treated with elective laparoscopic cholecystectomy.ConclusionsCholelithiasis is rare in children, and calcified stones that will appear on plain abdominal x-rays are even rarer. If symptomatic, cholecystectomy by a pediatric surgeon is the treatment of choice. We discuss some of the recent developments in treatment of this condition in this patient population.

Emergency management of pancreatic injury in a 5-year-old.

Pediatric pancreatic injuries are less common than many other intra-abdominal organ traumatic injuries; failure to identify pancreatic injury during the emergency phase will result in delayed diagnosis, delayed treatment, and potentially poor health outcomes. Injured children may present to nontrauma center/nonpediatric hospitals or urgent care settings where practitioners may not be experienced in diagnosing and treating pediatric pancreatic injuries. This case study explores the medical course of a child with persistent abdominal pain after a fall from a horse. He was evaluated in a nonpediatric trauma center and was discharged home, continued with symptoms, presented to a different community emergency department, and then transferred to the emergency department at a Level 1 pediatric trauma center. Educating health care providers about pediatric pancreatic injuries in emergency or urgent care settings will help improve quality of care for injured children who are not initially evaluated in a pediatric specific hospital or trauma center.

Colonic venous malformation and portal hypertension: Association, management, and review of the literature

We present a case of an adolescent with lower gastrointestinal bleeding caused by a colorectal venous malformation (VM) with concomitant portal hypertension. After an episode of massive gastrointestinal bleeding, we performed an extended right hemicolectomy and resection of the VM and selective portosystemic shunt. Here, we present the case and review the literature regarding portal hypertension and gastrointestinal vascular malformations. Additionally, we discuss the physiologic and hemodynamic effects of gastrointestinal vascular malformations on the portal system.