Mark A. Hoffman

Diagnosis and incidence of cardiac injury in children with blunt thoracic trauma

Over a 20-month period, we prospectively studied 41 children with blunt thoracic trauma (BTT) to determine the incidence and morbidity of cardiac injury in this population. Four patients died, and the data were incomplete in 10, leaving 27 for analysis. Serial electrocardiograms (ECG) were abnormal in 36% of the patients studied, serial creatine phosphokinase isoenzyme (CK-MB) ratios were elevated in 31%, echocardiogram showed septal dysfunction in 14%, and pyrophosphate scan showed grade 1 uptake in 14%. There was poor correlation among tests, since only four patients had more than one abnormal test. There was no significant difference in Injury Severity Score or Thoracic Abbreviated Injury Scale between patients with and without abnormal investigations. No patient in the study developed arrhythmias or cardiac failure. In 13 trauma-related deaths undergoing autopsy over the same period, including the four with thoracic trauma, none had evidence of cardiac injury. These results indicate a striking lack of consistency in the diagnosis of posttraumatic cardiac injury in children using standard investigations. The absence of adverse cardiac events in surviving patients and the lack of autopsy evidence of cardiac injury in the trauma deaths suggest that the actual incidence and clinical significance of these lesions in children is lower than generally reported. Children with BTT should be followed clinically, and reliance on screening tests should be avoided.

Central venous catheters—No X-rays needed: A prospective study in 50 consecutive infants and children

A technique of central venous line (CVL) placement using ECG guidance is described. The method utilizes equipment found in most operating room departments, is easily learned and taught, and obviates the need for x-rays. CVL placement in 50 consecutive infants and children was performed over a 4-month period by the ECG-guided method, with catheter tip position subsequently determined by x-ray study. The technique demonstrated a 96% success and 100% accuracy rate. The two technical failures were both preventable. Equipment malfunction was responsible for one failure. The second failure was secondary to a preexisting supraventricular arrhythmia, and patients with arrhythmias or pacemakers are not suitable candidates for this technique of central venous catheterization. Radiologic methods of CVL placement were necessary in these two patients.

Unilateral pulmonary agenesis with esophageal atresia and distal tracheoesophageal fistula: Report of two cases

The combined anomalies of pulmonary agenesis with esophageal atresia and distal tracheoesopahgeal fistula are an exceedingly rare and highly lethal association. The longest survivor in the literature is 10 months. We describe two neonates with this association who underwent primary repair shortly after birth and who are alive and well at 24 and 18 months. One of these neonates also demonstrated duodenal atresia. The prime goal in the management of these patients is early protection and preservation of respiratory units. This goal is best accomplished by primary repair of the tracheoesophageal lesion, when feasible, rather than by more complex procedures.

Pediatric blunt liver injury and coagulopathy managed with packs and A silo : case report

Packing the abdomen can be lifesaving when severe hepatic trauma is complicated by refractory hypothermia, coagulopathy, and continuing hemorrhage requiring large-volume transfusion. This report describes the successful use of abdominal packs and a modified silo in a child following blunt liver injury.

Cyclic neutropenia with colonic perforation and nonhealing colocutaneous fistula

Cyclic neutropenia is an hereditary disorder of white blood cells, characterized by profound neutropenic episodes approximately every three weeks. Septic complications are usually limited to cutaneous and oropharyngeal infections. A 4-year-old boy with known cyclic neutropenia was in shock with neutropenia, clostridial septicemia, and right lower quadrant peritonitis when he was admitted. At the time of laparotomy, inflammation of the cecum, with no gross perforation, was found; no resection or appendectomy was done. He subsequently developed a right lower quadrant abscess that was drained, resulting in a colocutaneous fistula. For the next 8 months his fistula persisted, with intermittent episodes of fever, increased fistula output, and abdominal pain during his neutropenic periods. Standard nonoperative approaches to healing the fistula failed (ie, elemental feeds, total parenteral nutrition, irrigations, antibiotics, and drains). Attempts to medically abolish his neutropenic episodes using lithium, gammaglobulin, and steroids also failed. Ultimately, he underwent an ileocecal resection with primary anastamosis; the operation was done immediately following a neutropenic episode, in order to allow adequate healing of his anastamosis before his next period of neutropenia. Postoperative course was satisfactory, and he remains well after 8 months follow-up. This case, and several similar previously reported cases, illustrate that cyclic neutropenia may present with serious surgical complications. They also underlines the important role that neutrophils play in the healing of enteric fistulae.

Laryngotracheal separation and diversion for complicated esophageal atresia with intractable salivary aspiration.

Chronic salivary aspiration results in progressive pulmonary deterioration. Laryngotracheal separation and diversion were performed to prevent salivary aspiration in a patient following complex repair for esophageal atresia with distal tracheoesophageal fistula. This highly effective and potentially reversible procedure should be considered for treatment of chronic salivary aspiration in selected patients.

Technique of the transabdominal uncut Collis-Nissen fundoplication

Antireflux operations are commonly performed in infants and children with complicated gastroesophageal reflux. The Nissen fundoplication has emerged as the “gold standard” antireflux procedure, although troublesome problems with wrap slippage over the stomach, complete or partial wrap disruption, and herniation of the wrap into the posterior mediastinum are frequent complications, leading to recurrent symptoms of reflux and a difficult reoperative procedure. We presently perform the uncut Collis-Nissen fundoplication as a primary antireflux procedure. This operation is particularly useful in the treatment of children with failed Nissen fundoplication. In this report, we describe our technique of performing this operation through a transabdominal approach and outline the advantages of the procedure.

EXPERIMENTAL VOLUME REPLACEMENT THROUGH LOWER EXTREMITY VEINS

Hypovolemic shock was produced in anesthetized pigs by removal of 40% of blood volume over 10 minutes. Following blood loss, the inferior vena cava (IVC) was occluded below the renal veins to simulate the hemodynamics of emergency surgical treatment. Control animals were not treated. Experimental animals received intravenous lactated Ringers solution equal to three times the blood loss given through catheters either in the IVC or the superior vena cava (SVC) to determine if lower extremity access would be efficacious in this model. To define the path taken by the resuscitation fluids, an additional group of animals received technetium-99m-labelled crystalloid through lower extremity catheters with continuous recording of isotope counts in the IVC and right atrium. The treated animals in all experimental groups had significant improvements in mean arterial pressure, cardiac output, and pH compared with controls. There was no significant difference in hemodynamic response in animals receiving volume replacement through the IVC compared with the SVC. When fluid was infused below a clamped IVC, the arrival of isotope in the right atrium was delayed only 1.5 seconds. We conclude that in a model simulating emergency control of potentially lethal hemorrhage, the beneficial effects of fluid resuscitation are unrelated to the site of venous access. Lower extremity veins provide a valuable site for volume replacement even with IVC occlusion. These findings should have direct application to resuscitation and surgical care of seriously injured patients.

Intraoperative placement of transpyloric jejunal feeding catheters in children

Transpyloric jejunal feeding catheters (TPJC) were placed in 45 children at the time of fundoplication and gastrostomy via the gastrostomy and exteriorized through the abdominal wall in close proximity to the gastrostomy tube. Forty-three children received full enteral nutritional support until gastrostomy tube or oral feeding was established. Thirty-two children receiving essential preoperative oral bronchodilator or anticonvulsant therapy had these medications continued via the TPJC commencing in the immediate postoperative period. The technique of catheter placement and a protocol for usage are presented. There were no complications related to PTJC placement or use. We conclude that PTJC is a useful adjunct to the care of children requiring fundoplication and gastrostomy. These catheters permit: (1) the early postoperative institution of full enteral nutritional support; (2) the continuation of essential oral medications by the enteral route during postoperative recovery; and (3) the early discontinuation of intravenous access.

Ileocolic intussusception presenting as acute duodenal obstruction

We present a case of ileocolic intussusception in a 5-month-old male infant with associated type III malrotation who presented with acute duodenal obstruction. The clinical presentation and initial radiologic studies suggested a midgut volvulus. The intussuceptum was incarcerated within the paraduodenal recess, causing extrinsic duodenal compression with complete obstruction. The intussusception was surgically reduced and a Ladds procedure with appendectomy was performed. No intrinsic duodenal pathology was found at surgery. The infants recovery was uneventful. The relationship between intussception, paraduodenal hernias, and anomalies of intestinal rotation and fixation are discussed.