Martha J. Barthel

Factors influencing posttraumatic seizures in children

&NA; The ideal treatment of children with head trauma would include prevention of posttraumatic seizures. Ninety‐two of 937 children with head injuries (9.8%) experienced posttraumatic seizures. In 94.5% of these patients (87 of 92), seizures developed within the first 24 hours after injury. Three children convulsed between 24 hours and 7 days, but only 2 children developed seizures after the 1st week. Factors found to influence the likelihood of seizures included severe head injury (GCS, 3 to 8), diffuse cerebral edema, and acute subdural hematoma (P < 0.001). Seizures occurred in 35% of severely head‐injured children compared to 5.1% with minor head injury (P < 0.001). A less significant correlation (P < 0.1) was noted between seizures and open, depressed skull fractures. We found no significant correlation between seizure occurrence and numerous other factors including age, sex, fracture location and type (other than open, depressed fractures), parenchymal injuries, fixed neurological deficits, and cranial operation. Based on our observations, we recommend the prophylactic use of anticonvulsants in children at higher risk for posttraumatic seizures: those with diffuse cerebral edema, acute subdural hematoma, open, depressed skull fracture with parenchymal damage, or severe head injury (GCS ≤ 8).

Head injuries in children under 36 months of age - Demography and outcome

Head injuries in children under the age of 3 years have not been extensively studied, due in part to the lack of an objective tool for neurological assessment. We have developed a Childrens Coma Scale (CCS) by modifying the verbal response subscore of the Glasgow Coma Scale (GCS) to overcome this limitation. When applied prospectively to children under 3 years of age, we found the CCS to be useful in predicting outcome. During the 5-year study period from 1981 to 1985, there were 738 patients with head injuries (0–16 years) admitted to the Childrens Memorial Hospital in Chicago, including 318 (43.1%) less than 3 years of age. Initial data demonstrated the following observations. The most common mechanism of injury was a fall (75.5%). Although a brief loss of consciousness (LOC) was reported in three-fourths of the patients, prolonged LOC of more than 6 h was uncommon (16/318, 5.0%). The classically described “lucid interval” was seen in only 7 children (2.2%) and was not a reliable indicator of epidural hematoma. Post-traumatic seizures developed more commonly in children under 2 years of age (15.7%) than in older children (11.6% under 3 years of age, 9.6%, entire group), (P<0.001). Oculovestibular reflex and bilateral fixed dilated pupils had the most reliable correlation with outcome. Other brain-stem reflexes were less useful. Intracranial pressure greater than 40 torr in children with CCS scores of 3, 4 or 5 was inevitably fatal; however, 10 of 16 children with ICP less than 40 torr showed a good outcome.

Developing a clinical algorithm for early management of cervical spine injury in child trauma victims

To define a subset of injured children for whom emergency cervical spine radiography may be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: All injured children, from birth through 16 years, who had received cervical spine radiographs at The Childrens Memorial Hospital from September 1983, to September 1984, were included. All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Childrens Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. Each childs chart was reviewed, and 84 clinical variables were recorded. All radiographs were reviewed by a pediatric neuroradiologist. Of 206 children studied, 59 had cervical spine injuries. A clinical algorithm was derived using the following eight variables: neck pain; neck tenderness; limitation of neck mobility; history of trauma to the neck; and abnormalities of reflexes, strength, sensation, or mental status. The following decision rule was selected: Positive findings in any of these eight variables mandates cervical spine radiography. This algorithm correctly identified 58 of 59 children with cervical spine injury, yielding a sensitivity of 98% and specificity of 54%. Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice.

Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci

We evaluated the efficacy of rifampin in eradicating chronic pharyngeal carriage of group A streptococci. Carriers were defined as healthy children whose throat cultures showed persistence of group A streptococci 3 weeks after receiving benzathine penicillin G intramuscularly. Subsequent M and T typing of group A streptococcal isolates and limited serologic studies confirmed that enrolled patients were carriers. Thirty-eight carriers (37 completed the study) were randomly assigned to three groups: group 1 (13 patients) received no treatment; group 2 (10) received benzathine penicillin intramuscularly; group 3 (14) received benzathine penicillin intramuscularly plus rifampin orally (10 mg/kg twice a day for eight doses). Throat cultures were obtained every 3 weeks for at least 9 weeks. Group 2 and 3 patients who still had positive cultures 3 weeks after treatment were crossed to the opposite group. Cultures became negative in 93% (13 of 14) of patients in group 3, compared with 23% in group 1 and 30% in group 2 (P less than 0.001 and P less than 0.01, respectively). Including patients crossed over, the penicillin plus rifampin regimen was effective in 17 (89%) of 19 treatment courses and was significantly superior to no therapy or to penicillin alone (P less than 0.0005 and P less than 0.005, respectively). We conclude that rifampin plus benzathine penicillin intramuscularly is an effective regimen for those selected patients in whom eradication of group A streptococcal carriage is judged to be desirable.

Pediatric Falls from Heights

Injuries resulting from falls from heights still constitute a significant portion of urban trauma. At this pediatric trauma center, 70 children were admitted from 1985 to 1988 after sustaining a fall of 10 feet or greater or at least one story. The mean patient age was 5 years and 68% of the patients were boys. Seventy-eight percent of falls occurred from 2 stories or less and usually took place at or near the home. Most patients sustained a single major injury and all survived. The majority of injuries involved the head or skeleton and residual functional deficits were uncommon. The incidence of falls from heights has remained high in urban areas despite public education and building codes that require window guards and safety rails.

Transfusion requirements in conservative nonoperative management of blunt splenic and hepatic injuries during childhood

Nonoperative management of splenic and hepatic injuries in children is safe, and the majority of those with isolated injuries do not require blood transfusion. Thirty-seven children were treated for blunt splenic or hepatic trauma from November 1983 to September 1989. There was one death in a patient with a lethal head injury. No operations were performed on those with isolated splenic or hepatic injuries. Three of those with multiple injuries underwent delayed laparotomy. Two had perirenal and retroperitoneal hematomas without active bleeding, and one had a bowel obstruction secondary to an intramural jejunal hematoma. There were no late complications related to the splenic or hepatic injuries. Eight children (22%) required surgery for other injuries. Twelve children were not transfused, including the majority (8/11) of those with isolated splenic or hepatic injury. The hematocrit of four of these children fell to below 28% and this anemia was well-tolerated. Two children with bleeding disorders (factor VIII [antihemophilic factor] and factor XII [Hageman factor] deficiency) did not require packed red blood cells transfusion. Two clinically distinct groups of children received blood transfusions: (1) eight patients with multiple injuries were transfused during initial resuscitation when unstable or during early operation for other system trauma (mean, 62.0 mL blood/kg body weight); and (2) three hemodynamically stable patients with isolated injuries and 14 stable patients with multiple injuries were transfused empirically after initial resuscitation solely because of decreasing blood counts. They received an average of 16.5 and 21.1 mL blood/kg body weight, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The impact of level 1 pediatric trauma center designation on demographics and financial reimbursement

A retrospective analysis of medical and financial records of trauma patients admitted over a 4-year period was undertaken to determine the impact of level 1 pediatric trauma center designation on demographics and financial reimbursement. Three hundred fifty-four patients were admitted from November 1, 1985, to October 31, 1986 (Prelevel 1 designation [PREL1]). Five hundred seven patients were admitted from November 1, 1986, to October 31, 1987 (Postlevel 1 designation [PostL1]) (P less than .005). Mechanisms of injury were similar in both groups, with falls being most prevelant (PreL1, 50.8%; PostL1, 43.4%). The magnitude of injuries in the PostL1 period, as expressed by Pediatric Trauma Scores and Injury Severity Scores, did not change significantly. The types of injuries, as indicated by organ systems involved, did not change. The exception was thoracic injuries, which increased from 1.7% to 4.5% (P = .037). Total hospital charges per patient increased (

RIFAMPIN TREATMENT FOR GROUP A STREPTOCOCCAL CARRIERS

5,820 PreL1;

Kids 'N' Cars, An Ongoing Study of Pedestrian Injuries: Description and Early Findings

7,691 PostL1) (P = .034). Collection rates did not change (77.6% PreL1; 76.4% PostL1). The institution incurred a financial loss per patient of

Falls from heights in children: An urban liability

1,149 PreL1 and