Martin R. Eichelberger

Rib fractures in children: a marker of severe trauma

The early recognition of life-threatening injury is paramount to the prompt initiation of appropriate care. This study assesses the importance of multiple rib fractures as a marker of severe injury in children. We analyzed physiologic, etiologic, and injury data for 2,080 children with blunt or penetrating trauma aged 0-14 years consecutively admitted to a Level I pediatric trauma center. Analysis of variance, Students t-test, and the Chi-square test of independence were used to test for differences between children with rib fractures and other children. Probability of survival was modeled using stepwise logistic regression. There were 14 deaths among 33 children with rib fractures, a mortality rate of 42%. Child abuse accounted for 63% of the injuries to children less than 3 years old, while pedestrian injuries predominated among older children. Children with rib fractures were significantly more severely injured than children with blunt or penetrating trauma but without rib fractures. When compared to children without rib fractures, children with rib fractures had a higher mortality rate, but no statistically significant difference in morbidity. The mortality rate for the 18 children with both rib fractures and head injury was 71%. A logistic model with variables measuring severity of head injury and number of ribs fractured correctly predicted survival in more than 85% of children with thoracic trauma. Although rib fractures are rare injuries in childhood, they are associated with a high risk of death. The risk of mortality increases with the number of ribs fractured. The combination of rib fractures and head injury was usually fatal.

Patterns of injury in children

Trauma is the leading cause of death for children over 1 year of age. This study was undertaken to identify the patterns of injury among children admitted to a regional pediatric trauma center. During a 34-month period, 3,472 injured children were consecutively admitted to a regional pediatric trauma center. Data were collected on medical, etiological, and financial aspects of injury. Eight subgroups were defined by mechanism of injury: motor-vehicle crash occupants, pedestrian and cycle injuries, falls, child abuse, gunshot and stab wounds, burns, poisonings, and foreign body ingestions or aspirations. Analysis of variance, Duncans multiple range test, and contingency table analysis were used to determine differences among subgroups of children. Blunt and penetrating trauma accounted for 64.3% of all admissions. The mean age of injured children was 5.5 years; 64% of the children were boys. Sixty-seven percent of the children were admitted directly from the scene of injury. One-way analysis of variance yielded significant differences in mean age, mean hospital length of stay (LOS), mean intensive care LOS, mean trauma score, mean injury severity, and mean hospital charges by mechanism of injury (P less than .01). The overall mortality rate was 2.4%. Child abuse, gunshot/stab wounds, and drowning had the highest mortality rates, but injuries to motor-vehicle crash occupants and pedestrians accounted for the greatest number of deaths.

Nonoperative management of blunt hepatic and splenic injury in children.

OBJECTIVEnThe authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991.nnnMETHODnOne hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Students t test).nnnCONCLUSIONnPediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.

Predictors of abdominal injury in children with pelvic fracture.

During a 48-month period, 2,248 children (aged less than 15 years) were consecutively admitted to a regional pediatric trauma center with blunt trauma (ICD-9-CM code greater than or equal to 800). Fifty-four children (2.4%) had injury to the pelvic circle, as diagnosed by radiographic examination; 13 of these children had concomitant abdominal or genitourinary (GU) injury. Contingency table analysis and stepwise logistic regression were used to determine the best predictors of abdominal injury. The mean age of the children was 8.6 years. Eighty-nine percent of the injuries were motor-vehicle related (59% pedestrian; 30% crash occupant). Nine children (17%) required transfusions of packed red blood cells; 9 children (17%) required surgery. There were 6 deaths in this group, a mortality rate of 11.1%. The most common fracture sites in the pelvis were the pubic rami (59%), ilium or pelvic rim (17%), and the sacrum (6%). Ten children (19%) had multiple pelvic fractures. Location of fracture was strongly associated with the probability of abdominal injury: 80% of children with multiple pelvic fractures had concomitant abdominal or GU injury, compared with 33% with fracture of the ilium or pelvic rim, and 6% with isolated pubic fractures (p less than 0.001). The variables that best predicted abdominal or GU injury using a backward-elimination, stepwise logistic model were the presence of multiple pelvic fractures (p less than 0.002) and unweighted Revised Trauma Score (p less than 0.05); age of child, systolic blood pressure, respiration rate, Glasgow Coma Scale score, and mechanism of injury were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective, Randomized Study of the Efficacy of Mepitel*on Children With Partial-thickness Scalds

We performed a randomized clinical trial in which children with partial-thickness scald burns of less than 15% total body surface area were assigned treatment with either Mepitel (Mölnlycke Health Care) or silver sulfadiazine. Data were collected on time to wound healing, pain at dressing change, infection, and resource use. Students t and chi-square tests were used to determine differences in the two groups. Healing times were compared using Kaplan-Meier survival curves. Wounds of children treated with Mepitel healed significantly faster than did controls (p < 0.001), exhibited less eschar formation (p < 0.05), and experienced less pain at dressing change (p < 0.05). They also had significantly lower mean daily hospital charges (

Patterns of injury to restrained children in side impact motor vehicle crashes: the side impact syndrome

1937 vs

The relationships of skeletal injuries with trauma score, injury severity score, length of hospital stay, hospital charges, and mortality in children admitted to a regional pediatric trauma center

2316; p = 0.025); as well as significantly lower charges for dressing changes and narcotics. There was no significant difference in wound infection. We believe the use of Mepitel represents a significant advance in the treatment of partial-thickness scald wounds in children.

Colon interposition for the short bowel syndrome

BACKGROUNDnInjury patterns among children in frontal collisions have been well documented, but little information exists regarding injuries to children in side impact collisions.nnnMETHODSnRestrained children 14-years-old or younger admitted to the hospital for crash injuries were analyzed. Data concerning injuries, medical treatment, and outcome were correlated with crash data. Case reviews achieved consensus regarding injury contact points. Side impacts were compared with frontal impacts. These results were then compared with data from the National Automotive Sampling System.nnnRESULTSnThere were no differences between the groups with respect to age, sex, restraint type, or seat position. Compared with frontal crashes, children in side impacts were more likely to have an Injury Severity Score > 15 (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7-5.8) and were more likely to have Abbreviated Injury Scale score 2+ injuries to the head (OR, 2.5; 95% CI, 1.4-4.4), chest (OR, 4.0; 95% CI, 2.0-8.0), and cervical spine (OR, 3.7; 95% CI, 1.2-11.3). When compared with National Automotive Sampling System data, similar trends were seen regarding Abbreviated Injury Scale score 2+ injuries to the head, chest, and extremities.nnnCONCLUSIONnIn this study population, side impacts resulted in more injuries to the head, cervical spine, and chest. Knowledge of this pattern-the side impact syndrome-can help guide diagnosis, treatment, and prevention strategy.

Lumbar compression fractures secondary to lap-belt use in children

Thirty-four-hundred and seventy-two children were consecutively admitted for acute traumatic injuries over a 34 month period to the Childrens National Medical Center. The study comprised 805 patients who sustained 953 fractures and dislocations. The male to female ratio was 2:1. Age at the time of admission was evenly distributed over 16 years, with a mean of 8.3 years. Pedestrian accidents and falls each accounted for 34% of the musculoskeletal injuries, whereas motor vehicle accidents accounted for an additional 13%. The femur was the most commonly fractured bone, representing 22% of all fractures and dislocations, followed by the humerus (16%), tibia/fibula (12%), ankle/foot (13%), and radius/ulna (8%). Nine percent of the fractures were open. The average length of hospital stay was 8.6 days, and the average cost per hospital admission was

Percutaneous subclavian venous catheters in neonates and children

8,765. The mortality rate was 3%. Central musculoskeletal injuries (spine, clavicle/scapula, and pelvis) in our hospitalized patients were associated with the longest hospital stays and intensive care unit admissions, and lowest Trauma Scores, as well as the highest Injury Severity Scores, hospital charges, and mortality rates.