Mary J. Edwards

Blast injury in children: an analysis from Afghanistan and Iraq, 2002-2010.

BACKGROUND Throughout history, children have been victims of armed conflict, including the blast injury complex, however, the pattern of injury, physiologic impact, and treatment needs of children with this injury are not well documented. METHODS The Joint Theatre Trauma Registry provides data on all civilians admitted to US military treatment facilities from 2002 to 2010 with injuries from an explosive device. The data were stratified by age and analyzed for differences in anatomic injury patterns, Injury Severity Score (ISS), Revised Trauma Score (RTS), mortality, intensive care unit days, and length of hospitalization. Multivariate logistic regression was done to determine independent predictors of mortality. All operative procedures with a specified site were tabulated and categorized by body region and age. RESULTS A total of 4,983 civilian patients were admitted, 25% of whom were younger than 15 years. Pediatric patients aged 8 to 14 years had a higher ISS and hospital stay than other age groups, and children younger than 15 years had a longer intensive care unit stay. Injuries in children were more likely to occur in the head and neck and less likely in the bony pelvis and extremities. Children had a lower RTS than the other age groups. Mortality correlated highly with burns, head injury, transfusion, and RTS. Adolescent patients had a lower mortality rate than the other age groups. Improvised explosive devices were the most common cause of injury in all age groups. CONCLUSION Children experiencing blast injury complex have an anatomic pattern that is unique and an RTS that reflects more severe physiologic derangement. Injuries requiring transfusion or involving the head and neck and burns were predictive of mortality, and this persisted across all age groups. The mortality rate of children with blast injury is significant (7%), and treatment is resource intensive, requiring many surgical subspecialties. LEVEL OF EVIDENCE Epidemiologic study, level III.

Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data.

BACKGROUND Massive transfusion (MT) in pediatric patients remains poorly defined. Using the largest existing registry of transfused pediatric trauma patients, we sought a data-driven MT threshold. METHODS The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head injury, and missing Injury Severity Score (ISS) were excluded. MT was evaluated as a weight-based volume of all blood products transfused in the first 24 hours. Mortality at 24 hours and in the hospital was calculated for increasing transfusion volumes. Sensitivity and specificity curves for predicting mortality were used to identify an optimal MT threshold. Patients above and below this threshold (MT+ and MT−, respectively) were compared. RESULTS The Department of Defense Trauma Registry yielded 4,990 combat-injured pediatric trauma patients, of whom 1,113 were transfused and constituted the study cohort. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at 40.1-mL/kg and 38.6-mL/kg total blood products in the first 24 hours, respectively. With the use of a pragmatic threshold of 40 mL/kg, patients were divided into MT+ (n = 443) and MT− (n = 670). MT+ patients were more often in shock (68.1% vs. 47.0%, p < 0.001), hypothermic (13.0% vs. 3.4%, p < 0.001), coagulopathic (45.0% vs. 29.6%, p < 0.001), and thrombocytopenic (10.6% vs. 5.0%, p = 0.002) on presentation. MT+ patients had a higher ISS, more mechanical ventilator days, and longer intensive care unit and hospital stay. MT+ was independently associated with an increased 24-hour mortality (odds ratio, 2.50; 95% confidence interval, 1.28–4.88; p = 0.007) and in-hospital mortality (odds ratio, 2.58; 95% confidence interval, 1.70–3.92; p < 0.001). CONCLUSION Based on this large cohort of transfused combat-injured pediatric patients, a threshold of 40 mL/kg of all blood products given at any time in the first 24 hours reliably identifies critically injured children at high risk for early and in-hospital death. This evidence-based definition will provide a consistent framework for future research and protocol development in pediatric resuscitation. LEVEL OF EVIDENCE Diagnostic study, level II. Prognostic/epidemiologic study, level III.

Thoracoscopic segmentectomy for treatment of congenital lung malformations

PURPOSE Congenital lung malformations (CLM) predispose patients to recurrent respiratory tract infections and pose a rare risk of malignant transformation. Although pulmonary lobectomy is the most common treatment of a CLM, some advocate segmental resection as a lung preservation strategy. Our study evaluated lung-preserving thoracoscopic segmentectomy as an alternative to lobectomy for CLM resection. METHODS We conducted a retrospective review of patients who underwent thoracoscopic segmentectomy for CLM from 2007 to 2010. RESULTS Fifteen patients underwent thoracoscopic segmentectomy for CLM. There were five postoperative complications: three asymptomatic pneumothoraces and a small air leak that resolved without intervention. One patient developed a bronchopulmonary fistula requiring thoracoscopic repair. At follow-up, all patients are asymptomatic. One patient has a small amount of residual disease on postoperative computed tomography (CT), and re-resection has been recommended. CONCLUSIONS Thoracoscopic segmentectomy for CLM is a safe and effective means of lung parenchymal preservation. The approach spares larger airway anatomy and has a complication rate that is comparable with that of thoracoscopic lobectomy. Residual disease can often only be appreciated on postoperative CT scan and may require long-term follow-up or reoperation in rare cases. This lung preservation technique is best suited to smaller lesions.

Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012

BACKGROUND The purpose of this study was to define the scope of combat- and noncombat-related inpatient pediatric humanitarian care provided from 2002 to 2012 by the United States (US) Military in Iraq and Afghanistan. STUDY DESIGN A review of the Patient Administration Systems and Biostatistics Activity (PASBA) database for all admissions from 2002 to 2012 by US military hospitals in Afghanistan and Iraq for children 14 years of age and younger provided data to analyze the use of medical care. North Atlantic Treaty Organization Standardization Agreement (STANAG) injury codes provided injury cause and the ICD-codes provided diagnosis. In-hospital mortality, blood usage, number of invasive procedures, and hospital stay were analyzed by country and injury category. RESULTS There were 6,273 admissions that met inclusion criteria. In Afghanistan, there were more than twice as many pediatric noncombat-related admissions (2,197) as pediatric combat-related admissions (1,095). In Iraq, the difference was minimal (1,391 noncombat vs 1,590 combat). The most common cause of noncombat-related admission in both countries was injury: primarily motor vehicle related and burns, which varied significantly by age. Older patients (older than 8 years in Afghanistan and older than 4 years in Iraq) were more likely combat victims. Mortality was highest for combat trauma in Iraq (11%) and noncombat trauma in Afghanistan (8%). The in-hospital mortality in both countries was 5% for admissions unrelated to trauma. Resource use was highest for combat trauma in both countries. CONCLUSIONS Noncombat-related medical care was the primary reason for pediatric humanitarian admissions to United States military combat hospitals in Iraq and Afghanistan from 2002 to 2012. Combat-related injuries have a higher mortality than noncombat injuries or other admissions.

Minimally invasive colopexy for pediatric Chilaiditi syndrome

Chilaiditi syndrome is a rare disorder characterized by abdominal pain, respiratory distress, constipation, and vomiting in association with Chilaiditis sign. Chilaiditis sign is the finding on plain roentgenogram of colonic interposition between the liver and diaphragm and is usually asymptomatic. Surgery is typically reserved for cases of catastrophic colonic volvulus or perforation because of the syndrome. We present a case of a 6-year-old boy who presented with Chilaiditi syndrome and resulting failure to thrive because of severe abdominal pain and vomiting, which did not improve with laxatives and dietary changes. He underwent a laparoscopic gastrostomy tube placement and laparoscopic colopexy of the transverse colon to the falciform ligament and anterior abdominal wall. Postoperatively, his symptoms resolved completely, as did his failure to thrive. His gastrostomy tube was removed 3 months after surgery and never required use. This is the first case of Chilaiditi syndrome in the pediatric literature we are aware of that was treated with an elective, minimally invasive colopexy. In cases of severe Chilaiditi syndrome refractory to medical treatment, a minimally invasive colopexy should be considered as a possible treatment option and potentially offered before development of life-threatening complications such as volvulus or perforation.

Transient Hypothyroidism in Premature Infants After Short-term Topical Iodine Exposure: An Avoidable Risk?

Studies in preterm infants have shown that prolonged treatment with topical iodine (multiple doses, often over multiple days) can transiently suppress thyroid function. However, it is uncertain if topical iodine exposure for very short periods of time can cause significant changes in thyroid function. We report two cases of transient hypothyroidism in preterm infants after short-term exposure to topical iodine during surgical preparation, and review their clinical and laboratory findings before and after iodine exposure. We conclude that premature infants are at risk of developing transient hypothyroidism in response to a single, short-term exposure to topical iodine, even in iodine-sufficient geographical areas. We advise monitoring of thyroid function in these infants after iodine exposure, as treatment with levothyroxine may be needed for a limited duration to prevent the sequelae of untreated hypothyroidism. Consideration of using alternative cleansing agents is also advised.

Surgical interventions for pediatric blast injury: an analysis from Afghanistan and Iraq 2002 to 2010.

BACKGROUND Acute blast injury requires aggressive operative intervention. This study documents therapeutic procedures required for children with blast injury in Afghanistan and Iraq from 2002 to 2010 at US military treatment facilities, to understand pediatric operative resources required after explosions. METHODS The Joint Theatre Trauma Registry provides data for the previously mentioned population. The data were stratified by years of age as follows: 0 to 3, 4 to 8, 9 to 14, 15 to 19, older than 19 years. Therapeutic procedures were defined by DRG International Classification of Diseases—9th Rev. codes 0 to 86.99. These were analyzed by age, body region, and Abbreviated Injury Scale (AIS) score. RESULTS A total of 5,026 patients with a known age requiring a total of 22,677 therapeutic procedures were analyzed; 25% (n = 1,205) were children 14 years or younger. On average, 4.5 procedures were required per patient and varied significantly by age. Soft tissue debridement, vascular access procedure, laparotomy, and thoracostomy were the most common procedures for all ages. For all body regions, severe injury (AIS score ≥ 3) was associated with an increased need for an invasive procedure (30–90%) in that region. Children 9 years to 14 years of age underwent significantly more procedures on average (5 procedures per patient) compared with adults (4.5 procedures per patient); children 3 years and younger underwent significantly less (3.15 procedures per patient). Children 4 years to 14 years of age were more likely than older patients to undergo a procedure for a severe head injury (40% vs. 29%), and those 9 years to 14 years old were more likely to undergo a procedure for severe thoracic injury (72%). After 4 years of age, procedures trend away from the head toward the extremity and amputation. CONCLUSION Blast-injured children require significant operative resources during the acute phase of injury. In the event of an explosive attack, pediatric operative resources and expertise are required. LEVEL OF EVIDENCE Epidemiologic study, level III.

Caudal anesthesia with sedation for inguinal hernia repair in high risk neonates

BACKGROUND/PURPOSE The use of caudal anesthesia with sedation (CAS) has theoretical benefits over general anesthesia (GA) in high risk neonates undergoing inguinal hernia repair. This benefit has not been established in clinical studies. We compare outcomes of these two approaches at a single institution. METHODS A retrospective review was performed of all neonates and preterm infants undergoing inguinal hernia over an 8year period. RESULTS Of 71 infants meeting inclusion criteria, 50 underwent repair with caudal block and systemic sedation, and 21 with general anesthesia. Minor incidents of respiratory depression requiring non invasive interventions were common in the first 24h post operatively (24% for CAS, 14% with GA), 4% of patients receiving CAS had a respiratory complication which prolonged their hospital stay beyond 24h post operation. Both required conversion to general anesthesia. Statistically significant differences between the two groups were lacking in terms of preoperative risk and post operative outcome. CONCLUSIONS CAS is a safe, effective anesthetic option for high risk neonates undergoing inguinal hernia repair. Patients requiring conversion to GA from CAS may be at increased risk for complications. Large, randomized trials are needed to determine any benefit over GA.

Pancreatic atrophy and diabetes mellitus following blunt abdominal trauma

Following pancreatic trauma, loss of uninjured parenchyma as a result of surgical management is expected, and atrophy of parenchyma following nonoperative management has been described. While endocrine insufficiency as a sequela of pancreatic trauma has been reported in adults, it is not a described entity in children. We report a case of pancreatic atrophy following blunt injury in an 8 year old boy who presented 3 years later with diabetes mellitus. Further analysis revealed significant genetic predisposition to diabetes.

Providing care to children in times of war.

The Geneva Conventions stipulate that an occupying power must ensure adequate health care delivery to noncombatants. Special emphasis is given to children, who are among the most vulnerable in a conflict zone. Whether short-term pediatric care should be provided by Military Treatment Facilities to local nationals for conditions other than combat-related injury is controversial. A review of 1,197 children without traumatic injury cared for during 10 years in Iraq and Afghanistan was conducted. Mortality rates were less than 1% among patients with surgical conditions and resource utilization was not excessive. In view of international humanitarian law and these outcomes, children with nontraumatic conditions can and should be considered for treatment at Military Treatment Facilities. The ability to correct the condition and availability of resources necessary to do so should be taken into account.