Perry W. Stafford

Impact of pediatric trauma centers on mortality in a statewide system.

Background: Regional pediatric trauma centers (PTC) were established to optimize the care of injured children. However, because of the relative shortage of PTC, many injured children continue to be treated at adult trauma centers (ATC). As a result, a growing controversy has evolved regarding the impact of PTC and ATC on outcome for injured children. Methods: A retrospective analysis of 13,351 injured children entered in the Pennsylvania Trauma Outcome Study between 1993 and 1997 was conducted. Patients were stratified according to mechanism of injury, injury severity, specific organ injury, and type of trauma center: PTC; Level I ATC (ATC I); Level II ATC (ATC II); or ATC with added qualifications to treat children (ATC AQ). Mortality was the major outcome variable measured. Results: Most injured children were treated at a PTC or ATC AQ. The majority of children below 10 years of age were admitted to PTC. Patients treated at PTC and ATC had similar injury severity as determined by median Injury Severity Score, mean Revised Trauma Score, and Glasgow Coma Scale. Overall survival was significantly better at PTC and ATC AQ compared with ATC I and ATC II. Survival for head, spleen, and liver injuries was significantly better at PTC compared with ATC AQ, ATC I, or ATC II. Children who sustained moderate or severe head injuries were more likely to undergo neurosurgical intervention and have a better outcome when treated at a PTC. Despite similar mean Abbreviated Injury Scores for spleen and liver, significantly more children underwent surgical exploration (especially splenectomy) for spleen and liver injuries at ATC compared with PTC. Conclusion: Children treated at PTC or ATC AQ have significantly better outcome compared with those treated at ATC. Severely injured children (Injury Severity Score > 15) with head, spleen, or liver injuries had the best overall outcome when treated at PTC. This difference in outcome may be attributable to the approach to operative and nonoperative management of head, liver, and spleen injuries at PTC.

Necrotizing enterocolitis in neonates with congenital heart disease: risk factors and outcomes.

Objective. Necrotizing enterocolitis (NEC) is primarily a disease of the premature infant. Among children born at term, however, congenital heart disease may be an important predisposing factor for this condition. To determine risk factors for NEC in patients with congenital heart disease, we conducted a case–control study of neonates with cardiac disease admitted to the cardiac intensive care unit at our center during the 4-year period from January 1995 to December 1998. Methods. Cardiac diagnosis and age at admission were analyzed for association with NEC among the 643-patient inception cohort. Demographic, preoperative, and operative variables were recorded retrospectively in 21 neonates with congenital heart disease who developed NEC and 70 control neonates matched by diagnosis and age at admission. Using parametric and nonparametric analysis, cases and controls were compared with respect to previously identified risk factors for NEC. Results. Among the entire cohort of 643 neonates with heart disease admitted to the cardiac intensive care unit, diagnoses of hypoplastic left heart syndrome (odds ratio [OR] = 3.8 [1.6–9.1]) and truncus arteriosus or aortopulmonary window (OR = 6.3 [1.7–23.6]) were independently associated with development of NEC by multivariable analysis. In the case–control analysis, earlier gestational age at birth (36.7 ± 2.7 weeks vs 38.1 ± 2.3 weeks), prematurity (OR = 3.9 [1.2–12.5]), highest dose of prostaglandin >0.05 μg/kg/minute (OR = 3.9 [1.2–12.5]), and episodes of low cardiac output (meeting specific laboratory criteria) or clinical shock (OR = 6.5 [1.8–23.5]) correlated with the development of NEC. Earlier gestational age and episodes of low output were the only factors that remained significantly associated with NEC by multivariable analysis. Although there was no difference in hospital mortality between patients with and without NEC, mean hospital stay was significantly longer in those who developed NEC (36 ± 22 days vs 19 ± 14 days). Conclusions. The risk of NEC in neonates with congenital heart disease is substantial. Factors associated with an elevated risk of NEC in infants with heart disease include premature birth, hypoplastic left heart syndrome, truncus arteriosus, and episodes of poor systemic perfusion or shock. Heightened suspicion is warranted in newborns with these risk factors.

Conservative management of pancreatic trauma in children.

Many adults and most children with a solid-organ abdominal injury can be managed nonoperatively. To date, however, little is known about the outcome of nonoperative management of pancreatic injury. To analyze current treatment patterns of pancreatic injury in children, all children (age < 19 years) identified in the National Pediatric Trauma Registry (49,540 patients) and admitted to two level I pediatric trauma centers with a diagnosis of injury to the pancreas (International Classification of Disease-9 codes 863.81-863.84 and 863.91-863.94) were reviewed. Over a 7-year period, 154 children were identified with pancreatic injury. Thirty-one (20%) sustained severe injuries (grades III, IV, or V) and 123 (80%) sustained lower-grade injuries (grades I and II). Sixteen (52%) of the children sustaining grades III, IV, or V injury required pancreatic procedures (9 distal resections, 3 simple repairs, 2 enteric anastomoses, 2 others). Only 26 (21%) of the grades I and II injuries required surgical intervention specific to the pancreas (11 resections, 9 catheter drainage of pseudocysts, 2 enteric anastomoses, 4 others). Ninety-seven (79%) grades I and II injuries were successfully managed conservatively. Overall, 15 (10%) children required drainage procedures for pseudocyst. The frequency of operative intervention decreased during the last 4 years of the study (18 vs. 26%, p > 0.05), coinciding with a decrease in the frequency of drainage procedures for pseudocysts. The need for surgical intervention was not influenced by age, Injury Severity Score, or Pediatric Trauma Score (p > 0.05). Associated abdominal injuries were common but did not influence operations on the pancreas (p > 0.05). No deaths were attributed to the pancreatic injury. These data indicate that early intervention for pancreatic injury, in the absence of clinical deterioration or major ductal injury (grades III, IV, or V), is unwarranted, and careful observation may supplant the conventional surgical therapy recommended for adults.

Trends in Operative Management of Pediatric Splenic Injury in a Regional Trauma System

Objective. Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade. Methods. The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00–865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type. Results. From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0–6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4–8.7) for level 1 trauma centers, 6.3 (5.3–7.4) for level 2 trauma centers, and 5.0 (4.2–5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity. Conclusions. The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.

Severe head injury caused by airbag deployment

Passenger-side airbags are present in over 21 million automobiles and will be required on all passenger vehicles by the model year 1999. Although airbags are effective supplemental restraint systems and have saved over 1,500 lives, airbag-related injuries have been reported. The National Highway Traffic Safety Administration recently reported 15 child deaths caused by airbag deployment. All of these children were believed to be improperly restrained in the front passenger position of a car equipped with a passenger-side airbag. This case represents the first serious injury caused by airbag deployment in a child that was properly positioned in an approved child restraint.

Esophageal Replacement Using the Colon: Is It a Good Choice?

Thirty-eight children (2 months to 26 years of age) underwent esophageal replacement at our institution between 1962 and 1993. Twenty-four patients had esophageal atresia, with the replacement performed at a mean age of 17 months. The remaining patients (37%) had strictures and were older (mean, 7.4 years). Replacement procedures involved the right colon in 61% of cases and the transverse left colon in the others (39%). Sixty-three percent were placed substernally and 37% were done in transthoracic fashion. The average length of stay in the hospital was 34 days (range, 11 to 256 days.) Early complications (within 30 days) included cervical anastomotic leaks (11 patients; 29%) pneumonia (4), would infection (2), pneumothorax/hemothorax (3), wound dehiscence (1), prolonged ventilation (2), vocal cord paralysis (1), Horners syndrome (1), pancreatitis (1), and perforated graft (1). Despite the incidence of early leaks, only two persisted long-term (more than 3 months). Other late complications included significant proximal strictures (5), and cologastric strictures developed in five patients. Seven cases were considered graft failures (18%), and all of these eventually require graft replacement. Additional problems included redundant graft requiring revision (4) and dumping syndrome (2). There were six cases of intestinal obstruction caused by adhesions. Four of these involved intrathoracic obstruction of the graft and two involved small bowel obstruction. There was only one death, which occurred late and was not related to the primary disease or procedure. Long-term follow-up data were available for 20 patients (53%). The follow-up period ranged from 1 to 33 years (mean, 12 years). Fourteen had excellent results after the initial interposition, being able to eat and function well without any further intervention. Seven patients (18%) have had poor results and 17 (45%) required additional procedures to obtain good functional results. In our experience, the colon continues to be a good option for esophageal replacement, but additional procedures frequently are necessary to optimize the functional outcome. Good results can be expected in the majority of cases, but late problems (ie, redundant colon and poor emptying) are not unusual, and careful follow-up is essential in the management of such patients.

The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures.

BACKGROUND Computed tomographic (CT) scanning is sensitive in detecting pelvic fractures in the pediatric patient. Pelvic fractures in the pediatric population rarely require emergent intervention, thus providing time to obtain the optimal imaging study. The objective of this study was to compare pelvic radiographs and abdominal pelvic CT scans of all pediatric trauma patients with pelvic injury to determine the role of pelvic imaging in the immediate trauma resuscitation. METHODS A retrospective review was performed of pediatric patients (age < 18 years) with a pelvic fracture identified from the registry of a Level I pediatric trauma center for the period 1993 to 2001. Patients with a documented pelvic injury and both a pelvic CT scan and pelvic radiograph available for review were extracted for analysis. For this study, all films were re-reviewed by an attending pediatric radiologist, and the abnormalities were categorized by the area of injury. The data were comparatively analyzed according to the area of injury and the soft tissue findings. RESULTS For the 8-year period, 130 pediatric patients with a pelvic fracture were identified, including 103 patients with both a pelvic CT scan and radiographs. Of the 151 fractures identified by pelvic CT scan, 81 were also identified by the pelvic radiograph (54%). There were 38 soft tissue hematomas noted by pelvic CT scan and only 2 identified by the pelvic radiograph. The greatest discrepancy was noted in comparison of the sacral region (16 abnormal pelvic CT scans vs. 3 abnormal radiographs); the least discrepancy was noted in the evaluation of the hip (6 abnormal pelvic CT scans vs. 5 abnormal radiographs). CONCLUSION The pelvic radiograph lacked the sensitivity of the pelvic CT scan for detecting pelvic fractures in all anatomic areas evaluated. Pelvic CT scan also offers additional information regarding soft tissue injury not available on most pelvic radiographs. In the trauma patient that will undergo abdominopelvic CT scanning as part of the trauma evaluation, a pelvic radiograph may be superfluous. Screening pelvic radiography should be reserved for the rare unstable patient or the patient in whom an abdominopelvic CT scan is not otherwise indicated.

Firearm injury among urban youth during the last decade: An escalation in violence

PURPOSE To better characterize firearm violence in urban youth, the authors investigated the circumstances and outcome of shootings among youths under 17 years of age. METHODS A retrospective case review was undertaken of all patients under 17 years of age treated for a gunshot wound at two adjoining level I Trauma Centers (adult and pediatric) administering to a predominantly lower socioeconomic population from January 1986 to December 1995. Demographics, injury severity, circumstances, and outcome of injury were analyzed. RESULTS 323 youths were wounded by firearms. The mean age was 12.8 years, and 82.3% were boys. There was a 110% increase in frequency of wounding noted during the second half of study (219 v 104), predominantly in the adolescent subset (160% increase for age greater than 12 years v 30% increase for age 12 years and under). The mean injury severity score and trauma score were 9.3 and 14.4, respectively. Violent circumstances (assault, crossfire, drive-by shooting, suicide) accounted for 60.4% of injuries and more than doubled over the study period (26.7% of total in the first 2 years [n = 4], 68.8% in the last 2 years [n = 55]). Unintentional injuries (self nonsuicide, family, friend) accounted for 26.3% of the injuries and declined in relative frequency over the study period (46.7% of total in the first 2 years [n = 7], 20.0% in the last 2 years [n = 16]). Black boys had the highest wounding incidence (9.2/1,000 population), were most commonly injured by assault (29.0%), and had a higher mean number of wounds (1.8). White boys had a lower wounding incidence (3.1/1,000 population), were more often injured unintentionally by a friend (41.2%), and had a lower mean number of wounds (1.3), none as a result of violence. Girls had a wounding incidence of less than 2/1,000 and were most commonly injured in crossfire (40.7%). Ten percent of shootings were fatal. The assailant was known to the victim in 52.8% of children less than 6 years of age, but only 24.7% of children over 12 years of age. CONCLUSIONS The incidence of gunshot wounds in the youth of this urban population has increased substantially over the past decade. Adolescent black boys were the most frequent victims of these shootings. There has been a disproportionate growth in violent circumstances surrounding the shootings.

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

Management of Penetrating Colon and Rectal Injuries in the Pediatric Patient

PURPOSE:Management of civilian penetrating colon injuries in the adult has evolved from the universal use of fecal diversion to the highly selective use of colostomy. We hypothesized that a similar management approach was appropriate for the pediatric population.METHODS:A retrospective review of pediatric patients (age <17 years) with a penetrating colorectal injury was performed at six Level I trauma centers for the period January 1990 through June 2001.RESULTS:For the period of review, 53 children with a penetrating colorectal injury were identified. Firearms caused 89 percent of the injuries. The colon was injured in 83 percent (n = 44) of patients and the rectum in 17 percent (n = 9) of patients. The colorectal injury was managed without colostomy in 62 percent (n = 33) and with colostomy in 38 percent (colon = 11, rectum = 9). All rectal injuries were treated with colostomy. The hospital length of stay was longer in the colostomy group (17.6 days vs. 11.4 days). The complication rate was higher in the colostomy group (55 percent vs. 27 percent), which included two patients with stoma-related complications. There was no mortality in this series.CONCLUSIONS:Primary repair was used safely in most cases of civilian penetrating colon injuries in the pediatric population. All rectal injuries were treated with colostomy in this series. Fecal diversion was used selectively. Colostomy was performed for selected cases of colon wounds associated with shock, multiple blood transfusions, multiple other injuries, extensive contamination, and high-velocity weapons. In the absence of these associated factors, primary repair appears justified.