Richard J. Peterson

Pediatric and Adult Thoracic Trauma: Age-Related Impact on Presentation and Outcome

UNLABELLED To assess the impact of age on presentation and outcome, 2,415 cases involving blunt and penetrating thoracic trauma over an 8-year period were reviewed retrospectively from a single level I trauma center. Of the 2,073 patients alive on arrival, 79 were 12 years of age or less (children), 137 were 13 to 17 years of age (adolescent), 1,742 were 18 to 59 years of age (adults), and 115 were 60 years of age or more (elderly). Chi-square analysis was performed relative to presentation (blunt versus penetrating), need for thoracotomy, and hospital mortality. Although blunt thoracic trauma comprised 64/79 of children (81%) and 90/115 of the elderly (78%), penetrating thoracic trauma was more common for adolescents 79/137 (58%) and adults 1013/1742 (58%) (p < 0.05). There was no significant difference in need for thoracotomy among the four age groups after blunt thoracic trauma. For penetrating trauma, however, there was a significantly higher incidence of thoracotomy in children as compared with the other three age groups (p < 0.05). IN CONCLUSION (1) Blunt injuries comprised a greater proportion of thoracic trauma in children and the elderly. (2) In this series, children with penetrating thoracic trauma underwent thoracotomy more frequently. (3) Hospital mortality appeared to be increased for the elderly. (4) Analyses of pediatric thoracic trauma must separate children from adolescent age groups.

Ultra-fast track hospital discharge using conventional cardiac surgical techniques.

BACKGROUND Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra-fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection). METHODS From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively. RESULTS A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients operated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra-fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra-fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether. CONCLUSIONS Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment.

Extravasation rates and complications of intraosseous needles during gravity and pressure infusion

OBJECTIVE To compare the extravasation rates and insertion complications under gravity and 300 mm Hg (40 kPa) pressure infusion of threaded (SurFast and Sussmane-Raszynski intraosseous needles, Cook Critical Care, Bloomington, IN); and nonthreaded needles (16-gauge disposable intraosseous needle with 45 degrees trocar Cook Critical Care, Bloomington, IN; Jamshidi bone marrow needle; Baxter Health Care Corp, Valencia, CA). DESIGN A prospective, randomized study. SETTING An animal laboratory at a university center. SUBJECTS Five healthy mix breed piglets, weighing 15 to 15.5 kg. INTERVENTIONS Piglets were anesthetized and ventilated. Tibial, femoral, and humeral osseous sites were exposed by dissection of overlying tissue. All bleeding points were cauterized and oozing was prevented by sealing with cyanoacrylate. Intraosseous access devices then were inserted one at a time in random order and rated for difficulty of insertion. Normal saline solution was infused under gravity or 300 mm Hg (40 kPa) pressure. Extravasation rates then were calculated from the increase in weight of a gauze sponge wrapped tightly at the base of the needle during infusion. MEASUREMENTS AND MAIN RESULTS No significant (p > .05) differences in extravasation rates were noted among the different types of needles, either under gravity or pressure infusions. The Sussmane-Raszynski needle was significantly more difficult to insert than the others (rated difficult to insert and control in 16 of 34 attempts). Inadvertent penetration of both cortices occurred with nonthreaded needles only (three of 66 attempts). The SurFast needle provided greatest penetration control and was most resistant to accidental dislodgement. CONCLUSIONS Under ideal conditions, needle type does not influence extravasation rates. However, difficulty with insertion and penetration of both cortices occur commonly and may lead to extravasation during stressful emergency situations or when performed by unskilled personnel.

Comparison of pH and carbon dioxide tension values of central venous and intraosseous blood during changes in cardiac output

ObjectiveTo compare the pH and Pco2 values determined from of simultaneously corrected samples of central venous and intraosseous blood during sequential changes in cardiac output. DesignProspective, descriptive study. SettingAn animal laboratory in a university medical center. SubjectsFourteen mixed breed 4-wk-old piglets. InterventionsAnimals were anesthetized with ketamine hydrochloride and neuromuscular blockade was induced by the administration of pancuronium bromide. After endotracheal intubation and the institution of mechanical ventilation, a 4-Fr pulmonary artery catheter and a carotid artery cannula were inserted via a cutdown into the right neck of each piglet. A 16-gauge intraosseous needle was inserted into the anteromedial surface of the right tibia. Measurements and Main ResultsCentral venous and intraosseous blood gas samples were obtained simultaneously with thermodilution cardiac output measurements. Cardiac output measurements were as follows: during steady state (0.80 ± 0.14 L/min), after volume loading of 15 mL/kg (1.00 ± 0.25 L/min), after three successive bleeds of 15 mL/kg each at 30-min intervals (0.70 ± 0.28, 0.54 ± 0.22, and 0.43 ± 0.16 L/min, respectively) and at exsanguination (unrecordable). Paired t-tests demonstrated no significant differences in pH and Pco2 values between intraosseous and central venous samples under all study conditions. Limits of agreement for difference in Pco2 between sites, within the range of cardiac outputs studied, were −12.86 to 11.38 torr (-1.71 to 1.46 kPa) and for pH were −0.09 to 0.15. ConclusionsIntraosseous blood samples can be obtained without difficulty even during extreme hypovolemia. The pH and Pco2 values of intraosseous and central venous blood samples were similar under all study conditions. Intraosseous blood may be a useful alternative to central venous blood to assess tissue acid-base status during hemorrhagic shock and other low-flow states. (Crit Care Med 1994; 22:1010–1015)

The evaluation of pediatric trauma care using audit filters.

Objective To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. Design Descriptive review of concurrent audit. Setting A tertiary care referral adult and pediatric trauma center. Patients All pediatric trauma victims in the trauma registry (includes patients ≤14 years old, who died or were hospitalized for ≥24 hours) Interventions None. Measurements and main results Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed. Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled. In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or long-term morbidity. Conclusion Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.

Pediatric penetrating thoracic trauma: a five-year experience

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS <8 underwent surgical intervention, whereas only two of the eight patients with a PTS >8 needed surgery (P <0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.

Surgical repair of d-transposition with aortopulmonary window: A case report

A 3.3 kg. white male neonate with dysmorphic features consistent with Goldenhars syndrome had cyanosis at 8 hours of age. An echocardiogram revealed normal intracardiac anatomy with D-transposition of the great arteries (D-TGA), a type 11 aortopulmonary window (APW), and a patent ductus arteriosus. The patient was begun on a regimen of prostaglandin g 1 infusion and underwent cardiac catheterization with balloon atrial septostomy on the second day after birth. Coronary artery anatomy was the type most commonly seen with D-TGA2: a two-vessel system with origin of the left vessel from the left cusp of the aortic (anterior semilunar) valve and of the right vessel from the posterior cusp of the aortic valve. The circumflex and anterior descending coronary arteries arose from the left main coronary artery. The origin of the left coronary artery was in close proximity and slightly inferior to the inferior margin of the APW (Fig. 1). On the seventh day after birth, the patient underwent surgical repair under hypothermic (25 ° C) cardiopulmonary bypass. After ductal ligation and patch closure of the atrial septostomy, the great arteries were dissected free and the APW was located. The great arteries were transected at the level of the APW, with care taken to avoid injury to the aortic and pulmonic valves. The APW was transected at the same level. Right and left coronary ostia and surrounding buttons of aortic tissue were repositioned to the proximal portion of the neoaorta after corresponding buttons of tissue had been removed. The pulmonary confluence was moved anterior to the aortic root and pulmonary continuity was reestablished. Defects in the neopulmonary artery from the excision of the coronary ostia were repaired with pericardial patches. The APW margins were incorporated into the suture lines during reanastomosis of the great arteries (Fig. 2). The postoperative course was uneventful, with brief periods of junctional tachycardia (controlled with digoxin). Nitroglycerin and dobutamine were used for less than 24 hours. At his 12-month check-up, the patient was receiving no cardiovascular medications. An echocardiogram demonstrated normal ventricular size and function. There was mild

Comparison of transtracheal and extravascular Doppler determinations of stroke volume and cardiac output at various states of volume loading in piglets.

OBJECTIVE To assess the applicability of a new technology in neonates. Transtracheal Doppler and extravascular Doppler determinations of stroke volume and cardiac output were compared with thermodilution measurements at various states of volume loading in an animal model. DESIGN Prospective, descriptive study. SETTING Animal research laboratory at a university medical center. SUBJECTS Fourteen newly weaned piglets, weighing 2.8 to 6.5 kg. INTERVENTIONS Doppler probes were placed on the endotracheal tube tip (transtracheal Doppler) and directly on the aortic adventitia (extravascular Doppler). A 4-Fr thermodilution catheter was inserted in the pulmonary artery. Stroke volume and cardiac output determinations were recorded at baseline, after a 15-mL/kg volume load and after successive 15-mL/kg blood withdrawals to exsanguination or a systolic blood pressure of < 20 mm Hg. MEASUREMENTS AND MAIN RESULTS Transtracheal and extravascular Doppler measurements of cardiac output were not significantly different from thermodilution at any physiologic state. These techniques were able to measure stroke volumes and cardiac outputs at the low levels seen in severe hemorrhagic shock. CONCLUSIONS Transtracheal Doppler and extravascular Doppler measurements of cardiac output compare favorably with thermodilution. These methods effectively followed trends from alterations in intravascular volume, even at very high heart rates and small stroke volumes. Transtracheal Doppler and extravascular Doppler should yield useful information in critically ill neonatal patients, where data regarding stroke volume and cardiac output may be useful in clinical management.

Transtracheal Doppler in infants and small children following surgery for congenital heart disease : rational use of an improved technology

To compare measurements of cardiac output utilizing an improved transtracheal Doppler technology with measurements obtained using two-dimensional echocardiography. Design:Prospective, descriptive study. Setting:Cardiovascular intensive care unit at a university medical center. Patients:Fourteen children ranging in age from 14 days to 3 yrs (mean 1.3 ×.97 yrs) following surgery for complex congenital heart disease. Interventions:Simultaneous cardiac output determinations using transtracheal Doppler and two-dimensional echocardiography were compared. Cardiac output was determined using measurement of blood velocity and diameter of the ascending aorta following surgery. Direct aortic diameter measurements made at operation were compared with measurements obtained by transtracheal Doppler, two-dimensional echocardiography and angiography. Results:The mean difference in aortic root diameter between measurements made directly at operation and transtracheal Doppler was 5%, compared with 13% by two-dimensional echocardiography, and 21% by angiography, a significant difference by analysis of variance (F[3,31], p < .007). Post hoc comparisons demonstrated significant (p < .05) differences between echocardiography and angiographic aortic diameters. The mean difference between transtracheal Doppler and echocardiographic determination of cardiac output was 10.9% (t[10] = −1.37, p = .007). Conclusions:An improved transtracheal Doppler technology compares favorably with echocardiographic determination of cardiac output in infants and young children. This improved technology may provide a useful means to assess cardiac output and may allow titra-tion of therapy in critically ill infants and children. (Crit Care Med 1994; 22:1294–1300)