S.V.S. Soundappan

Role of an Extended Tertiary Survey in Detecting Missed Injuries in Children

BACKGROUND There are limited data on the incidence of delayed diagnosis of injuries in children. We sought to investigate the role of an extended tertiary survey in pediatric trauma patients. METHODS All children that were admitted to The Childrens Hospital at Westmead with an Injury Severity Score (ISS) >/= 9 were included in the study. The trauma fellow performed the tertiary survey the day after admission. This was repeated after extubation in ventilated patients and in head injury patients when they were more mobile and cooperative. RESULTS Seventy-six patients satisfied the criteria for the study (50 boys and 26 girls). Age ranged from 1 month to 15 years. The median ISS was 14. Sixteen (16%) of the patients had missed injuries, of which skeletal injuries were the most common (10 of 12). Delayed diagnosis of injury occurred most frequently in children involved in motor vehicle injuries. Sixty-six (66%) of the injuries were detected within the first 24 hours. Inadequate assessment and head injury were the most common contributing factors. CONCLUSION The incidence of missed injury (16%) in our study was comparable to reported figures in the adult literature. There was no correlation between missed injuries and intensive care unit stay or ISS. Head injury often delayed diagnosis and thus ongoing evaluation in this group is recommended. Missed injuries did not result in mortality, but there was significant associated morbidity. A tertiary survey should be part of the evaluation of the pediatric trauma patient.

Retrocaval ureter in children: a report of two cases.

Retrocaval ureter is a relatively rare anomaly that usually manifests in the third or fourth decades. Symptoms are due to ureteric obstruction, either extrinsic by the abnormal inferior vena cava (IVC), or intrinsic ureteric hypoplasia. Surgery is needed for symptomatic cases and involves transection and relocation of the ureter anterior to the IVC. We report our experience with two such children who needed surgery because of increasing hydronephrosis and who have done well since.

Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia

Paediatric trauma centres seek to optimise the care of injured children. Trends in state-wide paediatric care and outcomes have not been examined in detail in Australia. This study examines temporal trends in paediatric trauma outcomes and factors influencing survival and length of stay. A retrospective review was conducted using data from the NSW Trauma Registry during 2003-2008 for children aged 15 years and younger who were severely injured (injury severity score >15). To examine trauma outcomes descriptive statistics and multivariable logistic and linear regression were conducted. There were 1138 children severely injured. Two-thirds were male. Road trauma and falls were the most common injury mechanisms and over one-third of incidents occurred in the home. Forty-eight percent of violence-related injuries were experienced by infants aged less than 1 year. For the majority of children definitive care was provided at a paediatric trauma centre, but less than one-third of children were taken directly to a paediatric trauma centre post-injury. Children who received definitive treatment at a paediatric trauma centre had between 3 and 6 times higher odds of having a survival advantage than if treated at an adult trauma centre. The number of severe injury presentations to the 14 major trauma centres in NSW remains constant. It is possible that injury prevention measures are having a limited effect on severe injury in NSW. This research provides stimulus for change in the provision and co-ordination in the delivery of trauma care for injured children.

VIDEOCONFERENCING SURGICAL TUTORIALS: BRIDGING THE GAP

The expansion in medical student numbers has been associated with a move to increase the amount of time students spend in rural and remote locations. Providing an equivalent educational experience for students in surgical subspecialties in this setting is a logistical challenge. We sought to address this issue by providing synchronous tutorials in paediatric surgery using videoconferencing (VC) at two rural sites with the tutor located at a metropolitan paediatric clinical school. Between March 2005 and July 2006, 43 graduate students in the University of Sydney Medical Program were assigned to receive the paediatric component of the course at one of two sites within the School of Rural Health. During this 9‐week rotation, students were involved in two or three surgical tutorials by videoconference. Students were then invited to complete a confidential, anonymous 20‐point structured evaluation using a Likert scale. Valid responses were received from 40 students, a response rate of 93%. There were 21 females (52%), with 21 students based in Dubbo and 19 in Orange. Students agreed or strongly agreed that VC surgical tutorials were useful, the content well covered and student involvement encouraged (mean scores 4.7, 4.5 and 4.5; standard deviation 0.56, 0.72 and 0.72, respectively). Overall, the majority of students strongly agreed that participation in VC of surgical tutorials was valuable (mean 4.68, standard deviation 0.57). VC surgical tutorials were highly valued by graduate medical students as an educational method. Our data suggest that tutorials can be successfully provided at remote sites using VC.

A trauma series in the injured child: do we really need it?

Background: To study the use of trauma series radiographs in children that required activation of a trauma call. Methods: A retrospective review of patients younger than 16 years who presented to The Childrens Hospital at Westmead between January and December 2004 with an injury that required activation of the trauma team. Patients transferred from other institutions were excluded. Results: Two hundred seventy-four children were included in the study, with 166 boys. The mean age was 8 years, and average Injury Severity Score was 4. Sixteen children had an Injury Severity Score of above 15. One hundred thirty-one children had a complete trauma series performed; 104 had one or more of the series performed, whereas 39 had no radiographs. Data analysis revealed that patients with findings in a chest radiograph (13) had either chest wall contusion(s) or reduced air entry on the involved side. Logistic regression analyses identified features that were significantly associated with a positive finding on the radiographs of the anteroposterior chest including a distracting injury in the chest area (odds ratio [OR], 10.49; 95% confidence interval [CI], 2.98-36.97), abnormal air entry on auscultation (OR, 31.86; 95% CI, 2.80-365.12), and need for intubation (OR, 6.23; 95% CI, 1.56-24.91). However, no clinical variable(s) showed a statistically significant correlation with abnormal radiographic findings on the lateral cervical spine (2) or anteroposterior pelvis (4). Conclusions: This study suggests that selective use of individual components of the full trauma series in the conscious pediatric patient, when an adequate clinical examination can be performed, would be safe. This approach should reduce the exposure to ionizing radiation of pediatric trauma patients and hospital staff.

Catheter balloon-related urethral trauma in children

Aim:  To review urethral injuries arising from incorrect balloon inflation in children undergoing urinary catheterisation.

Outcomes of oesophageal atresia and tracheo-oesophageal fistula repair.

Oesophageal atresia and tracheo‐oesophageal fistula are congenital anomalies of the oesophagus requiring surgical repair in infancy, either by open or thoracoscopic approach. Although mortality rates associated with this procedure are low, children may go on to have complications throughout childhood and into adulthood, most commonly related to ongoing gastrointestinal and respiratory symptoms. This review outlines the early, mid and long‐term outcomes for these children in terms of quality of life and incidence of symptoms.

Pediatric "off-road vehicle" trauma: determinants of injury severity and type

Objectives This study aimed to describe the determinants of the severity and type of injuries sustained by children hurt in off-road vehicle (ORV) accidents. Methods This was a retrospective clinical study for which data were obtained from the trauma database at the Children’s Hospital at Westmead covering the 10-year period between January 1, 1998, and December 31, 2007. Data points collected included age, sex, Injury Severity Score (ISS), body region injured, type of vehicle, accident setting, mechanism of injury, estimated speed, position of the rider, use of a helmet and/or protective clothing, and hospital length of stay. The study end points were determinants of injury severity and type. Statistical analysis of the collected data was done with the standard statistical software package, SPSS. Results A total of 288 children (242 male [84%] and 46 female [16%] patients) presented for ORV-related trauma. Helmets significantly diminished the chance of sustaining a head injury occasioning a skull fracture. Jumping was associated with increased ISS and a higher chance of sustaining an abdominal and/or thoracic injury. Older children were more likely to sustain pelvic and spinal injures, be injured while traveling at high speed, and be injured while going over a jump. Mean ISS was significantly lower if trauma was sustained while riding a mini motorcyle in any setting and any ORV at home. Conclusions Further research (prospective, federal, and multi-institutional) is needed with a view to optimizing training schedules, rules, regulations, and licensing requirements for pediatric ORV riders.

NEONATAL TESTICULAR TORSION OR NOT

Henoch-Schonlein purpura with minimal urinary findings. Arch. Dis. Child 2001; 84: 163–64. 4 Whyte DA, Van Why SK, Siegel NJ. Severe hypertension without urinary abnormalities in a patient with Henoch-Schonlein purpura. Pediatr. Nephrol. 1997; 11: 750–51. 5 Truttmann AC, Beretta-Piccoli BC, Carvajal-Busslinger MI, Bianchetti MG. Arterial hypertension with normal urinalysis in Henoch-Schonlein disease: a further case. Pediatr. Nephrol. 1998; 12: 523. 6 Darteyre S, Ludwig C, Lalande M, Rodière M, Guillaumont S, Morin D. Hypertension in the absence of renal involvement during childhood Henoch-Schonlein purpura. Arch. Pediatr. 2008; 15: 1193–6.

Unusual neck sinus—first or second cleft?

A sinus tract presenting with an opening around the angle of mandible is suggestive of first cleft remnant. We present the case of a 4-year-old boy with a recurrent discharging sinus around the angle of the right mandible whose internal opening was near the tonsil on imaging. Complete excision was performed with facial nerve monitoring. We discuss technical aspects of the surgery and possible embryology.