A comparison of accidental and nonaccidental trauma: it is worse than you think.

BACKGROUND: Child abuse, or nonaccidental trauma (NAT), is a major cause of pediatric morbidity and mortality, and is often unrecognized. Our hypothesis was that injuries due to accidental trauma (AT) and NAT are significantly different in incidence, injury, severity, and outcome, and are often unrecognized. OBJECTIVE: Our aim was to carry out an examination of the differences between pediatric injuries due to AT and NAT regarding incidence, demographics, injury severity, and outcomes. METHODS: A 4-year retrospective review of the Trauma Registry at Children's Medical Center Dallas, a large Level I pediatric trauma center, comparing incidence, age, race, trauma activation, intensive care unit (ICU) need, Injury Severity Score (ISS), and mortality between AT and NAT patients was carried out. RESULTS: There were 5948 admissions, 92.5% were AT and 7.5% were NAT victims. The NAT patients were younger (1.8 ± 3.3 years vs. 6.8 ± 4.2 years for AT patients; p < 0.01), more often required an ICU stay (NAT 36.5% vs. 13.8% for AT patients; p < 0.0001), and had a higher ISS 14.0 ± 9.7 vs. 7.5 ± 7.2; p < 0.0001). The mortality rate in NAT was 8.9% vs. 1.4% for AT (p < 0.001). Of the 40 NAT patients who ultimately died, 17.5% were not initially diagnosed as NAT. CONCLUSIONS: NAT victims differ significantly from the AT patients, with a greater severity of injury and a 6-fold higher mortality rate. Delayed recognition of NAT occurred in almost 20% of the cases. It is generally accepted that NAT is underestimated. Its increased mortality rate and severity of injury are also not well recognized compared to the typical pediatric trauma child.

Impact of wait time on outcome for inguinal hernia repair in infants.

BACKGROUND: Prolonged surgical wait times are a problem in many health care systems. We used data from two pediatric surgical centers, one Canadian and one American, in order to determine if increased wait times are related to rates of incarceration and adverse outcomes. METHODS: Data were collected for children under the age of 2 who presented with an inguinal hernia to either the emergency department or clinic in the two hospitals in 2002 and 2003. RESULTS: Infants in the Canadian center were older at presentation and were more likely to present to the emergency department. Wait time for hernia repair was longer in the Canadian than the American hospital (99 +/- 103 vs. 27 +/- 53 days, P < 0.001). The incidence of incarceration was higher in the Canadian hospital, and infants in the Canadian center were more likely to have episodes of recurrent incarceration. Emergency department usage was greater in the Canadian hospital both at the time of diagnosis as well as during the waiting period for surgery. DISCUSSION: Prolonged wait time for inguinal hernia repair in infants is associated with a higher rate of incarceration as well as greater usage of emergency department resources. These data are important for those surgeons working in systems with limited resources in which strategies to shorten wait times are necessary.

Trauma stat and trauma minor: are we making the call appropriately?

OBJECTIVES: Trauma accounts for a significant number of pediatric emergency room visits and is the leading cause of death in pediatric patients over 1 year of age. To provide quality care, protocols are used to mobilize personnel to treat injured patients. We reviewed our experience at a level 1 pediatric trauma center, where a 2-tiered trauma activation protocol is used in treating children with significant injuries. METHODS: We analyzed data in our trauma registry from 1994 to 1999 of patients with Injury Severity Score > or = 9 in whom trauma activations were called. Data reflected demographics, severity of injury, hospital course and outcome. Trauma activations were based on standard protocols that took physiologic status, anatomic area of injury, and mechanism of injury into account. Nineteen personnel were notified in a Trauma Stat Activation, and 8 were notified in a Trauma Minor Activation. RESULTS: There were 470 trauma activations: Trauma Stat = 220 and Trauma Minor = 250. As a group, Trauma Stat patients were more hemodynamically unstable, had a lower GCS and a higher Injury Severity Score than Trauma Minor patients. Patients in the Trauma Stat group were also more likely to require intensive care and have a prolonged hospitalization. The Trauma Stat group had a mortality rate of 20%. There were no deaths in the Trauma Minor group. CONCLUSIONS: Trauma activations result in heavy resource utilization and must be appropriate. The 2 trauma activation levels were associated with differences in injury severity, medical resource utilization, and outcome. With no deaths in the Trauma Minor group and a 20% mortality rate in the Trauma Stat group, we conclude that the protocol used was neither too conservative, nor too liberal.

Improving perioperative performance: the use of operations management and the electronic health record.

PURPOSE: Perioperative services require the orchestration of multiple staff, space and equipment. Our aim was to identify whether the implementation of operations management and an electronic health record (EHR) improved perioperative performance. METHODS: We compared 2006, pre operations management and EHR implementation, to 2010, post implementation. Operations management consisted of: communication to staff of perioperative vision and metrics, obtaining credible data and analysis, and the implementation of performance improvement processes. The EHR allows: identification of delays and the accountable service or person, collection and collation of data for analysis in multiple venues, including operational, financial, and quality. Metrics assessed included: operative cases, first case on time starts; reason for delay, and operating revenue. RESULTS: In 2006, 19,148 operations were performed (13,545 in the Main Operating Room (OR) area, and 5603, at satellite locations); first case on time starts were 12%; reasons for first case delay were not identifiable; and operating revenue was $115.8M overall, with $78.1M in the Main OR area. In 2010, cases increased to 25,856 (+35%); Main OR area increased to 13,986 (+3%); first case on time starts improved to 46%; operations outside the Main OR area increased to 11,870 (112%); case delays were ascribed to nurses 7%, anesthesiologists 22%, surgeons 33%, and other (patient, hospital) 38%. Five surgeons (7%) accounted for 29% of surgical delays and 4 anesthesiologists (8%) for 45% of anesthesiology delays; operating revenue increased to $177.3M (+53%) overall, and in the Main OR area rose to $101.5M (+30%). CONCLUSIONS: The use of operations management and EHR resulted in improved processes, credible data, promptly sharing the metrics, and pinpointing individual provider performance. Implementation of these strategies allowed us to shift cases between facilities, reallocate OR blocks, increase first case on time starts four fold and operative cases by 35%, and these changes were associated with a 53% increase in operating revenue. The fact that revenue increase was greater than case volume (53% vs. 35%) speaks for improved performance.

Complications associated with an implantable vascular access device.

PURPOSE: Implantable vascular access devices (ports) are well accepted in the management of many pediatric conditions. Modifications have improved port function, patient satisfaction, and enhanced compatibility with imaging studies. We reviewed our experience with a port system and identified unique mechanical complications. METHODS: From 1998 to the present, 301 patients underwent 296 port insertions and 175 port removals. We assessed medical records, radiographs, and operative findings. The 6.6F MRI Low-Profile Implanted Port (Bard Access Systems, Salt Lake City, Utah) was used almost exclusively and was assembled by the operating surgeon. Outcome measures included port reservoir leakage, catheter dislodgment, and number of device days until complication. Ports were implanted for multiple medical problems including 74.2% in hematology/oncology patients. RESULTS: For 296 port insertions, 15 complications (5.1%) were identified in 13 patients (mean age, 8.4 years). Eleven leaks (3.7%) in 9 patients were found, with 9 leaks resulting from needle perforation of the port base and 2 leaks seen at the catheter connection site. Average port duration was 425 days (range, 12-1266 days) before leakage. Four patients had catheter dislodgment (1.4%), with 3 of 4 catheters embolizing to the heart or pulmonary artery. Patients were asymptomatic, and catheters were retrieved by interventional radiology. Dislodgment at the catheter-port connection site was seen in 3 of 4 cases, and average port duration was 1075 days (range, 269-2657 days) until catheter separation. Twelve of 13 patients had successful implantation of a new port system. CONCLUSIONS: This study identifies that (1) mechanical port complications (5.1%) are not rare for this device; (2) regardless of port age, the thin plastic base may result in a risk of perforation not seen in other devices; (3) the extended period before embolization likely indicates device wear rather than faulty assembly; and (4) complications could be successfully managed including retrieval of embolized catheters.

Treatment of toxic epidermal necrolysis in a pediatric patient with a nanocrystalline silver dressing.

BACKGROUND/PURPOSE: To report a case of toxic epidermal necrolysis (TEN) involving 90% body surface area, successfully treated with a nanocrystalline silver dressing (Acticoat, Smith & Nephew, Largo, FL). METHODS: A review of the hospital and acute wound center patient records and the recent English medical literature regarding TEN and nanocrystalline silver dressing. RESULTS: We found only 1 report of TEN treated with a nanocrystalline silver dressing. The nanocrystalline silver dressing was both effective in preventing wound infection and convenient for treating our patient with TEN. CONCLUSION: The use of nanocrystalline silver dressing should be considered for the treatment of TEN.

Unsafe at any speed--kids riding all-terrain vehicles.

BACKGROUND: All-terrain vehicle (ATV) sales have climbed 89% in the last 5 years. We sought to determine if pediatric ATV accidents have increased in frequency and morbidity. METHODS: Medical records of children treated in our emergency unit for ATV accidents from 1993 to 2003 were reviewed. The 11 years were divided into 2 periods, January 1993 to June 1998 and July 1998 to December 2003, to allow comparisons and analysis of trends over time. RESULTS: We treated 184 children, with 90% requiring admission. Comparing the first and second halves of the study, patients treated increased from 8.7 +/- 4.8 (mean +/- SD) to 24.5 +/- 11.1 per year (P < .01), patients requiring immediate operation increased from 4 (9%) of 44 to 24 (17%) of 140, and patients with serious injuries (resulting in direct intensive care unit admission, immediate operation, or death) rose from 12 (27%) of 44 to 51 (36%) of 140. Patient age was 11.5 +/- 3.9 years. Sixty-eight percent of the children sustained multiple injuries and 50% required surgery. Only 35% of the children wore helmets. CONCLUSION: Over the 2 periods, there was a significant increase in number of patients treated, and considerable increases in serious injuries, and need for immediate operation. Despite inherent risks with riding ATVs, helmet use and patient age were remarkably low.

Evolving treatment in a decade of pediatric burn care.

BACKGROUND: Over the last decade, an ambulatory burn care (ABC) and procedural sedation (PS) program was instituted at St Louis Children's Hospital (SLCH). This study assessed the effect of these interventions on resource utilization. METHODS: The authors reviewed the hospital experience comparing 1993 with 2002 data regarding gender, age, burn depth, patient admissions, inpatient days, and ABC visits. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges. RESULTS: Gender, age, and burn depth were similar; 192 patients were admitted in 1993. In 2002, there were 167 admissions and 118 patients treated solely on an ABC basis resulting in a total of 285 burn patients treated (+48%). Hospital days decreased from 2,041 (1993) to 963 (2002 [-53%]). LOS declined from 10.4 +/- 8.3 days (1993) to 5.8 +/- 14.2 days (2002 [-44%; P <.05]). PS was used sporadically in 1993, and increased to 71% in patients in 2002. There were no ABC visits in 1993 and 501 visits in 2002. The incidence of infection was 5.2% in 1993 versus 3.0% in 2002 (P <.05) Average charge per patient fell 45% from 13,286 dollars (1993) to 7,372 dollars (2002), adjusted to 1993 dollars using medical care price index. CONCLUSIONS: Over a 10-year period, the program achieved a significant reduction in resource utilization while increasing the number of patients treated and maintaining a low incidence of infection. This was due in large part to a shift to ABC and the use of PS.

Evaluation of angioarchitecture of pulmonary sequestration in pediatric patients using 3D MDCT angiography.

OBJECTIVE: The goal of this study was to show the ability of 3D MDCT angiography to display the arterial and venous vascular anatomy of pulmonary sequestration in children. CONCLUSION: MDCT angiography with 3D rendering shows the anomalous feeding artery and the draining veins that allow a diagnosis of pulmonary sequestration. These features may prove useful in distinguishing intra- and extralobar sequestration and in surgical planning.

An analysis of pediatric gunshot wounds treated at a Level I pediatric trauma center.

BACKGROUND: We reviewed the incidence and injury severity of children with gunshot wounds (GSWs) at our hospital. METHODS: We compared trauma registry, emergency unit (EU), and admissions data from January 1993 to June 1996 (period I) and July 1996 to December 1999 (period II). Outcome measures included EU disposition (death, immediate operation, pediatric intensive care unit, ward), injury severity, mortality, and injury cause (accidental, intentional). RESULTS: We treated 437 children for GSWs in the EU, with 238 (54%) admissions and 199 discharges. Comparing period I versus period II, patients treated declined from 288 to 149 (-52%, p < 0.001), and admissions decreased from 159 to 79 (-50%, p < 0.001). Injury severity increased from 35% to 57% (p < 0.001). Patients requiring immediate operations increased from 20% to 42% (p < 0.001). Direct ward admissions declined from 65% to 43% (p < 0.001). Deaths occurred in 3% of patients in both time periods. Accidental and intentional GSWs were evenly divided. CONCLUSION: An alarming number of children, an average of 62 children annually, were treated for GSWs at our hospital. Despite a 52% reduction in GSWs, the percentage of severely injured patients increased by 63%. These data emphasize the importance of prevention, education, early assessment, and operative treatment.

Management of late-stage parapneumonic empyema.

PURPOSE: Despite the reported value of early video-assisted thoracoscopic surgery (VATS) for empyema, many children are still referred to the surgeon late in the disease process. The authors wished to determine the optimal management strategy for this group of children. METHODS: Medical records of all children (n = 70) from 1990 to 2000 with late-presenting empyema (stage II or III) were reviewed. Patients were grouped as (G1) successful management with chest tube (CT), (G2) surgery after initial CT, (G3) thoracentesis followed by surgery, and (G4) surgery alone. RESULTS: There were no significant differences with respect to age, gender, pleural cultures or fluid analysis. Fifty-one (73%) patients required surgical intervention. Treatment using CT (G1, G2) or thoracentesis (G3) was associated with prolonged length of stay (LOS) when compared with surgery alone (G4; 12 v 8 days). For G2, G3, and G4, rapid clinical improvement and early discharge (6 days) was seen after surgery. For all surgery groups (G2, G3, G4), video-assisted thoracoscopic surgery (n = 19) was associated with a longer postoperative fever (4 v 2 days; P <.05), but a shorter total LOS (12 v 15 days; P <.05) when compared with open decortication (n = 32). CONCLUSIONS: Over 70% of children with late presenting empyema required surgery, including more than half of the children who received initial chest tube drainage. Delay in surgery was associated with more procedures, more radiographs, and an increased LOS. Despite later intervention, patients undergoing surgery as an initial approach had the shortest length of stay. Early surgical intervention is indicated for most children referred with established empyema.

Neutropenic enterocolitis as a presenting complication of acute lymphoblastic leukemia: an unusual case marked by delayed perforation of the descending colon.

Neutropenic enterocolitis (NE) is a life-threatening complication most commonly seen in patients receiving intensive chemotherapy for acute leukemia. The condition usually affects the terminal ileum, cecum, or ascending colon. In rare instances, NE may occur before the initiation of chemotherapy or involve more distal bowel. The authors report the case of a 2-year-old girl who had NE affecting the descending colon as a presenting complication of acute lymphoblastic leukemia. Despite aggressive medical interventions, including granulocyte infusions, she had a delayed bowel perforation that was managed successfully with surgery. This case highlights the challenges of treating patients who have NE as an initial manifestation of acute leukemia.