Early cardiac pacemaker placement for life-threatening bradycardia in traumatic spinal cord injury.

BACKGROUND: High cervical spinal cord injury (CSCI) can cause life-threatening bradycardia from autonomic instability that may be resistant to pharmacologic interventions. Placement of a cardiac pacemaker, traditionally reserved for patients refractory to drug therapy, may be lifesaving. METHODS: Our Level I trauma center registry found all patients with CSCI from 2003 to 2009. A retrospective chart review identified major events involving the circulatory system: those exhibiting bradycardia (minor, heart rate 40-60/min; major, heart rate <40/min), hypotension (systolic blood pressure <80 mm Hg), asystole, and cardiac arrest. Records of pharmacological interventions (e.g., atropine) and details of pacemaker placement (e.g., timing and any complications) were reviewed. Statistical differences were determined by Wilcoxon signed-rank test, with p < 0.05 as significant. RESULTS: Of the 106 patients with CSCI, 15 (14%) had bradycardia and 7 of those (47%) underwent cardiac pacemaker placement. Six of seven patients had reviewable data. A total of 35 events occurred in these six patients before pacemaker placement. Subsequent to placement, there were zero events of cardiovascular instability (p = 0.0135). Major bradycardic episodes were reduced from 9 to 0 (p = 0.0206) and incidents requiring atropine administration from 9 to 0 (p = 0.0197). Four survived; two patients died from pulmonary complications. There were no complications related to pacemaker insertion. CONCLUSIONS: Patients with CSCI life-threatening complications of bradycardia benefit from early placement of a cardiac pacemaker. Early stabilization may facilitate transfer out of the intensive care unit, mobilization, physical therapy, rehabilitation, and outcome.

Using a Checklist to Improve Family Communication in Trauma Care.

Modern concepts of patient-centered care emphasize effective communication with patients and families, an essential requirement in acute trauma settings. We hypothesized that using a checklist to guide the initial family conversation would improve the family's perception of the interaction. Institutional Review Board-approved, prospective pre/post study involving families of trauma patients admitted to our Level I trauma center for >24 hours. In the control group, families received information according to existing practices. In the study group, residents gave patient information to a first-degree family member using a checklist that guided the interaction. The checklist included a physician introduction, patient condition, list of known injuries, admission unit or intensive care unit, any consultants involved, plans for additional studies or operations, and opportunity for family to ask questions. An 11-item survey was administered 24 to 48 hours after admission to each group that evaluated the trauma team's communication in the areas of physician introduction, patient condition, ongoing treatment, and family perception of the interaction. Responses were on a Likert scale and analyzed using the Wilcoxon-Mann-Whitney test. There were 130 patients in each group. The study group had significantly (P < 0.05) better responses in 8 of 11 items surveyed: physician spoke to family, physician introduction, understanding of their relative's injuries, admitting unit, consultants involved, urgent surgical procedures required, ongoing diagnostic studies, and understanding of the treatment plan. In conclusion, using a checklist improves the perception of the initial communication between the trauma team and family members of trauma patients, especially their understanding of the treatment plan.

Quality and extent of locum tenens coverage in pediatric surgical practices.

The prevalence and quality of locum tenens coverage in pediatric surgery have not been determined. An Internet-based survey of American Pediatric Surgical Association members was conducted: 1) practice description; 2) use and frequency of locum tenens coverage; 4) whether the surgeon provided such coverage; and 5) Likert scale responses (strongly disagree, disagree, neutral, agree, strongly agree) to statements addressing its acceptability and quality (two × five contingency table and χ(2) analyses, significance at P < 0.05). Three hundred sixteen of 1163 members (27.2% response rate) responded. One-fourth (24.1%) used a locum tenens regularly. Reasons were long-term inability to recruit a full-time surgeon (35.2%) and short-term vacancies (32.4%). One-fifth (20.4%) did locum tenens work; one-fourth (27.0%) plan to do so in the future. Two-thirds (64.2%) believe that surgical care in a locum tenens situation does not provide the same level of care as a full-time community-based surgeon. Most support locum tenens for short-term coverage (87.3%) and recruitment problems (72.1%), but not long-term vacancies (38.8%; P < 0.001) or permanent coverage (27.0%; P < 0.001). locum tenens coverage is an established feature of pediatric surgery. Most view it as a stopgap solution to the surgical workforce shortage.

Sigmoid volvulus in 16-year-old boy with an associated anomalous congenital band.

Sigmoid volvulus, a condition generally seen in debilitated elderly patients, is extremely rare in the pediatric age group. Frequent predisposing conditions that accompany pediatric sigmoid volvulus include intestinal malrotation, omphalomesenteric abnormalities, Hirschsprung's disease, imperforate anus and chronic constipation. A 16-year-old previously healthy African American male presented with a 12 hour history of sudden onset abdominal pain and intractable vomiting. CT was consistent with sigmoid volvulus. A contrast enema did not reduce the volvulus, but it was colonoscopically reduced. Patient condition initially improved after colonoscopy, but he again became distended with abdominal pain, so he was taken to the operating room. On exploratory laparotomy, a band was discovered where the mesenteries of the sigmoid and small bowel adhered and created a narrow fixation point around which the sigmoid twisted. A sigmoidectomy with primary anastomosis was performed. The diagnosis of sigmoid volvulus may be more difficult in children, with barium enema being the most consistently helpful. Seventy percent of cases do not involve an associated congenital problem, suggesting that some pediatric patients may have congenital redundancy of the sigmoid colon and elongation of its mesentery. The congenital band found in our patient was another potential anatomic factor that led to sigmoid volvulus. Pediatric surgeons, accustomed to unusual problems in children, may thus encounter a condition generally found in the debilitated elderly patient.

Traumatic disruption of the abdominal wall: lap-belt injuries in children.

Traumatic abdominal wall hernia (TAWH) from high speed mechanism is a unique finding in adult trauma, and exceedingly rare in pediatrics. The majority of reports are of low-speed "handlebar" hernias associated with direct injury by bicycle handlebars. We report a series of three pediatric patients in motor vehicle collisions (MVC) who experienced TAWH by lap-belt and associated intra-abdominal injuries necessitating immediate operative intervention. Different operative approaches were used in each case to manage the varying types of disruptions. This adds to the pediatric literature the largest series of its kind.