Treatment of Hypothermic Cardiac Arrest in the Pediatric Drowning Victim, a Case Report, and Systematic Review.

OBJECTIVES: Drowning is the second leading cause of death in children. Extracorporeal membrane oxygenation (ECMO) has become the criterion standard therapy to resuscitate the hypothermic drowning victim in cardiac arrest. We present our own experience treating 5 children with hypothermic cardiac arrest in conjunction with a systematic review to analyze clinical features predictive of survival. METHODS: Our search resulted in 55 articles. Inclusion criteria were as follows: (1) younger than 18 years, (2) ECMO therapy, and (3) drowning. Ten articles met our inclusion criteria. We included studies using both central and peripheral ECMO and salt or fresh water submersions. We compared clinical features of survivors to nonsurvivors. RESULTS: A total of 29 patients from the 10 different studies met our criteria. Data analyzed included presenting cardiac rhythm, time to initiation of ECMO, submersion time, pH, potassium, lactate, duration of chest compressions, and survival. There was a significant increase in mortality for presenting rhythm of asystole and with hyperkalemia (P < 0.05). CONCLUSIONS: Extracorporeal membrane oxygenation is an important resuscitation tool for the hypothermic drowning victim. Hyperkalemia and presenting cardiac rhythm correlate with survival although they are not reasons to end resuscitation. More studies are needed to compare the outcomes in using ECMO for the hypothermic drowning victim.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children.

BACKGROUND: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes. METHODS: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests. RESULTS: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75). CONCLUSIONS: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery. LEVEL OF EVIDENCE: III STUDY TYPE: Case series.

Concussion Among Youth Skiers and Snowboarders: A Review of the National Trauma Data Bank From 2009 to 2010.

OBJECTIVE: There are limited data regarding concussion among youth skiers and snowboarders. The objective of this study was to examine the frequency of concussion among helmeted and unhelmeted youth skiers and snowboarders presenting to trauma centers. METHODS: Subjects 18 years or younger with a ski- or snowboard-related injury were studied using data from the National Trauma Data Bank from 2009 to 2010. We further selected those with head/neck injuries and stratified based on helmet status. Concussive injuries were identified from International Classification of Diseases, 9th Revision codes. Severity analysis was based on the Glasgow Coma Scale and Injury Severity Score. RESULTS: A total of 1001 subjects met inclusion criteria with 678 subjects having documented helmet status. Subjects 12 years or younger were more likely to use helmets compared to 13-18 year-olds (odds ratio, 2.21; 95% confidence interval [95% CI], 1.52-3.21). Skiers were more likely to use helmets compared to snowboarders (odds ratios, 1.60; 95% CI, 1.16-2.19). Snowboarders had a greater likelihood of concussion (estimated-ß, 2.1; 95% CI, 1.48-2.85) after adjusting for helmet status and age. There was no significant difference in the frequency of concussion among helmeted compared to unhelmeted subjects. Imputing missing values for helmets status had no effect on outcome for concussion. We found no difference in injury severity among helmeted compared to unhelmeted subjects. CONCLUSIONS: Among youth skiers and snowboarders who present to trauma centers with a head injury, the likelihood of that injury involving a concussion was not associated with helmet use.

Childhood death attributable to trauma: is there a difference between accidental and abusive fatal injuries?

BACKGROUND: Trauma is a leading cause of death among children worldwide. Detailed knowledge of the epidemiology of childhood fatal injuries is necessary for preventing injuries. OBJECTIVE: To determine clinical differences between children who were treated in an emergency department for accidental or abusive injuries. METHODS: A retrospective review of all deceased patients who were treated in two urban pediatric emergency departments between 1998 and 2010 was performed. Patients were categorized into two groups, accidental and abusive, for comparison. RESULTS: A total of 1498 patients died during the study period, with 124 deaths being attributable to injury for a rate of 9.5 injury-related deaths per year. Most fatal injuries were accidental. Children with abusive fatal injuries were younger and more likely to have been seen for an injury in a clinic or emergency department within 2 months of their death. Eighty-two percent of abusive fatal injuries had documented subdural hematomas, whereas only 7.2% of accidental fatal injuries had a subdural hematoma documented. Nearly 50% of abusive fatal injuries had retinal hemorrhages reported, although no child with an accidental fatal injury had this type of injury documented. CONCLUSION: Younger children, especially those previously seen in an emergency department or clinic for injury, are more likely to sustain an abusive fatal injury. Sentinel physical findings associated with abusive fatal injuries include subdural hematomas and retinal hemorrhages, and the presence of these findings should prompt an investigation into the circumstances of injury.

Pediatric Farm Injuries Presenting to United States Emergency Departments, 2001-2014.

PURPOSE: While it is well-known that injuries are a common cause of morbidity among children, limited information is available on injuries that occur in agricultural settings. This study characterizes pediatric farm injuries that present to United States emergency departments and compares them to injuries that occur in the normal course of childhood, at homes and residences. METHODS: A retrospective analysis of the National Electronic Injury Surveillance System-All Injury Program, 2001-2014, compared injuries occurring on farms to those at homes in youth ages <20 years. Linear regression models assessed injuries over the time period among demographic subgroups. FINDINGS: Between 2001 and 2014, there were an estimated 279,279 injuries that occurred on farms in youth <20 years. Farm injuries most commonly occurred among youth ages from 15 to 19 years (44%, 95% confidence interval [CI]: 39%-49%), whereas home injuries were often among children <5 years (42%, 95% CI: 39%-45%). After adjusting for confounders, farm injuries were 60 times more likely to be caused by machinery and 4 times more likely to result in hospitalization than home injuries. Overall, the number of farm injuries decreased by 44% between 2001 and 2014. CONCLUSIONS: Characteristics of youth farm injuries are much different from injuries occurring at homes. Although the overall number of farm injuries among youth has decreased substantially over time, injury prevention initiatives targeted toward these particular injuries are important to continue due to the significant morbidity of these injuries.

Current issues in the diagnosis of pediatric cervical spine injury.

Cervical spine injury in pediatric trauma occurs rarely; however, there is significant potential for considerable morbidity when it does occur. Screening for cervical spine injuries has been shown to be most sensitive in adult trauma centers when combined with reliable physical examination findings. Because pediatric trauma patients suffer from a different range of injuries than adults, and often are not reliable due to age limitations or associated head injury, the same strategies employed in adult trauma do not always hold true in children. We look at the differences in adult and pediatric cervical spine anatomy and traumatic mechanisms, as well as the differences between cervical spine injury in infants/children and adolescents/teens. In addition, we examine the literature currently available in each population and derive consensuses on the issues that are important in managing the pediatric cervical spine. We hope to provide a framework that trauma centers can use to develop safe and effective cervical spine clearance protocols.

Transdiaphragmatic adrenalectomy for metastatic cervical adenocarcinoma: a technical case report.

We present a 60-year old woman with recurrent cervical adenocarcinoma who presented with metastasis to both lungs and to her right adrenal gland. A thoracotomy was performed for resection of her pulmonary metastasis and then the right adrenal gland was excised through a trans-diaphragmatic approach. The adrenal gland resection was more complex due to involvement of the tumor with the inferior vena cava (IVC) which was repaired with a PTFE patch graft. This case demonstrates both an interesting approach to surgical resection of multiple metastases as well as a safe, although more challenging, alternative to partially resect and repair the IVC.

American Academy of Pediatrics Section on Surgery hernia survey revisited.

BACKGROUND: The aim of the study was to describe current treatment and trends in surgical management of pediatric inguinal hernias (IHs), specifically contralateral exploration. METHODS: Surveys were sent to 599 Surgical Section members. Questions paralleled the 1993 American Academy of Pediatrics survey and addressed recent controversial topics. Statistical analysis by chi2 was performed. RESULTS: Three hundred ninety-five (66%) surveys returned. For full-term boys with reducible IH, 79% (82%) repair electively, regardless of age or weight. For full-term girls with reducible ovary, 49% (27%) repair electively, 36% (59%) next available slot, 5% (10%) emergently (P < .01). In former premature infants, 53% (65%) repair reducible IH when convenient, regardless of age. For unilaterally presenting IH, 44% (65%) routinely explore contralateral groins in boys 2 years or younger (P < .01); 47% (84%) routinely explore girls 4 years or younger (P < .01). No significant association between routine exploration patterns and years in practice, region of country, or training program affiliation was found. Laparoscopic evaluation for contralateral IH was reported by 37% (6%), (P < .01) 1993 results italicized. CONCLUSION: Reports of routine contralateral inguinal exploration had absolute decreases of 21% for boys 2 years or younger, 37% for girls 4 years or younger. There has been a shift toward elective repair for girls with reducible ovaries. Use of laparoscopy for diagnostic contralateral evaluation has increased dramatically.