Three-wheel and four-wheel all-terrain vehicle injuries in children.

In January 1988, sales of new three-wheel all-terrain vehicles (ATVs) were banned in the United States because of the high incidence of injury associated with their use, especially by children. Four-wheel ATVs remain on the market. A retrospective review of all ATV injuries seen in a level I pediatric trauma center was conducted to compare the nature and severity of injuries in three-wheel vehicles with those associated with four-wheelers. A total of 36 ATV injuries were seen from April 1986 to August 1988. All patients were less than 16 years of age; 72% were less than or equal to 12 years of age. Of the patients, 56% were boys; 44% were girls. Although 56% of incidents involved three-wheelers, a larger number of more serious injuries, defined as the presence of indicators of injury severity (eg, death, Injury Severity Score greater than or equal to 10, intensive care unit admission, or need for surgery), involved four-wheel vehicles. A total of 15 injuries occurred in 1987; 12 injuries, including the first death involving an ATV at the pediatric trauma center, occurred in the 7 months since the sales ban. Immature judgment and/or motor skills were the most common factors contributing to injury. Existing information regarding injuries involving three-wheel ATVs is supported by our data, according to which it is suggested that four-wheel vehicles may be dangerous in the hands of immature or unskilled operators less than 16 years of age. Injury prevention efforts should be directed at prohibiting any ATV use by persons less than 16 years of age.

Pediatric firearm injuries, Kansas City, 1992: a population-based study.

OBJECTIVE: To determine the morbidity, mortality, and epidemiologic features of pediatric powder-firearm injuries in a defined urban population. DESIGN AND SETTING: A population-based, descriptive epidemiologic study was conducted of firearm injuries to children in a mid-size urban community (total population: 435,178) in 1992. The population was 56% white and 39% black. Data from prehospital care providers, all city and adjacent community hospitals, and medical examiner and police records were searched for cases of firearm injury. The 1990 United States census provided denominator data. CASE DEFINITION: Subjects were all 0- to 16-year-old residents of Kansas City, Missouri who sought medical treatment at a hospital for a powder-firearm injury or who presented to the medical examiner with a fatal firearm injury in calendar year 1992. RESULTS: Seventy-two children met the case definition, for an incidence of 70 per 100,000 persons per year. There were 12 (16.7%) fatalities, for a mortality rate of 11.7 per 100,000 persons per year. Almost 10% of the patients sustained permanent disability. Mean and median ages of the patients were 14.9 years and 15.8 years, respectively; 79% were male and 82% were black. The majority of the children (63%) lived in census tracts with a high proportion of families in poverty. Black males had the highest rates of firearm injury, with a 1-year incidence of 233 per 100,000 persons per year. At younger than 12 years, the rates were equal among the races; however, for those 12 years and older, black adolescents had 13 times the risk of white adolescents (541 compared to 42 per 100,000 persons per year). The majority (71%) of injuries were due to assaults, with drive-by shootings the most frequent circumstance. The majority of unintentional injuries occurred to adolescents as the result of an unplanned discharge of a handgun as it was being placed in or removed from concealment. Among the patients, 39% were admitted to the hospital and 26% required surgery. CONCLUSIONS: 1) Black male adolescents had the highest risk of firearm injury or fatality. 2) The majority of victims lived in census tracts characterized by poverty. 3) injuries were alarmingly severe. 4) Interpersonal violence was the leading contributor to fatal and nonfatal injuries. 5) Unintentional injuries characteristically occurred during the process of weapon concealment. 6) The leading contributor to injury and death was the interaction of adolescents and guns, particularly handguns. The main implication for firearm-injury prevention in this population is the limiting of access to guns by adolescents. In addition, measures aimed at preventing violent behavior, such as education in nonviolent methods of conflict resolution, should be explored.

The rockets' red glare, the bombs bursting in air: fireworks-related injuries to children.

OBJECTIVE: To describe the epidemiology of fireworks-related injuries to children treated in a pediatric emergency department. DESIGN: A descriptive study of a consecutive series of patients. SETTING: The emergency department of a large urban children's hospital. PARTICIPANTS: Children treated for injuries associated with fireworks during the 22-year period from 1972 through 1993. RESULTS: Three hundred sixteen children were treated for fireworks-related injuries. Ninety-five percent of patients were injured during the 3-week period of June 22 to July 14 during the study years. Seventy-one percent of patients were male, and the average age was 8.5 years, with a range of 1 month to 17 years. The child was a bystander in 26% of cases, and adult supervision was present in 54% of cases. One patient died, and 11% of children required admission to the hospital, with an average length of stay of 7.8 days (range, 1 to 37 days). Fifteen children (5%) went to the operating room for treatment of injuries. Thirty-three patients (10%) had permanent sequelae from their injuries, including 7 children (2%) with complete or partial loss of vision in one eye. The eyes were injured in 29% of cases, followed by hands and fingers (22%), other head and face sites (18%), and lower extremities (16%). The primary injury was a burn in 72% of cases. Firecrackers were associated with 42% of injuries, followed by bottle rockets (12%), other types of rockets (7%), Roman candles (11%), sparklers (7%), fountains (5%), jumping jacks (4%), and class B (illegal) fireworks (4%). Sixty-seven percent of sparkler-related injuries occurred among children 5 years and younger (Fisher's exact test, P = .000002; odds ratio [OR] = 10.00, 95% confidence interval 3.52 < OR < 29.24). Permanent sequelae were more common for eye injuries caused by rockets than eye injuries caused by other types of fireworks (Fisher's exact test, P = .03; OR = 6.72, 95% confidence interval 1.18 < OR < 38.18). Charges for medical care of a fireworks-related injury averaged $1385 per patient (range, $44 to $15 071). CONCLUSIONS: Fireworks are associated with serious injuries. Findings of this large consecutive series describe the epidemiology of these injuries. Children and their families should be encouraged to enjoy fireworks at public fireworks displays conducted by professionals. Fireworks for individual private use should be banned.

Removing the pediatric cervical collar: current practice patterns.

OBJECTIVES: To identify the current practice patterns of emergency medicine practitioners and the typical criteria used in discontinuing cervical spine immobilization (CSI) in the pediatric patient. DESIGN: Mail-in survey. PARTICIPANTS: All physicians on the mailing list of the American Academy of Pediatrics Section of Emergency Medicine and an equal number of randomly chosen members of the American College of Emergency Physicians. The total number of participants was 1360. METHODS: The survey consisted of a case scenario describing a 3-year-old child brought to the emergency department with CSI. The approach to such a scenario was assessed. Surveys were mailed with self-addressed stamped envelopes; repeat mailings were sent at 4 and 8 weeks after the first mailing. Those not currently in active practice or not involved in the decision to discontinue CSI were excluded from the study. RESULTS: The response rate was 55%. Most respondents were younger than 44 years (71%), in practice less than 10 years (56%), and practiced in an urban setting (68%). Nearly two thirds (62.6%) had completed residency training in pediatrics, 24% in emergency medicine and 36% a pediatric emergency medicine fellowship. Most (63%) would discontinue CSI without obtaining radiographs. Factors associated with removal were residency training in pediatrics and being in practice for less than 10 years. The most common criteria for discontinuing CSI were normal neurological (96%) and cervical spine (98%) examinations, normal mental status (92%), and absence of neck pain (93%). CONCLUSIONS: Discontinuing CSI without obtaining radiographs is common, especially among those with residency training in pediatrics and those in practice for less than 10 years. Knowledge of current practice is essential to future development of guidelines for managing pediatric trauma patients for whom cervical spine injury is a consideration.

Bridging the emergency medical services for children information gap.

OBJECTIVE: To determine the epidemiological features of pediatric usage of prehospital emergency medical services (EMS) in a defined urban population. METHODS: Residents of Kansas City, Mo, younger than 15 years who used EMS during the calendar years 1993-1995 were included. In this geographic area there is a single provider of prehospital care; all numerator data were taken from this single source. Denominator data were provided by 1995 intercensal estimates based on the 1990 US Census. Rates were calculated as an annual average and reported as the number of children transported per 1 000 persons per year. RESULTS: There were a total of 7296 pediatric EMS transports during the study period, for an annual rate of 21.9. Infants younger than 1 year had the highest rate (47.4), followed by those aged 1 to 4 years (26.2), 10 to 14 years (17.5), and 5 to 9 years (17.3). Medicaid was the insurer for half and 27% were uninsured. One quarter of the patients used EMS more than once. Children living in ZIP codes in the lowest median income tertile were 5.8 times more likely to use EMS than those in the upper income tertile (95% confidence interval, 5.4-6.3). One third of all transports occurred between the hours of 4 and 8 PM. CONCLUSIONS: Children using the Kansas City EMS were more likely to be infants, insured by Medicaid or uninsured, and live in low-income ZIP codes. Further study is needed to determine if this increased usage is due to greater incidence and severity of illness and injury, lack of transportation, lack of education, or other factors.

Cardiopulmonary response to maximal exercise in young athletes following the Ross procedure.

BACKGROUND: Aortic prosthetic devices offer limitations that make them less than optimal valve substitutes because the vast majority are innately obstructive, especially at increased levels of hemodynamic function. The present study is designed to demonstrate the hemodynamics of the pulmonary autograft in 11 conditioned athletes who have undergone the Ross (pulmonary autograft) procedure. Data was compared to a group of 13 age-matched "normal athletes." METHODS: All the Ross athletes had undergone the autograft procedure using the root replacement technique and were at least 3 months into their postrecovery phase. All athletes (both normal and Ross) underwent resting transthoracic echo followed by maximal exercise stress test (modified Bruce protocol) to exhaustion. Post-operative transesphogeal echocardiogram obtained within 90 seconds documented aortic valve gradient and velocity across the aortic valve. RESULTS: In the Ross athlete group, maximum heart rate was 188 beats per minute, peak aortic valve gradient at rest (mm Hg) 7.69 (mean), velocity across the aortic valve at rest (cm per second) 129.40 (mean), peak aortic valve gradient at maximal exercise (mm Hg) 16.30 (mean), velocity across the aortic valve at maximal exercise (cm per second) 190.00 (mean). In the normal athlete group, maximum heart rate was 176 beats/minute, peak aortic valve gradient at rest (mm Hg) 5.97 (mean), velocity across the aortic valve at rest (cm per second) 120.54 (mean), peak aortic valve gradient at maximal exercise (mm Hg) 14.61 (mean), velocity across the aortic valve at maximal exercise (cm per second) 190.23 (mean). CONCLUSION: The pulmonary autograft exhibits hemodynamic characteristics similar to the normal human aortic valve under conditions of enhanced cardiac output.

Scalp colonization by Trichophyton tonsurans in an urban pediatric clinic. ?Asymptomatic carrier state.

Random culturing of the scalp in 200 healthy children in a large metropolitan children's hospital revealed that eight (4%) of the patients had cultures that were positive for Trichophyton tonsurans variety sulfureum. Infections were not clinically apparent and were asymptomatic. All of the patients with positive cultures were black and six braided their hair. Trichophyton tonsurans appears to exist in an asymptomatic state in this well-defined population of children.

Interpreting the toxicologic significance of alterations in anogenital distance: potential for confounding effects of progeny body weights.

Anogenital distance (AGD) is an endpoint that was recently added to the U.S. EPA testing guidelines for reproductive toxicity studies. This endpoint is sensitive to hormonal effects of test chemicals. It is possible that apparent alterations in AGD might occur after treatment with agents that affect overall pup body size. In such cases, hormonal activity might be associated incorrectly with the test treatment. The analyses in this report evaluated statistical correlations between pup body weight and AGD in control litters. AGDs were measured on postnatal day 1 in 1501 pups derived from 113 untreated female Sprague-Dawley rats in two independent two-generation reproductive toxicity studies. Significant correlations were detected between AGD and body weight and between AGD and the cube root of body weight. In males, AGD increased 0.26 mm for each 1 g increase in body weight. In females, AGD increased 0.13 mm per 1 g increase in body weight. Although there were essentially no differences between the regression models developed to predict AGD in either males or females using body weight as a covariate and those based on the cube root of body weight, such similarities in predictivity might not occur in larger animals with broader weight ranges than those encountered in this analysis. Normalization of AGD by dividing by body weight significantly overcompensated for differences in body size. Normalizing with the cube root of body weight resulted in an AGD/cube root of body weight ratio that was constant across the range of body weights observed in this study. In conclusion, as a preferred method to account for body size effects on AGD, analysis of covariance is recommended. If a normalization is done directly, the ratio of AGD to the cube root of body weight is the more appropriate metric.

The impact of children witnessing violence.

Over the past decade, Americans have recognized that violence has deeply permeated the lives of the most vulnerable among us--children. There is great concern over the effect these terrible experiences will have on present and future generations. It has also awakened the collective consciousness of our society that the impact of violence extends well beyond the child who is physically victimized to other larger groups of children such as those who witness these events. This article reviews the impact violence has on children.

Updates in wound management for the pediatrician.

Lacerations are common in children, and skills in wound management, especially laceration repair, are important. The minimization of pain and anxiety should be considered an essential part of the procedure. Newer techniques using topical anesthetics and tissue adhesives have significantly simplified the process of laceration repair promoting application in office, clinic, and emergency department settings. In situations inappropriate for topical anesthesia and closure, the use of buffered lidocaine and attention to the technique of infiltration are important. Although infection is the most common complication, the percentage of lacerations, which become infected in children, is low. Antibiotic prophylaxis is seldom needed. Human and animal bites raise special concerns in the assessment for primary repair and prophylactic antibiotic use.

Evaluation of the prenatal developmental toxicity of orally administered arsenic trioxide in rats.

A thorough review of the literature revealed no published repeated-dose oral developmental toxicity studies of inorganic arsenic in rats. In the present study, which was conducted according to modern regulatory guidelines, arsenic trioxide was administered orally beginning 14 days prior to mating and continuing through mating and gestation until gestational day 19. Exposures began prior to mating in an attempt to achieve a steady state of arsenic in the bloodstream of dams prior to embryo-foetal development. Groups of 25 Crl:CD(SD)BR female rats received doses of 0, 1, 2.5, 5 or 10mg/kg/day by gavage. The selection of these dose levels was based on a preliminary range-finding study, in which excessive post-implantation loss and markedly decreased foetal weight occurred at doses of 15 mg/kg/day and maternal deaths occurred at higher doses. Maternal toxicity in the 10mg/kg/day group was evidenced by decreased food consumption and decreased net body weight gain during gestation, increased liver and kidney weights, and stomach abnormalities (adhesions and eroded areas). Transient decreases in food consumption in the 5mg/kg/day group caused the maternal no-observed-adverse-effect level (NOAEL) to be determined as 2. 5mg/kg/day. Intrauterine parameters were unaffected by arsenic trioxide. No treatment-related foetal malformations were noted in any dose group. Increased skeletal variations at 10mg/kg/day were attributed to reduced foetal weight at that dose level. The developmental NOAEL was thus 5mg/kg/day. Based on this study, orally administered arsenic trioxide cannot be considered to be a selective developmental toxicant (i.e. it is not more toxic to the conceptus than to the maternal organism), nor does it exhibit any propensity to cause neural tube defects, even at maternally toxic dose levels.

The interpretation of urogenital findings in children with straddle injuries.

Because urogenital trauma frequently raises the question of sexual abuse, it is important to be able to relate the mechanism of injury to expected examination findings. This study was undertaken to characterize the trauma that results from straddling and correlate such injuries with the history, examination, and patient characteristics. The charts of 100 patients examined in an urban pediatric emergency department were reviewed; their conditions met the criteria of straddle injury--a blow to the perineum as a result of falling or striking a surface or an object with the force of one's own body weight. Ages ranged from 9 to 187 months (mean, 77.9; median, 67.2); 72% were female. Most injuries were minor lacerations and abrasions of the genitalia. Eleven percent had injury to the posterior fourchette. Hymenal and vaginal injuries were primarily caused by penetrating mechanisms. Five patients who presented with a history of straddling subsequently received the diagnosis of sexual assault based on disclosure by the patient or a witness and inconsistency of physical findings. There were no urethral or perianal injuries resulting from nonpenetrating straddle mechanisms. Straddle injuries include a variety of mostly minor urogenital injuries. Perianal, hymenal, or vaginal trauma suggests a penetrating mechanism, either unintentional or from sexual assault. An investigation for sexual assault should be initiated in the following cases: infants younger than 9 months of age; perianal, hymenal, or vaginal injury; extensive or severe injury; concurrent nonurogenital injuries; and whenever there is lack of correlation between history and physical findings.

Oral hemorrhage associated with periodontal surgery and hypertensive crisis.

A case of accelerated hypertension associated with severe oral hemorrhage is described. The evidence in this case suggests that a hypertensive crisis may have been caused by a failure to take medication as prescribed, or may have occurred as a sequel to severe postoperative hemorrhage. The reopening of the surgical site was probably caused by masticatory trauma, and the hemorrhage exacerbated by localized fibrinolytic activity.

Treatment of triple tooth: report of case.

A case of a young girl with a triple primary tooth that retarded normal development of the maxillary left lateral incisor is described. The primary tooth was extracted to encourage normal development of the permanent tooth. Subsequent examination of the extracted triple tooth suggests that it was composed of the primary left lateral incisor fused either to a geminated central incisor or to a fused central incisor and supernumerary tooth.

Practical issues in the care of pediatric trauma patients.

Childhood injuries are a preventable problem that continue to occur with alarming frequency. The pediatrician has a broad role in the prevention and treatment of injuries. When primary prevention fails, trauma care providers must recognize that an injured child is a unique patient who requires special considerations. Use of an organized approach will assure that injuries are not missed. The care of an injured child presents pediatricians with a tremendous responsibility. Injury prevention presents the pediatrician with a formidable challenge.

Recognition and emergency management of infectious causes of upper airway obstruction in children.

Infections represent one of the most common causes of upper airway obstruction in the pediatric age group. Because obstructive processes may lead to respiratory failure and subsequent cardiopulmonary arrest, prompt recognition is crucial. This discussion provides a brief review of the unique anatomic and physiological characteristics of the child's airway, which may contribute to obstructive processes, followed by basic principles of pediatric airway management. Finally, we review many of the infectious causes of upper respiratory obstruction, with emphasis on early recognition and acute management.