Long-term outcome of the shaken baby syndrome and medicolegal consequences: a case report.

INTRODUCTION: Studies of long-term outcome of the shaken baby syndrome (SBS) are scarce, but they usually indicate poor outcome. OBJECTIVES: To describe long-term outcome of a child having sustained a SBS, to ascertain possible delayed sequelae and to discuss medicolegal issues. METHODS: We report a single case study of a child having sustained a SBS, illustrating the initial clinical features, the neurological, cognitive and behavioural outcomes as well as her social integration. RESULTS: The child sustained diffuse brain injuries, responsible for spastic right hemiplegia leading to secondary orthopaedic consequences, as well as severe cognitive impairment, worsening over time: the developmental quotient measured at 15 months of age was 55 and worsened as age increased. At 6 years and 8 months, the child's IQ had fallen to 40. Behavioural disorders became apparent only after several months and precluded any social integration. The child eventually had to be placed in a specialised education centre at age 5. DISCUSSION AND CONCLUSION: The SBS has a very poor outcome and major long-standing sequelae are frequent. Cognitive or behavioural sequelae can become apparent only after a long sign-free interval, due to increasing demands placed on the child during development. This case report confirms severity of early brain lesions and necessity for an extended follow-up by a multi-disciplinary team. From a medicolegal point of view, signaling the child to legal authorities allows protection of the child, but also conditions later compensation if sequelae compromise autonomy.

Nonoperative management of blunt abdominal trauma: the role of sequential diagnostic peritoneal lavage, computed tomography, and angiography.

STUDY OBJECTIVE: To determine the usefulness of sequential nonoperative diagnostic studies in the evaluation and treatment of stable patients after blunt abdominal trauma. DESIGN AND SETTING: Retrospective review of a prospective treatment plan in a large urban Level I trauma center. PARTICIPANTS: Fifty-two patients deemed stable after initial evaluation following blunt abdominal trauma. INTERVENTIONS: Patients with a positive diagnostic peritoneal lavage for red blood cells underwent abdominal computed tomography (CT) scanning. If CT demonstrated a visceral injury, it was followed by diagnostic angiography. Attempts were made to treat on-going bleeding by transcatheter embolization. RESULTS: Fifteen patients had negative CT scans and were successfully observed. In the other 37 patients, CT identified 17 liver, 16 splenic, and eight kidney injuries; eight extra-peritoneal bleeds; and one mesenteric hematoma. Six of these patients were observed. Thirty underwent diagnostic angiograms. Twelve had no active bleeding, and all were observed successfully. Seventeen underwent successful embolization of the bleeding site(s). One had injuries not controllable by embolization and required exploration. Six patients required laparotomy later in their course, but none had intra-abdominal bleeding or a missed intestinal injury. Despite being performed after diagnostic peritoneal lavage, CT missed only two injuries. There was one main complication, delayed recognition of a diaphragmatic injury. Three patients died, two from multiple organ failure and one from a pulmonary embolus; none was believed to be related to this technique. With our algorithm, 45 patients (86%) were spared laparotomy. CONCLUSION: Diagnostic peritoneal lavage and CT are complementary when evaluating blunt abdominal trauma. Diagnostic peritoneal lavage is an effective screening tool. CT may be reserved for stable patients with a positive diagnostic peritoneal lavage to specify the organs injured. Bleeding often may be treated by embolization, limiting the rate of surgery.

The management of vascular injuries of the extremity associated with civilian firearms.

A penetrating extremity trauma registry was created to prospectively study the physical findings, use of arteriography, nonoperative management with embolization or observation and operation in the management of vascular injuries. During a recent ten month period, 228 patients with 320 injuries of the extremity secondary to firearms were admitted to the Trauma Service. Twenty-four percent of the patients had more than one injury, and there were six perioperative deaths related to associated injuries. Fifty-one patients had 50 arterial and 17 venous injuries. Limb salvage was 100 percent. Twenty-two patients with obvious arterial injuries were taken directly to the operating room without arteriography. Arteriography was performed immediately after admission in 41 patients and the findings were positive in 46.4 percent of the patients; nine required operation. Arteriography was performed for injuries in proximity to a major vessel as the indication in 153 injuries and revealed seven arterial injuries (4.6 percent). Three patients underwent operation. Five patients with arterial injuries had successful embolization during the initial arteriography and five patients with intimal injuries were observed, four healed and one patient was lost to follow-up evaluation. Operative repair of arterial injuries included the use of saphenous vein (21 patients), prosthetic grafts (seven patients) and ligations (four patients). Seventeen venous injuries were either repaired (eight patients) or ligated (nine patients). In the patients undergoing operative repairs, 68.7 percent had fasciotomies performed. The excellent results in the current study (no amputations with 51 survivors of arterial injuries) were obtained by a multidisciplinary approach, involving selective arteriography to avoid unnecessary operation and operative repair in those with extensive vascular injuries. The use of arteriography for proximity characterized a few vascular injuries requiring operation or observation. It should serve as the standard for evaluating noninvasive diagnostic studies and for studying the natural history of asymptomatic injuries.

Packing and re-exploration for patients with nonhepatic injuries.

We retrospectively reviewed the clinical records of 11 patients admitted to the trauma service at Kings County Hospital who underwent packing and temporary closure for severe nonhepatic injuries. The mean ISS was 37 and the mean Abdominal Trauma Index value was 48. Operative findings included 17 major vascular injuries. Although the mean blood pressure was 105 mm Hg during the procedure, the patients required an average of 17 units of blood and all were acidotic, hypothermic, and coagulopathic. Acidosis persisted in all patients and the mean base excess was -13 at closure. A conscious decision was made to terminate the procedure when surgical bleeding was controlled. Patients were resuscitated and warmed in the ICU and returned to the operating room within 48 hours. Seven of the 11 patients survived. Of the eight patients who survived to return to the operating room, all required gastrointestinal procedures at re-exploration. This preliminary experience supports packing to control coagulopathic bleeding, use of temporary abdominal closure, and further ICU resuscitation with a planned second laparotomy for definitive management of gastrointestinal injuries in patients with severe nonhepatic injuries.

Percutaneous antegrade ureteral stenting as an adjunct for treatment of complicated ureteral injuries.

We report our use of percutaneous antegrade ureteral stenting (PAUS) as an adjunct for the management of dehisced ureteral repairs and delayed-presentation ureteral injuries secondary to penetrating trauma. This procedure was performed in treating six patients with ureteral injuries. Four patients had dehiscence of a lacerated ureter that had been primarily repaired. Two other patients had ureteral contusions that subsequently became full-thickness disruptions postoperatively. One of these patients developed a pancreaticoureteral fistula. The sepsis resolved in all six patients and in five of the six patients the ureteral disruption healed within 2 months after PAUS without operative intervention. In one patient the ureter healed with stricture, necessitating ureteral reanastomosis. All urinomas resolved with percutaneous drainage. The PAUS technique was used to successfully treat four dehisced ureteral repairs and was the primary method used to successfully treat two disrupted ureteral contusions that were associated with multiple collections and fistulas. These techniques can be utilized for complex ureteral injuries associated with pancreatic leaks, colon or duodenal injuries, and multiple abscesses.

Traumatic rupture of the thoracic aorta.

Because the diagnosis of a traumatic rupture of the aorta can be subtle, a high index of clinical suspicion must be maintained to arrive at a prompt and correct diagnosis. When chest radiography shows that the mediastinum is greater than 8 cm in width or that the arch or descending aorta are obscured, direct transfemoral arteriography remains the procedure of choice in hemodynamically stabilized patients. At the present time, computed tomography is not recommended as a definitive diagnostic modality.

Indications for barium enema preceding colostomy closure in trauma patients.

The need for a barium enema (BE) preceding colostomy closure is controversial. In the process of evaluating the usefulness of BE before closure of colostomies performed for colorectal injuries, we reviewed our experience with 84 trauma patients who underwent BE before colostomy closure. Patients who had their colonic injuries repaired or diverted during the initial procedure did not benefit from the precolostomy closure contrast study. In this group of patients artifacts on BE had to be ruled out by endoscopy or repeat radiography in 9.5% of patients. Barium enema was found beneficial in evaluating colorectal injuries below the peritoneal reflection in one out of 20 patients. However, since the rectal injuries are not usually explored and repaired during the initial procedure, investigation by endoscopy and contrast studies may still be indicated preceding colostomy closure.

Evaluation of occult cardiac injuries using subxiphoid pericardial window.

During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVP's less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)