Diagnosis and treatment of urethral prolapse in children.

OBJECTIVES: To review published reports on urethral prolapse in the pediatric population, with a focus on diagnosis and management, and to do a retrospective review of 20 cases of urethral prolapse at an urban hospital. METHODS: A retrospective chart review of 20 consecutive cases of urethral prolapse in the pediatric population at Kings County Hospital was done. A review of the published reports on urethral prolapse from 1937 to the present was included in this study. RESULTS: Twenty patients with urethral prolapse were treated at Kings County Hospital during a 10-year period. Patients were identified by perineal bleeding and diagnosed by physical examination. All patients were successfully treated by excision of the prolapsed urethral mucosa and suturing of the remaining mucosa to the vestibule. CONCLUSIONS: Urethral prolapse is an uncommon entity that occurs primarily in prepubertal black girls. Patients may be successfully treated by excision of the prolapsed mucosa and suturing of the proximal urethra to the vestibule.

Pearls and perils in the management of prolonged, peculiar, penetrating esophageal foreign bodies in children.

BACKGROUND/PURPOSE: Most retained esophageal foreign bodies (FB) are identified soon after ingestion and are easily extracted. A minority of FB ingestions are not identified for weeks to years and present significant problems for retrieval. The purpose of this study was to describe the diagnostic and therapeutic strategies needed to care for children who have chronic esophageal FBs. METHODS: Five children were identified as having retained esophageal FBs 2 months to 2 years after ingestion. During the same 3-year period, 100 children who had acute FBs were identified and had their foreign bodies removed endoscopically. The average age of the children was 3 years (range, 2.4 to 3.5). RESULTS: The average age of the five children identified in this study was 3 years. The items ingested included coins, a heart pendant, a clothespin spring, and a toy soldier. Complications from chronically retained foreign bodies were bronchoesophageal fistula, mediastinitis, esophageal diverticulum, and lobar atelectasis. One patient died from an aortoesophageal fistula. In all children, endoscopic removal was attempted. Barium esophagram was then performed, and foreign bodies were eventually removed via right thoracotomy. CONCLUSIONS: Long-retained esophageal FBs are extremely morbid and life threatening. History most often identifies excess salivation, new onset asthma, and/or recurrent upper respiratory infections. Three diagnostic adjuncts are helpful in identifying the presence of a long retained FB: (1) Chest x-ray (PA and lateral), (2) barium swallow, and (3) esophagoscopy. Indications for thoracotomy for removal of foreign body include (1) Poor endoscopic visualization of FB because of inflammatory tissue and (2) Herald bleeding during endoscopy.

The pediatric trauma center.

The types of facilities providing care to injured children vary greatly. Some have organized, planned, and functioning Pediatric Trauma Units with all the appropriate personnel, equipment, and facilities needed to provide whatever is needed. Other institutions have done no planning, have no trained personnel, and are, in short, ill prepared to provide any type of care. The resources needed to provide optimum care to the injured child are described for two types of facilities--the Regional Pediatric Trauma Center (RPTC), which provides the most comprehensive of pediatric trauma services, and the Trauma Center with Pediatric Commitment (TCPC), which is the type of institution at which the majority of pediatric trauma care is rendered.

ATLS-based videotape trauma resuscitation review: education and outcome.

Trauma resuscitations (TRs) can be improved with ongoing videotape review. Unrecognized errors, delays, and system problems can be identified and corrected. Previous studies have demonstrated the importance of a short TR on survival and that videotape education can shorten TR time. Trauma resuscitation efficiency depends on details of TR including timing, organization, and appropriateness of care. Videotape education review monitors TR detail and improves TR efficiency by eliminating wasted time and treatment errors. Eight hundred eighty-three patients were evaluated. Group I included a control group prior to the incorporation of an ATLS based videotape review process. Group II included patients who were resuscitated after the educational review process was established. Subgroups based on ISS, direct OR transfer, DPL, and CT scan were also compared. Time and outcome were compared. Videotape educational review based on ATLS guidelines has improved TR efficiency. The benefits of ongoing videotape review include more efficient time utilization, correction of conceptual and technical errors, elimination of "wasted time," and improved survival.

Necrotizing enterocolitis in multiple-birth infants.

Over a 5-year period, 20 infants of multiple-gestation births (16 twin, 2 triplet) developed necrotizing enterocolitis (NEC) (15 infants) or suspected NEC (5 infants). During the same period, 532 infants of multiple gestations were admitted to our neonatal intensive care unit, yielding a NEC incidence in this population of 3.8%. In two twin sets, both infants developed NEC or suspected NEC, and in three sets only the affected twin was transferred to our nursery. Five infants required surgical intervention (25%) and three infants died (overall mortality, 15%). Fifteen siblings who did not develop NEC served as a control group. Analysis showed that the 1-minute Apgar score was the most significant factor in predicting NEC (P less than .028) and need for surgical intervention (P less than .020). In this series, 82% of the infants with 1-minute Apgar less than 6 developed NEC, whereas 31% with 1-minute Apgar greater than 6 developed NEC.

Mortality and head injury: the pediatric perspective.

The records of 10,098 children entered into the National Pediatric Trauma Registry (NPTR) were analyzed to define the characteristics of pediatric head injury and the impact of extracranial trauma on Central Nervous System (CNS) injury. The 4,400 NPTR head injuries were then compared with 16,524 head injuries recently reported from a predominantly adult trauma registry to illustrate potential population differences. Results indicate that children have a lower mortality, that the addition of extracranial injury significantly reduces recovery potential, that CNS injury is the predominant and most common cause of pediatric traumatic death, and that the automobile is the most lethal component of a child's environment.

Organ injury scaling: spleen, liver, and kidney.

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) was appointed by President Trunkey at the 1987 Annual Meeting. The principal charge was to devise injury severity scores for individual organs to facilitate clinical research. The resultant classification scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. A number of similar scales have been developed in the past, but none has been uniformly adopted. In fact, this concept was introduced at the A.A.S.T. in 1979 as the Abdominal Trauma Index (A.T.I.) and has proved useful in several areas of clinical research. The enclosed O.I.S.'s for spleen, liver, and kidney represent an amalgamation of previous scales applied for these organs, and a consensus of the O.I.S. Committee as well as the A.A.S.T. Board of Managers. The O.I.S. differs from the Abbreviated Injury Score (A.I.S.), which is also based on an anatomic scale but designed to reflect the impact of a specific organ injury on ultimate patient outcome. The individual A.I.S.'s are, of course, the basic elements used to calculate the Injury Severity Score (I.S.S.) as well as T.R.I.S.S. methodology. To ensure that the O.I.S. interdiffuses with the A.I.S. and I.C.D.-9 codes, these are listed alongside the respective O.I.S. Both the currently used A.I.S. 85 and proposed A.I.S. 90 are provided because of the obligatory transition period. Indeed, A.I.S. 90 contains the identical descriptive text as the current O.I.S.'s. The Abdominal Trauma Index and other similar indices using organ injury scoring can be easily modified by replacing older scores with the O.I.S.'s.(ABSTRACT TRUNCATED AT 250 WORDS)

Chest injuries in childhood.

Differences in anatomy and mechanisms of injury are believed to contribute to the unique response of children to thoracic trauma. To characterize the scope and consequences of childhood chest injury, we reviewed the records of 105 children (ages 1 month to 17 years, mean 7.6 years) with chest injuries admitted to a level I pediatric trauma center from 1981 to 1988. Nearly all injuries (97.1%) were due to blunt trauma, and more than 50% were traffic related. Rib fractures, commonly multiple, and pulmonary contusions occurred with nearly equal frequency (49.5% and 53.3%, respectively), followed by pneumothorax (37.1%) and hemothorax (13.3%). One fourth of all pneumothoraces were under tension. Significant intrathoracic injuries occurred without rib fractures in 52% of cases with blunt trauma. Associated head, abdominal, and orthopedic injuries were present in 68.6% of children reviewed. One in five received endotracheal intubation and ventilatory support for 1 to 109 days. Presence or absence of head injury neither increased the need for respiratory support (29.4% vs. 17.2%, respectively; p = 0.24) nor affected the duration of support for those who were ventilated (6.8 +/- 8.9 days vs. 3.3 +/- 2.6 days, excluding one ventilator-dependent head-injured patient and five early deaths). The presence of associated injuries, intubation, and pneumothorax or hemothorax all resulted in significantly longer hospitalizations and more severe injury as measured by Injury Severity Score (ISS). Age, rib fracture, and contusion had no effect. Rarely encountered were ruptured diaphragm (2 cases), transection of the aorta (1), major tracheobronchial tears (3), flail chest (1), and cardiac contusion (2). Only two of the three children with penetrating injuries and three of the 83 (3.6%) with blunt injuries underwent chest operations. Six children (7%) died, one from a penetrating injury and five from blunt mechanisms. Chest Abbreviated Injury Scale (AIS) and ISS correlated significantly with mortality; age and head AIS did not. Rib fractures, lung contusions, and associated head, abdominal, and skeletal injuries are common because of the predominance of blunt-injury mechanisms. Nearly one half of chest injuries occurred without rib fractures. The need for ventilatory support is uncommon; when required, its duration is generally brief. Aortic transection, flail chest, and penetrating injuries more frequently encountered in adults and are uncommon in children. Thoracotomy generally is not required.(ABSTRACT TRUNCATED AT 400 WORDS)

National Pediatric Trauma Registry.

The National Pediatric Trauma Registry (NPTR) is a multi-institutional database designed to compile information concerning all aspects of pediatric trauma care. The registry is designed and operated in a manner that maximizes data accuracy and provides this information to all participating investigators. The growth of the database has allowed the NPTR to provide the first accurate epidemiologic description of pediatric trauma as a national disease, as well as to develop national norms for pediatric trauma care. The registry presently contains 10,177 patients, and is undergoing revisions (phase II) to allow a more focused evaluation of various aspects of the clinical care and rehabilitation of the pediatric trauma patient.

Emergency medical services for children and pediatric trauma system components.

The concept of an emergency medical service for children (EMS-C) is new. Although adult EMS systems exist in every region of the United States, the needs of the child suffering from acute injury or illness have not been previously addressed. The development and incorporation of an EMS-C system into the existing adult EMS system is the most time- and cost-effective method to achieve efficient care for the acutely injured or ill child. The components of an EMS-C system include system design, education, prevention, standards of care, research and development, quality assurance, and funding.

Complications of Crotalidae antivenin therapy.

Polyvalent antivenin is the mainstay of treatment of serious snake envenomation. Its use, however, has been challenged as being unnecessary in minor envenomations and potentially hazardous due to allergic complications. Our institution routinely uses antivenin, and this report focuses on the allergic complications of this therapy. Forty patients with Crotalidae snake bites were evaluated and treated over a 7-year period. Twenty-six patients received a total of 507 vials of antivenin, the dose correlating with the clinical severity of envenomation. All patients were skin tested. Immediate hypersensitivity reactions occurred in six patients (23%). Cutaneous manifestations alone occurred in three of these patients, while systemic anaphylaxis occurred in three. Twenty patients were available for followup, and ten (50%) developed serum sickness. Skin testing was not reliable in predicting the development of immediate (anaphylaxis) or delayed (serum sickness) hypersensitivity reactions. Treatment of antivenin allergic reactions was uniformly effective, with no mortality, minimal morbidity, and no chronic sequelae.

The predictive validity of the Pediatric Trauma Score.

The Pediatric Trauma Score was evaluated in 450 injured children by a paramedic in the field and a physician in an E.D. There was agreement between the scores of these two individuals 93.6% of the time, correlation coefficient 0.991, r2 = 0.982. Further testing at the 0.01 level of significance indicated that a positive association existed between these two variables in the population from which our sample was drawn. Mortality for the group was 2.9%. No deaths occurred in patients whose PTS was greater than 8, which was defined as the Critical Triage Point. The sensitivity of the PTS when used for triage at the critical triage point was 95.8%. The specificity of the PTS was 98.6%. The Pediatric Trauma Score appears to be highly accurate, reliable, predictable, and easy to use for assessing the severity of injury and hence is a straightforward modality for triage of injured children.

The Pediatric Trauma Score as a predictor of injury severity: an objective assessment.

The ability of the Pediatric Trauma Score (P.T.S.) to predict injury severity and mortality was evaluated by analysis of its relationship with the Injury Severity Score (I.S.S.) of 615 children entered into the National Pediatric Trauma Registry (N.P.T.R.). Mean age was 8.2 years and mortality was 3.5%. Mean I.S.S. of survivors was 8.1 in comparison to 59.7 for nonsurvivors. Linear regression coefficient determined from analysis of these variables produced a slope of -3.7 with a statistically significant correlation of P.T.S. to I.S.S. (p less than 0.001; r2 = 0.89). Analysis of the mortality for each cohort of patients with the same P.T.S. identified three categories of mortality potential. Children whose P.T.S. was greater than 8 had a 0% mortality. Children whose P.T.S. was between 0 and 8 had an increasing mortality related to their decreasing P.T.S. (r2 = 0.86), and children whose P.T.S. was below 0 had 100% mortality. This study documents the direct linear relationship between P.T.S. and injury severity, and confirms the P.T.S. as an effective predictor of both severity of injury and potential for mortality.

Resuscitative thoracotomy in children and adolescents.

Accidental injury continues as the leading cause of mortality in children and adolescents. With the recent push for improvement in emergency medical services and specialized trauma centers for this age group, more moribund patients can be expected to reach these centers. Multiple reports document the efficacy of resuscitative thoracotomy in the moribund adult trauma victim, but published reports of this technique in children and adolescents are lacking. From January 1981 to July 1986, 19 patients ranging in age from 4 to 18 years (mean 14) underwent resuscitative thoracotomy. Eleven patients sustained penetrating trauma while eight sustained injuries from blunt trauma. Five patients survived and were discharged from the hospital (26%). There were no survivors in the 0-15 year age group in five penetrating injuries and four blunt trauma victims. This review confirms the efficacy of resuscitative thoracotomy in the patient with penetrating trauma. Salvage in the blunt trauma victim is possible, but less than in penetrating injuries (12.5% versus 36%). Further studies in this age group will be necessary to establish appropriate guidelines for the use of RT in children and adolescents.

Surgical problems in the fetus: a multidisciplinary approach.

Over a 2 year period, 90 cases of potential fetal pathologic conditions were presented to a multidisciplinary fetal board. Members, including persons from perinatology, neonatology, genetics, radiology, pathology, pediatric surgery, neurosurgery, and urology, met monthly to discuss new referrals, follow-up ongoing cases, and present findings and treatment in delivered cases. Of 90 referred cases, 76 surgical diagnoses occurred in 71 fetuses (79 percent), with central nervous system and genitourinary anomalies predominating. A formal presentation during a single meeting with the variety of specialists necessary to manage surgical problems in the fetus facilitated perinatal management and allowed for the appropriate specialist to counsel the parents as early as possible.

Pediatric maxillofacial trauma: unique features in diagnosis and treatment.

The purpose of this study was to review mechanisms, etiologies, associated injuries, and treatment of maxillofacial trauma in children and to compare them to similar adult injuries. Thirty blunt injuries (1984-1986) comprised the children's group, and 176 injuries, the adult group. Multiple associated injuries were more common in children, the most frequent being CNS and orthopedic injuries. Detailed anatomy of mandibular fractures required pleuridirectional tomography in 63% of the pediatric cases compared to 12% in adults. In the children's group, the mandibular fractures were favorable in 56% of cases compared to 15% in adults. Children required shorter periods of intermaxillary fixation with no child requiring reapplication of fixation. Based on these comparisons, a protocol for the management of pediatric maxillofacial injuries has been developed.