[Management of unintentional pediatric female genital trauma]. / Prise en charge des traumatismes du périnée accidentels chez la jeune fille.

INTRODUCTION: Unintentional pediatric female genital trauma is frequent in the daily practice of emergency wards. However, scientific data are rare in the literature, leading to variability in their management. The aim of this study was to evaluate our practice in order to obtain epidemiological data and define clinical guidelines. MATERIAL AND METHODS: We conducted a retrospective study from March 2013 to January 2015 and identified all emergency visits for this pathology. Data were extracted from the patients' charts and a statistical analysis was performed. RESULTS: One hundred and eighteen patients were admitted during the study period, with an average age of 5.9years. Straddle injuries accounted for 73 % of the injury mechanisms. Most wounds involved the majora and minora labia. Sixty-five patients did not require stitches (55.9 %); 29 patients were examined with Meopa® but 43 % required a more precise surgical exploration in the OR, due to the lack of compliance. Forty-six patients were sutured in the OR. Associated lesions (undiagnosed in the emergency department) were diagnosed during surgical exploration in 13 patients (22 %) with two urethral wounds. Significant wound size differences were observed in 69 % of patients between the pre- and intraoperative assessments. CONCLUSION: Surgical exploration under general anesthesia should be proposed for all unintentional female genital trauma unless the patient is older than 8 and allows complete examination at the emergency department consultation.

[Home falls in infants before walking acquisition]. / Accidents domestiques par chute avant l'âge de la marche.

UNLABELLED: Minor head trauma is frequent among infants and leads to numerous visits to emergency departments for neurological assessment to evaluate the value of cerebral CT scan with the risk for traumatic brain injuries (TBI). OBJECTIVES: To analyze the epidemiological characteristics of nonwalking infants admitted after falling at home and to analyze associated factors for skull fractures and TBI. PATIENTS AND METHODS: Between January 2007 and December 2011, all children aged 9 months or younger and admitted after a home fall to the pediatric emergency unit of a tertiary children's hospital were included. The data collected were age, sex, weight and height, body mass index; geographic origin, referral or direct admission, mode of transportation; month, day and time of admission; causes of the fall, alleged fall height, presence of an eyewitness, type of landing surface; Glasgow Coma Scale (GCS) score, application of the head trauma protocol, location and type of injuries, cerebral CT scan results, length of hospital stay, progression, and neglect or abuse situations. RESULTS: DESCRIPTIVE ANALYSIS: within the study period, 1910 infants were included. Fifty-four percent of children were aged less than 6 months with a slight male prevalence (52%). Falls from parental bed and infant carriers accounted for the most frequent fall circumstances. GCS score on admission was equal to 14 or 15 in 99% of cases. A cerebral CT scan was performed in 34% of children and detected 104 skull fractures and 55 TBI. Infants aged less than 1 month had the highest rate of TBI (8.5%). Eleven percent of patients were hospitalized. A situation of abuse was identified in 51 infants (3%). UNIVARIATE ANALYSIS: Male children and infants aged less than 3 months had a higher risk of skull fractures (P = 0.03 and P = 0.0003, respectively). In the TBI group, children were younger (3.8 ± 2.6 months versus 5.4 ± 2.5 months, P < 0.0001), fell from a higher height (90.2 ± 29.5 cm versus 70.9 ± 28.7 cm, P < 0.0001), were more often admitted on a weekend or day off, and had more skull fractures (54% versus 6%, P < 0.001). MULTIVARIATE ANALYSIS: all variables showing P < 0.2 in the univariate analysis were entered into the model. In the final model, three variables continued to be associated with a risk of TBI: being referred by a physician (OR 4.6 [2.2-9.6], P < 0.0001), being younger than 3 months old (OR 3.1 [1.7-5.7], P = 0.0002), falling from a height greater than 90 cm (OR 3.1 [1.7-5.6], P = 0.0002). COMMENTS: Before walking acquisition, children are particularly vulnerable and have the highest rate of TBI after a vertical fall. In this age group, the rate of abuse is also higher. Given this double risk, numerous cerebral CT scans are performed (35-40% of the target population). This protocol, however, leads to a low proportion of detected TBI (<10%) compared to the high number of CT scans and an additional risk of irradiation. CONCLUSION: As no validated predictive score exists and pending the contribution of the S-100B protein assay, the identification of infants at high risk for TBI and justifying neuroimaging is based on the search for predisposing factors and circumstances.

[Pediatric adder bites]. / Morsures de vipères chez l'enfant.

UNLABELLED: Adder bites and their progression to severe envenomations are more frequent in children than in adults. AIM: To describe the clinical, biological, and therapeutic characteristics of children bitten by adders and to identify risk factors associated with severe envenomations corresponding to grades II and III of the Audebert et al. classification (Toxicon 1992). MATERIAL AND METHODS: A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary children's hospital. The data collected were: age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity based on the Audebert et al. classification; presence of fang marks; prehospital care; use of specific immunotherapy (Viperfav(®)), associated treatments; length of stay; orientation, progression, and any complications. RESULTS: Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years (range, 1.8-15 years). Bites occurred more often between 12:00 pm and 6:00 pm (62%), and were most often located in the lower extremities (77%). The classification of envenomation was: 83% low grade (grade 0, absence of envenomation, fang marks present; grade I, minor envenomation) and 17% high grade (grades II and III, moderate and severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav(®) F(ab')(2) fragments against Vipera aspis, Vipera berus, and Vipera ammodytes). The mean time from bite to Viperfav(®) injection was 23 ± 11 h (range, 8-36 h). Being bitten on the upper extremities (p < 0.001), during the afternoon (p = 0.025), feeling an immediate violent pain (p = 0.037), and high initial glycemia (p = 0.016) were associated with a significant risk of progressing to high-grade envenomation. There was no significant correlation between age, gender, and upper extremity bite. In the final model of the multivariate statistical analysis, three factors remained associated with this risk: bite location in the upper extremities (relative risk [RR] = 60.5 [3.5-1040[; p = 0.005), immediate violent pain (RR = 21.5 [1.3-364.5[; p = 0.03), and female gender (RR = 17.5 [0.9-320.3[; p = 0.053). CONCLUSION: A certain number of criteria seem related with a more significant risk of progression to high-grade envenomation following an adder bite. These results need to be studied on a larger cohort of patients. Bites to the upper extremities should be handled with caution because of the association with more severe envenomation.