Prehospital classification combined with an in-hospital trauma radio system response reduces cost and duration of evaluation of the injured patient.

BACKGROUND: This study was undertaken to determine whether a prehospital trauma classification system (PHTCS) in combination with an in-hospital trauma radio system response (IHTRSR) impacts emergency care of the injured patient. METHODS: In 1991 our trauma center used no prehospital trauma classification system. A PHTCS was implemented in 1992, and in 1993 the PHTCS was integrated with an IHTRSR: RESULTS: Implementation of the PHTCS and IHTRSR resulted in a significant reduction in the time required for initial evaluation of the trauma patient with an associated reduction in cost. Reduction in time of the initial trauma evaluation was noted in both adult and pediatric populations, in patients with a blunt mechanism of injury, and in the injured patients posing the greatest strain to health care resources. CONCLUSIONS: Integration of a PHTCS with an IHTRSR has a significant impact on the cost and time of emergency treatment of the trauma victim with no adverse effect on patient outcome. Use of an integrated trauma response provides cost-effective and expeditious care of the injured patient and should be considered in trauma system development.

Effect of very delayed repair of congenital diaphragmatic hernia on survival and extracorporeal life support use.

BACKGROUND: Since November 1992, operative repair in neonates with congenital diaphragmatic hernia (CDH) at this institution was delayed until respiratory insufficiency had resolved. METHODS: A retrospective analysis was performed (n = 33) comparing delayed repair with our previously reported institutional experience with immediate repair from January 1988 to October 1992 (n = 66). Infants with severe genetic defects or moribund conditions or who were premature were not considered candidates for repair or extracorporeal life support (ECLS), but they were included in the survival analysis. Survival was defined as hospital discharge. Data were compared with an independent t test or Pearson chi-squared test. RESULTS: Mean age at repair was 8.9 +/- 4.5 days (range, 3 to 20 days). Eleven infants in the study group were placed on ECLS (33% versus 68% in the comparison group; p = 0.001). Six of these infants survived (55% versus 58% in the comparison group; p = 0.846). Of these survivors, one patient was repaired while on ECLS, and the remainder underwent repair after decannulation from ECLS. All 20 of the remaining candidates for repair survived without need for ECLS. Overall survival was 79% versus 56% in the comparison group (p = 0.027). CONCLUSIONS: Our current data suggest that very delayed repair of newborns with CDHs is associated with an increase in the overall survival and a decrease in the use of ECLS when compared with previous experience at this institution.

A second look at delayed splenic rupture.

From 1968 to 1976, 314 patients were treated by splenectomy for blunt splenic injuries. Three hundred four of these were operated on within 24 hours. All had typical splenic lacerations with intraperitoneal bleeding from the time of injury. This was true also of seven of the ten operated on after 24 hours. In only three of this late group was the evidence in favor of possible delayed rupture of a subcapsular hematoma. These data support our conclusion that delayed rupture is an unusual sequel to blunt splenic trauma, and that most patients thought to have delayed rupture of the spleen have, instead, delayed recognition of splenic rupture.

Hepatic pathology as a determinant of prognosis after portal decompression.

The status of 124 patients who had liver biopsies and underwent portal decompression was analyzed and correlated with certain clinical features and hepatic histologic findings. Child risk class, the urgency of operation, the presence of many Mallory bodies, the presence of cirrhosis and the cause of portal hypertension as determined histologically were found to correlate with prognosis. The estimate of hepatic reserve by Child risk class system and the presence of many Mallory bodies were found to have an independent predictive value. The observed differences in prognosis determined by other factors may be accounted for by variations in hepatic reserve. The presence of few or many Mallory bodies appears to be a contraindication to urgent operative portal decompression because of an exceedingly high mortality rate. In addition, the presence of many Mallory bodies regardless of Child class appears to correlate with a poor diagnosis. Since Mallory bodies may occur in all Child risk classes, preoperative liver biopsy is recommended whenever feasible to better define the actual operative risk of any portal decompressive procedure.

Special problems in management of pediatric trauma.

Until recently, concern over the care of the trauma victim has largely involved the adult population; although 7% of emergency calls are for the pediatric patient, insufficient attention has been paid to the care of these children. This article concentrates on those unique problems encountered in the management of pediatric trauma in prehospital and hospital settings.

Congenital biliary dilatation: a spectrum of disease detailed by ultrasound.

Recently we have examined six children with the diagnosis of choledochal cyst who demonstrate a greater spectrum of biliary involvement than expected. Classically choledochal cysts have been divided into types and subtypes based on the configuration of common bile duct dilatation; however, this simplified information is misleading since surgical management is dependent on the exact extent of intrahepatic and extrahepatic biliary abnormalities. The pre-operative ultrasound examination must be meticulous to provide enough pertinent anatomic details. Much of the intrahepatic anatomy is not visualized at surgery nor on the operative cholangiograms where reflux of contrast into the intrahepatic ducts may not be consistently achieved.

Surgical management of ambiguous genitalia in the infant and child.

Proper gender assignment to a neonate born with ambiguous genitalia is a social emergency of the newborn period. Once an appropriate sex assignment has been made, the next critical step is performance, if needed, of a reconstructive procedure in a timely fashion. In an attempt to evaluate our experience with this unique group of patients, we have retrospectively reviewed the course of 69 children with ambiguous genitalia managed surgically at this institution between 1974 and 1989. This series consists of 32 genotypic females with congenital adrenal hyperplasia (CAH), 10 children with mixed gonadal dysgenesis (MGD), 10 male pseudohermaphrodites, 3 true hermaphrodites, 8 genotypic females with urogenital sinus anomalies (UGS), and 6 genotypic males with bilateral undescended testes and penoscrotal hypospadius. All newborns initially seen at this institution received proper sex assignment within the first week of life. Prior to 1980, 17 of the children with CAH underwent clitorectomy and vaginoplasty and three underwent clitoral recession and vaginoplasty. After 1980, 10 patients with CAH were managed with clitoral recession and vaginoplasty and 2 with vaginoplasty alone. Eight of 10 cases of MGD were given a female sex assignment and all 8 underwent gonadectomy due to the high risk of gonadoblastoma; the other 2 children were raised as males. There were 3 true hermaphrodites of which 2 were assigned female gender roles and were managed with a clitoral recession and vaginoplasty. All 10 male pseudohermaphrodites were raised as females and all underwent bilateral orchidectomy. The 8 children with UGS were raised as females and underwent vaginal reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic diagnosis and excision of Meckel's diverticulum.

Meckel's diverticulum is one of the primary concerns in the differential diagnosis of the pediatric patient with massive, acute gastrointestinal bleeding, intussusception, or abdominal pain of uncertain cause. The hospital course of two children with Meckel's diverticulum, successfully treated by laparoscopic excision, is presented, along with details of the operative procedure. Both patients recovered from the procedure without incident and were discharged at 24 and 48 hours after surgery. The authors believe a laparoscopic approach is safe and effective in the diagnosis and treatment of Meckel's diverticulum.

Achalasia in children: treatment by anterior esophageal myotomy (modified Heller operation).

Although rare in children, achalasia can be the cause of debilitating symptoms and growth retardation. During a 4-year period, six patients (mean age 9.9 years) underwent a modified Heller operation (anterior esophageal myotomy) without complication. A concomitant modified Belsey fundoplication was performed in three patients who were judged at the time of operation to be at high risk for postoperative gastroesophageal reflux. Preoperative symptoms of dysphagia, postprandial vomiting, retrosternal pain, and pulmonary complications were eliminated in all patients. Follow-up interviews seven to 48 months (mean 23 months) following operation revealed normal diet and normal growth in all six children, with no recurrence of preoperative symptoms or evidence of gastroesophageal reflux. Technical details which we believe contribute to success in the operative management of pediatric achalasia include the transthoracic approach and the selective performance of complementary anti-reflux procedures.

Trauma scores, accident deformity codes, and car restraints in children.

The importance and effectiveness of the appropriate use of automobile restraints by young children has been emphasized in several studies. Once the child has entered the emergency care system, however, restraint use may not be the best predictor of injury severity. This study was undertaken to investigate the relationship of restraint status to morbidity and mortality in children examined in a hospital emergency facility following involvement in a motor vehicle crash (MVC). The emergency room charts of 101 children under 18 years of age, who were victims of MVCs, were reviewed and the following trauma scores were calculated: Glascow Coma Scale, Pediatric Trauma Score, Revised Trauma Score, Injury Severity Score, and Maximum Abbreviated Injury Score. In addition, the Traffic Accident Damage (TAD) score, an estimate of crash severity determined by the police at the accident scene, was recorded. The patients were age stratified as follows: 0 to 4 years (n = 24), 5 to 11 years (n = 29), and 12 to 17 years (n = 48). Fifty patients were appropriately restrained at the time of the crash. There was a significant correlation between mean trauma scores and mean TAD codes (P < .05). There were no significant differences in mean trauma scores between improperly restrained (n = 11) and unrestrained (n = 40) children (P > .05) across all age groups, and these children were grouped together as "unrestrained" in further analyses.(ABSTRACT TRUNCATED AT 250 WORDS)

Resolution of splenic injury after nonoperative management.

Numerous studies have demonstrated success with nonoperative management of splenic injuries in pediatric patients. However, the resolution of the splenic injury has not been previously evaluated. The records of 50 pediatric patients with splenic injuries from blunt trauma treated nonoperatively between 1984 to 1992 were reviewed retrospectively. Abdominal computed tomography (CT) was performed at the time of injury and 6 weeks postinjury in 25 patients. These scans were reviewed and categorized by a modification of a previously reported grading system for parenchymal injury. All patients had healing of the splenic injuries, with complete resolution of the healing process observed at 6 weeks postinjury in 44%. Even those with shattered spleens (n = 6) had consistent improvement in splenic architecture, with resolution of fractures and/or contusions and return of splenic perfusion. Ten (77%) of 13 grade 1 and 2 injuries were completely resolved by the 6-week follow-up examination, whereas only one (8%) of 12 grade 3 to 5 injuries showed radiological resolution of splenic injuries. None of the 25 follow-up CT scans affected clinical decision-making or led to a deviation from the established protocol, which included a 3-month period of reduced activity. All 50 patients did well, without evidence of morbidity, mortality, or complications after return to full activity 3 months postinjury.(ABSTRACT TRUNCATED AT 250 WORDS)

A modified technique for small-bowel transplantation in the rat.

The rat model for small-bowel transplantation is becoming increasingly popular. The currently accepted microsurgical technique, however, is complicated by extensive dissection in the donor rat vascular system requiring a great deal of manipulation of the vessels themselves, with consequent complications of thrombosis and vascular injury. We describe a procedure for small-bowel transplantation in the rat that simplifies the currently accepted technique. The peripheral portion of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) is used as the vascular pedicle of the segment of bowel to be transplanted rather than the SMA with an aortic cuff and the portal vein as previously described. The SMA and SMV are anastomosed to recipient aorta and inferior vena cava respectively. The bowel extremities are exteriorized, thus leaving access to the lumen for further studies. All anastomoses are performed with interrupted 10-0 nylon sutures. The procedure was performed in 11 animals. Good revascularization of the transplant was defined as immediate filling of the transplant vasculature with normal (pink) appearing bowel. Eight of the recipients had excellent revascularization. Venous occlusion was the cause of early failure in the remaining three animals. All animals were killed, autopsies performed, and the anastomoses examined. The longest survivors were killed at 7 months. Biopsies were obtained immediately and at daily intervals. Early ultrastructural changes of rejection in the transplanted bowel were studied by electron microscopy. Changes in the microvasculature were seen early after transplantation. Immunologic changes were apparent only later in the course of rejection. We conclude that this technique is successful in achieving functional small-bowel transplants in the rat.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluid resuscitation in live Escherichia coli shock in puppies.

The infusion of live E. coli in the puppy produces a severe and usually lethal model of pediatric septic shock with characteristic reduction in cardiac output and blood pressure. Hemodynamic abnormalities are partially reversed with fluid resuscitation alone, and large volumes, supplemented with albumin well within tolerated fluid loads, produce the most pronounced corrections of these derrangements. Certain metabolic changes appear to be unique to the young animal and their correction is less successful regardless of resuscitation regimen. These findings suggest that the initial fluid management of the bacteremic pediatric patient should include Ringer's lactate and 5% albumin at approximately 105% of patient's blood volume. Further resuscitation fluid, as well as the role of steroids and antibiotics, remain work currently being carried out in our laboratory.

The development of necrotizing enterocolitis following repair of gastroschisis: a surprisingly high incidence.

We recently observed the development of necrotizing enterocolitis (NEC) in two consecutive newborn infants after gastroschisis repair. Because this association was unexpected, a retrospective review of our 11-year experience was performed using a multivariant computer analysis. The cohort consisted of 54 newborns with gastroschisis. All infants with omphalocele were excluded. Ten of 54 infants (18.5%) developed NEC as defined by classical clinical findings and pneumatosis intestinalis. Twenty-one distinct episodes of NEC occurred with up to three episodes (mean, 2.1) per patient. Twenty of the 21 episodes were successfully treated nonoperatively. Two infants developed pneumoperitoneum, one of whom underwent laparotomy upon which no perforation or intestinal infarction was found. Eight of the ten patients survived--a survival rate no different than for the remainder of the study group. Neither of the two deaths was attributable to NEC. The NEC was atypical in that no significant relationship was established with known predisposing conditions such as prematurity or low Apgar scores. Suspected risk factors such as time of feeding, type of closure, type of formula, total parenteral nutrition (TPN), and composition of TPN were not statistically related. Significant associations included concurrent TPN associated cholestatic liver disease in nine of the ten infants, antecedent intestinal surgery other than abdominal wall closure in five of the ten infants, and delay in initiation of enteral feedings (greater than 30 days) in eight of ten infants. In addition, the NEC occurred significantly later (range, 32 to 79 days; mean, 52 days) in the clinical course than usual; in fact, three of ten infants were rehospitalized with NEC following discharge. We conclude that a relationship exists between NEC and gastroschisis.(ABSTRACT TRUNCATED AT 250 WORDS)

Prenatal diagnosis of congenital cystic adenomatoid malformation and its postnatal presentation, surgical indications, and natural history.

BACKGROUND/PURPOSE: Regression of a cystic adenomatoid malformation (CAM) in a fetus is well described. Little, however, is known about the postnatal course of these infants. This study attempts to correlate the prenatal course of CAMs with postnatal symptoms, radiological manifestations, and need for surgery. METHODS: The clinical course of patients with a CAM diagnosed prenatally were retrospectively reviewed. Inclusion in the study required a prenatal ultrasound scan documenting a CAM. RESULTS: Over 10 years, 14 patients with a CAM were diagnosed prenatally. Six (43%) showed a partial in utero regression. Four patients were symptomatic at birth and underwent a resection as newborns. Ten patients were asymptomatic at birth, and eight of these had normal chest x-rays. Elective resection has been performed in 3 of these 10, and two additional children are scheduled to undergo an excision near 1 year of age. The remaining five patients have undergone follow-up nonoperatively for a mean of 36 +/- 15 months. Of the seven asymptomatic patients not undergoing immediate surgery, only one has shown a slight postnatal regression, despite five of these showing regression in utero. None have become symptomatic. CONCLUSIONS: The results suggest that regression of a CAM on prenatal ultrasound scan is common, but this process does not continue after birth. A normal chest x-ray does not indicate complete regression of a CAM; a computed tomography (CT) scan is required to evaluate such patients, and will generally demonstrate a CAM. Asymptomatic patients with a CAM may be followed up nonoperatively with no apparent adverse effects. The decision and timing of an excision in an asymptomatic patient remains controversial among pediatric surgeons.

The lateral approach for open splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) has been used increasingly to treat children with hematologic disorders and has been reported to have advantages over open splenectomy performed through a standard vertical or subcostal incision. The authors perform open splenectomy (OS) through a lateral, muscle-splitting approach, and believe their approach is more reasonable in comparison with LS. METHODS: Thirty-nine consecutive open splenectomies performed between 1991 and 1995 were reviewed retrospectively and compared with recent reports of LS. The series included 24 boys and 15 girls with an average age of 9 years and average weight of 37.5 kg. Indications included immune thrombocytopenic purpura (n = 20), hereditary spherocytosis (n = 18), and sickle cell anemia (n = 1). The operation was performed with the child in the lateral decubitus position through a left upper abdominal muscle-splitting incision (off the 11th rib), sparing the rectus muscle. RESULTS: All 39 cases were completed without intraoperative complications with an average surgical time of 98.0 minutes (range, 30 to 302). The average surgical blood loss was 89 mL (range, 10 to 300). The children started feeding an average of 1.2 days (range, 0 to 4) postoperatively, were on a regular diet at an average of 2.0 days (range, 1 to 6) postoperatively, and had an average length of stay of 2.7 days (range, 1 to 6). There was no mortality or morbidity. CONCLUSIONS: Open lateral splenectomy is performed with shorter surgical times, less blood loss, an excellent cosmetic result, no complications, and a length of stay comparable to any of the published series on laparoscopic splenectomy in children. This approach provides a reasonable basis for comparison with laparoscopic splenectomy.

Malrotation in patients with duodenal atresia: a true association or an expected finding on postoperative upper gastrointestinal barium study?

We retrospectively reviewed the imaging and surgical findings in 17 patients with duodenal atresia to determine (a) the frequency of coexistent malrotation in patients with duodenal atresia and (b) the reliability of the upper gastrointestinal barium study (UGI) in differentiating malrotation from postoperative deformity of the duodenal sweep after repair of duodenal atresia. Postoperatively, 9 (53%) of the 17 patients had UGI findings consistent with malrotation. Of these nine, only two had malrotation coexistent with duodenal atresia, while the other seven had normal midgut rotation demonstrated intraoperatively. The radiographic appearance of malrotation was simulated in two patients in whom the ligament of Treitz had been surgically divided, in three in whom the ligament had not been taken down, and in two in whom the status of the ligament was not specified in the surgical report. Although there is an association between duodenal atresia and malrotation, this cannot be accurately documented on postoperative UGI examination. Malrotation cannot be detected preoperatively because contrast material cannot pass beyond the level of the atresia. Postoperatively, surgical deformity of the duodenal sweep cannot be reliably distinguished from malrotation.

A randomized, controlled trial of parenteral clindamycin in neonatal necrotizing enterocolitis.

For an assessment of the efficacy of clindamycin in preventing bowel necrosis (intestinal gangrene or perforation), 42 premature infants with radiographically confirmed necrotizing enterocolitis (NEC) (pneumatosis, intraportal gas, or both) were randomly assigned to receive parenterally either ampicillin and gentamicin (control group, n = 22) or ampicillin, gentamicin, and clindamycin (n = 20), 20 mg/kg/d at 8-hour intervals for 10 to 14 days. Infants who had received antibiotics for greater than 24 hours before randomization and those developing intestinal gangrene or perforation less than 12 hours after randomization were excluded. Intestinal gangrene or perforation developed in four infants in the control group and six in the clindamycin group. Four in each group died of NEC. In the control group, one of 18 survivors developed a late stricture requiring surgical resection, whereas six of 15 survivors in the clindamycin group developed such strictures (P = 0.022). Routine inclusion of clindamycin in medical treatment of NEC does not reduce the frequency of intestinal gangrene or perforation and may be associated with an increase in late stricture formation.

A ten-year experience with ninety-two cases of Hirschsprung's disease. Including sixty-seven consecutive endorectal pull-through procedures.

From July 1974 through November 1984, 92 patients with Hirschsprung's disease (congenital aganglionosis) have been treated at the University of Michigan-Mott Children's Hospital. This series includes 67 consecutive modified endorectal pull-through (ERPT) procedures in children. Fifty-one of these 67 patients had standard rectosigmoid disease and underwent a successful ERPT with only two major complications. One of these 51 children underwent a successful ERPT but died in the late postoperative period from severe congenital heart disease. Eighteen of the 92 patients suffered from total aganglionosis or long-segment disease. Sixteen of these have undergone an ERPT with no mortality or operative morbidity. The follow-up ranges from 6 months to 10 years. All of the children who have reached 3 years of age are continent. Of the remaining 23 patients, 12 were referred following an unsuccessful pull-through at another hospital. The 12 operations included five Swenson pull-throughs, five Duhamel procedures, one ERPT, and one subtotal colectomy. It was possible to redo or revise the pull-through procedures successfully in all but one patient, who required a permanent colostomy. Finally, 11 children were referred for management of a variety of complications following pull-through procedures performed at other institutions. None of these 11 patients required a reperformance of their pull-through, and all were successfully treated with lesser surgical procedures or with medical management. The excellent functional results and the low morbidity and zero operative mortality are attributed to the technical ease of performing the modified ERPT.

Gastric perforation following cardiopulmonary resuscitation in a child: report of a case and review of the literature.

We report a case of gastric rupture complicating cardiopulmonary resuscitation in a 13 year old. The tear occurred on the lesser curvature of the stomach as in reported adult cases. A tear was not discovered until autopsy, despite extensive premortem investigation. In a comatose or paralyzed patient, laparotomy may be indicated in the evaluation of pneumoperitoneum following cardiopulmonary resuscitation.