The rural-urban continuum: variability in statewide serious firearm injuries in children and adolescents.

OBJECTIVE: To compare rates of serious firearm injuries among children and adolescents treated in a statewide trauma system. MATERIALS AND METHODS: We reviewed the Pennsylvania Trauma Systems Foundation (Mechanicsburg) registry from January 1, 1987, through December 31, 2000, for all pediatric and adolescent patients (age 0-19 years) who sustained a serious firearm injury. Data included age, sex, weapon, geographic region, injury circumstance, and outcome. RESULTS: During the 14-year period, 3781 children and adolescents sustained a serious firearm injury and were treated at a participating Pennsylvania trauma center. The population was 90.7% male, with a mean age of 16.5 years. Adolescents (age 15-19 years) represented more than 85% of the study population. There were 744 deaths (19.7%). The urban counties had an average annual population-based rate of serious firearm injury of 28.3/100 000; suburban counties, 2.8/100 000; metropolitan counties, 2.4/100 000; and nonmetropolitan counties, 2.4/100 000. Urban counties had a higher rate for all injury circumstances (unintentional, assault, and self-inflicted) than all nonurban counties. Assault was the most common overall injury circumstance (78.7%), and was the most common circumstance in urban counties (88.5%) and among adolescents (age 15-19 years [84.2 %]). Unintentional injuries predominated in nonmetropolitan counties (56.7%) and in young children (aged <5 years [50.6%] and 5-9 years [61.4%]). Handguns were the most common weapon type in all age groups, geographic regions, and injury circumstances. CONCLUSIONS: Rates of serious firearm injuries among children and adolescents are 10-fold higher in urban than nonurban regions. Assaultive injury mechanisms predominated in urban areas, unintentional injuries in the nonurban counties. Firearm injury statistics are heavily influenced by events in the urban counties. Intervention and prevention strategies need to account for these regional discordances to optimize efficacy.

Practical points in evaluation and resuscitation of the injured child.

The ultimate goal of resuscitation of an injured child is delivery of oxygen to intracellular organelles in order to maintain aerobic metabolism. This can be obtained by following ATLS protocols with immediate attention to the "ABCDE's" and compulsive reevaluation of the adequacy of resuscitation maneuvers. After stabilization, seriously injured children should be transferred to trauma centers with established pediatric trauma programs utilizing preexisting transfer agreements and protocols. Pediatric trauma is indeed a team endeavor, requiring the coordinated expertise and teamwork of prehospital EMS providers, trauma team members, and the pediatric trauma and rehabilitation centers. With careful and compulsive communication and coordination, injured children can be returned to their families in better mental and physical condition than pre-injury with reasonable expectation of a full and productive life.

Peliosis hepatis in a child with myotubular myopathy: successful treatment using hepatic artery embolization.

Peliosis hepatis (PH) is a rare condition characterized by multiple blood-filled spaces within the hepatic parenchyma that can lead to fatal hemorrhage. There is no consensus on the best treatment algorithm for PH, and therapy is directed at removing the potential causative agent with operative intervention when necessary. Here we present the first known case of PH in a child with myotubular myopathy who was successfully treated with angiography and hepatic artery embolization as a first line therapy, without the need for operative intervention. Awareness of this condition and the available treatment modalities may lead to favorable outcomes in future cases.

Trends in operative management of pediatric splenic injury in a regional trauma system.

OBJECTIVE: Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade. METHODS: The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00-865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type. RESULTS: From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0-6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4-8.7) for level 1 trauma centers, 6.3 (5.3-7.4) for level 2 trauma centers, and 5.0 (4.2-5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity. CONCLUSIONS: The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.

Nonoperative management of blunt extrahepatic biliary duct transection in the pediatric patient: case report and review of the literature.

An 11-year-old boy sustained a grade IV liver injury and complete disruption of the left hepatic duct (LHD) secondary to a sledding accident. Although he became hemodynamically stable after initial resuscitation in the emergency department and the intensive care unit (ICU), serial paracentesis procedures were necessary to manage abdominal compartment syndrome (ACS). The fluid initially was serosanguinous but subsequently became bile stained. A bile leak was confirmed by a technetium 99m dimethyliminodiacetic acid (HIDA) scan and an endoscopic retrograde cholangiogram (ERCP). The LHD transection was treated with percutaneous drainage of the subhepatic space and a transampullary biliary stent. The leak sealed within 8 days, and follow-up ERCP as an outpatient showed no extravasation but could not visualize the LHD. Repeat computed tomography (CT) scan 3(1/2) months after injury showed the liver laceration to be healed with atrophy of the left lobe and no ductal dilatation. The patient has had a complete recovery, resumed all activities, and currently is 20 months after his injury with no sequelae.

Nonintracranial fatal firearm injuries in children: implications for treatment.

BACKGROUND: Understanding the injury characteristics of nonintracranial fatal (NIF) gunshot wounds in children treated in a statewide trauma system will help guide effective treatment strategies. METHODS: This study was a retrospective analysis of children fatally injured with firearms. The review included demographic information, firearm injury characteristics, and outcome. The setting included trauma centers participating in a statewide trauma registry. Patients were all children (age < 18 years) treated in trauma centers for NIF gunshot wounds from January 1988 through December 2000. The main outcome measures were characteristics of fatal firearm injuries in children. RESULTS: Over the 13-year period, there were 1,954 children with firearm injuries including 368 (18.8%) children with fatal wounds. Of the fatally wounded children, 177 (48.1%) had no intracranial injury. The NIF injury population was 90.4% male, with a mean age of 14.9 years (range, <1-17 years) and an Injury Severity Score of 38.2 (range, 9-75). Over 95% of deaths in this group occurred within 24 hours of admission. Although injuries to the thorax were most common (78.5%), 48.6% of the NIF cohort had injuries to multiple body regions, including 31% with injuries in both the abdomen and thorax. Compared with all children wounded by firearms, NIF firearm injury patients had, on average, more body regions injured (1.6 vs. 1.1, p < 0.001) and a greater total number of injuries (6.0 vs. 3.5, p < 0.001). Patients with an NIF injury were more likely to suffer a major vascular injury (54.8% vs. 13.8%, p < 0.001), lung injury (56.5% vs. 12.9%, p < 0.001), or cardiac injury (44.6% vs. 4.6%, p < 0.001) than all children with a firearm injury. CONCLUSION: Most children who arrive at trauma centers alive and subsequently die from NIF firearm injuries do so rapidly from major vascular and thoracic injury. Almost half of these children have injuries to multiple body regions, further complicating management. Innovative, aggressive treatment approaches should be sought to improve survival in this extremely injured cohort of children.

Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients.

BACKGROUND: Nonoperative management of radiographically defined solid organ injuries has proven highly successful in children with blunt splenic and hepatic injuries. The role of nonoperative management protocols is less well defined for blunt renal injuries. The purpose of this study was to review the management and outcome of a consecutive series of children with blunt renal injury. METHODS: The trauma registry from a Level I pediatric trauma center was reviewed to identify all children (age < 19 years) who were treated for a blunt renal injury for the period January 1995 through December 2002. Demographic, anatomic, physiologic, management, and outcome data were analyzed. RESULTS: For the 8 years of review, 101 children with a blunt renal injury were identified, including 95 with accessible and complete data. The renal injury population had a mean age of 10.4 years (range, 0.5-18 years) and was 72.6% male. The renal injuries were distributed as follows: grade 1, n = 22; grade 2, n = 40; grade 3, n = 20; grade 4, n = 11; and grade 5, n = 2. Hematuria was present in 88.1% of children (in whom urinalysis results were available). Four children had underlying congenital renal anomalies. The mean hospital length of stay and intensive care unit stay were 6.0 and 2.6 days, respectively. Overall, 5 children (5.3%) required laparotomy, including 1 nephrectomy (isolated grade 4 injury) and 1 renorrhaphy, for an overall renal salvage rate of 98.9%. In children with isolated renal injuries (n = 48), one child (2.1%) required laparotomy. Seven children required adjunctive urologic procedures (ureteral stenting, n = 5; cystoscopy/cystogram, n = 2). There were seven deaths (7.4% overall; five because of head injury and two because of severe abdominal bleeding at presentation). CONCLUSION: A nonoperative management strategy was advantageous and successful in pediatric blunt renal injuries (94.7% successful nonoperative rate, 98.9% renal salvage rate). Adjunctive urologic procedures (e.g., ureteral stenting) were beneficial in selected cases.

The significance of contrast blush on computed tomography in children with splenic injuries.

PURPOSE: Most children and adults with blunt splenic injuries are treated nonoperatively by well-established management protocols. The "blush sign" is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the "blush sign" as an indication for embolization or surgical intervention. This study was designed to evaluate the implications of the "blush sign" in children with blunt splenic injuries. METHODS: A review was performed of all children with blunt splenic injuries treated between January 1996 and December 2001 at a level I pediatric trauma center using an established solid organ injury protocol. The demographic, CT imaging, and outcome data were recorded. Treatment was categorized as operative or nonoperative. A single pediatric radiologist retrospectively reviewed all available CT scans to confirm injury grade and the presence or absence of a "blush sign." RESULTS: There were 133 eligible children admitted with blunt splenic trauma, with a mean age of 9.1 years (range, 1 to 15), including 86 children with an abdominal CT available for review. A "blush sign" on initial CT scan was noted in 6 children, all with grade 3 or above splenic injuries, 5 of who were treated nonoperatively. In this series, the single child with a "blush sign" who did not respond to nonoperative treatment had a severe polytrauma requiring urgent splenectomy and left nephrectomy. None of the children died of their splenic injury. CONCLUSIONS: Although associated with higher grades of injury, the blush sign did not mandate embolization or surgical intervention in children with blunt splenic trauma in this series. Severe splenic injuries with a blush sign on the initial CT scan may be successfully treated nonoperatively when using an established treatment protocol. Management should be based primarily on physiological response to injury rather than the radiologic features of the injury.

The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures.

BACKGROUND: Computed tomographic (CT) scanning is sensitive in detecting pelvic fractures in the pediatric patient. Pelvic fractures in the pediatric population rarely require emergent intervention, thus providing time to obtain the optimal imaging study. The objective of this study was to compare pelvic radiographs and abdominal pelvic CT scans of all pediatric trauma patients with pelvic injury to determine the role of pelvic imaging in the immediate trauma resuscitation. METHODS: A retrospective review was performed of pediatric patients (age < 18 years) with a pelvic fracture identified from the registry of a Level I pediatric trauma center for the period 1993 to 2001. Patients with a documented pelvic injury and both a pelvic CT scan and pelvic radiograph available for review were extracted for analysis. For this study, all films were re-reviewed by an attending pediatric radiologist, and the abnormalities were categorized by the area of injury. The data were comparatively analyzed according to the area of injury and the soft tissue findings. RESULTS: For the 8-year period, 130 pediatric patients with a pelvic fracture were identified, including 103 patients with both a pelvic CT scan and radiographs. Of the 151 fractures identified by pelvic CT scan, 81 were also identified by the pelvic radiograph (54%). There were 38 soft tissue hematomas noted by pelvic CT scan and only 2 identified by the pelvic radiograph. The greatest discrepancy was noted in comparison of the sacral region (16 abnormal pelvic CT scans vs. 3 abnormal radiographs); the least discrepancy was noted in the evaluation of the hip (6 abnormal pelvic CT scans vs. 5 abnormal radiographs). CONCLUSION: The pelvic radiograph lacked the sensitivity of the pelvic CT scan for detecting pelvic fractures in all anatomic areas evaluated. Pelvic CT scan also offers additional information regarding soft tissue injury not available on most pelvic radiographs. In the trauma patient that will undergo abdominopelvic CT scanning as part of the trauma evaluation, a pelvic radiograph may be superfluous. Screening pelvic radiography should be reserved for the rare unstable patient or the patient in whom an abdominopelvic CT scan is not otherwise indicated.

Pattern of abdominal free fluid following isolated blunt spleen or liver injury in the pediatric patient.

BACKGROUND: This study correlated isolated, blunt liver or spleen injury with the presence, location, and amount of free fluid in the pediatric blunt trauma patient. METHODS: The hospital trauma registry was reviewed for the period 1/89 to 12/99 for pediatric patients (age < or = 17 years) who sustained blunt, isolated spleen or liver injury and had an abdominal CT scan. Patients with other intraabdominal injuries or inadequate scans were excluded. CT scans were reviewed by two radiologists and the isolated liver or spleen injury confirmed and graded. The presence, location, and amount of free fluid were evaluated in the RUQ, LUQ, and pelvis. Free fluid was quantified as 0 = no fluid, 1 = small amount, 2 = moderate, and 3 = large for each area. RESULTS: There were 134 pediatric patients with an isolated spleen (n = 66) or liver (n = 68) injury. Free fluid was noted in 101 patients (75%), more commonly with spleen (82%) than with liver (69%) injuries. As injury grade increased, so did frequency of patients with free fluid (grade 1 = 50% to grade 5 = 100%) and mean total volume (sum of fluid scores from each region) of free fluid (grade 1 = 0.75 to grade 5 = 6.5). The mean total volume of free fluid was greater for splenic injury (3.1) than for liver injury (1.7). The pelvis was the most common location for free fluid (liver 53%, spleen 71%) and had the greatest mean volume of free fluid (liver 0.9, spleen 1.5) of any single region. CONCLUSION: There is a direct correlation between the severity of the isolated injury and the likelihood and volume of associated free fluid. The pelvis was the most common location to detect free fluid and had the greatest estimated fluid volume.

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children.

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.

Successful management of concommitant blunt injury to the trachea, esophagus, and cervical spine in a 6-year-old girl.

A 6-year-old girl sustained an unusual constellation of injuries after blunt trauma sustained in a motor vehicle accident. Transection of the trachea and esophagus were managed successfully by repair through a median sternotomy while the patient was on cardiopulmonary bypass. A cervical spinal injury was fixated with halo traction and a femur fracture with internal fixation.

Management of penetrating colon and rectal injuries in the pediatric patient.

PURPOSE: Management of civilian penetrating colon injuries in the adult has evolved from the universal use of fecal diversion to the highly selective use of colostomy. We hypothesized that a similar management approach was appropriate for the pediatric population. METHODS: A retrospective review of pediatric patients (age <17 years) with a penetrating colorectal injury was performed at six Level I trauma centers for the period January 1990 through June 2001. RESULTS: For the period of review, 53 children with a penetrating colorectal injury were identified. Firearms caused 89 percent of the injuries. The colon was injured in 83 percent (n = 44) of patients and the rectum in 17 percent (n = 9) of patients. The colorectal injury was managed without colostomy in 62 percent (n = 33) and with colostomy in 38 percent (colon = 11, rectum = 9). All rectal injuries were treated with colostomy. The hospital length of stay was longer in the colostomy group (17.6 days vs. 11.4 days). The complication rate was higher in the colostomy group (55 percent vs. 27 percent), which included two patients with stoma-related complications. There was no mortality in this series. CONCLUSIONS: Primary repair was used safely in most cases of civilian penetrating colon injuries in the pediatric population. All rectal injuries were treated with colostomy in this series. Fecal diversion was used selectively. Colostomy was performed for selected cases of colon wounds associated with shock, multiple blood transfusions, multiple other injuries, extensive contamination, and high-velocity weapons. In the absence of these associated factors, primary repair appears justified.