Adult Tourniquet for Use in School-Age Emergencies.

BACKGROUND: Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population. The Pediatric Trauma Society supports the use of tourniquets for exsanguinating hemorrhage in severe extremity trauma. The Combat Application Tourniquet (CAT) used with success in adults has not been prospectively tested in children. Our objective with this study was to determine if the CAT is successful in arresting extremity arterial blood flow in school-aged children. METHODS: Sixty school-aged volunteers (ages 6-16 years) recruited by age cohort had the CAT applied to an upper arm and thigh while peripheral pulse was monitored by Doppler. The number of windlass turns (maximum allowed: 3 [1080°]) required to arrest arterial pulse was recorded. Success was analyzed by BMI percentile for age and extremity circumference. RESULTS: The CAT was successful in occluding arterial blood flow as detected by Doppler pulse in all 60 (100%) of the upper extremities tested. In the lower extremity, 56 (93%) had successful occlusion. The 3-turn maximum allowed by the protocol was not adequate in some obese, older subjects (BMI >30). In both the upper and lower extremity, the number of turns required to occlude blood flow gradually increased with an increase in arm and thigh circumference. CONCLUSIONS: Prospective testing of a cohort of school-aged children 6 to 16 years revealed the CAT tourniquet to be suitable for use in both the upper and lower extremity.

Patterns of satellite tagged hen harrier disappearances suggest widespread illegal killing on British grouse moors.

Identifying patterns of wildlife crime is a major conservation challenge. Here, we test whether deaths or disappearances of a protected species, the hen harrier, are associated with grouse moors, which are areas managed for the production of red grouse for recreational shooting. Using data from 58 satellite tracked hen harriers, we show high rates of unexpected tag failure and low first year survival compared to other harrier populations. The likelihood of harriers dying or disappearing increased as their use of grouse moors increased. Similarly, at the landscape scale, satellite fixes from the last week of life were distributed disproportionately on grouse moors in comparison to the overall use of such areas. This pattern was also apparent in protected areas in northern England. We conclude that hen harriers in Britain suffer elevated levels of mortality on grouse moors, which is most likely the result of illegal killing.

The pediatric trauma center and the inclusive trauma system: Impact on splenectomy rates.

BACKGROUND: Before 2006, the Delaware Trauma System (DTS) did not include a designated pediatric trauma center (PTC). In 2006, the Delaware Trauma System designated and the American College of Surgeons Committee on Trauma verification/consultation program verified Nemours AI DuPont Hospital for Children, a freestanding children's hospital, as a PTC. We evaluated the impact of the addition of the PTC to the state trauma system on pediatric traumatic splenectomy rates. METHODS: The study cohort comprised DTS trauma registry recorded children younger than 16 years with spleen injury (ICD-9 codes 865.0-865.9) from January 1998 through December 2012. This cohort was categorized into pre-PTC (1998-2005) and post-PTC (2006-2012) groups. Penetrating injuries were excluded. Comparisons between groups included age, gender, length of stay, organ-specific injury grade, Injury Severity Score, incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1-3) and high grade (OIS score, 4-5) were also compared. Pearson's χ analysis was performed for categorical variables. Continuous variables were reported as mean (standard deviation) and compared by Student's t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p < 0.05 was considered significant. RESULTS: Of the 231 pediatric spleen injuries, 118 occurred pre-PTC and 113 occurred post-PTC. There were no significant differences in age, gender, length of stay, Injury Severity Score, OIS grade, or incidence of polytrauma. Splenectomy rates decreased from 11% (13 of 118) pre-PTC to 2.7% (3 of 113) post-PTC (p = 0.012). CONCLUSION: The addition of an American College of Surgeons-verified PTC within an inclusive trauma system that was previously without one was associated with a significant reduction in the rate of blunt trauma-related splenectomy. Integration of a verified PTC is an influential factor in achieving spleen preservation rates equivalent to published American Pediatric Surgery Association benchmarks within a trauma system. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III.

Pilot study using an Internet-based program in informed consent.

PURPOSE: To examine the effect of an internet-based aid to informed consent on parent recall of potential surgical complications. METHODS: Parents of children scheduled for elective inguinal hernia repair were assigned to a control group or were enrolled in an internet-based program designed to aid in the consent process. Nine potential surgical complications were presented to the parent(s) in the consent discussion and in the Internet program. Parent recall of potential surgical complications was assessed immediately after the consent discussion and on the day of surgery. RESULTS: Overall recall of complications was poor in both groups, both immediately and on the day of surgery. Parents in the control group (n = 13) recalled a mean of 2.9 complications immediately and 1.5 on the day of surgery, approaching statistical significance (P = .056). The parents in the internet program group (n = 17) recalled a mean of 2.6 complications immediately and 2.9 on the day of surgery (P = NS). There was no significant difference in immediate recall between the two groups, but there was a trend towards statistically significant improvement in recall in the study group the day of surgery vs. controls (P = .06). CONCLUSION: Although overall recall of potential surgical complications was poor in both groups, there was a trend towards a significant improvement in recall in the study group after viewing the Internet-based program.

Conservative therapy of esophageal perforation with neck abscess in a child.

Conservative management of complicated esophageal perforations has gained favor in recent years. However, there are limited data concerning the applicability of this approach in the pediatric population. We describe the care and outcome of a 14-year-old girl who sustained an esophageal perforation after accidental ingestion of a shard of glass. The patient was treated using ultrasound-guided drainage catheter placement with simultaneous esophagoscopy and postoperative antibiotics. She was discharged within 1 week of presentation and enjoyed an uncomplicated recovery. We believe that selected cases of pediatric esophageal perforation may be safely and effectively treated using a conservative approach.

Gastric volvulus after laparoscopic Nissen fundoplication with gastrostomy.

The authors present the case report of a 13-year-old boy in whom organoaxial gastric volvulus developed four months after a laparoscopic Nissen fundoplication and placement of gastrostomy. Intraoperative findings were significant for volvulus about an axis defined by 2 fixation points, one at the fundoplication site and the other in the area of the gastrostomy tube, positioned close to the pylorus. Of the 142 pediatric cases of gastric volvulus reported to date, only 7 describe it as a complication subsequent to gastric surgery, and just one case has been reported after laparoscopic Nissen fundoplication. This case shows that fundoplication and gastrostomy, a recommended treatment for gastric volvulus, does not always preclude its development. Increasing numbers of pediatric surgeons are performing laparoscopic Nissen fundoplication procedures. The authors advise surgeons to consider this potentially fatal complication, both intraoperatively when selecting a location for gastrostomy and postoperatively when evaluating complaints.

Intraoperative ultrasound reduces ECMO catheter malposition requiring surgical correction.

BACKGROUND/PURPOSE: One hundred ninety-three cannulation procedures for extracorporeal membrane oxygenation (ECMO) have been performed at the authors' institution from 1994 to now. Before 1996, their practice had been to position these catheters exclusively by clinical assessment and chest radiograph. Since then, the authors have utilized intraoperative ultrasound guidance during cannulation procedures to confirm proper tip position. This retrospective analysis was undertaken to establish whether this practice has reduced the rate of surgical repositioning of ECMO catheters in these patients. METHODS: A retrospective chart review was performed for all infants who underwent ECMO cannulation procedures at the authors' institution. Numbers of infants requiring surgery to readjust ECMO catheter position were totaled. Cases were categorized according to the presence or absence of intraoperative ultrasound scan. Statistical significance was determined using X(2) analysis, Student's t test, or analysis of variance where appropriate. RESULTS: There were 193 ECMO cannulations performed. Of the 101 procedures done without ultrasound scan, 18 necessitated surgical repositioning. In contrast, only 3 of the 92 catheters placed with ultrasound assistance required reoperation. This represents a reduction the rate of repositioning from 17.8% to 3.3% of cannulations (P =.003). CONCLUSIONS: Based on these findings, the authors advocate the use of intraoperative ultrasound imaging to optimize the position of ECMO catheters. This high rate of initial success helps avoid the potential morbidity of ECMO circuit malfunction, repeat neck dissection, and catheter manipulation in these critically ill, anticoagulated patients.