Emotional considerations and attending involvement ameliorates organ donation in brain dead pediatric trauma victims.

PURPOSE: The purpose of this study was to ascertain a strategy for maximizing parental consent for organ donation in traumatically injured children suffering from brain death. Our hypothesis was that appropriate attending surgeon involvement and delay in evaluating children for brain death leads to an increased percentage of organ donors. METHODS: From January 1993 to August 1999, the records of all children who died in a Level I trauma center were evaluated. Those children suffering brain death that were suitable for organ donation were entered into the study. Cases were reviewed for patient demographics, time to entry into brain death protocol (measured from time of admission), time to parent notification about brain death (measured from time of admission), specific attending involved in the case (with level of involvement), and success of organ donation request. In all, 43 charts were reviewed. RESULTS: Of 43 deaths, 33 were deemed suitable for donation. Age of suitable donors ranged from 1 month to 18 years. In all, 11 attending physicians were involved in the care of these children. Overall, 20 of 33 were organ donors (60%). When the attending surgeon was involved, donation success for organ retrieval was 86%, whereas if the attending was not involved personally, the success rate dropped to 23% (p < 0.04). One senior pediatric surgeon obtained a success rate of 12 of 12 children. It was this surgeon's policy to not initiate brain death protocols in children immediately on entry into the emergency room, but rather to delay initiation until family could be gathered and spend time with the affected child in order that the family could recover from the initial shock of trauma (always at least overnight). When time to initiation of brain death protocol was examined, success was obtained when a delay of 15.5 hours was respected, versus 7.0 hours when donation was requested but denied (p < 0.03). CONCLUSION: These data indicate that attending involvement is important when parents of brain dead children are asked about organ retrieval (p < 0.04). Delay in initiating brain death protocols in order for family members to deal with the shock of the initial trauma appears to increase willingness to participate in organ donation.

Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry.

BACKGROUND: Pediatric trauma centers (PTCs) were developed to improve the survival of injured children, but it is currently unknown if children admitted to PTCs are more likely to survive than those admitted to adult trauma centers (ATCs). METHODS: Fifty-three thousand one hundred thirteen pediatric trauma cases from 22 PTCs and 31 ATCs included in the National Pediatric Trauma Registry were reviewed to evaluate survival rates at PTCs and ATCs. RESULTS: Overall, 1,259 children died. The raw mortality rate was lower at PTCs (1.81% of 32,554 children) than at ATCs (3.88% of 18,368 children). However, patients admitted to ATCs were more severely injured. When Injury Severity Score, Pediatric Trauma Score, mechanism (blunt or penetrating), gender, age, clustering, and American College of Surgeons (ACS) verification status were controlled for using a single logistic regression model, there was no statistically significant difference in survival between PTCs and ATCs (odds ratio, 1.02; 95% confidence interval, 0.83-1.26; p = 0.587). A similar comparison of the 12 ACS-verified trauma centers with the 41 nonverified centers showed verification to be associated with improved survival (odds ratio, 0.75; 95% confidence interval, 0.58-0.97; p = 0.013). CONCLUSION: Although PTCs have higher overall survival rates than ATCs, this difference disappears when the analysis controls for Injury Severity Score, Pediatric Trauma Score, age, mechanism, and ACS verification status. ACS-verified centers have significantly higher survival rates than do unverified centers.

Mandatory admission after isolated mild closed head injury in children: is it necessary?

BACKGROUND/PURPOSE: Children with closed head injuries diagnosed as concussion alone or concussion with brief loss of consciousness are admitted routinely for observation despite a normal central nervous system finding, negative computed tomography (CT) scan, and a Glasgow Coma Score (GCS) of 15. Recent studies have questioned the necessity of such an admission. The purpose of this study was to review a large pediatric database and study the length of stay as well as any required procedures or complications in these children. The hypothesis was that routine admission is unnecessary in this population. METHODS: The National Pediatric Trauma Registry-Phase II was reviewed for the period from October 1988 to January 1996. Entry criteria included age less than 18 and an isolated closed head injury after blunt trauma with an admission GCS of 15. Variables studied included age, gender, mechanism of injury, length of stay, procedures, and outcome. RESULTS: A total of 1,033 children met criteria for this study. The average age was 8.3 years. Males predominated at 61.9%. Falls, sports, and motor vehicle crashes were the most common mechanisms of injury. The average length of stay was 1.19 days, and 60 children were not admitted. A total of 583 children had no procedures performed, whereas 386 received a CT scan, and 148 had x-rays. None required neurosurgical intervention, and all were discharged alive. CONCLUSION: These findings indicate that routine admission may not be necessary for children with isolated mild closed head injuries with a negative CT scan and a normal neurologic finding and allows for a prospective randomized trial to confirm this.

Receptor tyrosine kinase inhibition suppresses growth of pediatric renal tumor cells in vitro.

PURPOSE: Children who undergo standard therapy for renal tumors are at an increased risk for treatment sequelae such as congestive heart failure, abnormal trunk development, and secondary malignancies. Therefore, research on the use of novel chemotherapeutic agents with fewer side effects is justified. Recent experimental evidence suggests that growth factor receptors such as epidermal growth factor receptor (EGFR) and platelet-derived growth factor receptor (PDGFR) play an important role in growth and development of pediatric renal tumors especially that of Wilms' tumor. In this study we investigated the effects of genistein, AG1478, and AG1295, from the class of growth factor receptor tyrosine kinase (GFR-TK) inhibitors, on proliferation and colonigenic growth of 2 pediatric renal tumor cell lines. METHODS: The authors studied the effect of genistein (broad-spectrum GFR-TK inhibitor), AG1478 (EGFR-specific GFR-TK inhibitor), and AG1295 (PDGFR-specific GFR-TK inhibitor) on proliferation and colonigenic growth of rhabdoid tumor of the kidney and Wilms' tumor cell lines: G-401 and SK-NEP-1, respectively. The effect of genistein at concentrations of 0 to 200 micromol/L, and AG1478 and AG1295 at 0 to 10,000 nmol/L were tested on proliferation by using a growth inhibition assay. Viable cell counts at each concentration were obtained by hemocytometer and trypan blue exclusion, and percent growth inhibition was calculated based on control cultures at the same time-point. As a measure of colonigenic survival, the percent inhibition of colony formation in drug-treated dishes was calculated based on the number of colonies (>50 cells) in control dishes. RESULTS: Genistein at concentrations of 25 and 50 micromol/L inhibited the colonigenic growth of G-401 by 37% and 79% (P = .01 and 5E-06, 2-tailed t test, respectively) and that of SK-NEP-1 by 44% and 74% (P = .0001 and 9.9E-07). The mean percent growth inhibition at the above doses was 57% +/- 7.9% and 96% +/- 0.2% for G-401, and 47% +/- 11.2% and 60% +/- 2.7% for SK-NEP-1. AG1478 at concentrations of 1,000 and 5,000 nmol/L inhibited the colonigenic growth of G401 by 75% and 78% (P = .0005 and 7.38E-06, respectively) and that of SK-NEP-1 by 19% and 40% (P = .02 and .0001). The percent growth inhibition at the mentioned concentrations for G-401 were 53% +/- 9.3% and 63% +/- 6.3%, and for SK-NEP-1 were 55% +/- 14.5% and 65% +/- 20.1%, respectively. AG1295 did not appear to be as effective as AG1478. CONCLUSIONS: This is the first experimental study on the use of GFR-TK inhibitors as a potential treatment for pediatric renal tumors. GFR-TK inhibitors such as genistein occur naturally in soybean foods and have been shown to reach therapeutic levels in blood after consuming a soybean-based diet. Considering the significance of growth factor receptor activity in Wilms' tumor development, inhibition of GFR-TKs should be investigated as effective and potentially nontoxic adjunctive treatment for this childhood tumor. Furthermore, GFR-TK inhibitors may offer an effective alternative to the treatment of commonly fatal rhabdoid tumor of the kidney in children.

Changing patterns of treatment for blunt splenic injuries: an 11-year experience in a rural state.

PURPOSE: The aim of this study was to perform a population-based study evaluating the trend in management of pediatric blunt splenic injuries in a rural state and assess differences in the management of those injuries at a level I pediatric trauma center (PTC) and regional hospitals (RH) from 1985 through 1995. METHODS: ICD-9-CM diagnosis and procedure codes for children (age less than 19) discharged from all hospitals in a rural state with splenic injuries from 1985 through 1995 were reviewed. Hospital charges, age, and nonoperative management (NOM) rates were calculated for PTC and RH and compared using chi2 and linear regression. (P < .05 is statistically significant.) Patients were divided into 2 groups; G1, 1985 through 1989 (127 children); G2, 1990 through 1995 (140 children). RESULTS: The overall NOM rate increased from 21% (G1) to 64.2% (G2), P < .001. A total of 114 patients were treated at PTC and 153 patients received care at RH. PTC had a NOM rate of 54.3% versus 35.9% at RH (P = .003). There was no statistical difference in ages or ISS within the groups or between PTC and RH. NOM in RH rose from 7.7% in G1 to 56.9% in G2 (P < .000), and from 35.5% in G1 to 76.9% in G2 (P < .001) for PTC. Hospital charges were lower for patients receiving NOM versus those with surgical treatment of their injury, $8,094 versus $10,862 (P = .018). However, a higher percentage of children were treated at RH than PTC in G2 versus G1 (68.2% v 51.2%, P = .0541). CONCLUSIONS: Over the 10-year period studied, the NOM rate for splenic injuries significantly decreased. This trend was seen at both the PTC and RH, but the PTC maintained a higher rate of NOM. Unfortunately, more children were treated at RH in G2. Educational programs increased NOM in RH but not to a level equal to PTC. These programs had the negative effect of allowing more children to be treated at RH, actually increasing the splenic operation rate for this population.

Complications of intrauterine intervention for treatment of fetal obstructive uropathy.

The intrauterine surgical placement of vesicoamniotic shunts in the treatment of fetal obstructive uropathy associated with prune-belly syndrome to avoid such complications as renal damage and oligohydramnios remains controversial. We present a case of an infant born with prune-belly syndrome at 33 weeks and 5 days of estimated gestational age to a mother of two by vaginal delivery after a pregnancy complicated by fetal obstructive uropathy with attempted intrauterine intervention. After sonographic and laboratory diagnostic and prognostic evaluations, an intrauterine procedure was performed in which a vesicoamniotic shunt was placed under ultrasound guidance. Complications included dislodgment of the initial shunt, with a failed subsequent attempt at placement, oligohydramnios, preterm labor and delivery, and traumatic gastroschisis through the surgical abdominal wall defect. His hospital stay was further complicated by chronic renal insufficiency, prematurity, respiratory distress, bowel malrotation, an episode of gram-negative sepsis with Enterobacter cloacae, signs of liver failure, an exploratory laparotomy for severe enterocolitis, and orchiopexy for bilateral undescended testes. At present, it is unclear whether vesicoamniotic shunt placement can provide any significant improvement in the morbidity or mortality for patients with prune-belly syndrome. A large, prospective, randomized trial is needed to determine its efficacy.

Spinal anesthesia for preterm infants undergoing inguinal hernia repair.

HYPOTHESES: Use of spinal anesthesia is safe and effective in an outpatient population of preterm infants undergoing inguinal hernia repair (IHR) and eliminates routine postoperative hospital admission for apnea monitoring. METHODS: From October 1982 through October 1997, all preterm (gestational age [GA], < or =37 weeks), high-risk (preterm infants whose postconceptual age at surgery [PCAS] is <60 weeks) infants undergoing IHR with spinal anesthesia were studied prospectively. No exclusions were made for preexisting conditions. Elective IHRs and incarcerated hernias were both considered. A postoperative apnea rate was calculated and compared with published postoperative apnea rates in preterm infants after receiving general anesthesia. RESULTS: For 269 IHRs performed, 262 spinal anesthetic placements (97.3%) were successful in 259 infants; 246 placements were achieved on the first attempt and 16 on the second. The mean GA was 32 weeks (GA range, 24-37 weeks); mean PCAS, 43.7 weeks (PCAS range, 33.4-59.3 weeks); and mean birth weight, 1688 g (weight range, 540-3950 g). Two hundred six patients (78.6 %) did not require supplemental anesthesia; 56 (21.4%) did: 34 received intravenous anesthesia; 6, general; 12, local; and 4, other regional. One hundred fifty-three infants had a history of apnea. Thirteen episodes of apnea were noted in 13 infants (4.9%) following the 262 procedures; all 13 were inpatients undergoing concomitant therapy for apnea (mean GA, 28 weeks; PCAS, 42.9 weeks). Four of these infants received supplemental anesthesia. This apnea rate is significantly lower than the published rate (10%-30%) (P = .01). One hundred three infants underwent IHR on an outpatient basis, 39 of whom had a history of apnea. None of these developed apnea postoperatively. The mean birth weight of this group was 2091 g (weight range, 710-3693 g); mean GA, 33 weeks (GA range, 25-37 weeks); and mean PCAS, 44.3 weeks (PCAS range, 35.4-59.2 weeks). All 103 patients were discharged home the day of surgery. Average time from room entry to incision was 26.3 minutes, which is similar to anesthesia induction time for patients receiving general anesthesia. Average time from bandaging to leaving room was 1 minute, less than usual time for patients receiving general anesthesia. CONCLUSIONS: Spinal anesthesia is safe, effective, and eliminates the need for postoperative hospital admission in an outpatient population of preterm infants undergoing IHR. This results in considerable cost savings without compromising quality of care.

Rural trauma: the challenge for the next decade.

Improving the care of trauma patients in a rural environment requires that several important issues be addressed. First, a universal definition of what constitutes "rural" must be established. We propose that a combined effort of the Federal Government and the Committee on Trauma of the American College of Surgeons develop this definition. Second, data on rural trauma demographics and outcome must be collected in a national database. We propose that this database be incorporated in the "TRACS" database of the Committee on Trauma of the American College of Surgeons. Such a database will allow a "needs assessment analysis of existing care in rural environments and facilitate planning and implementation of efficient systems of care. Funding for the rural database should come from the federal government. Finally, increased public awareness of problems unique to rural trauma care is necessary. The rural trauma subcommittee of the ACSCOT should go from an ad hoc committee to a standing committee with the American College of Surgeons Committee on Trauma. We propose a national conference on rural trauma care hosted by the federal government for the purpose of addressing these issues and simultaneously increasing public awareness.

Perforation of the intrathoracic esophagus from blunt trauma in a child: case report and review of the literature.

Rupture of the intrathoracic esophagus from blunt trauma is an exceedingly rare injury in children and often presents on a delayed basis. The authors encountered a case of this unusual injury and review six additional cases found in the literature.

Focused abdominal sonogram for trauma: the learning curve of nonradiologist clinicians in detecting hemoperitoneum.

BACKGROUND: The focused abdominal sonogram for trauma (FAST) has been used by surgeons and emergency physicians (CLIN) to screen reliably for hemoperitoneum after trauma. Despite recommendations for "appropriate training," ranging from 50 to 400 proctored examinations, there are no supporting data. METHODS: We prospectively examined the initial FAST experience of CLIN in detecting hemoperitoneum by using diagnostic peritoneal lavage, computed tomography, and clinical findings as the diagnostic "gold standard." RESULTS: 241 patients had FAST performed by 12 CLIN (average, 20/CLIN; range, 2-43); 51 patients (21.2%) had hemoperitoneum and 17 patients (7.1%) required laparotomy. Initial experience with FAST by CLIN produced 35 true positives, 180 true negatives, 16 false negatives, and 3 false positives; sensitivity, 68%; specificity, 98%. Initial error rate was 17%, which fell to 5% after 10 examinations (chi2; p < 0.05). CONCLUSION: Previous recommendations for the number of proctored examinations for individual nonradiologist clinician sonographers to develop competence are excessive.

Financial aspects of providing trauma care at the extremes of life.

BACKGROUND: Children and the elderly are more likely to be underinsured compared with the general population of trauma patients. We performed financial analysis on all trauma patients admitted during an 18-month period to a Level I adult and pediatric trauma center to evaluate the financial impact of providing trauma care for children and the elderly. METHODS: Patients were categorized by age: PEDI<17 years, GERI>64 years and MID = 17 to 64 years. Reimbursement ratio (RR = reimbursement/cost; RR>1 = profit, RR<1 = loss), length of stay (LOS), and Injury Severity Score (ISS) were calculated for each age group. RESULTS: RR for GERI (RR = 0.99) was significantly lower than for PEDI (RR = 1.15) and MID (RR = 1.16). There was no difference in ISS, but the LOS of GERI was greater than that of PEDI and MID (p<0.05). Cost per patient and LOS were less in PEDI versus MID and GERI (p<0.05). CONCLUSION: Trauma care reimbursement for the elderly is inadequate, whereas pediatric trauma care costs less to deliver and is profitable to the trauma center.

Allogeneic fetal intestinal transplantation with FK506 immunosuppression.

PURPOSE: Small intestinal transplantation remains a significant clinical problem. Allogeneic fetal intestinal (AFI) transplantation shows promise, particularly regarding procurement; however, no studiesto date have evaluated the potential success of true allogeneic loci implantation. The authors hypothesized that isolated segments of AFI could be heterotopically transplanted but would require immunosuppression to survive. METHODS: Donor tissue was obtained from late-gestation Brown Norway rat fetuses with a histo-locus RTN and Fischer fetuses with a histo-locus RT1L. The recipients were adolescent male Fischer rats with a histo-locus RT1L. A 1.2-cm segment of fetal small bowel was implanted in the omentum of the recipient rat and allowed to mature for 5 weeks. Animals were then separated into five groups. Group A served as controls with syngeneic fetal intestinal (SFI) transplant. Group B received AFI with no immunosuppression; group C, AFI transplant with five days of FK506; group D, AFI with 10 days of FK506; and Group E, AFI with daily FK506 for the entire 5-week maturation period. Animals were killed on day 35. RESULTS: All animals gained weight over the maturation period. Groups B, C, and D had no viable transplant segments at day 35. Groups A and E both had well-developed viable segments confirmed by gross and histological evaluation. CONCLUSIONS: FK506 allows for normal intestinal development for use in allogeneic fetal bowel transplantation. With this observation, the use of fetal intestine transplanted into the portal circulation emerges as a potentially viable alternative to present intestinal transplant models.

Evaluation of alpine skiing and snowboarding injury in a northeastern state.

BACKGROUND: To demonstrate the injury patterns of Alpine skiing and snowboarding in a northeastern state and evaluate potential risk factors. METHODS: The medical records of a single pediatric and adult Level I trauma center were evaluated from January 1, 1990, through December 31, 1995. All admissions with injuries caused by Alpine skiing or snowboarding were reviewed. Those patients arriving from two local ski resorts, all of whose injuries are referred to the institution for care, were separated out for consideration. Age, sex, type of injury, date of injury, Injury Severity Score, operations performed, and outcome (including mortality) were evaluated. In addition, resort utilization for the study period was obtained from the two resorts included in the evaluation. Mortality data was obtained from the Vermont office of the Chief Medical Examiner for the same time period. RESULTS: For the 6-year period of the study approximately 2,978,000 skier and snowboarder days were recorded at the study sites. Approximately 447,000 of those days were attributed to snowboarders (15%). In all, 279 patients were admitted for injuries (0.01%), 238 were related to Alpine skiing (incidence 0.01%) and 40 to snowboarding (incidence 0.01%). Snowboarders were statistically younger (20 years; range, 4-44 years) than skiers (29 years; range, 6-70 years) (p < 0.001) and had a significantly lower Injury Severity Score (15 in snowboarders vs. 27 in skiers, p < 0.03). Two female patients were injured snowboarding and 68 female patients were injured skiing. Eight percent of injured snowboarders and 16% of injured skiers sustained multiple injuries (p < 0.01). Injury patterns were significantly different. Upper extremity injuries were almost exclusively found in snowboarders (24% vs. 7%, p < 0.003), whereas cruciate ligament injuries occurred far more commonly in skiers (45% vs. 4%, p < 0.001 Lower extremity injuries in general were more common in skiers (78% vs. 38%, p < 0.001). Central nervous system injuries, including head and spine, were evenly distributed over the two groups, although the snowboarders with central nervous system injuries were younger. In addition, splenic injuries were more common in snowboarders (13% vs. 2%, p < 0.01). Snowboarding accidents were far more common in December, March, and April than other months. Fifty-one patients sustained abdominal or chest injuries and only two of these required operative intervention (two splenectomies). Other operative interventions were limited to extremity injuries, injuries of the spine, or placement of an intracranial pressure monitor. There were no fatalities recorded in this population, although over the 6.5 years, there were 25 deaths related to alpine skiing and one to snowboarding in the State (incidence 0.0000009 skier days). Victims tended to be male: 96% of the skiers and the one snowboarder. The predominant cause of death was blunt head trauma followed by blunt chest trauma. Helmets were not worn by those sustaining head injuries or fatalities. Spine injuries were recorded only in extremely young snowboarders and skiers out of control. CONCLUSION: Snowboarders and Alpine skiers are equally prone to injury. Snowboarding accidents are typically less severe and show significantly different injury patterns than skiing accidents. Abdominal and chest injuries in this population are generally amenable to nonoperative management. Prevention programs are best targeted at safe skiing and snowboarding practices, not skiing or snowboarding in poor conditions, use of helmets for skiers, and restraint of snowboard use in very young children.

Conservative management of pancreatic trauma in children.

Many adults and most children with a solid-organ abdominal injury can be managed nonoperatively. To date, however, little is known about the outcome of nonoperative management of pancreatic injury. To analyze current treatment patterns of pancreatic injury in children, all children (age < 19 years) identified in the National Pediatric Trauma Registry (49,540 patients) and admitted to two level I pediatric trauma centers with a diagnosis of injury to the pancreas (International Classification of Disease-9 codes 863.81-863.84 and 863.91-863.94) were reviewed. Over a 7-year period, 154 children were identified with pancreatic injury. Thirty-one (20%) sustained severe injuries (grades III, IV, or V) and 123 (80%) sustained lower-grade injuries (grades I and II). Sixteen (52%) of the children sustaining grades III, IV, or V injury required pancreatic procedures (9 distal resections, 3 simple repairs, 2 enteric anastomoses, 2 others). Only 26 (21%) of the grades I and II injuries required surgical intervention specific to the pancreas (11 resections, 9 catheter drainage of pseudocysts, 2 enteric anastomoses, 4 others). Ninety-seven (79%) grades I and II injuries were successfully managed conservatively. Overall, 15 (10%) children required drainage procedures for pseudocyst. The frequency of operative intervention decreased during the last 4 years of the study (18 vs. 26%, p > 0.05), coinciding with a decrease in the frequency of drainage procedures for pseudocysts. The need for surgical intervention was not influenced by age, Injury Severity Score, or Pediatric Trauma Score (p > 0.05). Associated abdominal injuries were common but did not influence operations on the pancreas (p > 0.05). No deaths were attributed to the pancreatic injury. These data indicate that early intervention for pancreatic injury, in the absence of clinical deterioration or major ductal injury (grades III, IV, or V), is unwarranted, and careful observation may supplant the conventional surgical therapy recommended for adults.

Graft length affects outcome in fetal small bowel transplants.

Multiple studies have demonstrated the ability of the fetal rat small intestine to be transplanted successfully as a free graft, devoid of its mesentery. While maintaining normal histologic architecture, portal circulation, and digestive and absorptive properties, the initial myeloelectric activity is delayed. The purpose of this study was to investigate how abnormal early motility affects functional outcome and survival. Using a syngeneic model, fetal rat small intestine segments were transplanted into adolescent rat recipients as free grafts into the omentum. After a maturation period, viable segments measuring 1 or 2 cm were placed into continuity with the native intestine after a standardized resection of either jejunum-ileum, ileum-cecum, or cecum. Control animals had native intestinal resection without graft interposition. Survival, daily weight gain, oral intake, and fecal output were monitored. In this model, overall survival was improved with the use of the shorter 1-cm graft segment compared with the 2-cm and more distal interpositions. No animals survived with proximal graft placement after jejunal-ileal resection. Nutrient use was improved in the transplant recipients compared with nontransplant controls but did not differ between the two graft lengths. These data suggest that outcome in this model is improved using shorter fetal intestine graft lengths. The use of multiple segments in multistaged procedures and early defunctionalization may improve results.

Associated head injury should not prevent nonoperative management of spleen or liver injury in children.

The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.

Penetrating hepatic trauma in children: operating room or not?

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.

Management of complicated appendicitis. A rational approach based on clinical course.

OBJECTIVE: To better define the appropriate management of children with complicated appendicitis, using an outcome approach based on clinical parameters. DESIGN: Retrospective study. SETTING: A 500-bed tertiary care university-based hospital. PATIENTS: Fifty-six consecutively admitted children (age <19 years) with a diagnosis of complicated appendicitis (gangrenous or perforated) confirmed at laparotomy. INTERVENTION: All children were managed postoperatively using an institutionally established protocol requiring hospitalization and broad-spectrum intravenous antibiotics until three criteria were met permitting discharge: (1) resolution of fever for 24 hours; (2) normalization of white blood cell count; and (3) normal results of clinical examination. MAIN OUTCOME MEASURES: Length of stay, costs, and infectious complications. RESULTS: Overall, infectious complications occurred in only two patients (3.5%). No complications occurred in any patient who met the criteria for discharge. The average length of stay for all patients was 5.1+/-3.0 days (range, 3 to 18 days). Using this approach instead of current standards reported in the literature resulted in an estimated savings of over $4000 per patient and $224000 for the entire cohort. CONCLUSIONS: Postoperative management of complicated appendicitis can be safely based on a defined clinical algorithm that should replace empirical therapy as the "gold standard."

Continuous thoracic epidural infusions for postoperative analgesia after pectus deformity repair.

PURPOSE: To determine whether continuous epidural analgesia after repair of a pectus deformity is a viable and safe alternative to high-dose narcotics in children. METHODS: Data were collected prospectively for 19 children (4 to 17 years of age; 15 boys, 4 girls) who underwent pectus excavatum (14) or carinatum (5) repair between June 1, 1991 and July 1, 1994. Seventeen had a thoracic epidural catheter placed for postoperative pain control and two did not. The epidural catheter was routinely plead preoperatively by the anesthesiologist at the T3-T8 level, after induction of general anesthesia. Epidural catheters were test-dosed with local anesthesia alone or in combination with fentanyl, and afterward a continuous epidural infusion was maintained on the floor. Postoperative pain was assessed by nursing and house staff on the Wong-Baker scale, with adjustment of the dose rate or analgesic medication as appropriate. RESULTS: All patients had extubation before leaving the operating room and were sent to the general pediatrics ward after leaving the recovery room. The average duration of the epidural was 69 hours (range, 20 to 116 hours). Sixteen patients received their test epidural dose preoperatively, and one patient had his in the recovery room. Fifteen epidural initially were dosed with bupivicaine (1 to 2 mg/kg) alone or in combination with fentanyl (1 to 2 micrograms/kg). Two patients received initial doses of lidocaine (1 to 1.5 micrograms/kg). Ten of 17 patients received fentanyl (1 microgram/kg/h) with bupivicaine (0.5 to 1.0 mg/kg/h) in the epidural as their maintenance medication, and the remainder received bupivicaine alone at the same dosage rate. Eight of 17 patients required additional intermittent supplemental narcotics, with an average of two doses of intravenous morphine per day (0.1 mg/kg) over the first 3 postoperative days. In contrast, the two patients who did not have an epidural catheter for pain control required high-dose intravenous morphine (0.2 mg/kg) every 2 to 3 hours for the first 3 to 4 postoperative days. No catheter-related complications occurred. CONCLUSION: Thoracic epidural analgesia was completely successful in nine (53%) children who underwent repair of pectus deformity, and effectively reduced the intravenous narcotic demand in the other eight. Pain control was excellent, and no catheter-related complications were encountered. The data show that this method of analgesia in children is a safe and attractive alternative to intravenous narcotics, and eliminates the potential disadvantages of sedation and respiratory compromise.

Epidemiology of rural traumatic death in children: a population-based study.

To determine the epidemiology of traumatic death in pediatric patients in a rural state, we reviewed all deaths caused by injury in victims < 19 years old between 1985 and 1990. We hypothesized that mortality would be higher than equivalent populations in urban areas. During the study period, 5,322 children were hospitalized for trauma (14% of total admissions for children in the state) and 36 died (0.67%). For this subgroup, head injury was the most common cause of death (72%). When compared with data from the National Pediatric Trauma Registry from urban centers, the mortality rate for hospitalized children in this rural state was lower (0.67% vs. 2.7%, p < 0.001). On review of the population-based statistics for the entire state, we found that these numbers were deceivingly low. In all, 731 children died during the study period, of which 283 were determined by autopsy or coroner's report to have died of trauma (38.7%). Eighty-seven percent of children who died never reached the hospital. Mortality (age-adjusted) was highest in the 15- to 18-year-olds (68.5 of 100,000), then < 1-year-old (26.8 of 100,000), 1- to 5-year-olds (15.6 of 100,000), and 5- to 14-year-olds (11.8 of 100,000), which significantly exceeds the predicted national averages for these age groups.(ABSTRACT TRUNCATED AT 250 WORDS)