Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE

BACKGROUND: Nonoperative management of liver and spleen injury should be achievable for more than 95% of children. Large national studies continue to show that some regions fail to meet these benchmarks. Simultaneously, current guidelines recommend hospitalization for injury grade + 2 (in days). A new treatment algorithm, the ATOMAC guideline, is in clinical use at many centers but has not been prospectively validated. METHODS: A literature review conducted through MEDLINE identified publications after the American Pediatric Surgery Association guidelines using the search terms blunt liver trauma pediatric, blunt spleen trauma pediatric, and blunt abdominal trauma pediatric. Decision points in the new algorithm generated clinical questions, and GRADE [Grading of Recommendations, Assessment, Development, and Evaluations] methodology was used to assess the evidence supporting the guideline. RESULTS: The algorithm generated 27 clinical questions. The algorithm was supported by six 1A recommendations, two 1B recommendations, one 2B recommendation, eight 2C recommendations, and ten 2D recommendations. The 1A recommendations included management based on hemodynamic status rather than grade of injury, support for an abbreviated period of bed rest, transfusion thresholds of 7.0 g/dL, exclusion of peritonitis from a guideline, accounting for local resources and concurrent injuries in the management of children failing to stabilize, as well as the use of a guideline in patients with multiple injuries. The use of more than 40 mL/kg or 4 U of blood to define end points for the guideline, and discharging stable patients before 24 hours received 1B recommendations. CONCLUSION: The original American Pediatric Surgery Association guideline for pediatric blunt solid organ injury was instrumental in improving care, but sufficient evidence now exists for an updated management guideline.(AU)

Shock after blast wave injury is caused by a vagally mediated reflex.

OBJECTIVE: Bomb blast survivors occasionally suffer from profound shock and hypoxemia without signs of external injury. We hypothesize that a vagally mediated reflex such as the pulmonary defensive reflex is the cause of shock from blast wave injury. This study was a prospectively randomized, controlled animal study. METHODS: By using a previously described model of blast wave injury, we randomized rats to one of four groups: control, blast-only, bilateral cervical vagotomy plus atropine 200 microg/kg i.p. only, and bilateral cervical vagotomy plus atropine 200 microg/kg i.p. before blast injury. Cardiopulmonary parameters were recorded for 90 minutes after the blast or until death. RESULTS: Bradycardia, hypotension, and absence of compensatory peripheral vasoconstriction, typically seen in animals subjected to a blast pressure injury, were prevented by bilateral cervical vagotomy and intraperitoneal injection of atropine methyl-bromide. Hypoxia and lung injury were not statistically significant between the blasted groups, suggesting equivalent injury. CONCLUSION: Our data implicate a vagally mediated reflex such as the pulmonary defensive reflex as the cause of shock seen immediately after a blast pressure wave injury.

Treating the snakebitten child in North America: a study of pit viper bites.

BACKGROUND/PURPOSE: Snakebite envenomation is a potentially life-threatening form of trauma, the dangers of which are amplified in children because their smaller size increases the relative dose of venom received. The authors reviewed a large series of snakebitten children to address the medical and fiscal issues of treating these patients. METHODS: The records of 37 snakebitten children (1987 through 1997) were analyzed for demographic data, signs of envenomation, use of specific therapies (antivenin, blood products, or surgery), length of hospitalization, complications, and cost of care. RESULTS: Fifty-four percent of the children had a major envenomation demonstrated by systemic symptomatology, laboratory analysis, or need for surgery. All children made full recoveries with most receiving only supportive care (92%). The average time to emergency department presentation was 8 hours, where all children with major envenomations and those requiring specific therapies (surgery, clotting factors) were identified. Cost analysis showed an average of $2,450 dollars per child with the majority of expenses attributable to length of hospitalization. CONCLUSIONS: Most snakebitten children completely recover with minimal supportive care, and they can be cared for safely and cost effectively as outpatients if no signs of major envenomation are noted within 8 hours of the bite.

Global primary blast injury: a rat model.

Blast wave injury from bombs cause a unique but poorly understood spectrum of injuries. Previous blast wave models involved high energy explosives detonated in an open field without the sophisticated monitoring of laboratory equipment. We characterized a rodent model that produces a global blast injury in a safe laboratory environment. Male rats, prospectively randomized to four groups of ten, were anesthetized and subjected to a blast at 2.0 cm, 2.5 cm, or 3.5 cm from the blast nozzle. The control group received no blast. Intensity of the blast (80-120 psi peak pressure, 1-2 msec duration) was controlled by varying the distance of the blast wave generator to the rat. The rats were monitored for three hours following the blast and then euthanized. Bradycardia was an immediate but transient response to blast injury. Mean arterial pressure was bimodal with severe hypotension occurring immediately after the blast and, again, two to three hours later. The characteristic injuries from a blast wave, such as pulmonary hemorrhage with increased lung weight, intestinal serosal hemorrhage, and hemoperitoneum, were found in the rats subjected to the blast pressure wave. In conclusion, our rodent model accurately reproduces the clinical spectrum of injuries seen in blast victims and will provide a powerful tool for studying the pathophysiology and potential treatments of bomb blast victims.

Extracorporeal life support for nonimmune hydrops fetalis.

BACKGROUND/PURPOSE: Most babies born with idiopathic nonimmune hydrops fetalis (NIHF) suffer generalized cardiopulmonary collapse and die despite maximal medical therapy. With reported survival rates of less than 10%, many centers consider NIHF an unsalvageable situation and the babies who have this condition, untreatable. In this study, the authors questioned if the aggressive use of extracorporeal life support (ECLS) could salvage this condition and improve the chances of survival for babies born with NIHF. METHODS: The Extracorporeal Life Support Organization's (ELSO) neonatal registry was searched for all available information on babies treated for hydrops fetalis. The ELSO records of all hydropic babies were then reviewed to exclude those babies who had identifiable causes of hydrops. Survival statistics were then calculated for the remaining core group of idiopathic NIHF babies before separating them into two groups based on survival. A detailed analysis comparing the survivors with nonsurvivors was then performed. RESULTS: A total of 28 hydropic babies were identified in the ELSO registry. Four babies were excluded from analysis because of identifiable causes of hydrops (two with congenital diaphragmatic hernia, one with Rh incompatibility, and one with fetal anemia). Of the remaining 24 babies who had NIHF, 54% (13 babies) survived the neonatal period and were discharged from the hospital. Analysis comparing the survivors with the nonsurvivors in our study showed that the groups were similar in their gestational ages, birth weights, Apgar scores and the time to initial intubation. The most distinguishing factor of survival in our study was that the survivors, on average, received ECLS support 3 days sooner than nonsurvivors (mean, 17.5 +/- 1.3 hours of life for survivors v 105 +/- 36.6 hours for nonsurvivors, P < or = .05). CONCLUSION: Idiopathic NIHF should no longer be considered an untreatable condition but a new indication for ECLS that, when begun early, may significantly improve the chances of survival for these babies previously considered "unsalvageable."

Cardiopulmonary physiology of primary blast injury.

OBJECTIVE: Bomb blast survivors are occasionally found in profound shock and hypoxic without external signs of injury. We investigated the cardiovascular and pulmonary responses of rats subjected to a blast pressure wave. DESIGN: Prospectively randomized, controlled animal study. MATERIALS AND METHODS: Rats were instrumented and subjected to a blast pressure wave of different intensities from a blast wave generator. Cardiopulmonary parameters were recorded for 3 hours or until death. MEASUREMENTS AND MAIN RESULTS: The cardiovascular response to a blast pressure wave was immediate bradycardia, hypotension, and low cardiac index. Three hours later, the rats developed hypotension, low cardiac index, and low stroke volume. Interestingly, systemic vascular resistance remained unchanged. The pulmonary response was a decreased PaO2 and stable PacO2, suggesting a ventilation-perfusion mismatch from massive pulmonary hemorrhage. CONCLUSIONS: Blast-induced circulatory shock resulted from immediate myocardial depression without a compensatory vasoconstriction. Hypoxia presumably resulted from a ventilation-perfusion mismatch caused by pulmonary hemorrhage.

The spectrum of pediatric injuries after a bomb blast.

The spectrum of pediatric injuries seen after a bomb blast is poorly documented. The pathophysiology of blast injuries differ significantly from other forms of trauma and typically result in large numbers of distinctly patterned injuries. On April 19, 1995, a truck bomb was detonated directly adjacent to the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma. A total of 816 adults and children were injured or killed as a direct result of the blast. Twenty infants and children were seated by the window of the second floor day care center at the time of the explosion. The injuries incurred by all children involved in the blast were studied. Nineteen children, 16 of whom were in the day care center, died as a direct result of the blast. The injury patterns among the 19 dead children included a 90% (17 of 19) incidence of skull fractures, 15 of those with cerebral evisceration (skull capping); 37% with abdominal or thoracic injuries; 31% amputations; 47% arm fractures, 26% leg fractures; 21% burns; and 100% with extensive cutaneous contusions, avulsions, and lacerations. Forty-seven children sustained nonfatal injuries with only seven children requiring hospitalization. The injuries sustained by the seven hospitalized children included two open, depressed skull fractures, with partially extruded brain, two closed head injuries, three arm fractures, one leg fracture, one arterial injury, one splenic injury, five tympanic membrane perforations, three corneal abrasions, and four burn cases (1 > 40% body surface area [BSA]). After a bomb blast, pediatric patients sustain a high incidence of cranial injuries. Fractures and traumatic amputations are common. Intraabdominal and thoracic injuries occur frequently in the deceased but infrequently in survivors.

End-tidal carbon dioxide for monitoring primary closure of gastroschisis.

Previous criteria for primary reduction of the herniated viscera in newborn infants with gastroschisis included intraoperative respiratory rate, cardiac indices, degree of viscero-abdominal disproportion, size of defect, and lower extremity turgor. From 1976 through 1993, 129 neonates with gastroschisis were treated at Children's Hospital of Oklahoma. Intraoperative end-tidal carbon dioxide (ETCO2) monitoring was standard therapy beginning in 1985. The authors evaluated the effect of abdominal closure on ETCO2 to determine if there was a particular ETCO2 level at which closure was not feasible. There was no difference in overall mortality, birth weight, or postoperative ventilation requirements between children who had closure before 1985 (ie, without ETCO2 monitoring) and those who had repair after 1985. However, more cases in the 1985-1993 group had primary closure, and none of these required conversion to a staged procedure. An ETCO2 of > or = 50 suggests that primary closure may be unsafe. These data suggest that infants with gastroschisis can have primary closure based on intraoperative ETCO2 monitoring; no additional invasive monitoring would be necessary to assess closure.

Gastroschisis: a birth defect seen in increasing numbers in Oklahoma?

OBJECTIVE: To identify if an actual increase in children born with gastroschisis is occurring in Oklahoma. To compare findings with historical and current literature concerning the incidence of this congenital malformation of the abdominal wall. DATA: Derived from Children's Hospital of Oklahoma (CHO) medical records, inventory sheets completed by nurses and resident physicians on admission of gastroschisis infants at CHO, hospital records of Tulsa pediatric surgeons (Subramania Jegathesan, MD, and Richard Ranne, MD), and the state health departments of Oklahoma and Iowa. FINDINGS: 1. Increase in number of gastroschisis children born in Oklahoma. 2. Comparable findings in the state of Iowa. 3. No specific maternal or environmental factor to account for increase. CONCLUSIONS: Children born with gastroschisis in Oklahoma and other areas of the country, as well as internationally, have shown an increase in number over the past two decades. This increase cannot be attributed to any one identifiable factor.

Abdominal wall defects in infants. Survival and implications for adult life.

OBJECTIVE: The authors study reviewed patients who underwent operations for omphalocele and gastroschisis to determine survival, morbidity, and long-term quality of life. METHOD: Clinical follow-up of 94 patients cared for with omphalocele and gastroschisis during a 10- to 20-year period after birth. RESULT: Eighty-three patients survived initial treatment. Sixty-one had long-term follow-up. Mean follow-up in the group was 14.2 years. Survival was favorable in the absence of lethal or co-existing major congenital anomalies. Nineteen patients required 31 reoperations, most for abdominal wall hernias and the sequelae of intestinal atresia. Current quality of life was described as favorable (good) in 80% of patients. CONCLUSIONS: Survival rate in patients with abdominal wall defects is favorable and deaths occur substantially in patients with co-existing lethal, or multiple, congenital anomalies. Reoperative surgery is necessary principally in those patients who have postclosure abdominal wall hernias, and in those with bowel atresia at birth. Reoperations are not likely to be necessary after school age. Quality of life in survivors is patient-perceived as entirely satisfactory.

Transseptal decompression of the left heart during ECMO for severe myocarditis.

A 16-month-old boy suffered a cardiac arrest as a result of acute myocarditis, and venoarterial extracorporeal membrane oxygenation was instituted. Twelve hours later, acute left heart distention developed with cessation of left ventricular ejection. Under transesophageal echocardiographic guidance, a long introducer was placed into the left atrium through a transseptal puncture and connected in-line to the venous circuit. Within hours, left ventricular function improved and ejection returned. Left heart decompression was continued for 5 days, and the patient was weaned from extracorporeal membrane oxygenation after 6 days with normal cardiac and neurologic function.

Rapid isotonic fluid resuscitation in pediatric thermal injury.

Intravenous fluid resuscitation within the first 24 hours after a burn is critical to prevent shock and maintain organ function. The Parkland burn resuscitation formula suggests that one half of the first 24-hour fluid requirement be given in the first 8 hours. Results of recent studies in animals suggest that compression of the first half of the initial resuscitation from 8 to 4 hours may have a physiological benefit. We reviewed the medical records of 44 children under 12 years of age who had burns of greater than 29% of total body surface. Twenty-two children received a standard resuscitation of one-half volume given over the first 8 hours, followed by one-half volume over the next 16 hours. Twenty-two children received a rapid isotonic fluid resuscitation of one-half volume over 4 hours or less, followed by the remainder given over 20 hours. Vital signs, urine output, urine specific gravity, blood gases (acidosis), ventilator need, morbidity, and mortality were compared between the two groups. The rapid group had increased normalization of vital signs (P < .001), increased urine output and normalization of urine specific gravity (P < .01), and decreased requirement for ventilator support (P < .05). The authors conclude that rapid isotonic fluid resuscitation is well tolerated by pediatric patients and may be better than the standard burn resuscitation technique.

Dog bites in children.

Dog bites, a common cause of traumatic injury, tend to be a greater source of morbidity and mortality in children than in adults. We evaluated 13 children, who, during a 10-year period, required surgical intervention for dog bites. The greatest cause of morbidity in these children was the penetrating component of the dog bite. Most initial evaluations focused on the crushing component of the bite, but in children with serious dog bites, wounds must be evaluated with respect to both the crushing and penetrating injury components.

Advances in pediatric surgical critical care.

The advances in pediatric intensive care outlined here point out the differences between children and adults that need to be considered when taking care of children with surgical diseases. In the past, advances in pediatric critical care have not kept pace with advances in adult care, but these and other new techniques have rapidly closed this gap in knowledge.

Operative treatment of anterior ectopic anus: the efficacy and influence of age on results.

In our experience, anterior ectopic anus (AEA) is a common cause of constipation in children. We have performed 54 anoplasties for AEA in the past 8 years. Seventy-eight percent of the patients were girls. The average age at surgery was 23.8 months and the average stool frequency prior to surgery was once every 3.2 days. Eighty percent of the children had undergone attempts at medical therapy. We compared the functional results of anoplasty in children by age. The children who had surgery prior to the age of 6 months had a significantly better outcome than did older children. These data suggest that patients with AEA have a better response to operative therapy when anoplasty is performed prior to 6 months of age. Early recognition, referral, and surgery is appropriate therapy in this patient group.

Improvement in catheter sepsis rate in burned children.

Routine frequent central venous catheter (CVC) changes in burned patients (either change in insertion site or change over guidewires) has been advocated to decrease catheter-related sepsis. The need for this management has not been verified for children with burns. We reviewed our pediatric burn population with regard to CVC sepsis rate and individual CVC longevity to confirm this traditional policy. From 1978 to 1988, 70 children admitted to the Children's Hospital of Oklahoma Burn Unit required central venous access. Patients in whom CVCs were changed frequently (FC), (n = 10; no. of CVC, 46) were compared with those in whom CVCs were changed only for mechanical complications or sepsis (NFC), (n = 60; no. of CVC, 74). There were 10 septic CVCs in each group. The difference in mean length of individual CVC use between FC and NFC was significant (4.6 v 17.7 days; P less than .01). The difference in the number of septic CVCs per total number of catheter days in each group was highly significant (FC: 10 CVC/212 d. = 0.05; NFC: 10 CVC/1,112 d = 0.009; P less than .001). This study demonstrates a significant decrease in catheter-related sepsis when CVCs are not changed on a routine frequent basis.

An appropriate negative bronchoscopy rate in suspected foreign body aspiration.

Aspiration of foreign bodies in children can lead to illness and even death if not recognized and treated promptly. Seventy-six patients were referred to our hospital for suspected foreign body aspiration. The following is a retrospective review of their diagnosis and treatment. There was no foreign body found at bronchoscopy in seven patients (9 percent), and there were nine patients (12 percent) with bronchial foreign bodies who had a delay in diagnosis of foreign body aspiration. The delay averaged 35 days. These children, as a result of a prolonged period before diagnosis, were treated unnecessarily for pneumonia and asthma. Once correctly diagnosed, they had a significantly longer hospital stay. We propose that some negative bronchoscopies are necessary in order to prevent the morbidity that occurs from a missed foreign body aspiration.

Effects of naloxone on splanchnic perfusion in hemorrhagic shock.

Endogenous opiate peptides are released in early hemorrhagic shock and may mediate hypotension during hypovolemia. We compared the effects of naloxone alone versus incomplete volume resuscitation on survival and splanchnic blood flow. Dogs were bled to a MAP of 35 mm Hg for 2 hours. In eight dogs, shed blood was returned; eight dogs received naloxone (2 mg/kg bolus and 2 mg/kg/hr in 0.5 ml/kg/hr normal saline) with no shed blood returned. Seven dogs received normal saline alone without shed blood or naloxone and served as untreated controls. Untreated dogs survived a mean of 18.6 minutes. All other dogs survived for 180 minutes. Naloxone and shed blood were equally effective in improving hepatic and renal blood flow; gastric, intestinal, pancreatic, and splenic blood flow remained unchanged from shock values in both groups. These data indicate that in the face of hypovolemia naloxone improves survival and blood flow (ml/min/gm) to splanchnic organs despite no return of shed blood.