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.

Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries.

BACKGROUND: Nonoperative management (NOM) of abdominal solid organ (ASO; liver, spleen, kidney) injuries from blunt trauma in adults has gained acceptance, but multisystem trauma remains a relative contraindication to NOM. METHODS: We reviewed the charts of 126 adult patients who underwent NOM of an ASO injury for success of NOM, transfusions, and complications. Patients were divided into two groups: group I had isolated ASO injuries (n = 48); group II had an ASO injury and at least one additional injury with an Abbreviated Injury Score > or = 2 (n = 78). RESULTS: NOM was successful 89.6% of group I and 93.6% of group II patients (p = 0.55). Group II had higher Injury Severity Scores (20.7 +/- 9.8 vs. 8.3 +/- 4.9 p < 0.05) and transfusion requirements (30.8% vs. 14.6%,p < 0.05) than group I. Complication rates were not different (group I, 20.8% vs. 26.9% group II, p = 0.58). CONCLUSION: NOM of ASO injuries may attempted in adult patients with multiple injuries without increased morbidity.

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 splenic injuries: expansion of the nonoperative theorem.

BACKGROUND/PURPOSE: Delayed complications (hemorrhages, abscesses, and pseudo-aneurysms) of nonoperative management (NOM) in pediatric spleen injuries are rare but reportedly result in failure of NOM. This study was undertaken to elucidate the rate of delayed complications and their impact on NOM of splenic injuries. METHODS: Forty children who underwent NOM of splenic injuries over 5 years were reviewed for complications and success of NOM. All injuries were diagnosed and graded by computed tomography (CT) scans. Follow-up imaging studies were obtained in all children 6 to 12 weeks postinjury; additional scans also were obtained when clinically indicated. RESULTS: NOM was successful in all children, but 3 (7.5%) had delayed complications. A 3 year old with a grade III splenic injury and a distal pancreatic transection, and a 13 year old with a grade IV injury had pseudoaneurysms, which were noted on follow-up CT scan (14 days postinjury). The pseudoaneurysms were treated expectantly and resolved spontaneously. A 16 year old (grade IV injury) had a splenic abscess 8 days postinjury that was drained percutaneously with CT guidance. CONCLUSIONS: Development of delayed complications may not preclude successful NOM of pediatric spleen injuries. Splenic artery pseudoaneurysms in children appear to resolve spontaneously without intervention.

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.

Pediatric blunt carotid injury: a review of the National Pediatric Trauma Registry.

Blunt carotid injury (BCI) is an uncommon yet potentially devastating entity which has received little attention in the pediatric literature. In an attempt to better characterize pediatric BCI, a review of the National Pediatric Trauma Registry was performed. Records were obtained from all children diagnosed with internal or common carotid injury associated with blunt trauma. The incidence of BCI was 0.03% (15 of 57,659 blunt trauma patients). Variables examined included: age, gender, mechanism of injury, associated injuries, various injury severity scores, and outcome. Various injuries were associated with an increase in BCI incidence including chest trauma (4-fold), combined head and chest trauma (6-fold), basilar skull fractures (4-fold), intracranial hemorrhage (6-fold), and clavicle fractures (8-fold). Thirty-three percent of the patients diagnosed with BCI suffered neurological complications directly attributable to their carotid injuries. Current practices regarding screening, diagnosis, and treatment are reviewed.