A pilot hospital-school educational program to address teen motor vehicle safety.

BACKGROUND: Texting while driving has emerged as a significant distracted driving behavior among teenage drivers. A unique hospital-school collaborative pilot intervention (called "Be in the Zone" or "BITZ") was implemented to combat this growing problem. This intervention was hypothesized to lead to a decline in texting while driving among high school students. METHODS: This collaborative intervention consisted of two separate phases. In Phase 1, small groups of high school student leaders participated in a half-day interactive educational session in a pediatric hospital. Pre- and post-follow-up surveys were administered to this group. In Phase 2, these same students took the lessons they learned from the hospital to plan and implement a yearlong peer-to-peer campaign that focused on a clear "no texting while driving" message at their schools. Two unannounced driver observations were conducted to evaluate the effectiveness of the pilot program. RESULTS: Sixty-one high school students participated in Phase 1. Self-reported texting while driving rates decreased significantly among the participants after Phase 1. Two schools were recruited to participate in Phase 2. Unannounced driver observations were conducted before the campaign and toward the end of the campaign. Postintervention, there was a significant decrease in the percentage of drivers who texted while driving. CONCLUSION: Preliminary results from this pilot program suggest that a strategy of combining hospital-school partnerships with a peer-driven educational approach can be effective in reducing texting while driving among teenagers in the short-term.

Analysis of pediatric all-terrain vehicle trauma data in Middle Tennessee: implications for injury prevention.

BACKGROUND: Trauma registries capture data about injuries that can be used to objectively guide injury prevention initiatives. This article analyzes trauma registry data to describe the nature and distribution of all-terrain vehicle (ATV) injuries in Middle Tennessee. A community injury prevention effort, based on this analysis, is also presented. METHODS: A retrospective analysis of data (2007-2009) from the trauma registry of a Level I pediatric trauma center in Middle Tennessee was conducted. Patients younger than 16 years with ATV-related injuries were included in the analysis (n = 163). The key variables examined were demographics, injury severity, helmet use, injury mechanism, length of stay, and patient's county of residence. In addition, Geographic Information Systems software was used to examine the distribution of injuries and graphically represent counties with highest injury rates in the youth population. RESULTS: ATV injuries were more prevalent among boys than girls (66% vs. 34%; p < 0.001). Approximately 64% of the ATV injuries were in the age group 10 years to 15 years. Most injuries were either moderately severe (44%) or severe (30%). Injury mechanism varied by age; younger children experienced more rollovers while older children tended to be injured from ejections (p < 0.05). Helmet use was low (33%). Data from this study suggest that helmet use resulted in fewer injuries to the head, neck, and face. Counties with high rates of ATV injuries were targeted for ATV training programs. 4-H agents trained by the ATV Safety Institute provided ATV training classes. CONCLUSION: Rural youth are clearly at greater risk for ATV injuries than urban populations. Young ATV riders are often self-taught and lack the knowledge to ride ATVs safely. Organizations such as the 4-H, provide effective injury prevention outreach. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Race disparities in firearm injuries and outcomes among Tennessee children.

PURPOSE: The aim of this study was to identify race and socioeconomic factors associated with worse outcomes among Tennessee children who sustain firearm injuries. METHODS: We queried our institutional pediatric trauma registry and the Davidson County Regional Medical Examiner database for children ages 15 years and younger who sustained firearm injuries between July 1998 and July 2010. Descriptive statistics and logistic regression modeling were used to analyze demographic data, circumstance of injury (unintentional or intentional), odds of death, and characteristics of zip codes (total population, race distribution, and median income) where injuries occurred. RESULTS: One hundred eighty-eight children (median age, 13.2 years; range, 1.1-15.8 years) sustained a firearm injury and were either admitted to our institution or were referred directly to the medical examiner. More whites (n = 109, or 58%) sustained a firearm injury than blacks (n = 79, or 42%), but blacks were overrepresented 2.5-fold more compared with the general Tennessee population. Fifty-four children (29%) died, of whom 35 (65%) were black and 19 (35%) were white (P < .001). Ninety-three children sustained unintentional firearm injuries, and 84 were intentional (n = 67, assault; n = 17, suicide). When data were stratified by intent, 67% of blacks and 12% of whites were assaulted (P < .001). After controlling for age and intent, black children were 4 times more likely to die of firearm injuries than whites (P = .008; 95% confidence interval, 1.4-11.3). CONCLUSION: In a sample of firearm-injured Tennessee children, blacks were notably overrepresented and far more likely to die than whites. Using zip code data will help to establish firearm injury prevention programs specific to disparate populations and to reduce both violent and accidental childhood firearm injuries.

Age variability in pediatric injuries from falls.

OBJECTIVE: The objective of this study is to examine the nature and circumstances surrounding pediatric fall-related injuries for specific age groups and their implications for age-appropriate injury prevention efforts. METHODS: This is a retrospective analysis of data (October 2006 to April 2009) from the trauma registry of a level 1 pediatric trauma center. Inclusion criteria are patients admitted because of fall-related injury younger than 15 years (n = 675). Injury mechanism specifics were obtained from medical records. RESULTS: Falls were the leading cause of admissions and accounted for 37% of all cases during this period. Most pediatric fall-related injuries (73%) occurred between 1 and 9 years of age. Although infants accounted for only 8% of fall injuries, a greater proportion of these children were more severely injured. The mean Injury Severity Score for infants was significantly greater than the overall average (P < .001). Causes of fall injuries vary by age and have been discussed. CONCLUSIONS: The high incidence of pediatric fall injuries warrants dedicated injury prevention education. Injury prevention efforts need to be age appropriate in terms of focus, target audience, and setting. Recommendations for injury prevention are discussed.

Perioperative management of infants undergoing fundoplication and gastrostomy after stage I palliation of hypoplastic left heart syndrome.

Infants with hypoplastic left heart syndrome (HLHS) represent a high-risk population when they present for noncardiac surgery. To assist clinicians in the care of these infants, we present our experience of 36 HLHS patients who underwent abdominal surgery after stage I palliation. We reviewed patients with HLHS who underwent gastrostomy and/or fundoplication after stage I palliation during an 18-month period. We assessed the impact of preoperative echocardiographic predictors and regional anesthesia on use of intraoperative inotropes, extubation in the OR, perioperative instability, postoperative escalation of care, and length of hospital and intensive care unit stay. Of 39 abdominal operations, all but 2 were performed with open laparotomy. There was a positive association between regional anesthesia and instability during induction. Escalation of respiratory care occurred in 9 (23.1%) cases, and escalation of hemodynamic care occurred in 6 (15.4%) cases. Neoaortic valve insufficiency was associated with increased length of stay, and ventricular outflow obstruction was associated with escalation of hemodynamic care. Extubation in the OR was successful in 31 cases (79.5%). In-hospital death occurred in 1 patient (2.7%). HLHS infants often undergo abdominal surgery, but intraoperative instability and need for escalation of care is common. Specific echocardiographic findings were associated with length of stay and escalation of care. Regional anesthesia was associated with transient intraoperative instability but not with other adverse outcomes.

Operative intervention for complete pancreatic transection in children sustaining blunt abdominal trauma: revisiting an organ salvage technique.

Complete pancreatic transection (CPT) in children is managed commonly with distal pancreatectomy (DP). Alternatively, Roux-en-Y distal pancreaticojejunostomy (RYPJ) may be performed to preserve pancreatic tissue. The purpose of this study was to review our experience using either procedure in the management of children sustaining CPT after blunt abdominal trauma. We retrospectively reviewed the records of all children admitted to our institution during the last 15 years who were confirmed at operation to have CPT after blunt mechanisms. Summary statistics of demographic data were performed to describe children receiving either RYPJ or DP. CPT occurred in 28 children: 15 had DP, 10 had RYPJ, and three had cystogastrostomy. RYPJ children, compared with DP, were younger (7.5 vs. 12.3 years, P = 0.039) and sustained more grade IV pancreatic injuries (70% vs. 14%, P = 0.01). DP patients were 5.63 times more likely to tolerate full enteral feeds (P = 0.009). Nevertheless, when controlling for age, injury severity score, and pancreatic injury grade, procedure type did not statistically affect total and postoperative lengths of stay and postoperative complications. In the operative management algorithm of children sustaining CPT, DP may afford an earlier return to full enteral feeds. RYPJ seems otherwise equivalent to DP and preserves significant pancreatic glandular tissue and the spleen.

Management strategies for severe closed head injuries in children.

Brain injuries represent the most common cause of mortality and long-term morbidity from trauma in children. The management of closed head injuries focuses on prevention of secondary injury by optimizing the delivery of oxygen and nutrients to the injured brain while minimizing neuronal metabolic demand. Despite the known differences between the immature and mature brain, treatments used in head-injured children are mainly extrapolated from those employed in adults due to the paucity of class one and two studies focused on the pediatric age group. Therapies intended to minimize secondary brain injury, such as cerebrospinal fluid drainage, hypertonic saline infusion, barbiturate coma induction, brain cooling, and decompressive craniectomy, vary widely in their clinical application among practitioners and trauma centers and have unclear indications, benefits, and long-term consequences. Prospective studies on brain injury management in children are needed to develop treatment strategies that optimize outcomes.

Physiologically focused triage criteria improve utilization of pediatric surgeon-directed trauma teams and reduce costs.

INTRODUCTION: Pediatric surgeon-directed trauma teams (STTs) provide lifesaving treatment but at a high cost. We used physiologically based criteria to improve STT utilization. METHODS: We reviewed 152 consecutive STT activations at one center, comparing standard and physiologically focused criteria and 24-hour hospital costs/charges for overtriaged patients vs level 2 (emergency department managed) blunt trauma patients matched for age, Injury Severity Score (ISS), and necessity for operation. RESULTS: Our cohort (73.0% male; 86.8% blunt; median age, 8.0 [interquartile range, 4.0-14.0] years) had 10 deaths (6.6%) and 18 (11.8%) emergent operations. Twenty-nine patients met neither standard nor physiologic criteria (group 1), 25 met standard but not physiologic criteria (overtriaged, group 2), and 98 met physiologic criteria (group 3). Group 3 had higher median ISS (19.0 [10.0-33.0] vs 10.0 [4.0-17.0] and 5.5 [5.0-16.75] for groups 1 and 2, P = .001), more intensive care unit admissions (67.2% vs 31.0% and 52.0%, P = .001), longer hospitalization (5.0 [3.0-9.25] days vs 3.0 [1.0-5.0] and 4.0 [2.0-5.0] days, P = .002), and all patients who died or required emergent operation (P < .001). Physiologic criteria maintained 100% sensitivity but improved specificity (49.2% vs 23.0%). Overtriaged patients (n = 18) had 78.2% higher charges ($4700; 95% confidence interval, 13.3%-180.1%; P = .013) and 53.4% higher costs ($800; 95% confidence interval, 1.8%-131.2%; P = .041) than level 2 patients (n = 259) after adjusting for age, ISS, and need for operation, largely because of computed tomography and emergency department charges (66% of overtriaged charges). CONCLUSIONS: Physiologic STT activation criteria would have saved 25 activations, $20,000 in costs, and $120,000 in charges annually without compromising patient safety.

Laparoscopic distal pancreatectomy in children: four cases and review of the literature.

INTRODUCTION: Laparoscopy has been utilized for children with pancreatic masses and blunt transection. In this article, we report our technique and experience. OPERATIVE TECHNIQUE: With supine positioning, an umbilical trocar and three 5-mm trocars are positioned across the epigastrium. The gastrocolic ligament is opened completely and the stomach is retracted superiorly. A vessel-sealing electrosurgical device is used to dissect along the inferior margin of the pancreas. Dissection proceeds proximally or distally, depending on the location of the pathology. The proximal pancreatic duct is oversewn or stapled closed. The distal pancreas is mobilized from the splenic vessels. If the vessels cannot be mobilized from the pancreas, they are divided and a laparoscopic splenectomy is performed. The specimen is removed through the umbilical trocar by using a retrieval bag. Drains are placed prior to closure. CASE EXPERIENCE: We report 4 cases: 2 with pseudopapillary tumors and 2 with traumatic injuries. One patient was male; the mean age was 13.0 +/- 1.4 years. Two spleens were removed due to pathology. Mean operative time was 256 +/- 46.6 minutes, with no open conversion or mortality. Patients initiated oral intake 2.0 +/- 1.4 days postoperatively. Hospital stay was 6.2 +/- 3.9 days. One patient required 15 days of total parenteral nutrition to resolve a pancreatic fistula. CONCLUSIONS: Laparoscopic pancreatic resection in children is feasible, safe, and leads to rapid recovery without significant morbidity. The spleen can often be spared, minimizing the risk of overwhelming postsplenectomy sepsis. This initial experience should encourage wider use of laparoscopy for pancreatic resection in children.

Endoscopic ultrasound to guide the combined medical and surgical management of pediatric perianal Crohn's disease.

BACKGROUND: Perianal fistulas are a debilitating manifestation of Crohn's disease (CD) in the pediatric population and present a management challenge. The aims of this study were to describe our experience using endoscopic ultrasound (EUS) to guide management of perianal CD (PCD) in a pediatric population, and determine whether using EUS to monitor healing after seton placement improves outcomes. METHODS: We conducted a retrospective study of 2 cohorts: pediatric subjects with PCD who underwent EUS and pediatric subjects who underwent seton placement between 2002 and 2007. RESULTS: In all, 25 children underwent a total of 42 EUS procedures. Of 28 EUSs performed to evaluate suspected perianal disease, complex fistulizing disease was identified in 15 (54%). Setons were placed after most EUSs demonstrating complex fistulizing disease and after none demonstrating superficial or no fistulizing disease. Of 14 EUSs performed to monitor healing around a seton, 7 (50%) demonstrated persistent peri-seton inflammation. Setons were more often left in place after an EUS revealing persistent inflammation (86% versus 0%), and the patients were more likely to have a biologic initiated or changed (57% versus 0%). Among all subjects who underwent seton placement, time from seton removal to recurrence was longer for those followed by EUS compared to those followed by physical exam only; however, we were not powered to test for statistical significance. CONCLUSIONS: EUS to guide the combined medical and surgical management of PCD is feasible in the pediatric population. Larger prospective studies are needed to determine if EUS-directed management improves outcomes in pediatric patients with PCD.

Suspected appendicitis in children: diagnostic importance of normal abdominopelvic CT findings with nonvisualized appendix.

PURPOSE: To determine whether lack of visualization of the appendix on otherwise normal abdominopelvic computed tomographic (CT) images can help exclude appendicitis in the pediatric population. MATERIALS AND METHODS: The study was institutional review board approved and HIPAA compliant. One thousand one hundred thirty-nine children suspected of having appendicitis were referred for CT examination between July 2002 and December 2006. Exclusion criteria included CT diagnosis of appendicitis or other cause of symptoms and lack of clinical follow-up. Consensus review was performed by two pediatric radiologists to determine normal examinations, leaving a final study group (nonvisualized appendix) of 156 patients (mean age, 9.6 years; boys, 7.2 years; girls, 10.2 years) and a control group (visualized appendix) of 421 patients (mean age, 11.0 years; boys, 9.8 years; girls, 11.2 years). In the control group, there were 168 subjects with a partially visualized (PV) appendix and 253 with a fully visualized (FV) appendix. Pericecal fat was graded according to published criteria. Diagnosis was confirmed at surgery or clinical follow-up. Negative predictive values were calculated with 95% confidence intervals (CIs). RESULTS: There were three false-negative findings (study group, two; control group, one [FV]). The negative predictive value of a normal CT examination in pediatric patients with a nonvisualized appendix was 98.7% (95% CI: 95.5%, 99.8%); that with a visualized appendix, 99.8% (95% CI: 98.7%, 99.99%); that with a PV appendix, 100% (95% CI: 97.8%, 100%); and that with a FV appendix, 99.6% (95% CI: 97.8%, 99.99%). CONCLUSION: Pediatric abdominopelvic CT images with nonvisualized appendix have a high negative predictive value, without significant difference from cases with a PV or even FV appendix. The false-negative rate was similar to those reported in two adult series.

Current management of appendicitis.

Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.

Esophageal foreign bodies in the pediatric population: our first 500 cases.

BACKGROUND: Children with esophageal foreign bodies are frequently seen by pediatric surgeons. Choking and dysphagia are common presentations; however, esophageal perforation has been reported. Historically, rigid esophagoscopy with extraction of the foreign body has been the recommended treatment. Alternatively, Foley balloon extraction is a safe and effective approach. METHODS: Over a 16-year period, 555 children presented with an esophageal foreign body. Retrospective analysis of the medical record was undertaken. Statistics were by univariate analysis. RESULTS: Two hundred ninety-eight boys and 257 girls presented with a mean age of 3.24 years. Dysphagia (37%) and drooling (31%) were the most common symptoms. Foreign bodies were lodged in the superior esophagus in 73%, and 88% of the objects were coins. Balloon extraction with fluoroscopy was performed in 468 children. Eighty percent of the objects were successfully removed with a mean fluoroscopy time of 2.2 min, and 8% were advanced into the stomach. The overall success rate was 88%, with failures necessitating rigid esophagoscopy under general anesthesia. Children younger than 1 year were the most likely to fail (25% failure rate). Airway aspiration never occurred. Significant savings in patient charges were observed with this approach. CONCLUSIONS: Balloon extraction of pediatric esophageal foreign bodies is a safe and cost-effective procedure. This technique is applicable for infants, children, and adolescents. Experienced practitioners should be able to achieve greater than 80% success rate.