The child with multiple injuries.

Information specific to the rapid resuscitation of pediatric patients is detailed and treatment of injury to specific systems, including the chest, abdomen, urinary tract, and diaphragm and esophagus, is described.

Radioisotope diagnosis of splenic trauma.

Multiple injury or delay in seeking medical attention may prevent confident clinical diagnosis of splenic trauma. The spleen scan is a rapid, simple, noninvasive test useful in such circumstances. When peritoneal lavage is contraindicated, unrevealing, or inapproapriate, radioisotope imaging of the spleen can help confirm a suspicion of splenic injury.

The "window" orchidopexy for prevention of testicular torsion.

Torsion of the testicle is often due to the "bell-clapper" deformity. This deformity is frequently bilateral. Prevention of future episodes of torsion depends upon the creation of a broad area of dense adhesion between the tunica albuginea and the scrotal wall. The results of this study indicate that this may be best accomplished by creating a window in the tunical vaginalis so that during healing a broad area of the tunica albuginea is held in apposition to a raw surface devoid of tunica vaginalis. Simply suturing the testical to the wall of the hemiscrotum does not always result in permanent fixation.

Teaching initial management of shock in children.

Common errors in managing shock in children are failure to recognize shock, failure to recognize continuing blood loss, and inadequate replacement due to lack of familiarity with the normal blood volume of children. For practical purposes, the normal blood volume of every child is considered to be 40 ml/lb (88 ml/kg). In hypovolemic shock the blood volume is reduced by at least one fourth. For initial management, an intravenous line is established, blood is drawn for cross matching, and 10 ml/lb (22 ml/kg) of Ringer's lactate solution is administered as rapidly as possible. If this bolus, which represents one fourth of the normal blood volume, brings the blood pressure to normal, only maintenance fluid is then administered. If the child remains hypotensive, a second bolus of 10 ml/lb (22 ml/kg) is administered rapidly. Children who require a second bolus of Ringer's lactate solution nearly always need blood transfusion also. Many have occult bleeding, usually in the abdomen. If intra-abdominal bleeding is thought to be possible but not definitely present, paracentesis using an angiocath is performed. If no blood returns, 10 ml/lb (22 ml/kg) of saline is instilled and the return considered significant if more than slightly pink.

Pediatric arterial injuries.

Forty-three children were treated for peripheral arterial injuries. Single injuries of the radial, ulnar, anterior or posterior tibial arteries with good collateral supply were best treated by ligation. Injuries about the elbow or knee, associated with fractures, carried the highest morbidity. Early arteriography, prompt exploration in doubtful cases, and a high level of expertise are essential for good results in these two areas.

Multiple lymphangioendothelioma of the spleen in a 13-year-old girl.

A 13-year-old girl had a history of an upper-quadrant abdominal mass for about six months. On exploratory laparotomy, multiple discrete large nodules were seen in the spleen. Histologically, the spleen had the unusual appearance of lymphangioma, in that there was a tremendous proliferatiion of endothelial cells that formed either papillary projections in the lumina of the cavernous lymphatic vessels or a solid mass of cells without the lumina. The changes were suggestive of sarcomatous transformation, but the evidence was not conclusive. A term "lymphangioendothelioma" is proposed for this multinodular tumor.

Renal injuries.

Renal injuries due to nonpenetrating trauma are common in children. Pre-existing renal abnormalities are found in 10 per cent of children who sustain kidney injuries. Associated injuries are found in approximately 40 per cent of childhood cases. The most common serious injuries are those to the brain and the spleen. A renal injury should be suspected in every child with flank tenderness and red blood cells in the urine. If the child is unconscious, gross or microscopic hematuria may be the only clue. The amount of blood in the urine does not correlate with the severity of the injury. Plain roentgenograms and an infusion pyelogram using 2 ml of 25 per cent Hypaque per pound of body weight should be obtained as soon after injury as possible. Bilateral visualization of contrast material implies intact renal vessels. Reduction of the amount of contrast seen on the injured side with compression of the collecting system and without extravasation is characteristic of renal contusion. Evidence of a coexistent flank mass implies disruption of the renal capsule. These injuries heal without either operation or prolonged bed rest. Extravasation of contrast material beyond the renal capsule signifies disruption of the collecting system, the parenchyma, and the renal capsule. Early elective debridement, repair, and drainage results in salvage of a useful kidney in about 90 per cent of cases. Nephrectomy is seldom necessary. Failure to demonstrate any contrast material on the injured side is an indication for immediate further study by renal scanning, retrograde pyelography, or aortography. If recognized and treated promptly, some kidneys deprived of blood supply by gradual arterial occlusion secondary to an intimal tear may be salvaged, whereas delay invariably results in death of the devascularized kidney.