Acute generalized peritonitis in African children: assessment of severity of illness using modified APACHE II score.

BACKGROUND: Generalized surgical acute abdomen is a significant cause of morbidity and mortality among children. Severity assessment is useful in order to prioritize treatment and reduce complications. Patients with a high severity score are often faced with high morbidity and mortality, thus, requiring more intensive treatment than those with low severity scores. The purpose of the present study was to assess the severity of the acute abdomen in paediatric patients using a modification of the acute physiological and chronic ill-health evaluation II score (APACHE II). METHODS: Children admitted and operated on for generalized acute abdomen over a period of 7 years from January 1993 to December 1999 were prospectively studied. A study proforma was drafted and demographic, clinical, preoperative, operative and postoperative data on each patient were entered. Each patient had severity of illness assessed using APACHE II parameters with minor modification to make it applicable to children. Postoperative outcome and severity of illness were compared to determine any correlation. RESULTS: There were 69 patients operated on within the period of the study. Age ranged from 3 months to 15 years, with a mean of 9.1 SD 4.3 years. Forty-two patients (61.2%) were male and 27 (39.8%) were female. Typhoid intestinal perforation accounted for 35 (50.7%) and intestinal obstruction with or without intestinal gangrene accounted for nine (13%). Modified APACHE II score ranged from 0 to 18, mean 8.5 SD 5. For survivors, the mean score was 8; for non-survivors, 13. Eight patients died (11.6%): four of 63 (6.4%) patients who scored 0-15 died; four of six (66.7%) patients who scored 16-18 (P < 00.05) died. A modified APACHE II score greater than 15 was associated with a significantly greater mortality. The data for postoperative morbidity and hospital stay were not conclusive. CONCLUSION: Although the APACHE II score was designed for adults, a modification can be suitably applied to predict mortality in children with generalized peritonitis. There will be a need to apply this to large number of patients in order to validate our finding.

Severity and outcome of falls in children.

Three hundred and five patients with falls over a period of 4 years were reviewed with the aim to determine the pattern, severity and outcome of childhood injuries from falls in our environment. The results showed that falls accounted for 25% of all childhood injuries. There were more male than female in ratio 2:1. The age ranges from 5 months-15 years with mean age of 6.15 years + or - 3.63. About 40% of the patients were preschool children. Home was the commonest site of falls in 55.3% followed by school in 38% of the patients. Falls from height accounted for 25% and at the ground level in 75% of the patients. Falls from stairs and storey buildings accounted for 68.3% of falls from height, whereas falls while playing on a ground level occurred in 83% of those whose falls were at ground level. Musculoskeletal injuries with fractures of bones were the commonest injuries sustained followed by head injuries. Fracture of lower limb bones accounted for 48% of all the bone injuries commonest bone being femur. The upper limb bones fractured occurred in 45.6%. There were two cases of skull fracture. Head injuries occurred in 6.2% of the patients and severe in 10% of the head injured patients. Other systemic injuries occurred rarely. Most of the injuries were trivial with Injury Severity Score ranges from 2-26. The mean Injury Severity Score was 2 in 235 patients (77%), 10.5 in 64 (21%), 12.5 in 4 (1.4%) and 21.5 in 2 patients(0.6%). Seventy-eight percent of the cases were treated as outpatient. Hospital stay ranges from 1-45 days with mean of 3.8 days. The hospital stay correlated very well with the Injury Severity Score. Wound Infection occurred in only 1.4% of the patients with mortality in 2 patients (0.6%) with Injury Severity Score of 17 and 26 respectively.