Emergency management of the injured child

Now that the crisis situation is past and the child appears to be stable, do not be lulled into a sense of security. Repeated examinations will be necessary to uncover significant internal injuries, such as a subcapsular hematoma of the spleen or liver that gives rise to continuous slow bleeding and may not show signs or symptoms until several hours after the time of injury. the first chest film may be within normal limits. A film several hours later may show the characteristic infiltrates of pulmonary contusion. Arterial blood gases may change before demonstrating other physical signs or symptoms of metabolic or respiratory deficiencies. The primary physician who cares for the multiply injured child must be familiar with the special needs of infants and children. They are not little adults. Dosages of medications differ; these children have special needs to meet for growth and development, and special psychologic needs. In dealing with the very young, do not give up too soon, especially with central nervous system injury. Many of these children have the ability to make a "miraculous' recovery, with little or no residual damage. I would like to make a special plea for the early use of hyperalimentation solution in the treatment of the multiple injury as a means of promoting optimum growth, development, and healing of the injured child.     

Care of the critically injured child: nonaccidental injuries

AIM: The established criteria for benignity or malignancy of lymph nodes when evaluated with B-mode ultrasound can be divided into quantitative measures (size, quantity, contour and density) and qualitative parameters (configuration and structure). The validity of these criteria is controversial. METHODS: Two cases of sinus histiocytosis with massive lymphadenopathy (SHML) are presented; this is a rare benign reactive disorder in which massive enlargement of cervical lymph nodes often occurs. These enlarged nodes offer a chance to demonstrate and discuss the validity of the sonomorphological criteria. RESULTS: The enlarged lymph nodes in SHML fulfill most of the criteria for malignancy. The same results are meet in other disorders with prominent but benign lymphadenopathy. CONCLUSION: The current ultrasonic criteria to determine benignity/malignancy in lymph nodes most likely simply indicate a large number of enlarged nodes. Pathologic diagnosis remains the gold standard.     

Critical care medicine

A postmortem case of HTLV-I associated myelopathy (HAM)/tropical spastic paraparesis (TSP) with a history of remission and exacerbation of neurological signs and symptoms, resembling those of multiple sclerosis is reported. MRI analysis revealed lesions in the periventricular white matter in addition to atrophy of the thoracic spinal cord, characteristic of HAM/TSP. The cerebral periventricular areas consisted of ill-defined paucity of myelin sheaths with astrocytic gliosis and hyaline thickening of blood vessels. The poorly demarcated white matter lesions found in both brain and spinal cord were different from plaques found in multiple sclerosis. It is suggested that, in some cases of HAM/TSP, inflammatory lesions that destroy myelin can involve not only the spinal cord but also the cerebral periventricular white matter.     

Can the age of entry into child care and the quality of child care predict adjustment in kindergarten?

Influences of age of child-care entry, quality of care, and family characteristics on social adjustment were contrasted in a longitudinal study of 80 children. Children at the toddler, preschool, and kindergarten periods and adult socialization in toddler period were assessed. Early-entry children in low-quality care had the most difficulty with peers in preschool and were distractible, low in task orientation, and less considerate of others in kindergarten. In 29 families observed prior to child-care entry, parents who would subsequently enroll children in low vs high quality care had more complex lives and used less appropriate socialization practices. Family socialization best predicted outcomes in children enrolled after infancy, and teacher socialization best predicted outcomes in children enrolled prior to 12 months. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Critical care for organ failure

We retrospectively studied the critical care regimen for multiple organ failure (MOF) in 141 surgical MOF patients treated in the intensive care unit of Chiba University Hospital between January 1988 and April 1998. Patients with gut failure received parenteral instead of enteral nutrition for various reasons such as concomitant ileus. Of the patients with respiratory failure. 138 were placed on a ventilator and 6 received percutaneous cardiopulmonary support. Continuous hemodiafiltration (CHDF) was performed in 98 patients with renal failure. Plasma exchange was carried out in 13 patients with liver failure. Of these patients, 62 (44%) survived. Colloid osmotic pressure was used as an indicator for fluid therapy. For prophylaxis against bacterial translocation, we performed selective digestive decontamination. Recently blood purification methods, particularly CHDF, have become common in the critical care setting. CHDF is efficacious not only as continuous renal replacement therapy but also as a humoral mediator modulator and is currently the first-choice method for blood purification in critical care. In conclusion, there have been many advances in the critical care of patients with organ failure. Multidisciplinary treatment, including artificial support for failing organs, is necessary for the survival of these patients.     

American child care today.

Child care has 2 purposes: mothers' employment and children's development. These are conflicting goals, because the first focuses on the quantity and affordability of child care whereas the second favors expensive quality services. Affordable child care fosters maternal employment and gender equality. With welfare reform demanding more child-care places to move mothers from welfare to work, the pressure for larger quantities of child care is great. Demanding regulations raise the quality of care and give more assurance of children's well-being, but they also increase the cost. More expensive regulations price more working parents out of licensed care and force them to use unregulated home care. Widely varying qualities of child care have been shown to have only small effects on children's current development and no demonstrated long-term impact, except on disadvantaged children, whose homes put them at developmental risk. Parents have far greater impact on their children's development through both the genes and environments they provide. Thus, greater quantities of affordable, regulated child care may be possible. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Monitoring the injured brain in intensive care: present and future

The methods of monitoring the injured brain in intensive care have relied mainly on intermittent measurement. There is now increasing clinical interest in newer continuous forms of bedside monitoring that can help direct therapy earlier and more precisely. This article reviews continuous methods of monitoring cerebral perfusion, oxygenation, brain chemistry and function.     

Critical care in an emergency department

A one year review of resuscitation in an emergency department (ED) was conducted. In the stabilization room (SR) within the ED at Hennepin County Medical Center, 852 cases were treated in the year ending July 31, 1978. There were 166 deaths in the SR (19.5%) overall, and 141 (47.9%) and 16 (5.3%) for cardiac and trauma cases, respectively. The 32 fatal cases of blunt trauma (six in the SR, 10 within 24 hours, and 16 late deaths) were reviewed and assigned an injury severity score (ISS). Of these, 12 deaths were unrelated to central nervous system causes. These had an average ISS of 42.8.     

Survey of intensive care of severely head injured patients in the United Kingdom

OBJECTIVES: To study practice in intensive care of patients with severe head injury in neurosurgical referral centres in United Kingdom. DESIGN: Structured telephone interview of senior nursing staff in intensive care unit of adult neurosurgical referral centre. SETTING: 39 intensive care units in hospitals that accepted acute head injuries for specialist neurosurgical management, identified from Medical Directory and information from professional bodies. MAIN OUTCOME MEASURES: Details of organisation and administration of intensive care and patterns of monitoring and treatment for patients admitted with severe head injury. RESULTS: Patients were managed in specialist neurosurgical intensive care units in 21 of the centres and in general intensive care units in 18. Their intensive care was coordinated by an anaesthetist in 25 units and by a neurosurgeon in 12. Annual case-load varied between units: 20 received > 100 patients, 12 received 50-100, and seven received 25-49. Monitoring and treatment varied considerably between centres. Invasive arterial pressure monitoring was used routinely in 36 units, but central venous pressure monitoring was routinely used in 24 and intracranial pressure was routinely monitored in only 19. Corticosteroids were used to treat intracranial hypertension in 19 units. Seventeen units routinely aimed for arterial carbon dioxide pressure of 3.3-4.0 kPa, and one unit still used severe hyperventilation to a pressure of < 3.3 kPa. CONCLUSION: The intensive care of patients with acute head injuries varied widely between the centres surveyed. Rationalisation of the intensive care of severe head injury with the production of widely accepted guidelines ought to improve the quality of care.     

Critical care nutrition: routes of feeding

The experiments were carried out with maize (Zea mays L.) seedlings, hybrid Kneja 530, grown hydroponically in a growth chamber. Twelve-day-old plants were foliar treated with putrescine, N1-(2-chloro-4-pyridyl)-N2-phenylurea (4-PU-30), and abscisic acid (ABA) at concentrations of 10(-5) m. Twenty-four hours later the plants were subjected to a water deficit program, induced by 15% polyethylene glycol (PEG; molecular weight, 6,000). Three days after drought stress half of the plants were transferred to nutrient solution for the next 3 days. The effects of the water shortage, rewatering, and plant growth regulator (PGR) treatment on the fresh and dry weights, leaf pigment content, proline level, relative water content (RWC), transpiration rate, activities of catalase and guaiacol peroxidase, hydrogen peroxide content, and level of the products of lipid peroxidation were studied. It was established that the application of PGRs alleviated to some extent the plant damage provoked by PEG stress. At the end of the water shortage program the plants treated with these PGRs possessed higher fresh weight than drought-subjected control seedlings. It was found also that putrescine increased the dry weight of plants. Under drought, the RWC and transpiration rate of seedlings declined, but PGR treatment reduced these effects. The accumulation of free proline, malondialdehyde, and hydrogen peroxide was prevented in PGR-treated plants compared with the water stress control. The results provided further information about the influence of putrescine, 4-PU-30, and ABA on maize plants grown under normal, drought, and rewatering conditions. Key Words. Maize-Putrescine-4-PU-30-ABA-Drought     

The critical care of the severely injured patient--II. Pulmonary and renal support

The management of pulmonary support in trauma patients is a balance of risk versus benefit. Decisions must be based upon the patient's physiologic needs, with constant attention to the potential complications of the therapy. The avoidance of renal failure by volume replacement, careful attention to the use of potentially nephrotoxic agents, and close monitoring of renal function can reduce the incidence and severity of this serious complication of trauma. If renal failure does occur, aggressive renal replacement therapy with either intermittent hemodialysis or CRRT should be tailored to the clinical situation.     

More on nonmaternal child care.

Cautions that C. Etaugh's (see record 1980-11778-001) conclusion that high-quality nonmaternal care does not appear to have adverse effects on a child's development could be interpreted as meaning that nonmaternal care is never harmful to children. More consideration to the developmental status of each family member and to each member's feelings about the childcare arrangement is needed in further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Maternal employment and child care.

Highlights selected demographic, social, and economic forces related to the increase in employment of women and notes the benefits and stresses experienced by employed mothers. These include difficulties associated with finding and affording good day care, concerns about the effects of maternal employment and day care on children, and the difficulties frequently inherent in managing the 2 full-time jobs of employment and motherhood. Suggestions for mental health professionals who work with employed mothers are presented: (1) focus on the woman's family and community systems that may be the source of problems, (2) assist the woman in identifying and priority-rating her multiple demands, and (3) inform individuals about potential stresses and practical problem-solving techniques. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Critical care management of the heart failure patient in the home

As part of a program to determine the underlying factors responsible for genotoxicity and perhaps lung cancer risk in Chinese women, we qualitatively identified the volatile components emitted during the heating of cooking oils to 265 degrees C. 1,3-Butadiene, benzene, and a series of aldehydes, olefins, and saturated hydrocarbons were elucidated in vapors from Chinese rapeseed oil. On a relative basis, the intensity of 1,3-butadiene vapors from this were 15.7-, 6.3-, and 1.4-fold greater than in the vapors from peanut, soybean, and Canola oils, respectively. Thus, the Chinese rapeseed oil yielded a higher emission rate of 1,3-butadiene than the other three oils investigated. The benzene formation rate followed a similar trend, i.e., its intensity in Chinese rapeseed oil was 14-, 6.6-, and 1.7-fold greater than in vapors from peanut, soybean, and Canola oils, respectively.     

The child care crisis in America.

Argues that for almost 2 decades the American government has recognized the lack of affordable, good quality child care in the US as a serious and pressing problem. Despite this, the US has made very little progress in terms of instituting major reforms in regard to child care. The authors discuss how and why the child care problem in the US has turned to crisis proportions. In addition, they highlight the developmental concerns that surround the issue of child care, and the different child care options currently available for American families to choose from. Finally, they propose a possible solution to this problem; a solution that could carry the US into the 21st century. (French abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)