Hollow visceral injury and blunt trauma

BACKGROUND: The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis. METHODS: A 9-year trauma registry review of all patients with HVI. RESULTS: A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05). CONCLUSION: HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.     

Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma

BACKGROUND: As nonoperative management of blunt abdominal trauma has become more popular, reliable models for predicting the likelihood of concomitant hollow viscus injury in the hemodynamically stable patient with a solid viscus injury are increasingly important. METHODS: The Pennsylvania Trauma Systems Foundation registry was reviewed for the period from January 1992 to December 1995 for all adult (age > 12 years) patients with blunt trauma and an Abbreviated Injury Scale (AIS) score > or = 2 for a solid viscus (kidney, liver, pancreas, spleen). Patients with an initial systolic blood pressure < 90 mm Hg were excluded. Hollow viscus injuries included only lacerations or perforations of the gallbladder, gastrointestinal tract, or urinary tract. RESULTS: In the 4-year period, 3,089 patients sustained solid viscus injuries, 296 of whom had a hollow viscus injury (9.6%). The mean age was 35.6 years, mean Injury Severity Score was 22.2, and mean Revised Trauma Score was 7.3; 63.3% of the patients were male. A solitary solid viscus injury occurred in 2,437 patients (79%), 177 of whom (7.3%) had a hollow viscus injury. The frequency of hollow viscus injury increased with the number of solid organs injured: 15.4% of patients with two solid viscus injuries (n = 547) and 34.4% of patients with three solid viscus injuries (n = 96) suffered a concomitant hollow viscus injury (p < 0.001 vs. one organ). A hollow viscus injury was 2.3 times more likely for two solid viscus injuries and 6.7 times more likely for three solid viscus injuries compared with a solitary solid viscus injury. For solitary solid viscus injury, the frequency of hollow viscus injury varied little with increasing AIS score (AIS score 2, 6.6%; AIS score 3, 8.2%; AIS score 4, 9.2%; AIS score 5, 6.2%) (p = 0.27 between groups), suggesting that the incidence of hollow viscus injury is related more to the number of solid visceral injuries than the severity of individual organ injury. Also, when the sum of the AIS scores for solid viscus injuries was <6, the mean rate of hollow viscus injury was 7.8%. This increased to 22.8% when the sum of the AIS scores for solid viscus injury was > or =6 (p < 0.001). A pancreatic injury in combination with any other solid viscus injury had a rate of hollow viscus injury of >33%. CONCLUSION: A model of organ injury scaling predicted hollow viscus injury. Multiple solid viscus injuries, particularly pancreatic, or abdominal solid viscus injuries with an AIS score > or = 6, were predictive of hollow viscus injury. Identification of these injury patterns should prompt consideration for early operative intervention.     

Evaluation of alpine skiing and snowboarding injury in a northeastern state

BACKGROUND: To demonstrate the injury patterns of Alpine skiing and snowboarding in a northeastern state and evaluate potential risk factors. METHODS: The medical records of a single pediatric and adult Level I trauma center were evaluated from January 1, 1990, through December 31, 1995. All admissions with injuries caused by Alpine skiing or snowboarding were reviewed. Those patients arriving from two local ski resorts, all of whose injuries are referred to the institution for care, were separated out for consideration. Age, sex, type of injury, date of injury, Injury Severity Score, operations performed, and outcome (including mortality) were evaluated. In addition, resort utilization for the study period was obtained from the two resorts included in the evaluation. Mortality data was obtained from the Vermont office of the Chief Medical Examiner for the same time period. RESULTS: For the 6-year period of the study approximately 2,978,000 skier and snowboarder days were recorded at the study sites. Approximately 447,000 of those days were attributed to snowboarders (15%). In all, 279 patients were admitted for injuries (0.01%), 238 were related to Alpine skiing (incidence 0.01%) and 40 to snowboarding (incidence 0.01%). Snowboarders were statistically younger (20 years; range, 4-44 years) than skiers (29 years; range, 6-70 years) (p < 0.001) and had a significantly lower Injury Severity Score (15 in snowboarders vs. 27 in skiers, p < 0.03). Two female patients were injured snowboarding and 68 female patients were injured skiing. Eight percent of injured snowboarders and 16% of injured skiers sustained multiple injuries (p < 0.01). Injury patterns were significantly different. Upper extremity injuries were almost exclusively found in snowboarders (24% vs. 7%, p < 0.003), whereas cruciate ligament injuries occurred far more commonly in skiers (45% vs. 4%, p < 0.001 Lower extremity injuries in general were more common in skiers (78% vs. 38%, p < 0.001). Central nervous system injuries, including head and spine, were evenly distributed over the two groups, although the snowboarders with central nervous system injuries were younger. In addition, splenic injuries were more common in snowboarders (13% vs. 2%, p < 0.01). Snowboarding accidents were far more common in December, March, and April than other months. Fifty-one patients sustained abdominal or chest injuries and only two of these required operative intervention (two splenectomies). Other operative interventions were limited to extremity injuries, injuries of the spine, or placement of an intracranial pressure monitor. There were no fatalities recorded in this population, although over the 6.5 years, there were 25 deaths related to alpine skiing and one to snowboarding in the State (incidence 0.0000009 skier days). Victims tended to be male: 96% of the skiers and the one snowboarder. The predominant cause of death was blunt head trauma followed by blunt chest trauma. Helmets were not worn by those sustaining head injuries or fatalities. Spine injuries were recorded only in extremely young snowboarders and skiers out of control. CONCLUSION: Snowboarders and Alpine skiers are equally prone to injury. Snowboarding accidents are typically less severe and show significantly different injury patterns than skiing accidents. Abdominal and chest injuries in this population are generally amenable to nonoperative management. Prevention programs are best targeted at safe skiing and snowboarding practices, not skiing or snowboarding in poor conditions, use of helmets for skiers, and restraint of snowboard use in very young children.     

A comparison of artificially-depleted, lyophilized coumarin and fresh coumarin plasmas in thromboplastin calibration. European Concerted Action on Anticoagulation

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.     

Pediatric penetrating thoracic trauma: a five-year experience

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS < 8 underwent surgical intervention, whereas only two of the eight patients with a PTS > or = 8 needed surgery (P < 0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.     

Driveway crush injuries in young children: a highly lethal, devastating, and potentially preventable event

BACKGROUND/PURPOSE: The aim of this study was to investigate driveway-related injuries in children, identify associated risk factors, and evaluate outcome compared with other mechanisms of blunt trauma. METHODS: A 6-year review (1991 to 1996) of pediatric (age less than 18 years) pedestrian injuries treated at two urban trauma centers was conducted: one regional pediatric trauma center and one level I trauma center with pediatric commitment. Five hundred twenty-seven children injured in pedestrian accidents were identified from the trauma registry; 51 children (10%) sustained traumatic injuries as a result of being struck in their driveway. Data are reported as mean +/- SEM. RESULTS: Children less than 5 years of age (n = 41) had an injury severity score (ISS) of 12.3+/-2.3, 15 (37%) sustained closed head injury, 13 (37%) had torso trauma, 19 (46%) skeletal trauma, and eight (20%) died. Children > or = 5 years old (n = 10) had an ISS of 10.7+/-2.4, three (30%) sustained closed head injury, four (40%) torso trauma, six (60%) skeletal trauma, and none died. In contrast, all other pediatric pedestrian accidents analyzed over the same time period had a mortality rate of only 2% (11 of 476). CONCLUSIONS: Pediatric driveway trauma carries a significant risk of head injury and a 10-fold increase in mortality in children under 5 years of age when compared with all other pediatric pedestrian accidents. More emphasis must be placed on injury prevention and public education to prevent this devastating mechanism of injury in these young, vulnerable children.     

The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs

OBJECTIVE: To describe the incidence and causes of pediatric head, spinal cord, and peripheral nerve injuries in an urban setting and to assess the implications of these data for injury prevention programs. METHODS: Pediatric deaths and hospital admissions secondary to neurological trauma included in the Northern Manhattan Injury Surveillance System from 1983 to 1992 were linked to census counts to compute incidence rates. Rates before the implementation of a nonspecific injury prevention program were compared with rates after the implementation, and rates for the target population were compared to rates for the control population. Rates were analyzed on the basis of the cause of injury as well as the age, gender, and neighborhood income level of the injured. RESULTS: The incidence of neurological injuries resulting in hospitalization or death was 155 incidents per 100,000 population per year; the mortality rate was 6 people per 100,000 population per year. Neurological injuries represented 18% of all pediatric injuries and accounted for 23% of all traumatic deaths. Spinal cord and peripheral nerve injuries were relatively rare (5%) compared to head injuries (95%). Minor head injuries, including isolated cranial fractures, minor concussions (<1 h loss of consciousness), and unspecified minor head injuries, accounted for the majority of neurological injuries (76%), whereas severe head injuries, including severe concussion (>1 h loss of consciousness), cerebral laceration/contusion, intracerebral hemorrhage, and unspecified major injuries, were less common (18% of all neurological injuries). Boys were more often affected than girls at every age, and this preference increased with age. Children younger than 1 year showed the highest incidence of both major and minor injuries. One- to 4-year olds showed the lowest rates, with steady increases thereafter. Traffic accidents and falls were the leading causes (38 and 34%, respectively), and assaults were the next leading causes (12%). Among children admitted to surveillance system hospitals, falls were most common in children younger than 4 years, pedestrian motor vehicle accidents were most common in late childhood, and assaults were most common in early adolescence. Case:fatality rates were 5 to 7% for all age groups except 5- to 12-year-olds, for whom the case:fatality rate was 1.9%. Residence in a low-income neighborhood was associated with an increased risk of injury (rate ratio, 1.71; confidence interval, 95%, 1.54, 1.89). The average hospitalization cost per injury was $8502. Medicaid (54%) and other government sources (5%) covered the majority of expenses, including indirect reimbursement of usually uncollected self-pay billing (19%). Although injury incidence rates fell in both the control and intervention cohorts during implementation of a nonspecific injury prevention program, targeted age and population groups demonstrated greater relative reductions in injuries than nontargeted ones, suggesting a positive effect. CONCLUSIONS: Deaths and hospital admissions secondary to pediatric neurological trauma represent a significant public health problem, with the majority of the direct cost being born by government agencies. Future efforts to prevent neurological trauma in children who live in inner cities should focus on families with low incomes and provide novel education programs regarding infant abuse, infant neglect, and infant injury avoidance. Age-appropriate school-based programs should also be developed to address traffic safety and conflict resolution.     

Results of treatment of multiple trauma in 130 children

Trauma remains the leading cause of death in the pediatric age group, despite recent advances in prevention and treatment. We retrospectively analyzed 130 cases of multiple trauma among 725 pediatric patients with injuries treated here during 1988-1989. Road accidents and falls from heights were the most common causes of injury. Mean age was 7 years (range 0.5-15) and the male to female ratio 2.7:1.0. Overall mortality was 9.2%. 57 patients (44%) did not get any prehospital medical care and 5 of them with injury severity scores (ISS) greater than 25 died. In contrast 11/18 (61%) of patients with ISS greater than 25 who were treated by medical teams survived. On arrival at the emergency room, 15% were hypothermic ( < 34 degrees C), and 6 were in hypovolemic shock--5 of whom died. Most common injuries were head trauma (91), limb injuries (69), abdominal trauma (34) and thoracic trauma (34). In 39 injury was severe, with pediatric trauma score (PTS) 6 or less, 12 of whom died. All deaths except 1 were associated with severe head injury and with ISS more than 25. There was no mortality in those with PTS more than 7 or ISS less than 25. Thus, the prehospital care of pediatric patients with head injury is associated with high mortality. Absence of mortality in patients with PTS of more than 7 emphasizes the importance of designated trauma centers for these patients.     

Computed tomography in injuries to the respiratory system in children. The correlation with adults

INTRODUCTION: Diagnostic imaging in emergency rooms may be inadequate and delayed, which makes chest traumas in children more severe and difficult to treat. We carried out a retrospective study on adults and children who had survived major chest traumas involving the respiratory tract to assess the differences between the two age groups and the role of emergency CT. MATERIAL AND METHODS: Our series consisted of fourteen children admitted to the emergency department for various accidents. Home accidents prevailed (9/14 = 64.3%). On admission, chest radiography was performed in most cases (11/14 = 78.6%); CT was carried out in 21.4% (3/14 patients). RESULTS: Trauma involved more organs in pediatric patients (11/14 = 78.6%) and lung involvement was always associated with other types of injury, namely contusion (14/14 = 100%), pneumothorax (11/14 = 78.6%), hemothorax (10/14 = 71.4%), tear (4/14 = 28.6%). CT corrected or integrated the radiographic findings of contusion focus in 67% (8/14) and that of pneumothorax in 63.6%; both patterns cannot be demonstrated otherwise. DISCUSSION: Mixed and multiple posterior parenchymal injuries with no rib fractures prevail in young subjects because their bones and ligaments are more elastic, which may lead to trauma underestimation. Tracheobronchial ruptures and pneumomediastinum are much more severe in children than in adults. Chest plain film is often the only diagnostic tool used, despite its major technical and interpretative limitations, also because skull and abdomen are the most investigated regions. Executive limitations are stronger in childhood, increasing the margin of error and the risk of delayed treatment. CT is as cost-effective as radiography and shows even the injuries missed or poorly depicted on conventional images; CT also gives accurate information on damage severity and nature. CONCLUSIONS: Traumatic injuries are more severe in pediatric patients due to their build and to biomechanical, clinical and management factors. Spiral CT should be considered the examination of choice to be performed in the emergency department equipped also for pediatric re-animation.     

Proton MR spectroscopy after acute central nervous system injury: outcome prediction in neonates, infants, and children

PURPOSE: To evaluate the usefulness of proton magnetic resonance (MR) spectroscopy in predicting 6-12-month neurologic outcome in children after central nervous system injuries. MATERIALS AND METHODS: Localized single-voxel, 20-msec-echo-time MR spectra (including N-acetylaspartate [NAA], choline [Ch], creatine and phosphocreatine [Cr]) were obtained in the occipital gray matter in 82 patients and 24 control patients. Patient age groups were defined as neonates (< or = 1 month [n = 23]), infants (1-18 months [n = 31]), and children (> or = 18 months [n = 28]). Metabolite ratios and the presence of lactate were determined. Linear discriminant analysis-with admission clinical data, proton MR spectroscopy findings, and MR imaging score (three-point scale based on severity of structural neuroimaging changes)-was performed to help predict outcome in each patient. Findings were then compared with the actual 6-12-month outcome assigned by a pediatric neurologist. RESULTS: Outcome on the basis of proton MR spectroscopy findings combined with clinical data and MR imaging score was predicted correctly in 91% of neonates and in 100% of infants and children. Outcome on the basis of clinical data and MR imaging score alone was 83% in neonates, 84% in infants, and 93% in children. The presence of lactate was significantly higher in patients with poor outcome than in patients with good-moderate outcomes in all three age groups (neonates, 38% vs 5%; infants, 87% vs 5%; children, 64% vs 10% [chi 2 test, P < .02]). In children with poor outcomes, NAA/Cr ratios were significantly lower in infants (P = .006) and children (P < .001), and NAA/Ch ratios were significantly lower in infants (P = .001) and neonates (P = .05). CONCLUSION: Findings at proton MR spectroscopy helped predict long-term neurologic outcomes in children after central nervous system injury.     

Nonoperative management of blunt hepatic and splenic injury in children

OBJECTIVE: The authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991. METHOD: One hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). CONCLUSION: Pediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.     

Pancreatic trauma: a ten-year multi-institutional experience

Our objective was to determine the incidence, management, and outcome of traumatic pancreatic injury. A retrospective review was performed of all patients with pancreatic injury admitted to two Level I trauma hospitals over a 10-year period. Comparisons were made with Chi square or Fisher's exact tests. Of 16,188 trauma admissions, 72 patients (0.4%) had pancreatic injury. The mean age was 30 years, and 30 patients (69%) were male. Mechanism of injury was gunshot in 32 (45%), blunt in 27 (37%), and stab wound in 13 (18%). The pancreas was involved in 1.1 per cent of patients with penetrating injuries compared to 0.2 per cent with blunt injuries (P < 0.01). There were 18 grade I (25%), 32 grade II (45%), 16 grade III (22%), and 5 grade IV (7%) injuries. Initial diagnosis was made intraoperatively in 63 patients and by computed tomography in 8. The mean injury grade was significantly lower on computed tomography compared to surgical exploration (0.4 vs 2.0; P < 0.05). Operative procedures included distal pancreatectomy in 23 (32%), exploration only in 22 (31%), external drainage in 13 (18%), pancreatorrhaphy in 4, internal drainage in 2, and proximal resection in 2. Mortality was 16.6 per cent and was not related to the mechanism or grade of injury. Mean Injury Severity Score and transfusion requirements were significantly greater in patients who died (P < 0.05). Morbidity occurred in 30 patients (42%), including pancreatic fistula (11%), pancreatitis (7%), and pancreatic pseudocyst (3%). Six patients (8%) developed intra-abdominal abscesses, and all had associated liver or intestinal injuries. In patients with grade I and II injuries, morbidity was higher with external drainage compared to exploration without drainage. Pancreatic injury is infrequent and is more often associated with penetrating trauma. Diagnosis is most commonly made by exploration and cannot be excluded by computed tomography. Drainage of low-grade injuries may not be necessary. Morbidity and mortality in patients with pancreatic trauma is significant and is primarily due to associated injuries.     

Fractures of the pelvis in children

Pelvic bony injuries are uncommon in children except for avulsion fractures. Medical records and radiographs of 54 children, in whom pelvic fractures were diagnosed from 1974 to 1993, were reviewed. Children 16 years of age and younger who were treated as inpatients were included in this study. Thirty-two patients were boys (59.3%) and 22 were girls (40.7%). In 47 (87.0%) patients, trauma was caused by motor vehicle accidents. The fractures were classified according to the Torode and Zieg classification and the Tile AO/Association for the Study of Internal Fixation classification. Forty-seven (87.0%) children had associated pelvic or extrapelvic injuries. The mean Injury Severity Score was 30.5 (range, 4-66). The AO classification correlated well with the severity of the injury. Eight children (14.8%) died. In most (38 patients = 70.4%) patients, the pelvic bony injury was treated by conservative means. External or internal fixation of the fracture was performed in 16 (29.6%) patients. A followup examination was conducted in 35 of 44 survivors (79.5%; 2 other patients died of unknown causes) with a mean followup of 135 months (range, 18-235 months); 1 additional patient was interviewed by telephone. In this series, long term morbidity was rare and was attributed to severe pelvic ring disruptions, acetabular fractures, or concomitant injuries. It is concluded that in unstable pelvic ring disruptions and acetabular fractures, the principles of management in children should not differ greatly from those in adults. Serious associated pelvic or extrapelvic injuries may pose more management problems than does the pelvic fracture.     

The impact of shopping cart restraints and adult supervision on near injuries to children in grocery stores

Factors influencing the likelihood of near injuries to 235 children in grocery stores were investigated. Two-person research teams observed children and accompanying adults in 29 supermarkets. Injuries, positioning of children in or around a grocery cart, handling of hazards, attempts to climb in or out of the cart, parental monitoring, and demographic features of the child and adult were recorded. Ten of the 235 children (4.3%) suffered minor injuries. The overall injury rate was equivalent to 43 injuries per 1,000 child shopping visits. The major predictor of injuries was being inside the shopping cart versus in the cartseat or outside the cart. Most at risk were children over the age of three inside the cart who attempted to climb out and who received poor adult supervision. Risk of injury for this group was more than six times the risk of injury for the entire sample. A majority of injuries were scrapes, pinches, or bumps that were the result of falling within the cart basket. Attempts to climb out of the cart were also associated with injury. Placing the child outside the grocery cart reduced the risk of injury. In conjunction with this, carts with shallow or small baskets may discourage parents from placing children in carts, thereby reducing the risk of injury. While duration of shopping trip was not significantly related to risk of injury, there was a tendency for accidents to occur when shopping trips exceeded 23 minutes.     

Helicopter use in the Swiss air rescue service for children. Inland transport in 1992

In 1992, the Swiss helicopter rescue service (REGA) transported 515 injured and 141 sick children (total n = 656). More than 60% of the children were boys; the age group from 10 to 16 years dominated. Primary care was provided in 415 of the flights, whereas the remaining cases were interhospital transfers to institutions with pediatric intensive care units. The main reason for primary interventions was sports accidents, followed by medical disease and traffic accidents. The majority of the sick children (70%) were severely ill with life-threatening diseases according to National Advisory Committee for Aeronautics (NACA) indices IV to VII. On the other hand, only 47% of the injured children had NACA indices of IV to VII. Most of these children had minor injuries suffered during sports activities; they were rescued mainly because of the site of the accident and not the severity of the injury. The remaining trauma victims had had traffic or home accidents and were usually severely injured. Head injuries were the most common reason for intervention due to accidents, and central nervous disorders and respiratory problems were the main reason for interventions in children suffering from serious illnesses. For primary REGA rescue interventions, the mean time from accident to arrival at the hospital was 64 minutes: 18 minutes from injury to alarm, 17 minutes from alarm to arrival at the scene, and 29 minutes for scene time and flight to the hospital. Costs for helicopter rescue are twice as high as for ground-based rescue (ambulance). However, considering the relatively high percentage of severely injured or life-threatened sick children involved, air rescue and its higher costs appear to be justified.     

Abdominal trauma and pelvic injury in the growth period

Children with pelvic fractures usually are polytraumatized. Concomitant abdominal and pelvic injuries are not uncommon. Medical records and X-rays of 54 children, in which a pelvic fracture was diagnosed at our institution from 1974-1993, were reviewed. Children ages < or = 16 years and treated as in-patients were included in this study. The fractures were classified according to the AO-Classification. 47 patients (87.0%) had concomitant injuries. The mean Polytrauma Score was 23.7 (mean Injury Severity Score 30.5). Nine Children sustained an open pelvic fracture with rectal and/or vaginal tear. 15 genitourinary lesions were found in 13 children. 18 patients underwent laparotomy. A large pelvic/retroperitoneal hematoma was found in 11 cases. There were 7 liver lacerations, 7 splenic injuries, 2 mesenteric tears, 2 kidney injuries and 1 small bowel lesion. Eight children (14.8%) died with 5 of them due to retroperitoneal or/and abdominal bleeding complications. A recent follow-up examination (81.8%) with a mean follow-up of 11.3 years showed that long-term morbidity usually was attributed to pelvic concomitant injuries.     

Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure

OBJECTIVE: To determine whether prevention of the abdominal compartment syndrome after celiotomy for trauma justifies the use of absorbable mesh prosthesis closure in severely injured patients. DESIGN: Retrospective analysis of case series from July 1, 1989, to July 31, 1996. SETTING: University-based level I trauma center. PATIENTS: Seventy-three consecutive trauma patients requiring celiotomy who received absorbable mesh prosthesis closure and 73 control patients matched for injury severity and trauma type who received celiotomy without a mesh prosthesis closure. INTERVENTIONS: Absorbable mesh prosthesis closure was used in cases of excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic defect, or planned reoperation. MAIN OUTCOME MEASURES: Demographics, Injury Severity Score, Abdominal Trauma Index, highest abdominal Abbreviated Injury Scale score, number of abdominal/pelvic injuries, highest head Abbreviated Injury Scale score, shock, indication for mesh closure, complications, number of operations and time required for closure, days in the intensive care unit, length of stay, and mortality were determined. The highest abdominal Abbreviated Injury Scale score was multiplied by the number of abdominal/pelvic injuries to calculate the abdominal pelvic trauma score. RESULTS: Group 1 consisted of 47 patients who received mesh at initial celiotomy, and group 2, 26 patients who received mesh at a subsequent celiotomy. These 2 groups were statistically similar in demographics, injury severity, and mortality. However, group 2 had a significantly higher incidence of postoperative abdominal compartment syndrome (35% vs 0%), necrotizing fasciitis (39% vs 0%), intra-abdominal abscess/peritonitis (35% vs 4%), and enterocutaneous fistula (23% vs 11%) compared with group 1 (P < .001). Group 1 patients with preoperative abdominal compartment syndrome had more abdominal/ pelvic injuries and higher abdominal trauma index than matched controls (P < .05). There was a trend toward higher abdominal pelvic trauma score in patients who developed abdominal compartment syndrome. The Pearson coefficient of correlation between the abdominal trauma index and the more easily calculated abdominal pelvic trauma score was 0.91 (P < .001). CONCLUSION: The use of absorbable mesh prosthesis closure in severely injured patients undergoing celiotomy was effective in treating and preventing the abdominal compartment syndrome.     

Pediatric trauma registry: analysis of 1200 cases

OBJECTIVES: We developed the first Spanish Pediatric Trauma Registry in order to collect and evaluate information concerning aspects of injuries in our pediatric population. METHODS: From January'95 to September'97, 28,713 children younger than 16 years were treated in our Hospital for acute injury: 1,200 were admitted and included in our database. Our file-registry consists of 108 data points including: patient identification, type, place and mechanism of injury, pre-hospital care, transport, assessment on admission, severity scores, diagnostic studies, injuries, treatments and morbidity-mortality. RESULTS: Accidents were more frequent in males (69%) than in females. The age-group predominantly was 12-15 years old (34%). Accidents were more frequent in the street (35.3%) than at home (18.7%) or school (14%). Falls and traffic-related accidents were the leading cause of injury (38 and 21.1%, respectively). The 16.7% of cases had Pediatric Trauma Score < or = 8 (n = 201). The 3.6% of this sustained multiple trauma (43 cases with Injury Severity Score > or = 15). Musculoskeletal and head trauma was the most frequent (62 and 42.3%, respectively). Surgical or orthopedic procedures were performed in 678 patients (56.5%). Average length of stay were 4.8 days (range 1-93 days), and functional impairments at discharge were found in 33.9% of patients older than 3 years (n = 338). Mortality rate in our series was 0.5% (n = 6), and 13.9% in children with ISS > or = 15. CONCLUSIONS: The utility of this Registry is to know the epidemiology of our injured pediatric population, to review patient care, to develop prevention programs and to compare results with other centers so potential deficiencies can be identified and corrected.     

Aetiological and epidemiological aspects of acute head injury in Malawi

One hundred and four patients (88 males and 16 females) with acute head injuries admitted to the Queen Elizabeth Central Hospital, Blantyre from July 1st to December 31st 1995 were prospectively studied using a questionnaire. Forty seven (45.2%) of the injuries were caused by road traffic accidents, 42(40.4%) by assaults, nine (8.7%) resulted from falls from heights, two (1.9%) from occupational injuries and the remaining four (3.8%) were of miscellaneous origins. RTA associated head injuries involved 17 (36.2%) pedestrians; 14 (29.8%) vehicular passengers, 10 (21.3%) pedal cyclists; five (10.6%) drivers and one motor cyclist. Malawi males aged between 20 and 29 were mostly involved. Assault related head injuries occurred also in young adult males commonly at the weekend with more than 50% occurring on Saturday and Sunday. Fifty per cent were sustained at home, a quarter on the streets and surprisingly few at drinking houses making them the safest place to be in Malawi to avoid assaults! Alcohol usage was not statistically significant among those assaulted; it was not possible to define its aetiological role among assailants. The head injuries associated with falls from heights (FFH) involved eight males and one female; five were children. Strategies for the prevention of assaults, the various types of road traffic accidents and falls from heights are discussed.