地震伤患儿挤压综合征及其严重程度的相关因素分析

目的 探讨汶川地震伤后儿童发生CS及其严重程度的相关因素,为临床应对突发灾难事件提供救治方法.方法 回顾性分析我院收治的98例汶川地震伤儿童,统计患儿年龄、性别、被困时间、受伤部位、受伤类型、伤口感染、透析治疗等资料,采用T-test/X2/Fisher精确概率以及Binarylogistic回归分析,对各个可能影响CS发生的相关因素及影响CS严重程度的各个危险因素进行统计分析.结果 15例CS患儿均来自四肢挤压伤患儿,CS在地震伤儿童发生率达15.3%,在四肢挤压伤发生率达25.4%.CS发生的多个相关因素的Binary logistic逐步回归分析中,患儿年龄、被困时间、闭合型挤压伤与CS的发生密切相关,其OR值分别为1.049、1.221、0.068(均P<0.05),而与患儿性别、上或下肢损伤、伤口感染无明显的相关性.各类伤口感染率比较,开放性损伤与CS减张切口感染率明湿高于其他切口,但两组间无统计学意义(P=0.754);在影响CS严重程度的各因素比较发现,CS减张切口感染在影响CS严重程度上有统计学意义(P=0.041).结论 儿童挤压伤后CS的发生主要是四肢损伤为主,与患儿年龄、被困时间以及闭合型挤压伤有关,减张切口感染是影响CS严重度的危险因素.     

地震中儿童创伤的类型和救治要点

肢体外伤在儿童地震创伤中最为常见。地震导致的颅脑外伤发生居多,而颅内损伤较少,但颅内损伤是地震创伤致死的首要原因。胸腹挤压伤易致内脏出血等危急情况,也是地震伤患儿主要致死原因之一。挤压综合征和骨筋膜室综合征常常并发急性肾脏功能衰竭。由于地震创伤出现时间集中,现场救援要遵循“救命第一,危重优先”的原则。条件允许时,伤员应及时转运。危重伤员治疗需采用多学科联合序贯方式,重视并发症的防治、康复治疗和心理疏导。     

地震灾害中儿童创伤危重症的救治

儿童自我防护能力较差,在自然灾害中,儿童是最易受到伤害的群体。地震中死亡的主要原因包括心搏呼吸骤停、严重颅脑损伤、休克、挤压综合征及多脏器功能衰竭。优先实施对儿童的集中、有效救治,并实现多学科交叉合作,将危重患儿集中在有条件的PICU平台上,可提高重症患儿的存活率、降低致残率。     

儿童肺炎支原体肺炎流行病学特征

目的：了解儿童肺炎支原体肺炎流行病学特点,为临床诊治提供参考。方法：对2011年2月至2012年1月确诊为社区获得性肺炎的3156例住院患儿应用酶联免疫吸附法检测血清肺炎支原体抗体IgM,同时对肺炎支原体肺炎患儿的鼻咽分泌物进行7种呼吸道病毒抗原检测。结果：（1）3156例患儿中,肺炎支原体抗体IgM阳性检出427例,阳性率为13.53%,其中女性患儿感染率高于男性（16.30% vs 11.70%, P<0.01）。（2）＜1岁、1岁～、3岁～、6～14岁肺炎支原体抗体IgM检出率分别为3.6%、12.5%、19.2%、24.4%（P<0.01）,其中≥3岁者总检出率高于<3岁者（P<0.01）。（3）不同季节肺炎支原体抗体IgM检出率不同,夏秋季节明显高于冬春季节（19.18% vs 9.61%,P<0.01）。（4）427例肺炎支原体抗体IgM阳性患儿中,合并呼吸道病毒感染 60例（14.1%）,合并比例最高的呼吸道病毒为呼吸道合胞病毒。结论：儿童肺炎支原体肺炎呈全年散发,以夏秋季节多见,学龄前及学龄期儿童高发,同时还存在混合感染现象。     

儿童重症社区获得性肺炎病毒学检测和危险因素分析

目的：了解儿童重症社区获得性肺炎病毒病原谱,探讨儿童重症社区获得性肺炎的危险因素。方法：收集2007年9月至2008年8月1096例社区获得性肺炎患儿的气道抽吸物标本,其中重症社区获得性肺炎100例。采用RT-PCR、PCR或巢式PCR方法对呼吸道病毒进行核酸检测。应用logistic回归法对患儿的临床相关资料进行单因素和多因素分析,以调查重症社区获得性肺炎的危险因素。结果：100例儿童重症社区获得性肺炎标本中,病毒总检出例数为82例(82％),其中RSV检出率最高（37％）,其次为HBoV(25％)和HRV (18％)。2种及2种以上病毒协同感染32例（32%）。Logistic回归分析显示,合并基础疾病及RSV感染为儿童重症社区获得性肺炎发病的危险因素（分别OR=6.623,P<0.01;OR=1.672,P<0.05）,月龄为保护因素（OR=0.475,P<0.01）。结论：RSV是儿童重症社区获得性肺炎最常见病毒病原;合并基础疾病及RSV感染是儿童重症社区获得性肺炎发病的危险因素,月龄为保护因素。     

儿童侵袭性真菌感染的临床特征及病原菌分析

目的：探讨儿童侵袭性真菌感染的临床特征及病原菌分布。方法：回顾性分析2008～2012年间诊断为侵袭性真菌感染的104例患儿的临床资料。结果：104例患儿中,新生儿20例,婴幼儿48例,学龄前期及学龄期儿童（年长儿）36例。新生儿组中,早产儿比例较高（70%）;多患有肺透明膜病（45%）、肺炎（30%）等基础疾病;给予全胃肠外营养的患儿比例较其他两个年龄组高（P<0.01）。新生儿组及婴幼儿组机械通气比例明显高于年长儿组（P<0.05）。年长儿组多为血液恶性肿瘤患儿,粒细胞减少及接受化疗的患儿比例较其他两个年龄组高（P<0.05）。感染部位以肺部多见（61.5%）,其次为败血症（14.4%）、肠道（12.5%）,神经系统感染仅见于年长儿。104例患儿中共分离出105株真菌,包括假丝酵母菌 90株,隐球菌6株和其他真菌9株,以白色假丝酵母菌最多（52/105,49.5%）,非白色假丝酵母菌比例也较高（38/105,36.2%）。假丝酵母菌对5-氟胞嘧啶及两性霉素B的敏感性较高,对三唑类药物敏感性相对较低。结论：侵袭性真菌感染可发生于各年龄儿童,各年龄组间危险因素有异同;假丝酵母菌是其主要病原菌,白色假丝酵母菌所占比例高,非白色假丝酵母菌也占较高比例。假丝酵母菌对5-氟胞嘧啶和两性霉素B较为敏感。     

儿童急性髓系白血病FLT3突变临床分析：单中心研究

目的：探讨FMS样酪氨酸激酶3(FLT3)基因的内部串联复制（ITD）及激酶结构域（TKD）点突变在儿童急性髓系白血病（AML）中的临床意义。方法：通过实时定量PCR法对116名初诊AML儿童进行骨髓FLT3/ITD及FLT3/TKD突变检测,分析FLT3/ITD及FLT3/TKD突变与AML临床特征、疗效之间的关系。结果：116名患儿中,伴有FLT3/ITD及FLT3/TKD突变分别为9例（7.8%）、13例（11.2%）。3例AML-M3(3/9,33.3%)及3例AML-M5(3/9,33.3%)患儿出现FLT3/ITD突变;FLT3/TKD突变以AML-M3最多见（10/13,76.9%）。伴FLT3/ITD突变患儿较不伴该突变的患儿初诊时具有更高的白细胞及骨髓幼稚细胞比例（P<0.01）。伴FLT3/ITD突变患儿3年总生存率明显低于不伴该突变患儿（38.9% vs 64.3%,P<0.05）。结论：FLT3/TKD突变多见于儿童AML-M3患者;伴FLT3/ITD突变患儿初诊时具有更高的白细胞及骨髓幼稚细胞比例,且预后更差。     

2005~2012年中国医科大学附属盛京医院PICU疾病谱分析

目的：总结中国医科大学附属盛京医院PICU 2005~2012年间收治患儿的疾病谱及导致死亡的常见疾病种类,以指导PICU的临床治疗工作。方法：回顾性分析2005~2012年间该院PICU收治的4484例患儿的临床资料。结果：2005~2012年间4484例患儿中,急性支气管肺炎居疾病谱中第1位,占24.51%(1099/4484);颅内感染、脓毒症、手足口病、外伤等疾病有逐年上升趋势,而非创伤性颅内出血、癫癎、先天性心脏病等疾病呈下降趋势。2005~2012年间病死率呈逐年下降趋势,由2005年的11.5%下降到2012年的3.1%,其中2005~2008年与2009~2012年前后4年病死率比较差异有统计学意义（11.98% vs 4.41%;P<0.01）。急性重症支气管肺炎、重度脓毒症、复杂性先天性心脏病、重度颅脑外伤、呼吸衰竭、重症手足口病、急性中毒、循环衰竭等为患儿主要死因。结论：急性支气管肺炎等感染性疾病是2005~2012年间该院PICU的主要病种,但疾病谱随着时间的变化发生了一些改变。2005~2012年间患儿病死率呈逐年下降趋势,急性重症支气管肺炎、重度脓毒症等为患儿主要死因。     

汶川大地震送院患儿的伤情特点及专科救治流程分析

目的 总结救治"汶川大地震"儿童伤员的经验.方法 评估截止2008年5月31日住院治疗的119例地震患儿伤情特点,分析各阶段专科救治流程的影响.结果 ①83%(98/119)患儿送院时间超过震后48 h,学龄期患儿(93/119)明显多于学龄前期(26/119);②89%(106/119)为骨关节创伤患儿,其中14%(17/119)伴有严重骨筋膜室综合征;其余11%(13/119)为胸部伤(4/119)、腹部伤(5/119)、广泛软组织挤压伤(4/119)等;65%(78/119)伴有震后心理障碍;③第一阶段(震后24h),按照常规急救原则,急诊科救治时间为(1.3±0.2)h,儿外亚专业组前救治时间为(3.5±0.4)h,术前等待时间为(7.5±0.3)h;第二阶段(震后24～72 h),调整专科救治流程,急诊科救治时间缩短为(0.5±0.1)h,亚专业组前救治时间为(0.5±0.1)h,术前等待时间为(4.5±0.3)h;第三阶段(震后4～19 d)增加气性坏疽筛查流程.第二、三阶段救治效率明显提高(P<0.05).结论 汶川大地震送院患儿以骨关节创伤为主;儿外专科医师主导的"专病专治"救治模式明显提高了急救效率.     

"5·12"汶川大地震小儿伤情特点

目的 了解地震后小儿的受伤特点.方法 对地震发生后72 h内我院收治的124例儿科伤员进行分析.结果 受伤者以13～18岁年龄段最多.受伤部位以骨关节最多,共74例,占59.7%;其次为头部15例,占12.1%;挤压综合征9例,占7.3%.在骨折伤员中,下肢骨折占54.1%,其次为上肢,占28.4%.重伤伤员15例,占12.1%,抢救成功率为100%.结论 本次地震中学组伤员较多,紧急救援时应合理配置各科医务人员比例,使更多的伤员得到合理救治.     

Impact of trauma system development on pediatric injury care

Purpose

Trauma systems improve survival by directing severely injured patients to trauma centers. This study analyzes the impact of trauma systems on pediatric triage and injury mortality rates.

Methods

Population-based data were collected on injured children less than 15 years who were admitted to any hospital in New England from 1996 to 2006. Data from three trauma system states were compared to three non-trauma system states. The percentages of injured children, severely injured children, and brain-injured children admitted to trauma centers were determined as well as injury hospitalization and death rates. Time trend analysis examined the pace of change between the groups.

Results

A total of 58,583 injured children were hospitalized during the study period. Injury hospitalization rates were initially similar between the two groups (with and without trauma systems) and decreased over time in both. Rates decreased more rapidly in trauma system states compared to those without, (P = 0.003). Injury death rates decreased over time in both groups with no difference between the groups, (P = 0.20). A higher percentage of injured children were admitted to trauma centers in non-trauma system states throughout the study period, and this percentage increased in both groups of states. A higher percentage of severely injured children and brain-injured children were admitted to trauma centers in non-trauma system states and both percentages increased over time. The increase was more rapid in trauma system states for children with severe injuries (P < 0.001) and children with brain injuries (P < 0.001).

Discussion

Trauma systems decreased childhood injury hospitalization rates and increased the percentage of severely injured children and brain-injured children admitted to trauma centers. Mortality and overall triage rates were unaffected.     

Intensive care unit variables and outcome after pediatric traumatic brain injury: a retrospective study of survivors.

OBJECTIVE: Traumatic brain injury is a leading cause of death and disability in children. Hypotension has been associated with poor survival and outcome in children after traumatic brain injury, but the effect of acute hypertension is less certain. The objective was to obtain acute physiologic variables during the early hospitalization period in a cohort of children prospectively enrolled in another study. DESIGN: Retrospective chart reviews. SETTING: University-affiliated pediatric rehabilitation center. PATIENTS: Fifty-seven survivors, 5-17 yrs of age, admitted for rehabilitation between 1992 and 1995 after sustaining a traumatic brain injury. INTERVENTIONS: Standard of care. MEASUREMENTS AND MAIN RESULTS: Outcomes were assessed at 1 yr postinjury through cognitive testing of the child and parent interview of the child's global functional skills. Cognitive outcome was measured using the Performance IQ from the Wechsler Intelligence Scale for Children, Third Edition. Overall functional outcome was assessed using the Disability Rating Scale. CONCLUSIONS: This study suggests that early markers of secondary injury after moderate to severe traumatic brain injury in children may be predictive of long-term outcome. This study reinforces the need for longer term, systematic, and more precise measurements of outcomes in children with traumatic brain injury and prospective studies to examine the predictive value of acute management variables on multiple types of outcomes after traumatic brain injury in children.     

Trauma in childhood—past and future

An analysis of the cases of the injuries in children, who were admitted as victims of accidents in Safdarjang Hospital and University College of Medical Sciences, New Delhi, over a period of 24 years i.e. from 1957 onward is reported. The highest incidence was of head injury, fractures and burns. Mortality was maximum in the children who suffered from head injury or burns. An effort is made in this study to bring into focus the problem of accidental injuries in childhood, and the basic guidelines for designing a trauma centre to provide adequate resucitation, evaluation, and management of the injured child are suggested.     

地震伤患儿感染创面病原菌分布与耐药性分析

目的 探讨地震伤患儿创面感染病原菌的分布和耐药情况.方法 2008年5月13日至6月12日,我院收治汶川地震伤患儿98例,对其临床诊断为创面感染的50例进行了创面分泌物分离培养,并就病原菌和耐药情况进行回顾性分析.结果 在50例临床诊断为创面感染的患儿中,有31例创而分离培养出病原菌,阳性率62.0%;其中21例为混合感染,占67.7%.共分离培养出病原菌99株,革兰阳性菌16株(16.16%),革兰阴性菌81株(81.82%),真菌2株(2.02%).革兰阳性菌以金黄色葡萄球菌5株(5.05%)、粪肠球菌3株(3.03%)、屎肠球菌2株(2.02%)为主,革兰阴性菌中以鲍曼不动杆菌27株(27.27%)、阴沟肠杆菌18株(18.18%)、铜绿假单胞菌13株(13.13%)为主.鲍曼不动杆菌居检出病菌的首位,患儿的被困时间和并发症情况与感染该菌有明显相关性.药敏结果显示病原菌对常用抗生素耐药较为严重.1株鲍曼复合醋酸钙不动杆菌和6株鲍曼不动杆菌对包括泰能在内的所有常用抗生素耐药.革兰阳性菌对万古霉素仍敏感.结论 地震伤患儿创面感染病原菌有所变化,以往分离率低的鲍曼不动杆菌反而成为主要的感染菌,产酶菌株多,细菌耐药率高,治疗困难.了解患儿创面感染病原菌的分布和耐药性情况,可指导临床合理用药,提高抢救成功率.     

Incidence, severity, and external causes of pediatric brain injury

The number of fatal brain injuries and hospital admissions for brain injuries in children up to 15 years old in San Diego County, California, were ascertained from emergency room and hospital records, coroners' reports, death certificates, and nursing home and extended-care records for 1981. The annual brain-injury rate per 100 000 children was 185 (235 for boys and 132 for girls). The major causes of pediatric brain injury were falls (35%), recreational activities (29%), and motor vehicle crashes (24%). The case-fatality ratio was six deaths per 100 injured children. Of those children admitted to a hospital alive, 88% had a mild brain injury and 44% had no evidence of loss of consciousness. Two thirds of children with mild brain injuries and one third of those with serious brain injuries were transported to a hospital in private nonemergency vehicles.     

Frequency of intracranial pressure monitoring in infants and young toddlers with traumatic brain injury.

OBJECTIVE: To examine the use of intracranial pressure monitors and treatments for elevated intracranial pressure in brain-injured children of <2 yrs of age and compare them with the recently published management guidelines. DESIGN: Prospective, population-based study. SETTING: All pediatric intensive care units in the state of North Carolina. PATIENTS: All patients of <24 months of age admitted to a pediatric intensive care unit with a traumatic brain injury between January 2000 and December 2001. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Use of intracranial pressure monitoring devices and treatments for elevated intracranial pressure were measured. There were 136 children admitted to a pediatric intensive care unit with brain injury. A total of 54 (39.7%) had an admission Glasgow Coma Score of < or =8, and 80% were infants. Thirty-three percent of children with a Glasgow Coma Score of < or =8 received monitoring. Hyperosmolar therapy was the most frequently used treatment (57.1%). Treatment for elevated intracranial pressure was more common in, but not limited to, children with monitors. Logistic-regression modeling showed that children of < or =12 months of age had an odds ratio of 0.2 (95% confidence interval, 0.1-0.6) of receiving a monitor compared with children aged 12-24 months. CONCLUSIONS: Brain injury in young children may lead to many years of lost quality of life. The utility of monitoring intracranial pressure in infants has not been well established, which may be a reason for its low use. As most infants with traumatic brain injury survive, high-quality studies with neurodevelopmental measures as the primary outcome are urgently needed to document best practice in this subpopulation.     

Diagnosis and management of pediatric closed head injury

Closed head injury in the pediatric population accounts for almost half of all new cases of traumatic brain injury. The incidence of severe brain injury appears to be less in children as compared to the adult population. Over the past several years, advances in recognition and treatment of traumatic brain injury have led to improved outcomes in both children and adults. It is imperative, therefore, for the pediatric surgeon dealing with head trauma to have an understanding of the common brain injuries in the pediatric population, their early recognition and initial management. In this article, early diagnosis and initial management of the most common forms of pediatric closed head injury are reviewed.