Transient electrocardiographic abnormalities following blunt chest trauma in a child

Blunt cardiac injury may occur in patients after suffering nonpenetrating trauma of the chest. It encompasses a wide spectrum of cardiac injury with varied severity and clinical presentation. Electrocardiographic abnormalities are frequently encountered. This article presents a case of a child who presented with complete right bundle branch block on the initial ECG at the emergency department. She suffered blunt chest trauma during a horseback riding accident. She was admitted for cardiac monitoring. The electrocardiographic abnormalities resolved within 12 hours. No signs of myocardial injury were found on repeat serum troponin measurement and echocardiography. The natural history of ECG abnormalities in the pediatric age group following blunt chest trauma is limited. Although a complete right bundle branch block may be transient in adult patients, this has not been previously reported in a children. Significant ECG abnormalities can be encountered in children following blunt chest trauma. Although a complete RBBB can be associated with severe injury to the RV, it can also occur with minor injury.     

Repair of bile duct perforation by omental inlay

A Perforation of the right hepatic duct following blunt trauma to the abdomen was successfully repaired by an inlay pedicled flap of omentum 3 weeks after the injury. Correspondence to: K. L. Narasimhan     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

Total prepyloric transection of stomach and vertebral trauma: case report and review of the literature

A rare injury of stomach associated with vertebral trauma in a 10-year-old girl, a victim of a traffic accident, is presented. Early X-ray and computerized tomography scan revealed no free abdominal air, only signs of pancreas contusion and fracture of the Th 12 and L 1 vertebral body were evident. Transection of stomach was revealed during endoscopy (an attempt to perform retrograde cholangio-pancreaticography) 20 h after the trauma. Primary suture of the rupture was performed. Sepsis and multiple organ dysfunction syndrome developed in the postoperative course. The girl subsequently underwent four laparotomies for abdominal infection, bleeding and colonic stricture. After resolution of the abdominal disorders the girl underwent surgical stabilization of spine. Currently, 2 years after trauma, she is doing well without any gastroenterologic dysfunction.     

Prehospital predictors of risk for pelvic fractures in pediatric trauma patients

Pelvic fractures are uncommon in children, but can occur as a result of high-energy impact injuries to the lower torso in association with blunt trauma. Pelvic fractures can be associated with significant morbidity while the work-up and treatment for these injuries is costly. The aim was to identify risk factors that help determine which pediatric trauma patients are at highest risk of sustaining a pelvic fracture to aid in the development of criteria for the targeted use of pelvic radiographic imaging. A retrospective analysis was conducted using the only pediatric trauma registry in the state of Maryland, located at The Johns Hopkins Children's Center. All blunt trauma patients who were younger than 15 years of age from 1990 to 2005 were included in the analysis (n = 13,360) with a final diagnosis of pelvic fracture as the primary outcome of interest. Comparisons were made using Pearson's chi-square for categorical and the Mann-Whitney rank sum test for non-normally distributed variables. Pelvic fractures following blunt trauma in children are associated with age, race, place and mechanism of injury. Compared to children 4 years and younger, pelvic fractures were more likely to occur in children aged 5-9 years (OR = 3; P = 0.000), as well as 10-14 years (OR = 5; P = 0.000). Compared to blunt trauma injuries from falls, children who were struck by vehicles or who were occupants in motor vehicle crashes (MVC) were six times (P = 0.000) and twice (P = 0.02) as likely to sustain a pelvic fracture, respectively. Four factors were demonstrated by this study to be significantly associated with pediatric pelvic fractures: being Caucasian, age between 5 and 14 years, being struck as a pedestrian or a motor vehicle crash occupant. Identification of these factors may aid clinicians in selecting patients who are at highest risk for pelvic fracture and may benefit most from pelvic radiography.     

Stricture of the common bile duct secondary to blunt abdominal trauma

A 3-year- 8-month-old girl developed obstructive jaundice associated with stricture of the distal end of the common bile duct 7 months after blunt abdominal trauma. Ultrasonography, computerised tomography, and percutaneous trans-hepatic cholangiography made the anatomical diagnosis before surgical reconstruction. Histological examination of the retroperitoneal tissue near the site of the stricture showed evidence of previous bile leakage due to rupture of the duct. Relief of obstruction was achieved by a Roux-en-Y choledochojejunostomy with complete resolution of symptoms and restoration of normal liver function. Offprint requests to: H. C. O Martin     

A comparison between scintigraphy and computed abdominal tomography in blunt liver and spleen injuries in children

Fifty consecutive paediatric patients with objective clinical signs of blunt abdominal trauma underwent both computed abdominal tomography (CT) and liver-spleen scintigraphy (LSS). All were managed non-operatively with no morbidity or mortality. Five splenic and 13 liver injuries were visualised on CT while LSS revealed 9 splenic and 29 liver injuries. Where injury to either organ was detected by both modalities, there was good correlation anatomically and also as to the extent of injury. LSS demonstrated injuries not shown on CT, which appeared to detect only more extensive injuries. We conclude that scintigraphy may be the more sensitive and therefore more appropriate method when blunt injury to the liver and spleen alone is clinically suspected. Abdominal CT remains the early investigation of choice in patients with clinical evidence of haemoperitoneum associated with shock or multiple injuries, particularly when injury to the kidneys as well as to the liver and spleen is suspected or when a concomitant brain scan is indicated. Offprint requests to: D. H. Bass     

Blunt trauma causing diaphragmatic rupture in children

Six children have been admitted over the last 10 years with blunt abdominal trauma causing diaphragmatic rupture. Four were acute presentations, with the emphasis on cardio-respiratory symptoms. There was a high incidence of associated injuries. Early laparotomy and repair of the diaphragm was performed successfully, and three out of four patients survived. Two patients presented late with gastrointestinal tract symptoms. A thoracotomy was necessary to free the adherent herniated bowel in one case. The peripheral nature of the lesion in children suggests that avulsion, aggravated by the increased elasticity and recoil of the thoracic cage, may play a major role in pathogenesis. Diaphragmatic rupture must be excluded in all severe cases of blunt abdominal trauma. Offprint requests to: R. A. Brown     

Post traumatic bile ascites

A 4 year old girl with progressive distension of abdomen and previous history of blunt abdominal trauma was found to have bile ascites due to left hepatic duct (LDH) injury. The management with a brief review of literature is discussed below.     

Blunt renal injuries in Turkish children: a review of 205 cases

A retrospective analysis of the medical records of 205 children with renal injuries secondary to blunt abdominal trauma is used to make recommendations regarding the initial diagnostic and therapeutic approaches in this type of patient. It was found that the absence of hematuria on initial urinalysis does not exclude a serious renal injury. Thus, following blunt abdominal trauma, all children should undergo imaging procedures to exclude renal injury, whether they have hematuria or not. Ultrasound is a good initial screening procedure in all patients. Computed tomography is recommended for the definitive evaluation of suspected major renal injuries. Since even major renal injuries may heal without surgical intervention, conservative management is the recommended initial treatment of choice. Surgery is reserved for those children who are hemodynamically unstable and those that develop complications.     

Compressive chylothorax after lumbar spine fracture

A 14-year-old boy was admitted to the hospital after an episode of blunt trauma to the thorax, resulting in a Chance fracture of L1 and a compressive chylothorax 72 h after admission. After initial drainage in the operating room, conservative management was successful. This case study documents one of the rare complications of spinal fractures in the context of high-energy blunt trauma. It is the first detailing a noniatrogenic post-traumatic compressive chylothorax in pediatrics responding positively to conservative management. Drainage should be considered the first-line procedure for both therapeutic and diagnostic purposes. Surgery is required if the leakage is still present after parenteral feeding and the implementation of a fat-free diet for 5–7 days.     

Pyogenic Liver Abscess due to Bacteroides fragilis

A 10-year-old boy with anaerobic pyogenic liver abscesses due to Bacteroides fragilis is reported. Blunt trauma was considered as the possible cause of the liver abscesses. Imaging methods such as ultrasonography, computed tomography and liver scannings were useful for the diagnosis of the case. The patient was cured after treatment with surgical debridement and drainage followed by a 10-day course of intravenous Lincomycin.     

Bronchial rupture in children following blunt chest trauma

We present five patients with fracture of the bronchus, in whom the diagnois of bronchial rupture was first suggested because of persistent leakage of air, atelectasis of a segment of the lung or of the entire lung, mediastinal and deep cervical emphysema. In all patients the bronchoscopy was essential to confirm the diagnosis and to determine the full extent of injury.     

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.     

Hypertension following minor trauma: a rare presentation of pheochromocytoma

The diagnosis of pheochromocytoma (Pheo) can be challenging due to the variety of potential presentations of this infrequent tumor. A 16-year-old boy presented with hypertension and sudden abdominal pain after minor blunt abdominal trauma. Both computer tomography (CT) and magnetic resonance (MR) scanning identified a right suprarenal mass, and raised the possibility of a Pheo. This diagnosis was confirmed through urine catecholamine testing and ¹³¹I metaiodobenzylguanidine (MIBG) scanning. An extra-adrenal Pheo was successfully resected. The presentation of Pheos is quite variable, and patients may often be essentially asymptomatic. Pheo should be considered in hypertensive pediatric patients with a history of blunt abdominal trauma. Accepted: 26 May 1998     

Embolization of traumatic hemobilia in a child

The management of a case of hemobilia in a child after abdominal trauma is described. Two intrahepatic false aneurysms and an arterioportal fistula in the right lobe of the liver were diagnosed by ultrasound and Doppler and successfully embolized during the diagnostic angiogram. Selective angiographic embolization may save the patient an operative procedure and appears to be an acceptable method for primary treatment of this condition in children. Offprint requests to: F. Gauthier     

Pediatric blunt splenic trauma: a comprehensive review

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.     

Tracheobronchial rupture in a child following blunt trauma

A 6-year-old boy sustained a crush injury to the upper chest that resulted in a linear laceration of the membranous part of the lower trachea and right main stem bronchus. He presented with extensive subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum. The diagnosis was indicated by a CT scan of the chest and confirmed by bronchoscopy. The trachea was intubated in the operating room after rigid bronchoscopy. Intraoperative leakage of gas from the tracheobronchial laceration was minimized by single left-lung manual ventilation and application of moist packs to the site of tracheal injury. Surgical repair was achieved with interrupted sutures of non-absorbable material; a pedicle pleural flap was used to buttress the suture line. The patient was discharged in good condition after 1 week. Complete healing of the anastomosis was attested at bronchoscopy 2 months postoperatively. The rarity of tracheobronchial lacerations in childhood is noted on review of the literature. Emphasis is placed on early recognition and expeditious management of tracheobronchial lacerations. Rarely, these lacerations have been reported to heal spontaneously.     

Rupture of the right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma

 The diagnosis of right-sided diaphragmatic rupture (RDR) due to blunt abdominal trauma is often missed in the acute setting, especially in the absence of other thoracoabdominal injuries. We describe two such children. The problems associated with the diagnosis and management of RDR are discussed to emphasize the need to have a high index of suspicion for this entity.