Pediatric trauma in the rural and low resourced communities

Death and disability associated with traumatic injury can be significantly decreased with timely and appropriate care. Patients in rural areas tend to have disproportionately decreased access to this care, with the pediatric age group acting as a particularly difficult challenge for pre-hospital and rural hospital settings due to the unfamiliarity of those trauma response teams with pediatric age specific management guidelines as well as a disparity in resource availability. In this review, we attempt to discuss the challenges facing pediatric trauma care in the rural and low resourced communities, as well as initiatives that are being carried out to optimize this kind of care, such as pediatric readiness, rapid transportation to higher levels of care, availability of blood in rural centers as well as in transit, and the utility of telemedicine in improving rural pediatric trauma care.     

Pediatric orthopedic trauma: principles of management

Musculoskeletal injuries in the pediatric population are unique and require a thorough evaluation by a trained specialist. Unlike adults, many of the injuries may be treated closed due to the amazing growth and remodeling potential of children. Special consideration should be taken in treating certain fracture patterns to prevent the long-term consequences of growth deformities and protect children from child abuse. It is the goal of this article to outline common orthopedic injuries in the pediatric population to facilitate proper care in the multidisciplinary evaluation and treatment of children.     

Pediatric patients in a regional burn center

Because scald burns are reported to be the leading cause of burn injuries to children, little is written about other etiologies of burn injury in the pediatric literature. To test the hypothesis that burns from other etiologies are more serious and require longer hospitalizations than scald burns, a retrospective chart review was undertaken. The charts of all patients less than 16 years of age who were admitted to Harborview Medical Center Burn Unit in the years 1979 to 1984 were reviewed. Four hundred sixty-four children were admitted to the regional burn center during that time. We found that children under four years of age are at greatest risk for being hospitalized for thermal injury, that the burn most commonly occurs inside the home between 6 PM and midnight, and that scalds are the most common etiology for thermal injuries in children (54%). However, 46% of the burns resulting in admission to our burn center were from etiologies other than scald injury. There was no significant correlation between etiology of the burns and length of hospital stay, rate of infection, or need for excision and grafting. Thermal injuries to children from any etiology are serious; pediatric health care providers should be aware that children may be burned in a variety of ways and should direct some of their well-child visit time to the topic of burn prevention in the home.     

The synergistic relationship between a level I trauma center and a regional pediatric trauma center

A regional pediatric trauma center and a level I trauma center with pediatric commitment in the same city developed a synergistic relationship addressing all aspects of care for pediatric trauma patients. Although it is unlikely that this model could be used in its entirety by all similar institutions, the principles may prove helpful in creating guidelines and relationships. Categorization, optimal use of resources, timely transportation of seriously injured children to the appropriate facility, and maintaining urgent care capabilities of each institution to care for seriously injured children are imperative. The combined effort resulted in our level I trauma center being verified by the American College of Surgeons and designated by our state Health Department as meeting all the criteria for pediatric trauma care. This experience should encourage every pediatric trauma center located in a children's hospital to become a regional pediatric trauma center. The real benefit from the relationship is that injured children receive optimal care at both institutions.     

Pediatric eye trauma

Ocular trauma is a much more common cause of visual loss than is generally recognized. The authors present guidelines for the examination of eye injuries and follow with a discussion of the more common and more serious traumatic injuries.     

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.     

Pediatric maxillofacial trauma.

The accurate diagnosis and timely, appropriate treatment of soft-tissue and bony maxillofacial injuries in children are of critical importance due to the potential adverse impact of maxillofacial trauma on subsequent facial growth and development. Guidelines are provided to assist the pediatrician in the evaluation and treatment of minor and major facial injuries.     

Pediatric blunt abdominal trauma

Blunt pediatric trauma is a major threat to the health and well-being of children. Nationwide, many practitioners care for children who face this issue. Some key principles related to the evaluation and management of these children are elucidated in this article.     

Pediatric dermatoses pattern at a Brazilian reference center

ObjectiveThe aim of this study was to identify the pattern of pediatric dermatoses of patients evaluated at a dermatologic clinic of a reference center in Brazil and to compare these results to similar surveys conducted in other countries.MethodsA retrospective study was performed of patients up to 18 years old, evaluated at a dermatologic clinic between January 1, 2017 and December 31, 2017. Variables collected for analysis included age, gender, dermatological diagnosis, multidisciplinary follow-up, hospitalization, and complementary exams.ResultsA total of 2330 patients were included for analysis, with a mean age of 9.7 years. 295 patients were diagnosed with more than one skin disease, leading to a total of 2668 diagnoses. Skin diseases were organized into categories and inflammatory dermatoses corresponded to the largest group (31.2%), mostly due to atopic dermatitis (18.3%). The other main categories were: genodermatoses (14.2%), infectious diseases (12.6%), adnexal disorders (12.5%), cysts and neoplasms (10.7%), and vascular disorders (7.0%). Fifty-six patients needed to be admitted to the dermatology ward; 25 of them (44.6%) for management of worsening of the skin disease, mainly atopic dermatitis, psoriasis, and drug reactions. There were 885 biopsies performed in 38.0% of the subjects and 751 patients (32.2%) required multidisciplinary care; most of them had some genodermatoses.ConclusionsDermatologic disorders are very common in the pediatric age group and differ from those in adults, suffering influence from cultural, ethnic, socioeconomic, and environmental factors. Knowing the magnitude and distribution of these dermatoses is important to better plan healthcare policies.     

Pediatric chest CT after trauma: impact on surgical and clinical management

Background

Chest CT after pediatric trauma is frequently performed but its clinical impact, particularly with respect to surgical intervention, has not been adequately evaluated.

Objective

To assess the impact of chest CT compared with chest radiography on pediatric trauma management.

Materials and methods

Two hundred thirty-five consecutive pediatric trauma patients who had both chest CT and radiography were identified. Images were reviewed and findings were categorized and correlated with subsequent chest interventions, blinded to final outcome and management.

Results

Of the 235 children, 38.3% (90/235) had an abnormal chest radiograph and 63.8% (150/235) had an abnormal chest CT (P?<?0.0001). Chest interventions followed in 4.7% (11/235); of these, the findings could be made 1 cm above the dome of the liver in 91% (10/11). Findings requiring chest intervention included pneumothorax (PTX) and vertebral fractures. PTX was found on 2.1% (5/235) of chest radiographs and 20.0% (47/235) of chest CTs (P?<?0.0001); 1.7% (4/235) of the children received a chest tube for PTX, 0.85% (2/235) seen on chest CT only. Vertebral fractures were present in 3.8% of the children (9/235) and 66.7% (6/9) of those cases were treated with spinal fusion or brace. There were no instances of mediastinal vascular injury.

Conclusion

Most intrathoracic findings requiring surgical management in our population were identified in the lower chest and would be included in routine abdominopelvic CT exams; this information needs to be taken into consideration in the diagnostic algorithm of pediatric trauma patients.     

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.     

Pediatric cardiopulmonary arrests in rural populations

We reviewed emergency department records that spanned a period of 5 years at seven rural hospitals to provide more specific data concerning pediatric resuscitation. The purpose was to plan better for preventive programs and to help rural health care providers prepare better for these difficult patients. Patients entered in the study had either cardiorespiratory arrest or respiratory arrest. Although the distribution by age was similar to studies from other areas, the outcome for cardiorespiratory arrests was as bad or worse (70 arrests with 3 survivors), and the outcome of respiratory arrests was as good or better (25 arrests with 21 survivors) as reported previously. Survival of arrest from trauma and accidents was markedly worse (16%) than survival from nontraumatic arrests (44%). The etiologies of the arrests were dominated by sudden infant death syndrome and pulmonary disease but with very few drownings or farm-related fatalities. This study should encourage rural health care providers to increase efforts in specific areas of trauma and accident prevention. Also, respiratory illness needs to be monitored aggressively and respiratory arrests treated more effectively to avoid the much more consistently lethal cardiac arrests. In addition, more careful prospective study of these patients may be able to identify care patterns that can be improved to increase survival in these groups.     

Pediatric cervical spine trauma imaging: a practical approach

Cervical spine trauma in children is rare and the diagnosis can be challenging due to anatomical and biomechanical differences as compared to adults. A variety of algorithms have been used in adults to accurately diagnose injuries, but have not been fully studied in pediatric patients. In this article we review suggested imaging protocols and the general characteristics, types of injuries, and measurements used to diagnose cervical spine injuries in children.