A pediatric trauma center without a pediatric surgeon: a four-year outcome analysis.

Approximately 25% of all injury victims are in the pediatric age group, and one in four injured children will require a pediatric trauma center. According to the American College of Surgeons as well as many state guidelines, a level I pediatric trauma team should be directed by a pediatric surgeon. In 1986, the pediatric surgeon left our pediatric trauma center, but the center remained open under a cooperative effort by the adult trauma surgeons and pediatric intensivists. We have retrospectively reviewed the charts of all pediatric trauma patients (age less than or equal to 15 years) for the subsequent 4 years to determine the outcome of treatment without a pediatric surgeon. During this period, we treated 303 pediatric patients with multiple or serious single-system injuries. The mean age was 6.9 +/- 0.3 (SEM) years and 66% were boys. Falls were the cause of injury in 31% of the patients, with pedestrian/bicycle, motor vehicle crashes, and penetrating injuries resulting in 26%, 19%, and 3% of the injuries, respectively. The mean ISS was 15.6 +/- 0.8, and 73% of the patients had at least one AIS greater than or equal to 3. Surgical procedures were required in 48% of the patients. There were 27 deaths in this group, most commonly related to head injury (89%). The mean Pediatric Trauma Score of the patients who died was 1.6 +/- 0.8 and no patient with a Pediatric Trauma Score greater than 7 died.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pedestrians injured by automobiles: relationship of age to injury type and severity

BACKGROUND: There is little research on the effect of age on the nature and severity of injuries to pedestrians struck by automobiles. STUDY DESIGN: Trauma registry study included all auto versus pedestrian trauma admissions of pedestrians injured by automobiles at an academic Level I trauma center over 10 years and 4 months. Injury Severity Score, severe body area (head, chest, abdomen, extremities) trauma with Abbreviated Injury Score >3, specific organ injuries, and mortality were calculated according to age groups (< or =14 years, 15 to 55 years, 56 to 65 years, >65 years). RESULTS: During the study period 5,838 admissions were reviewed. There were 1,136 patients (19.4%) 14 years old or less, 3,741 (64.1%) who were 15 to 55 years, 420 (7.2%) 56 to 65 years, and 541 (9.3%) older than 65 years. Overall mortality was 7.7% and ranged from 3.2% in the age group 14 years or less to 25.1% in patients over 65 years. The incidences of severe trauma (Injury Severity Score >15) in the four age groups were 11.2%, 18.7%, 23.6%, and 36.8%, respectively. The incidences of critical trauma (Injury Severity Score >30) were 2.3%, 3.9%, 5.7%, and 13.9%, respectively. The incidence of severe head and chest trauma (Abbreviated Injury Score >3) increased with age. The incidence of solid organ and hollow viscus injuries was similar in all age groups. Spinal injuries increased significantly with age and ranged from 0.4% in the pediatric group to 8.5% in the elderly group. Pelvic and tibial fractures were significantly more common in adults; femur fractures were significantly more common in the pediatric group. CONCLUSIONS: Age plays an important role in the anatomic distribution and severity of injuries and survival outcomes after pedestrian injuries.     

Pediatric pelvic fractures: a marker for injury severity

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.     

Injuries associated with pediatric liver trauma

Injury remains the leading cause of childhood mortality for children younger than 14 years of age, with the liver being particularly susceptible to blunt trauma in children. This study reviews the authors' institutions' experience with pediatric liver injuries in an attempt to establish current patterns of injury, management and outcomes. A single-center, retrospective review was conducted of 105 consecutive pediatric patients who presented with a traumatic liver injury from January 1996 through February 2004. Average patient age was 13.1+/-4.9 years and 58 per cent were male. Perihospital mortality was 8.6 per cent, with 67 per cent of mortality being attributed to head injury. The majority of patients were managed nonoperatively (81%). Liver injury was most often grade II (35%) by CT scan. Liver injury grade did not affect survival, but did affect injury management, with grade I and grade IV liver injuries more likely to be managed surgically (P < 0.001). Grade I liver injuries were associated with concomitant spleen injuries, whereas grade IV injuries were associated with pancreatic injuries. Surgical management was associated with a higher injury severity score (P = 0.005), higher mortality (P = 0.01), and with other associated injuries as well. Children experiencing blunt abdominal trauma are at risk of significant morbidity and mortality; however, these risks stem more likely from associated injuries than injury to the liver proper. Clinicians should maintain a high index of suspicion for potentially catastrophic associated injuries to the pancreas with high-grade liver injury.     

Paediatric trauma: urban epidemiology and an analysis of methods for assessing the severity of trauma in 598 injured children

This study is based on a 12 month prospective analysis of 598 paediatric trauma admissions, drawn principally from an urban environment. The spectrum of trauma is described, highlighting the minor nature of most injuries and the rarity of penetrating trauma. A subgroup of seriously injured children was identified and further analysed. All deaths were examined. The predictive value of the Trauma Score (TS) and Method of Injury (MOI) were assessed in terms of eventual injury severity using the Injury Severity Score (ISS), and morbid outcome. Most of the patients were not seriously injured, and sustained single system injury only. The injuries were related principally to falls (62%). Seventy-nine children (13%) were identified as seriously injured (ISS greater than or equal to 16). In this group pedestrian injuries were the major cause of injury (29%). Amongst seriously injured children, cranial injury was identified in 91%, followed by abdominal injury in 33%. There were nine deaths in the series, representing 1.5% of all paediatric trauma admissions, and 11% of seriously injured patients. All deaths were associated with a significant head injury. Although the TS had a specificity of 99% in predicting serious injury and a positive predictive value of 94%, its sensitivity was only 26%. The MOI was associated with an overtriage rate of 200%. Of children admitted following pedal cycle accidents, 86% of the total and 91% of seriously injured children were not wearing a helmet. Of passengers in a motor car, 37% of the total number were unrestrained. The results suggest triage in children requires more than a physiological measure (TS) or MOI.(ABSTRACT TRUNCATED AT 250 WORDS)     

Thoracic trauma in children: an indicator of increased mortality

This study was undertaken to assess the significance of thoracic trauma as a marker of morbidity and mortality in children. During a 34-month period, 2,086 children younger than 15 years old were consecutively admitted to a Level I pediatric trauma center with blunt or penetrating trauma. For each child we prospectively recorded Trauma Score (TS), Injury Severity Score, (ISS), medical, and etiologic data. One hundred four children (4.4%) presented with thoracic trauma. The most common mechanisms of injury were pedestrian injury (36%), motor vehicle crashes (32%), and armed assault (12%). The most common injuries were pulmonary contusion (48%), pneumothorax, hemothorax, or pneumohemothorax (39%), and rib fractures (32%). Multisystem injury was present in 82% of the children. The mean TS and ISS were 11 and 27, respectively, significantly worse than scores for children without thoracic injury (15 and 7; P less than .0001). Seventy-one percent of the children were admitted to the intensive care unit, where they stayed an average of 6 days; 20% required surgery. The mortality rate was 26%. Injuries to the heart or great vessels had the highest mortality rate (75%), followed by hemothorax (53%), lung laceration (43%), and rib fracture (42%). Mortality for children with isolated chest injury was 5%, compared with rates of 20% for abdominal and chest trauma, 35% for head and chest trauma, and 39% for trauma to the head, chest, and abdomen. Less than 5% of the admissions to a pediatric trauma center incurred thoracic injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Chest Trauma in Children, Single Center Experience

Trauma is the leading cause of mortality in children over one year of age in industrialized countries. In this retrospective study we reviewed all chest trauma in pediatric patients admitted to Mansoura University Emergency Hospital from January 1997 to January 2007. Our hospital received 472 patients under the age of 18. Male patients were 374 with a mean age of 9.2±4.9 years. Causes were penetrating (2.1%) and blunt trauma (97.9%). The trauma was pedestrian injuries (38.3%), motor vehicle (28.1%), motorcycle crash (19.9%), falling from height (6.7%), animal trauma (2.9%), and sports injury (1.2%). Type of injury was pulmonary contusions (27.1%) and lacerations (6.9%), rib fractures (23.9%) and flail chest (2.5%), hemothorax (18%), hemopneumothorax (11.8%), pneumothorax (23.7%), surgical emphysema (6.1%), tracheobronchial injury (5.3%), and diaphragm injury (2.1%). Associated lesions were head injuries (38.9%), bone fractures (33.5%), and abdominal injuries (16.7%). Management was conservative (29.9%), tube thoracostomy (58.1%), and thoracotomy (12.1%). Mortality rate was (7.2%) and multiple trauma was the main cause of death (82.3%) (P<.001). We concluded that blunt trauma is the most common cause of pediatric chest trauma and often due to pedestrian injuries. Rib fractures and pulmonary contusions are the most frequent injuries. Delay in diagnosis and multiple trauma are associated with high incidence of mortality.     

Intensive care unit outcome of vehicle-related injury in elderly trauma patients

Vehicle-related trauma is a common mechanism of injury in elderly (age > or = 65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.     

Determinants of survival after inferior vena cava trauma.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.     

Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons?

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.     

Blunt diaphragmatic rupture in children

BACKGROUND: Although several series of blunt diaphragmatic rupture in adults have been published, this injury remains largely uncharacterized in the pediatric population. METHODS: We queried our trauma registry for all children admitted with blunt diaphragmatic rupture over a 10-year period at a Level I pediatric trauma center. RESULTS: Six children (aged 2-15 years; mean, 7 years) were identified with blunt diaphragmatic rupture (three right, two left, one bilateral), representing 0.4% of admissions. All of the children had associated injuries (4.5 per child), with a mean Injury Severity Score of 32. Four diaphragmatic injuries were identified during the initial evaluation. The two missed injuries were diagnosed at postinjury days 5 and 8. There were no deaths and all children were eventually discharged without sequelae. CONCLUSION: Blunt diaphragmatic rupture occurs in children with a frequency and severity commensurate with that observed in adults. Our data suggest improved survival compared with adults with this injury.     

Nonoperative management of pediatric blunt hepatic trauma

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children < or = 16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean +/- standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 +/- 1.0 years (range 3-16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 +/- 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.     

Cost factors in Canadian pediatric trauma.

OBJECTIVES: To estimate the costs of Canadian pediatric trauma and identify cost predictors. DESIGN: A chart review. SETTING: A regional trauma centre. STUDY MATERIAL: The charts of all 221 children who suffered traumatic injuries with an Injury Severity Score (ISS) of 4 or more seen over 6 years at a regional trauma centre. MAIN OUTCOME MEASURES: Patient data, injury data, all hospital-based costs, excluding nursing, food and medication costs. RESULTS: Mean (and standard deviation) patient age was 12.8 (5) years. Sixty percent were boys. Motor vehicle accidents (MVAs) accounted for 71% of the injuries, followed by falls (11%). The mean (and SD) total cost of care was Can$7,582 (Can$12,370), and the cost of media was Can$2,666. Total cost correlated directly with age (r = 0.29, p < 0.001) and Injury Severity Score (ISS) (r = 0.34, p < 0.001) and inversely with the Pediatric Trauma Score (PTS) (r = -0.20, p = 0.003). The presence of extremity injuries correlated significantly with total cost (r = 0.22, p = 0.001) and PTS (r = -0.25, p < 0.001) but not with the ISS. Logistic regression analysis identified runk injury, ISS and PTS as the main determinants of survival. CONCLUSIONS: The cost of pediatric trauma in Canada can be predicted from admission data and trauma scores. The cost of extremity injuries is significant and can be predicted by the PTS but not the ISS.     

Helicopter transport of pediatric trauma patients in an urban emergency medical services system: a critical analysis

BACKGROUND: Helicopter transport of pediatric trauma patients in an urban Emergency Medical Services system remains controversial. METHODS: A retrospective review of pediatric patients transported by helicopter to a pediatric trauma center in Los Angeles, California, was conducted over a 3-year period. Pediatric patients (age < 15 years) are transported by helicopter if ground transport to a pediatric trauma center would exceed 20 minutes. Emergency Medical Services reports and hospital records were reviewed for key prehospital and outcome indicators. RESULTS: One hundred eighty-nine patients met the study inclusion criteria. The median age was 5 years (range, 0-14 years). The most common mechanisms of injury were falls and automobile versus pedestrian crashes. Eighty-two percent of patients had a Revised Trauma Score > 7. Of the 175 (93%) patients whose hospital records were available, 24 (14%) were intubated in the emergency department, 32 (18%) were admitted to the intensive care unit, and 7 (4%) were taken directly to the operating room. Injury Severity Scores (ISSs) were as follows: ISS 0 to 15, 146 (83%); ISS 16 to 30, 26 (15%); and ISS > 30, 3 (2%). Fifty-seven (33%) patients were discharged home from the emergency department. CONCLUSION: The majority of pediatric trauma patients transported by helicopter in our study sustained minor injuries. A revised policy to better identify pediatric patients who might benefit from helicopter transport appears to be warranted.     

Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries

BACKGROUND: Pancreaticoduodenectomy (Whipple's procedure) is a formidable procedure when undertaken for severe pancreaticoduodenal injury. The purposes of this study were to review our experience with this procedure for trauma; to classify injury grades for both pancreatic and duodenal injuries in patients undergoing pancreaticoduodenectomy according to the American Association for the Surgery of Trauma-Organ Injury Scale for pancreatic and duodenal injury; and to validate existing indications for performance of this procedure. STUDY DESIGN: We performed a retrospective 126-month study (May 1992 to December 2002) of all patients admitted with proven complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy. RESULTS: Eighteen patients were included; mean age was 32 +/- 12 years (SD), mean Revised Trauma Score was 6.84 +/- 2.13 (SD), and mean Injury Severity Score was 27 +/- 8 (SD). There were 17 penetrating injuries (94%) and 1 blunt injury (6%). One of 18 patients had an emergency department thoracotomy and died (100% mortality); 5 of the remaining 17 patients required operating room thoracotomies, and only 1 survived (80% mortality). There was 1 AAST-OIS pancreas grade IV injury, and there were 17 pancreas grade V injuries and 18 AAST-OIS duodenum grade V injuries. Indications for pancreaticoduodenectomy were: massive uncontrollable retropancreatic hemorrhage, 13 patients (72%); massive unreconstructable injury to the head of the pancreas/main pancreatic duct and intrapancreatic portion/distal common bile duct, 18 patients (100%); and massive unreconstructable injury, 18 patients (100%). Mean estimated blood loss was 6,888 +/- 7,866 mL, and overall survival was 67% (12 of 18 patients). CONCLUSIONS: Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy (Whipple's procedure) are uncommon but highly lethal; virtually all are classified as AAST-OIS grade V for both pancreas and duodenum. Current indications for performance of pancreaticoduodenectomy are valid and should be strictly applied during procedure selection.     

The baseball bat: a popular mechanism of urban injury.

From January 1989 through December 1990, 74 patients were admitted to our urban level I trauma center with injuries inflicted by baseball bats. We investigated the demographics and dynamics of injury in these patients by retrospective analysis of the patient's medical record and Trauma Registry data. The average victim was 30 years old. Ninety-two percent of the patients were male, and approximately 89% tested positive for substance abuse. Injury to both the head and body occurred in 80% of our patients, isolated head injury occurred in 42%. Twenty percent suffered injury to the body only. On admission, 7% went directly to the operating suite, 16% were admitted to the trauma ICU, one patient was admitted to the pediatric ICU, and the remainder were admitted to the floor shock/trauma unit. These patients had a length of stay (LOS) that was not significantly different than the LOS for patients with penetrating trauma or the general trauma population. The mean Trauma Score was 13.8 (range, 6-16), and the average Injury Severity Score was 10.5 (range, 1-34). The mortality in our study was 3%. Four percent of the patients were left with some degree of permanent disability. Intentionally inflicted injury is most commonly seen in the thorax and abdomen. In contrast, head injury was evident in 80% of our patients with baseball bat injury. This represents a departure from classic patterns of violent injury.     

Recent trends in the management of combined pancreatoduodenal injuries

In an effort to better characterize the natural history of pancreatoduodenal injuries, we present a review of clinical experiences in the treatment of combined traumatic pancreatoduodenal injuries, focusing on patients in extremis. Records of patients with abdominal trauma admitted to a level 1 trauma center from 1997 to 2001 were reviewed. Of 240 patients who sustained a pancreatic or duodenal injury, 33 had combined pancreatoduodenal injuries. Eighty-two per cent of the patients (27/33) in this series had penetrating injuries, 72 per cent (24) sustained gunshot wounds (GSW). Thirty-one patients were male, and the mean age was 33 years (range, 7-74). These patients presented with an average Injury Severity Score (ISS) of 22 +/- 12 and an average Glasgow Coma Score of 14 +/- 2. Overall length of stay was 39 +/- 59 days (range, 0-351 days). These 33 patients underwent a total of 57 laparotomies with an average of 1.7 operations per patient (range, 1 to 5 operations). Eighty-four per cent of the patients had an associated gastrointestinal injury and 45 per cent had a major vascular injury. Thirteen of the 33 (39%) patients presented in extremis, all 13 underwent an abbreviated laparotomy. The complication rate was 36 per cent, including fistula, abscess, pancreatitis, and organ dysfunction. There were 6 hospital deaths for a mortality rate of 18 per cent. Pancreatoduodenal injuries are associated with a variety of other serious injuries, which add to the overall complexity of these patients. Abbreviated laparotomy may be helpful when managing combined pancreatoduodenal injuries in patients who are in extremis.     

Dog bite injuries in children: a preliminary survey.

Dog bite injuries in children are a preventable health problem. To characterize this type of injury, we have undertaken to define demographic criteria and patterns of injury inflicted by dogs in our pediatric population. A retrospective chart review was conducted of pediatric patients with dog bite injuries admitted to a Level I pediatric trauma center from January 1986 through June 1998. Patient demographics, canine characteristics, and hospital patient data were collected and analyzed using the Excel program and appropriate statistical methodology. There were 67 patient records reviewed. Thirty-eight (57%) of the patients were male, and 29 (43%) were female. There were 43 (64%) white children, 22 (33%) African-American children, and 2 (3%) Hispanic children. The average age of the children was 6.2 +/- 4.2 years, with an average weight of 23.3 +/- 13.7 kg. More than half the attacks occurred in the afternoon and 55 per cent of these attacks were documented as "unprovoked" attacks. Thirty-one (46%) of these attacks involved family pets, and 30 (45%) dogs were known to the attacked child. The head and neck was involved in greater than 67 per cent of these injuries. Pit bulls caused 25 per cent of the bite injuries. Large dogs were responsible for 88 per cent of the attacks. Forty-four (66%) patients required operative intervention. Twenty-eight of these patients had multiple anatomical areas injured. There were 44 procedures involving the head and neck, 21 involving extremities, and 6 involving other areas of the body. All patients 5 years of age and under had head and neck injuries. Dog bite injuries requiring admission occur more in male children. Caucasian and African American children were the majority of children affected. The children under 5 years of age suffered the most devastating injuries. More than half of these attacks were not provoked. More than two-thirds of the injuries to these children involved the head and neck. We conclude that effective prevention strategies must stress careful supervision of young children and the family or neighbor's dog, a scenario that may easily lead to complacency and set the stage for a severe injury.     

Blunt liver injury in children and adults: is there really a difference?

Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (> or = 18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.