The effects of smoking on adolescent trauma patients: a propensity-score-matched analysis

Cigarettes have been demonstrated to be toxic to the pulmonary connective tissue by impairing the lung’s ability to clear debris, resulting in infection and acute respiratory distress syndrome (ARDS). Approximately 8% of adolescents are smokers. We hypothesized that adolescent trauma patients who smoke have a higher rate of ARDS and pneumonia when compared to non-smokers. The Trauma Quality Improvement Program (2014–2016) was queried for adolescent trauma patients aged 13–17 years. Adolescent smokers were 1:2 propensity-score-matched to non-smokers based on age, comorbidities, and injury type. Data were analyzed using chi square for categorical data and Mann–Whitney U test for continuous data. From 32,610 adolescent patients, 997 (3.1%) were smokers. After matching, 459 smokers were compared to 918 non-smokers. There were no differences in matched characteristics. Compared to non-smokers, smokers had an increased rate of pneumonia (3.1% vs. 1.1%, p = 0.01) but not ARDS (0.2% vs. 0%, p = 0.16). Compared to the non-smoking group, the smokers had a longer median total hospital length-of-stay (3 vs. 2 days, p = 0.01) and no difference in overall mortality (1.5% vs. 2.4%, p = 0.29). Smoking is associated with an increased rate of pneumonia in adolescent trauma patients. Future research should target smoking cessation and/or interventions to mitigate the deleterious effects of smoking in this population.     

Penetrating trauma in the pediatric patient

Penetrating trauma in the pediatric patient represents a small percentage of all traumatic injuries. However, the morbidity and mortalitya, as well as the overall costs for short- and long-term care, move this type of injury to the forefront of the emergency physician's attention. The injure circumstances significantly impacts the outcome, with firearm injuries producing a greater degree of injury to more body areas than any other penetrating mechanism. No body region is immune to penetrating injury, although some hear a higher risk for serious injury than others do. Care of penetrating injuries follows the same resuscitation algorithm as for all other types of trauma, although there must be increased awareness of circulatory problems and wound management. Finally, in contrast to blunt injuries, surgical management is more frequently required for the definitive care of the patient.     

Ovarian hyperthecosis in the adolescent patient.

The endocrine findings in two adolescents with hyperthecosis are compared to those in a patient with an androgenic ovarian tumor. In patients with hyperthecosis, luteinizing hormone values were elevated or in the upper normal range, and plasma testosterone and androstenedione values were increased. Following dexamethasone suppression, testosterone and androstenedione values remained elevated, but after administration of human chorionic gonadotropin, they increased further in only one patient. Baseline 17-ketosteroid values were normal, suppressed with dexamethasone, and stimulated to baseline levels following HCG. The patient with a lipoid cell ovarian tumor had low baseline LH levels, and elevated testosterone, androstenedione, and 17-ketosteroid values. Dexamethasone produced little change in urinary or plasma values, but the 17-ketosteroids increased markedly after administration of HCG. The finding of low serum LH values in patients with hirsutism and elevated androgen secretion should alert the clinician to the possibility of a tumor.     

The evaluation of minor cervical blunt trauma in the pediatric patient

Blunt trauma delivered directly to the neck of the pediatric patient may be associated with significant airway compromise. The external signs are not indicative of the extent or site of the trauma. A high index of suspicion is warranted in all patients with this type of injury. A patient with apparently minor direct trauma to the neck is presented to illustrate the principles of evaluation and treatment of these injuries.     

The use of high-dose daily cabergoline in an adolescent patient with macroprolactinoma

Prolactinomas are rare in children and adolescents but well studied in adults. Dopamine agonists are the treatment of choice for all ages. Bromocriptine is the only agonist approved for use in pediatric patients by the FDA. Cabergoline, a second-generation ergot derivative with a longer half-life, has been used in resistant prolactinomas and as first-line treatment in adults. The authors describe an adolescent boy with a pituitary macroadenoma with an initial prolactin level of 73,777 ng/mL. After failing to respond to bromocriptine and standard-dose cabergoline, he responded well to very high daily doses of cabergoline (1.5 mg daily), with a current prolactin level of 726 ng/mL and notable reduction in tumor size. Escalating doses of cabergoline should be considered in pediatric patients with dopamine-resistant prolactinomas.     

Nutritional support of the pediatric trauma patient

Of all the interventions available to aid recovery of the injured child, few have the power of proper nutritional support. Healing after trauma depends not only on restoration of oxygen delivery, but on "substrate delivery," or provision of calories to support metabolic power and specific nutrients to allow rebuilding of injured tissue. Failure to deliver adequate substrate to the cells is revealed as another form of shock. Nutritional interventions after trauma are most effective when informed by the specific ways that children diverge physiologically (metabolic rate, biomechanics, physiological response to trauma) from adults. This review describes these responses and outlines a general strategy for safely delivering energy and specific substrates to protect and heal injured children, regardless of body size and type of injury.     

Effective interviewing and counseling of the adolescent patient

A vast number of successful recommendations are available to physicians who want to learn how to strengthen their interactions with adolescent patients. Understanding that the physician-patient relationship is dynamic is the first step toward building a strong repertoire within this patient sample. Therefore, physicians may assume that adolescent perceptions of the physician-patient relationship and the services provided will change as they change developmentally or as the situation is modified. Finding a balance between family and patient concerns while gaining increased experience with skills less-practiced (eg, communication about sensitive topics) will improve adolescent perceptions of your expertise, knowledge, and abilities. Finally, following up on changes across time in adolescents' concerns, perceptions, abilities, and the physician-patient relationship itself, will help to ensure continued satisfaction and service use by adolescents and their families.     

The use of telemedicine in the care of the pediatric trauma patient

Telemedicine is increasingly becoming an important part of the health care system as it has the potential to help deliver quality medical care to underserved areas. When implemented correctly, it can be a cost-effective way of expanding access to excellent medical care. However, because it is a relatively new and quickly changing field, there are multiple issues and challenges that need to be addressed. This article reviews the current literature on various modalities of telemedicine, evidence for teletrauma, and challenges and barriers related to telemedicine.     

Follow-up of adolescent trauma victims: a new model of care

A comprehensive model of service delivery for the rehabilitative care of adolescents with closed head injuries is presented. Our data show that the Glasgow Coma Scale score on hospital admission correlates with the length of time required for follow-up. Adolescents with mild closed head injuries require more follow-up than adults with comparable injuries because of adolescent developmental stages that complicate the recovery process. Anticipatory guidance has helped the patient and family cope with stresses. Finally, we have identified a typical pattern of difficulties during the recovery process including: impaired judgment, reduced attention span, irritability, short-term memory loss, and ongoing memory deficits.