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.     

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.     

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     

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.     

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.     

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.     

Portal venous gas following trauma in a preterm infant

During the neonatal period, pneumatosis intestinalis (PI) and portal venous gas (PVG) are pathognomonic of necrotizing enterocolitis (NEC). Rare cases of such findings evolving after abdominal trauma have been reported in adults and children, but none in premature infants. We report a case of a 3-week-old premature infant where both PI and PVG were found following a fall from a scale. The presence of these findings prior to the evolvement of clinical symptoms suggestive of NEC strongly supports a traumatic etiology.     

Adrenal lacerations in child abuse: a marker of severe trauma

There are few reports of adrenal injuries complicating inflicted pediatric trauma. All child-abuse cases at the New York City Medical Examiner's Office over a 7-year period were reviewed. Of these 121 homicides, 50 sustained severe injuries to the torso. Five infants (10.0%) had adrenal laceration, a marker of major blunt-force injury. Accepted: 21 January 1999     

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.     

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.     

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.     

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     

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.     

A rare cause of hypertension in children: intrathoracic pheochromocytoma

Mediastinal pheochromocytomas account for only a small fraction of mediastinal tumors. Most commonly, these tumors are located in posterior mediastinum. Increasing number of cases of pheochromocytomas is being reported from middle mediastinum. Excision of mediastinal paraganglioma is often hazardous because of its rich blood supply and tendency to involve surrounding structures. It can be a big challenge to manage asymptomatic cases of pheochromocytoma intraoperatively. It is imperative that these patients receive adequate alpha adrenergic and if necessary beta adrenergic blockade. Adequate preoperative preparation with alpha and beta blockers may not prevent serious intraoperative hypertension. We report a case of posterior mediastinal pheochromocytoma which was biochemically active preoperatively. We review the presentation, diagnosis and management of intrathoracic pheochromocytomas including cardiac pheochromocytomas.     

Blunt abdominal trauma in children: epidemiology, management, and management problems in a developing country

Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5–9 years. Falls were the cause of trauma in 36%, 60% of them aged 10–15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorhage, and a lacerated accesory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available. Accepted: 28 October 1999     

Adrenal hemorrhage: a rare cause of severe neonatal jaundice

Adrenal hemorrhage in newborns is not uncommon. The clinical presentation may be very protean and the diagnosis difficult. Ultrasonography is useful in making the diagnosis. A patient presenting with severe neonatal jaundice due to adrenal hemorrhage is described.     

Traumatic adrenal hemorrhage in children: an indicator of visceral injury

Adrenal hemorrhage (AH) was identified in 1% of 313 children admitted to the trauma unit with abdominal or thoracoabdominal blunt trauma within a 10-year period (1989–1999). Ultrasound examination was useful as a first diagnostic measure in stable children, but computed tomography (CT) is considered to be a better diagnostic tool. Associated visceral injury is common, and liver trauma was present in all 3 cases. Lesions are mainly right-sided, but left-sided or bilateral injuries have also been reported. A few cases are only recognized during surgery or necropsy. Lower-chest injury was seen in one-half of the cases and can result in severe morbidity. AH should not be considered rare, and the widespread use of CT proves that it is a strong indicator of associated visceral injury. Accepted: 12 January 2000     

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.     

特殊的儿童嗜铬细胞瘤4例报告

目的探讨小儿特殊嗜铬细胞瘤的临床特点及治疗。方法报告2000-2004年间我院收治的4例小儿嗜铬细胞瘤病例，均为男性，年龄9～12岁。其中双侧肾上腺嗜铬细胞瘤2例，肾上腺外3例，异时再发者2例，有家族史1例。结果经妥善围手术期处理，顺利切除肿瘤，术后血压全部降至正常。结论儿童肾上腺外、双侧肾上腺．多发及再发的嗜铬细胞瘤发生率高于成人，手术切除肿瘤可获得良好的治疗效果。     

Ruptured interventricular septum after blunt chest trauma: Ultrasonographic diagnosis

Summary A 6-year-old child was found under a heavy bookcase that compressed her chest. On admission to the emergency room she was found to be dyspneic with a systolic murmur and complete atrioventricular (A-V) block. Her condition deteriorated rapidly, leading to cardiogenic shock and loss of consciousness. Echocardiographic Doppler evaluation demonstrated a large ventricular septal defect and tricuspid insufficiency. A pericardial patch was put over the tear in the septum, and torn chordae tendinae were reimplanted to the papillary muscles. A pacemaker was inserted. Her situation improved, but on the third day cardiogenic shock and right ventricular dysfunction ensued and the patient expired. A review of the previous 13 cases from the pediatric literature is presented.