Blunt Abdominal Trauma in the Pediatric Patient

Timely diagnosis and a rational approach to operative versus nonoperative management of intra-abdominal injuries in children are critical to providing optimal pediatric trauma care. Suspicion of IAI is based on the mechanism of injury and findings on examination. Subsequent evaluation and management of IAI is influenced by the patient's hemodynamic status and the presence of extra-abdominal injuries. The hemodynamically unstable patient with suspected IAI requires emergent laparotomy. The hemodynamically stable patient is evaluated using laboratory and imaging studies, most importantly, CT of the abdomen. Stable patients with hepatic or splenic injuries are almost always managed nonoperatively, whereas small bowel, colon, and pancreatic injuries with main duct disruption require laparotomy.     

Shaken baby syndrome and a baby's cry

The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact. During the period between January 1, 1997 and December 31, 2003, 26 cases of shaken baby syndrome (SBS) were identified in Estonia. The incidence of SBS was 28.7 per 100,000 children under 1 year of age during the whole study period. In this group there were four children from twin pairs: two twin boys and a girl from a twin pair and a boy from another twin pair. This represents 15.4% of the 26 cases. Twins in Estonia represent 2.12% of infant births. The mean age on admission was 3.9 months. According to outpatient records almost all parents (88.5%) in the study group (23/26) had contacted their family physicians and other specialists because of excessive crying or irritability of the baby prior to the admission to the hospital with SBS or death. We found that the time curve of crying was similar to the curve of highest incidence of cases of SBS except the crying curve began earlier. CONCLUSION. Our data confirm that the families with twins are at additional risk for SBS and parent's complaints of excessive crying of their infants should be taken as signal that parents need to be carefully counselled.     

Shaken baby syndrome in New Zealand, 2000-2002

Aim:   To describe the epidemiology of subdural haemorrhage (SDH) in New Zealand infants.
Methods:   Prospective enrolment of all cases of infantile SDH from 2000 to 2002. Retrospective analysis of national discharge and death data for the same period.
Results:   Seventy-seven cases of infantile SDH were identified prospectively, and a further 49 cases retrospectively. Of these 126 cases, 92 resulted from non-birth-related trauma. Forty-eight of these were attributed to abuse and 28 to accidental injury. Sixteen cases were undetermined. The 'minimum' annual incidence of inflicted infantile SDH in New Zealand is 14.7 per 100 000 (95% confidence interval(CI) 10.8–19.4), and the 'maximum' 19.6 per 100 000 (95% CI 15.1–25.0). Among Maori, the 'minimum' is 32.5 per 100 000 (95% CI 21.4–47.3), and the 'maximum' 38.5 per 100 000 (95% CI 26.3–54.4).
Conclusions:   The epidemiology of infantile subdural haemorrhage in New Zealand is similar to that described elsewhere. Non-accidental head injury is a significant child health issue in New Zealand, and the incidence is particularly high among Maori.     

Functional time limit and onset of symptoms in infant abusive head trauma

AIM: To analyse medical and witness evidence collected during investigations of infant abusive head trauma with a view to (i) isolating cases where a functional time limit could be established and (ii) examining those cases for evidence of the onset of neurological symptoms. METHODS: A retrospective study was undertaken of severe infant abusive head trauma cases investigated by the Queensland Police Service over a 10-year period. In cases where sufficient reliable (non-perpetrator) evidence was available, a functional time limit was documented. Those files were then examined for further medical, witness or perpetrator evidence of the infant victim's response to the assault. RESULTS: A functional time limit was established in 16 of 52 cases (31%). In 11 of the 16 cases there was evidence of an immediate neurological response on the part of the victim. CONCLUSION: The study suggests that the period between assault and onset of symptoms in infant abusive head trauma is brief, particularly in cases of an acute deterioration where proximate medical intervention is required. In those cases with sufficient evidence of the victim's condition post-injury, the symptoms presented without delay.     

Menace of childhood non-accidental traumatic brain injuries: A single unit report

Background:

Childhood traumatic brain injury (TBI) has high rate of mortality and morbidity worldwide. There are dearths of reports from developing countries with large paediatric population on trauma; neurosurgery trauma of nonaccidental origin is not an exemption. This study analysed menace of non-accidental TBI in the paediatric population from our center.

Materials and Methods:

This is a single unit, retrospective study of the epidemiology of non-accidental TBI in children starting from September, 2008 to March, 2014. The management outcomes of the epidemiology of the non-accidental TBI were analysed.

Results:

Total of 109 children age range from 0 (intra-natal) to 16 years with a mean of 5.8 ± 4.6 years (median, 5 years) were enrolled into the study. 34 (31.2%) were domestic violence, 26 (23.9%) street assaults, 16 (14.7%) were due to animal assaults and mishaps, 17 (15.6%) fall from heights. Seven (6.4%) cases of collapsed buildings were also seen during the period. Four (3.7%) industrial accidents and two (1.8%) were self-inflicted injuries. There were also three (2.8%) cases of iatrogenic TBI out of which two infants (1.8%) sustained TBI from cesarean section procedure while one patient (0.9%) under general anaesthesia felt from the operation bed resulting to severe TBI.

Conclusion:

Child abuse, unprotected child labour, parental/care-givers negligence are the main cause of nonaccidental TBI. Human right activists and government agents should be incorporated in curtailing the menace.     

Increased Intracranial Pressure

Traumatic brain injury and other causes of increased ICP are frequently seen in the emergency department. Further clinical studies comparing and evaluating the efficacy of various treatments are clearly needed. However, there are many established options for control of intracranial hypertension.In addition to general principles of patient management, such as airway, breathing, and circulation, several interventions may be immediately used if increased ICP is suspected. Proper positioning, including elevation of the head and maintaining a midline position, as well as adequate sedation and analgesia can result in a significant decrease in ICP. These simple maneuvers may be rapidly achieved, and they have been shown to improve long-term outcomes. Head imaging, such as a computed tomographic scan, is important in the workup of intracranial hypertension, but treatment should not be delayed to obtain imaging. Prompt recognition and treatment of increased ICP are crucial in minimizing morbidity and mortality.     

Predictive value of clinical and radiological findings in inflicted traumatic brain injury

Aims: The aim of this study is to evaluate the value of early radiological investigations in predicting the long‐term neurodevelopmental outcome of infants with inflicted traumatic brain injury (ITBI). Methods: Clinical and radiological investigations of 24 infants with ITBI were performed during the acute phase of injury (1–3 days), and during the early (4 days up to 3 months) and late (>9 months) postinjury phases. The clinical outcome in survivors (n = 22) was based on the Rankin Disability Scale and the Glasgow Outcome Score. Results: Five out of 24 infants (21%) had a poor neurodevelopmental outcome (death and severe disability), 17 infants (71%) had different developmental problems and 2 infants were normal at the mean age of 62 (54–70) (95% CI) months. A low initial Glasgow Coma Scale score of 8 or below [p < 0.05, OR 13.0 (1.3–133.3)], the development of brain oedema [p < 0.005, OR 13.0 (1.6–773)], focal changes in the basal ganglia during the acute phase [p < 0.01, OR 45 (2.1–937.3)], the development of new intracerebral focal changes early postinjury [p < 0.05, OR 24.1(1.0–559.1)], a decrease in white matter [p < 0.01, OR 33 (1.37–793.4)] and the development of severe atrophy before 3 months postinjury [p < 0.05, OR 24 (11.0–559.1)] were significantly correlated with a poor neurodevelopmental outcome. Conclusions: Early clinical and radiological findings in ITBI are of prognostic value for neurodevelopmental outcome.     

Mild traumatic brain injury: improving quality of care in the paediatric emergency department setting

Aim: Traumatic brain injury (TBI) in childhood can impose a significant threat to life and longer‐term disability. This study investigated the extent to which the documentation of key indicators of healthcare quality in the emergency department (ED) setting was consistent with clinical guidelines for the management of children with mild TBI (MTBI). Methods: The clinical records of a random sample of 60 children (stratified by ethnicity and age group), who were seen and discharged from a large metropolitan paediatric hospital ED following a head injury, were systematically reviewed to examine the processes of care and follow‐up. Results: Based on the documentation in clinical records, processes designed to identify and manage potentially life‐threatening acute complications (e.g. computed tomography scanning to identify intracranial haemorrhage) were consistent with best practice standards. However gaps existed between current and best practice for some aspects of care that could minimise risks of longer‐term disability from MTBI. For example, relevant clinical criteria were well documented, but this information did not appear to be applied systematically to identify and to follow up children with definite or possible MTBI. Conclusion: The apparent absence of a systematic approach to the diagnosis and follow‐up of MTBI in children presenting to ED suggests a missed opportunity to minimise the risk of disability following these injuries. Greater attention to an integrated care pathway that improves the identification, documentation, and follow‐up of children with MTBI presenting to ED is required.     

The acute management of children's brain injuries

Traumatic brain injury is the leading cause of death in children in the UK. The pathway of care for severely brain injured children involves ambulance services, local and regional hospitals and regional trauma, critical care and rehabilitation networks. With so many stakeholders, effective advocacy for these children requires an understanding of their whole journey. Indeed, review of the pathway provides an opportunity to reflect on how improvements may be achieved.     

The epidemiology of child maltreatment

Child maltreatment is a significant worldwide problem, with consequences that can include impaired physical and mental health throughout life, and adverse social and occupational effects that carry a heavy economic and social burden. One estimate of cost to the US economy in 2007, for example, was over US$100bn. In middle- and low-income countries, there have been fewer studies of incidence and prevalence, and the economic and social costs are harder to estimate. It is very difficult to obtain full case ascertainment even in the most severe forms of child maltreatment, and even for fatal cases. In general, self-reporting and surveys identify higher rates of child maltreatment than data from sources relating to official notification. This paper reviews the epidemiology of child maltreatment from a practical perspective, with a focus on factors in the social environment, and the clinical history and examination, that predict an increased risk of child maltreatment.     

Prehospital Evaluation and Management of Traumatic Brain Injury in Children

The care of patients with TBI has improved dramatically over the past 3 decades with an estimated 20% reduction in mortality rates, in part due to advances in diagnosis and prehospital care. However, a great deal of variation still exists in practice with respect to the diagnosis and management of pediatric head trauma. Training programs should be developed to educate EMS providers and medical control physicians on the Brain Trauma Foundation guidelines for management of TBI, taking into consideration aspects of care unique to children. The effect of utilization of these guidelines on patient outcomes should subsequently be evaluated. In the future, early intervention with antioxidants, glucocorticoids, and immunosuppressants may become part of trials in the prehospital setting aimed to decrease secondary injury.Prehospital providers are often responsible for the triage of children with minor TBI. Current practice in acute care settings ranges from clinical observation of children with minor TBI who are grossly intact neurologically, to obtaining plain films, CT scans, and rarely magnetic resonance imaging. When indicated, the ideal imaging modality for head injury is noncontrast CT scan, which can reliably detect both intracranial injury and skull fracture. The child with a normal neurological examination after isolated head trauma and a negative CT scan is at very low risk of later developing intracranial abnormalities and may be safely discharged home with close observation. Children who have had a concussion must not return to contact sports until they are completely symptom free both at rest and on exertion. At that time, a gradual return to sports is recommended. These children should be referred for neurocognitive screening and assessment when indicated.     

Fractures Resulting From Inflicted Trauma: Assessing Injury and History Compatibility

Determining whether a fracture is the result of inflicted or accidental trauma can be challenging; future safety for the child rests on the accuracy of this decision. Specific injury-focused questions, biomechanical considerations regarding fracture characteristics, and a careful assessment to identify skin as well as internal, occult injuries will improve diagnostic accuracy. Table 1 provides guidelines for the evaluation of possible inflicted skeletal trauma.