Post-traumatic stress reactions in children of war

The aims of this study were to estimate the rate of post-traumatic stress reactions in Palestinian children who experienced war traumas, and to investigate the relationship between trauma-related factors and PTSD reactions. The sample consisted of 239 children of 6 to 11 years of age. Measures included the Rutter A2 (parent) and B2 (teacher) scales, the Gaza Traumatic Event Checklist, and the Child Post-Traumatic Stress Reaction Index. Of the sample, 174 children (72.8%) reported PTSD reactions of at least mild intensity, while 98 (41%) reported moderate/severe PTSD reactions. Caseness on the Rutter A2 scale was detected in 64 children (26.8%), which correlated well with detection of PTSD reactions, but not with teacher-detected caseness. The total number of experienced traumas was the best predictor of presence and severity of PTSD. Intervention programmes for post-war children need to be evaluated, taking into account developmental and cultural aspects, as well as characteristics of the communities involved.     

Splenic abscess following blunt abdominal trauma

A rare case of splenic abscess occurring after blunt abdominal trauma in a previously healthy boy is reported. The diagnosis was made by ultrasonography. The patient recovered after splenectomy and drainage of subphrenic and intraperitoneal pus.     

Spinal chronic subdural haematoma in a 7-year old girl

A case is reported of chronic encapsulated spinal subdural haematoma which developed in a 7-year-old girl after minor spinal trauma. Surgical removal of the lesion was followed by complete recovery.     

Rupture of the trachea: an unusual complication of delivery

We describe a neonate whose trachea ruptured during delivery. The baby developed respiratory symptoms shortly after delivery and became dramatically ill after 6 h. This particular birth trauma appears to be very unusual: there are few cases reported in the literature. Rupture of the trachea should be considered as a differential diagnosis in a neonate who develops pneumomediastinum after a complicated delivery.     

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.     

Pericardial defect: Unusual presentation,location, and etiology

Three cases of pericardial defect are reported and their unique features are discussed.     

Lesion of iliac vessels in the course of cesarean section

A case of unusual birth trauma in the course of a cesarean section is reported. A lesion of the iliac vessels with disruption of the hip joint resulted in extensive necrosis of the lower limb and its eventual amputation. Offprint requests to: J. Czernik     

Pattern of pediatric ocular trauma in India

OBJECTIVE: The aim of the study is to identify the causes, demographic and clinical profile and evaluate final visual outcome of pediatric ocular injuries. METHODS: Two hundred and four children aged fourteen years or less presenting to the emergency services of a tertiary care centre with ocular injury were included. Demographic data, nature and cause of injury, duration between injury and presentation to an ophthalmologist and the diagnosis were recorded. Evaluation of visual acuity, anterior segment and fundus were done. All patients were appropriately managed and followed up on days 1, 7, 1 month, 3 and 6 months. RESULT: Majority of injuries occurred in children of 5 years and older (87.7%). There were 133 (65.1%) boys and 71 (34.9%) girls. Forty-nine (24%) cases presented within 6 hours of injury while 70 (34.3%) presented after more than 24 hours after trauma. Most common cause of injury was bow and arrow (15.2%) followed by household appliances(14.3%). Closed globe injuries accounted for 42.2% injuries, open globe for 53.9% and 3.9% were chemical injuries. Best corrected visual acuity of 6/12 or better was achieved in 79 eyes (91.86%) in closed globe group. However, only 17 eyes (15.45%) in open globe group could achieve this. CONCLUSION: Most ocular injuries in children are preventable and occur from unsupervised games like bow and arrow and firecracker, which can lead to significant visual loss.     

Pattern of pediatric ocular trauma in India

Objective : The aim of the study is to identify the causes, demographic and clinical profile and evaluate final visual outcome of pediatric ocular injuries.Methods : Two hundred and four children aged fourteen years or less presenting to the emergency services of a tertiary care centre with ocular injury were included. Demographic data, nature and cause of injury, duration between injury and presentation to an ophthalmologist and the diagnosis were recorded. Evaluation of visual acuity, anterior segment and fundus were done. All patients were appropriately managed and followed up on days 1, 7,1 month, 3 and 6 months.Result : Majority of injuries occurred in children of 5 years and older (87.7%). There were 133 (65.1%) boys and 71 (34.9%) girls. Forty-nine (24%) cases presented within 6 hours of injury while 70 (34.3%) presented after more than 24 hours after trauma. Most common cause of injury was bow and arrow (15.2%) followed by household appliances (14.3%). Closed globe injuries accounted for 42.2% injuries, open globe for 53.9% and 3.9% were chemical injuries. Best corrected visual acuity of 6/12 or better was achieved in 79 eyes (91.86%) in closed globe group. However, only 17 eyes (15.45%) in open globe group could achieve this.Conclusion : Most ocular injuries in children are preventable and occur from unsupervised games like bow and arrow and firecracker, which can lead to significant visual loss.     

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.     

EMBOLISM OF FETAL BRAIN TISSUE TO THE LUNGS AND THE PLACENTA

We describe a case of a 19-year-old G1P0 woman with an unremarkable prenatal course who presented at term in labor. Fetal bradycardia developed and forceps were used to deliver a male infant, who was born with Apgar scores of 0 and 0 and could not be resuscitated. Examination at autopsy revealed no gross evidence of trauma, but on microscopic examination of the lungs and the placenta, multiple fetal vessels contained emboli consisting of fragments of fetal cerebellar cortex. Previously reported cases of this rare phenomenon are reviewed and the pathogenesis is discussed.     

Traumatic experiences and post-traumatic stress reactions in children from Kurdistan and Sweden

This paper examines the types and scores of traumatic experiences, post-traumatic stress symptom and behavioural disorders among Kurdistanian refugee children in Sweden and a comparative Swedish group. The Harvard-Uppsala Trauma Questionnaire for Children (HUTQ-C), the Post-Traumatic Stress Disorder for Children (PTSS-C) and the Child Behaviour Checklist (CBCL) were administered in interview form to 32 children from each sample, controlled for age, gender and trauma levels. No significant differences were found between the 2 samples regarding types of traumatic events, frequencies of post-traumatic stress disorder, post-traumatic stress symptom scores or behavioural problem scores, except in 3 aspects: Kurdistanian children reported more war experience and being lost, while Swedish children presented higher frequencies of leisure-time accidents. CONCLUSION: This study supports the assumption that children differ from adults by showing more similarities than differences regarding traumatic experiences and post-traumatic stress reactions, after being exposed to an equivalent number of reported traumatic events. The refugee children's stay in Sweden can be considered as a healing factor.     

Assessing Exposure to Violence in Urban Youth

This study reports on the development of a structured interview, My Exposure to Violence (My ETV), that was designed to assess child and youth exposure to violence. Eighty participants between the ages of 9 and 24 were assessed. Data from My ETV were fit to a Rasch model for rating scales, a technique that generates interval level measures and allows the characterization of both chronic and acute exposure. Results indicated that the fit statistics for six scales, covering both lifetime and past year victimization, witnessing of violence, and total exposure, were all good. These scales were found to have high internal consistency (r=.68 to .93) and test-retest reliability (r=.75 to .94). Evidence of construct validity was provided by the item analysis, which revealed a theoretically sensible ordering of item extremity, and also by analysis of bivariate associations. As expected, younger subjects generally reported less exposure to violence than did older subjects, males reported more exposure than did females, African-American subjects reported higher levels of exposure than did White subjects, violent offenders reported more exposure than did non-offenders, and those living in high crime areas reported more exposure than did those residing in low crime areas. Future areas of investigation and the potential contribution to studies of antisocial behavior and post-traumatic stress disorder are discussed.     

Acquired growth hormone deficiency due to pituitary stalk transection after head trauma in childhood

Two patients are reported with growth hormone deficiency due to head trauma in childhood. Although their injuries were outwardly only slight and there was no loss of consciousness and no subsequent neurological deficits, they exhibited gradual growth retardation from the time of the trauma. Provocative endocrinological tests showed growth hormone deficiency and MRI showed transection of the pituitary stalk. These findings suggest that ordinary head trauma, as well as perinatal insult and congenital abnormalities, could be a cause of growth hormone deficiency.     

Pyogenic Liver Abscess due to Bacteroides fragilis

A 10-year-old boy with anaerobic pyogenic liver abscesses due to Bacteroides fragilis is reported. Blunt trauma was considered as the possible cause of the liver abscesses. Imaging methods such as ultrasonography, computed tomography and liver scannings were useful for the diagnosis of the case. The patient was cured after treatment with surgical debridement and drainage followed by a 10-day course of intravenous Lincomycin.     

Traumatic events and suicide-related outcomes among Mexico City adolescents

Background:  We report the prevalence and associations between traumatic events and suicidal ideation, suicide plans and suicide attempts among Mexican adolescents.
Methods:  The data are from a representative multistage probability household survey of 3,005 adolescents aged 12 to 17 years residing in the Mexico City Metropolitan Area that was carried out in 2005. We used discrete time survival analyses to model the net impact of retrospectively reported prior occurrence of traumatic events on ideation, plans and attempts, taking into account the onset of psychiatric disorders.
Results:  Prevalence of suicidality was high among respondents with traumatic events, ranging from a 43% prevalence of suicidal ideation among those with a history of 'Being raped' to a 25% prevalence of suicide attempts among those that reported 'Purposely injured, tortured or killed someone.' In cross-sectional estimates, any traumatic event was associated with an increase of 3.2 times the odds of suicide ideation, 5.1 times the odds of a plan and 6.6 times the odds of an attempt. Number of events was also associated with increasing suicidality such that those with three or more events were 13.7 times more likely to report a suicide attempt than those with none. Multivariate discrete time survival models that took into account a large number of demographic, suicide-related and psychiatric disorder variables reduced in strength but did not alter these basic relationships.
Conclusions:  We conclude that traumatic events such as rape and sexual assault have a profound impact upon suicidality and that this relationship is not entirely explained by the onset of psychiatric disorders. Comprehensive interventions for adolescent victims of traumatic events, especially those with a history of cumulative events, should include, but not be restricted to, treatment of any associated psychiatric disorder.     

Penetrating injuries in children: Is there a message?

OBJECTIVES: To determine the frequency, management and outcome of penetrating trauma in children. METHODS: A retrospective review of penetrating injuries in children under 16 years of age admitted to the Children's Hospital at Westmead (CHW), and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry, from January 1988 to December 2000. Patient details, circumstances of trauma, injuries identified, management and outcome were recorded. RESULTS: Thirty-four children were admitted to the CHW with penetrating injuries during the 13-year period. This represented 0.2% of all trauma admissions, but 3% of those children with major trauma. The injury typically involved a male, school-age child that fell onto a sharp object or was assaulted with a knife or firearm by a parent or person known to them. Twenty-five children (75%) required operative intervention for their injuries and 14 survivors (42%) suffered long-term morbidity. Thirty children were reported to the NPTD Registry over the same interval, accounting for 2.3% of all trauma deaths in New South Wales. Of these, a significant minority was injured by falls from a mower or a tractor towing a machine with blades. CONCLUSIONS: Penetrating injuries are uncommon, but cause serious injury in children. There are two clear groups: (i) those dead at the scene or moribund on arrival, in whom prevention must be the main aim; and (ii) those with stable vital signs. Penetrating wounds should be explored in the operating theatre to exclude major injury. Young children should not ride on mowers or tractors.     

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.     

Pediatric Trauma Care: An Ongoing Evolution

Trauma remains the leading cause of death and disability in children despite considerable advances in the treatment of injury in the pediatric population. As we move forward into the 21st century, the challenge will be to develop and implement appropriate triage systems to ensure that severely injured children will be treated at centers with a commitment to their care. Issues of overtriage and undertriage need to be addressed, so that the limited resource of PTCs is not overwhelmed by less severely injured patients or conversely, that the definitive management of severe injuries is not delayed by lengthy periods of evaluation at centers ill equipped to care for injured children. PTCs need to take the lead in the development of such integrated pediatric trauma systems. Finally, the importance of injury prevention strategies needs to be emphasized. The vast majority of injuries in children are potentially preventable. Institutions and individuals with a commitment to the care of those injured must also work toward the prevention of the problem in the first place through a combination of research, education, and advocacy. As those who work in the trauma field know, injury is no accident.     

Cardiac Trauma in Children

Although major penetrating or blunt cardiac trauma is rare in children, severe sequelae may result if patients are not managed in a thorough and systematic manner. Penetrating cardiac injuries are fatal in most patients, but survival is possible in patients who maintain vital signs until hospital arrival and can be transported to the OR without delay.The most common cardiac injury from blunt trauma is a cardiac contusion. Patients who have normal vital signs, examination findings, and ECG on arrival are very unlikely to have significant cardiac sequelae. Differences exist in the literature regarding the proper evaluation of blunt cardiac injury, but all patients should have an initial ECG and careful physical examination. Any significant abnormality requires admission for monitoring, frequent reexamination, and consideration of further testing such as troponins, serial ECGs, and/or an echocardiogram.