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.     

Cardiac arrest induced by blunt trauma in children.

BACKGROUND: There is incomplete knowledge regarding the outcome of children who suffer a cardiac arrest after blunt trauma. We sought to determine mechanisms of injury, mortality, and rate of organ donation in this population of children. METHODS: Since 1984, all traumatically injured children in San Diego County, California, have been treated at San Diego Children's Hospital. This review encompasses 10,979 pediatric trauma patients evaluated from August 1, 1984 through September 30, 1996. All patients who did not meet the following two criteria were eliminated from the review: 1) a mechanism of blunt trauma, and 2) cardiopulmonary resuscitation performed by a trained medical provider prior to arriving or on arrival to the hospital. A chart review of this set of patients was undertaken to determine mechanism of injury, severity of injury, mortality, and rate of organ donation. RESULTS: In this large metropolitan county, 65 children suffered cardiac arrest following blunt trauma. Accidents involving motor vehicles were the mechanisms responsible for 80% of these injuries. The average Injury Severity Score was 50.3. Mortality was largely related to severe head injury as manifested by a mean Abbreviated Injury Score for head and neck equal to 5.9. All but one of these patients died despite resuscitation. Ninety-four percent of these children died within the first 24 hours of injury. The single survivor was discharged in a vegetative state. Solid organs were obtained from 9% of the patients. CONCLUSION: The outcome from blunt cardiac arrest in children is rapidly and nearly uniformly fatal despite resuscitation. Because severe head injuries resulting in brain death are the leading cause of mortality, a significant percentage of organ donations are obtained from these patients.     

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.     

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.     

Current management of liver and splenic blunt trauma in children

Thirty-nine children with blunt liver and/or splenic injury were treated in our department from 1979 to 1987; 23 had a splenic injury, 10 a hepatic injury, and the remaining 6 had both. The diagnosis was suggested by the history and physical examination and was confirmed by CT and radioisotope scanning. Every hemodynamically stable patient was initially managed non-operatively. The children who failed to respond to conservative treatment and had unstable vital signs indicating intractable hemorrhage were eventually operated upon. Every effort was made to preserve the liver and spleen during the operation. Liver repair, splenorraphy alone or in combination with splenic artery ligation, and autotransplantation of splenic tissue were widely used procedures. Sixteen patients were successfully managed nonoperatively, but the remaining 23 required surgery. Only 5 children became completely asplenic and no liver lobe resection was performed. It is suggested that conservative management of children with liver and/or splenic injury is both safe and effective. When surgical intervention is inevitable great effort should be made to preserve liver and spleen.Presented at the XII International Congress of Greek Association of Paediatric Surgeons in Rhodes, 1987 Offprint requests to: G. Tryfonas     

Cardiac injuries caused by blunt chest trauma in children

Two illustrative cases with different features of cardiac injury caused by blunt chest trauma are described. The first patient had mild and obscure symptoms, detected on physical examination, and required observation only. The second patient had acute pericardial tamponade, necessitating surgical treatment. We present the different medical procedures that should be taken into consideration in management of such cases, although continuous monitoring, repeated physical examination, electrocardiograms, chest x-rays, and echocardiography proved sufficient in managing our two children. It is important that physicians who provide care to children suffering from blunt chest trauma have increased awareness of possible cardiac injuries.     

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.     

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.     

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     

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.     

儿童重度闭合性肾挫裂伤的处理

目的 探讨儿童重度闭合性肾挫裂伤的处理.方法 回顾性总结分析2000至2008年临床诊治小儿闭合性肾损伤33例,重点是其中的15例重度肾挫裂伤(3例系肾积水合并肾挫裂伤的特殊病例)的资料.结果 全组无死亡,无早期肾切除病例,18例轻度肾损伤经保守治疗愈合.15例重度闭合性肾挫裂伤患儿中,其中8例采用保守治疗成功,1例肾蒂血管损伤早期急诊行肾静脉修补术,3例行选择性肾动脉栓塞治疗,3例肾积水外伤后肾破裂.3例肾积水肾破裂中,2例行早期肾盂成形肾周引流术,1例因合并肾功能不全,对侧肾萎缩,早期作肾造瘘,延期肾盂成形术,重度肾损伤病例随访5～28个月(平均18个月).4例继发尿性囊肿,1例早期行肾盂输尿管吻合,3例延期做尿性囊肿剥离切除;1例6个月后出现高血压、受损肾萎缩行肾切除.结论 轻度的肾损伤采用保守治疗易于治愈,重度的肾损伤因应病情选用相宜的方法 处理,绝大多数不需早期手术探查,以减少肾切除,选择性肾动脉栓塞微创止血效果好,重度肾挫裂伤需要密切随访,以处理相续可能发生的尿性囊肿和高血压等并发症.     

Survival after emergency department thoracotomy in a child with blunt multisystem trauma

A 14-year-old boy sustained severe blunt, multisystem trauma. On presentation, vital signs were present but disappeared despite maximal resuscitation. Emergency department thoracotomy (EDT) resulted in return of vital signs and transfer to the operating room for a definitive procedure. Ultimately, the child survived with normal neurologic function and quality of life. This case illustrates the potential value of EDT in selected patients who present with detectable vital signs and deteriorate in the face of maximal conventional therapy.     

The evaluation of ocular trauma in children between ages 0-12

Ocular trauma is the leading cause of noncongenital unilateral blindness in children under 20 years old. In this study, 138 patients (36 female, 102 male) with ocular trauma between November 1983 and October 1996 were reviewed retrospectively at the Department of Ophthalmology, Ondokuz Mayis University Faculty of Medicine. Twenty-four of these patients were blunt trauma and 114 were perforating eye injury. The mean age of the patients was 6.96+/-3.01 years. Mean post-treatment follow-up was 10.7 months (range 1 to 121 months). Forty-five patients were admitted to the eye clinic within the first 24 hours after trauma. The most frequent finding was hyphema in blunt injury, and corneal laceration in perforating injury. The most frequent cause of injury was wood and stone in blunt trauma and glass and knife in perforating trauma. While the ratio of visual acuities equal to or better than finger counting was 37.5 percent (9 eyes) in blunt trauma cases and 20.2 percent (23 eyes) in perforating trauma cases prior to treatment, it was 79.2 percent (19 eyes) and 55.3 percent (63 eyes), respectively, at last visit examination post-treatment. The most frequent complication was traumatic cataract in blunt trauma and corneal leukoma and anterior synechia in perforating trauma. The results obtained suggested that socioeconomic and sociocultural status and family negligence are important factors in eye injuries in children that occur during games.     

Lung contusion-lacerations after blunt thoracic trauma in children

Chest trauma in children is an indicator of injury severity and is associated with a high mortality rate. The aim of this study was to investigate the impact of pulmonary contusion-laceration on short and long-term outcome of pediatric patients after blunt thoracic trauma. A retrospective analysis of records of 41 children aged 10 months to 17 years who were treated for pulmonary and associated injuries between 1986 and 2000 was done concerning mode of injury, types of injuries, management and outcome. In addition, a follow-up investigation was performed 4.5±1 years after injury. Of the patients 27 were involved in motor vehicle accidents (MVA group) and 14 patients suffered other types of accidents (others group). The mean injury severity score (ISS) was 30±2 (range 9–75) with no significant difference between the groups. Patients from the MVA group suffered more frequently bilateral pulmonary lesions and needed more often chest tube placement (p<0.05), 5 patients died (12%) all from the MVA group. The follow-up investigation of 34 patients showed unremarkable chest x-rays and normal lung function in all but 1 patient with bronchial asthma. In conclusion, children who recover after a pulmonary contusion-laceration trauma do not suffer from significant late respiratory problems.     

Ureteropelvic junction disruption following blunt abdominal trauma

We report here on a case of avulsion of the ureteropelvic junction in a 7-year-old boy who was injured in a car accident. Severe brain trauma took precedence over signs and symptoms of blunt abdominal trauma, but 24 hours after the accident, progressive distension of the abdomen required further evaluation. Ultrasound examination and a computed tomography scan revealed disruption of the ureteropelvic junction. Simple primary anastomosis was performed. We discuss the characteristics of this unusual injury and include a review of the literature.     

A comparison between scintigraphy and computed abdominal tomography in blunt liver and spleen injuries in children

Fifty consecutive paediatric patients with objective clinical signs of blunt abdominal trauma underwent both computed abdominal tomography (CT) and liver-spleen scintigraphy (LSS). All were managed non-operatively with no morbidity or mortality. Five splenic and 13 liver injuries were visualised on CT while LSS revealed 9 splenic and 29 liver injuries. Where injury to either organ was detected by both modalities, there was good correlation anatomically and also as to the extent of injury. LSS demonstrated injuries not shown on CT, which appeared to detect only more extensive injuries. We conclude that scintigraphy may be the more sensitive and therefore more appropriate method when blunt injury to the liver and spleen alone is clinically suspected. Abdominal CT remains the early investigation of choice in patients with clinical evidence of haemoperitoneum associated with shock or multiple injuries, particularly when injury to the kidneys as well as to the liver and spleen is suspected or when a concomitant brain scan is indicated. Offprint requests to: D. H. Bass     

Evolution of non-operative management for blunt splenic trauma in children

Until the late 1960s, splenectomy was routinely performed in children who had sustained blunt splenic injury. There was based on the ability to perform splenectomy without obvious consequence; the cited 90-100% mortality for splenic trauma and the possibility of delayed rupture of the spleen. In contrast, contemporary findings in immunology and surgery demonstrated that non-operative management was not only feasible but desirable in view of the potential for overwhelming post-plenectomy infection. The history of universal splenectomy following blunt splenic trauma has been reviewed and we outline the findings that have resulted in the current standard of non-operative management following blunt splenic trauma.     

Commotio cordis. The single, most common cause of traumatic death in youth baseball

Two cases of blunt chest trauma caused by a baseball are reported, including one death. At least one of these was in consequence of cardiac concussion or commotio cordis, an entity not described in teh pediatric literature. Concussion of the heart is a functional injury, in contrast to cardiac contusion or cardiac rupture, which pertains to structural injury. However, a cardiac concussion appears more likely to have immediate, dire consequences than the structural injury of cardiac contusion. Both of the cases presented occurred in the Little League baseball setting. Blunt chest trauma is reported to cause two to three deaths in youth baseball each year. There appears to be an increased pediatric susceptibility to this type of injury. Unfortunately, these cases are quite resistant to resuscitative therapy. Devices and techniques for primary and secondary prevention exist, but have yet to be systematically verified and implemented.     

Syncope in children and adolescents

We retrospectively reviewed the emergency department records of 77 children and adolescents seen in an emergency department with the chief complaint of fainting. Upon careful review, 20 patients had not had any type of syncopal or near-syncopal episode. Of the remaining 57 patients, 40 experienced syncope, and 17 patients had near-syncope. The most frequent diagnoses in the syncopal patients were vasovagal syncope (50%), orthostatic hypotension (20%), atypical seizure (7.5%), migraine headache (5%), and minor head trauma (5%). The most frequent diagnoses in the near-syncope group were lightheadedness (29%), seizure (18%), tension headache (12%), and migraine (6%). Seventeen and one half percent of syncopal patients had abnormalities of vital signs, orthostatic vital signs, glucose, hematocrit, or ECG; none of the near-syncopal patients had abnormalities. We conclude that initial evaluation of first-episode syncope should include orthostatic vital signs, glucose, hematocrit, and ECG with further studies performed as clinically indicated.     

Blunt injury of the abdomen: a plea for CT

A 3-year-old boy was brought to the emergency unit 1 h following a deceleration injury. On clinical examination there were no signs of injury and US showed only free intraperitoneal fluid. The following morning, contrast-enhanced CT showed the right kidney did not enhance and delayed scans showed contrast medium in the renal vein. This is an indirect sign of post-traumatic renal artery occlusion. Failure to recognise this sign may have disastrous consequences in a patient with solitary kidney or bilateral renal artery occlusion. Contrast-enhanced CT scan remains the most widely available investigation for accurate staging of blunt renal trauma. Received: 15 March 2000/Accepted: 29 March 2000