Hollow viscous injury in the pediatric patient

Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation

Children involved in car crashes can experience either direct trauma or inertial injuries resulting from interactions with external objects, such as other vehicles, or with the restraint system. Furthermore, improper use of restraint systems can lead to additional severe injuries. Recent reports from international institutions underscored the persistent prevalence of inadequate restraint systems utilization and this widespread issue increases children's vulnerability and risk of injuries.The aim of this study is to provide a systematic review of the literature on injuries sustained in children involved in road accidents describing and analyzing elements useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving pediatric passengers. A total of 69 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the accident was examined and discussed.The review highlights that in motor vehicle accidents involving children, the forensic evaluation of both the cause of death and accident dynamics needs to consider several factors, such as the child's age, the type of restraint system employed, and the specific passenger seat occupied. Considering the complexity of the factors that can be involved in this road accident, it is crucial that there is a comprehensive exchange of information between the judge and the medical expert.

A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

Pediatric Trauma: Management and Lessons Learned

Aim:

The aim is to prospectively study 125 trauma patients admitted in the pediatric surgery ward in our institute.

Materials and Methods:

Pediatric patients admitted in the ward after initial resuscitation in the triage room were included. Isolated neurosurgical and orthopedic injuries were excluded. X-ray cervical spine, hip, and chest and a focused assessment with sonography in trauma ultrasound were done for all patients. Computed tomography of the abdomen or chest was done where relevant. Injury profile and surgical intervention when needed were analyzed.

Results:

Road traffic accidents and fall from height caused 73.6% of the injuries. School-going children were most commonly affected (60.8%). Distinctive injuries were noted such as abdominal wall hernias and delayed bladder perforation. All solid organ injury irrespective of grade treated conservatively. Forty percent of the children required surgical intervention. Five patients after laparotomy were found to have surgical conditions unrelated to trauma, whereas another 14 required delayed surgery. Five patients had injuries secondary to sexual abuse. All except two patients were discharged in a satisfactory condition and are doing well in the follow-up.

Conclusion:

In spite of extensive injuries and the need for multiple surgeries, children with trauma have a good prognosis. Close observation during admission and also in follow-up are essential, as many patients may require delayed surgery ≥1 week from injury.

Are There Hallmarks of Child Abuse? II. Non-Osseous Injuries

Certain conditions have been considered hallmarks of child abuse. Such pathognomonic conditions have led to an inevitable diagnosis of inflicted injury. Forensic pathologists are faced with complex analyses and decisions related to what is and what is not child abuse. In this review, we examine the literature on the specificity of five conditions that have been linked to inflicted injury to varying degrees of certainty. The conditions examined include tears of the labial frena (frenula), cigarette burns, pulmonary hemorrhage and intraalveolar hemosiderin-laden macrophages as markers of upper airway obstruction, intraabdominal injuries, and anogenital injuries and postmortem changes. Analysis of the literature indicates that frena tears are not uniquely an inflicted injury. Cigarette burns are highly indicative of child abuse, though isolated cigarette burns may be accidental. Pulmonary hemorrhage is seen more commonly in cases with a history suggestive of upper airway obstruction, but is not diagnostic in an individual case. Hemosiderin-laden macrophages may be seen in cases with inflicted injuries and in natural deaths. Abdominal injuries may be seen in accidents and from resuscitation, though panreatico-duodenal complex injuries in children under five years of age are not reported to be seen in falls or resuscitation. The understanding of anogenital injuries is increasing, but misunderstanding of postmortem changes has led to miscarriages of justice.

The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography

OBJECTIVES

This review examines the prevalence of intra-abdominal injuries (IAI) and the negative predictive value (NPV) of an abdominal computed tomography (CT) in children who present with blunt abdominal trauma.

METHODS

MEDLINE, EMBASE, and Cochrane Library databases were searched. Studies were selected if they enrolled children with blunt abdominal trauma from the emergency department (ED) with significant mechanism of injury requiring an abdominal CT. The primary outcome measure was the rate of IAI in patients with negative initial abdominal CT. The secondary outcome measure was the number of laparotomies, angiographic embolizations, or repeat abdominal CTs in those with negative initial abdominal CTs.

RESULTS

Three studies met the inclusion criteria, comprising a total of 2,596 patients. The overall rate of IAI after a negative abdominal CT was 0.19% (95% confidence interval [CI] = 0.08% to 0.44%). The overall NPV of abdominal CT was 99.8% (95% CI = 99.6% to 99.9%). There were five patients (0.19%, 95% CI = 0.08% to 0.45%) who required additional intervention despite their initial negative CTs: one therapeutic laparotomy for bowel rupture, one diagnostic laparotomy for mesenteric hematoma and serosal tear, and three repeat abdominal CTs (one splenic and two renal injuries). None of the patients in the latter group required surgery or blood transfusion.

CONCLUSIONS

The rate of IAI after blunt abdominal trauma with negative CT in children is low. Abdominal CT has a high NPV. The review shows that it might be safe to discharge a stable child home after a negative abdominal CT.

Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient

BACKGROUND

Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to determine whether delay in treatment had an adverse affect on patient outcome.

METHODS

A multi-institutional retrospective chart review using the American Pediatric Surgical Association Committee on Trauma was initiated after Institutional Review Board approval was obtained at each of the 18 institutions. All children younger than 15 years diagnosed with a BII were identified, and only those with BII noted during surgery or autopsy from January 2002 through December 2007 were included. The data form was designed and approved before chart review, and all data were combined into one database.

RESULTS

Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to determine the interval between injury and operation. These were divided into 4 groups (<6, 6-12, 12-24, and >24 hours) based on time from injury to intervention. Early and late complications, as well as hospital days, were compared in each group. There were 3 deaths from an abdominal source in the less-than-6-hour group and 2 in the 6-to-12-hour group. Injury Severity Score was significantly greater in the less-than-6-hour intervention group. There was no correlation between time to surgery and complication rate, nor was there a significant increase in hospital days.

CONCLUSIONS

These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric BII. Appropriate observation and serial examination rather than repeated computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

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.

Lapbelt injuries and the seatbelt syndrome in pediatric spinal cord injury

BACKGROUND/OBJECTIVE

Approximately 250,000 patients are presently living with spinal cord injury (SCI) in the United States. Approximately 20% of patients with SCI are less than 20 years old, and 15% are less than 15 years old. The most common cause of pediatric SCI is a motor vehicle collision (MVC; approximately 40%); lapbelt injuries and the seatbelt syndrome are seen more often in children involved in MVCs.

METHODS

A search and analysis of current literature on lapbelt injuries, seatbelt syndrome, and pediatric SCI using PubMed.

RESULTS

Children involved in MVCs who are improperly restrained are at higher risk of sustaining injuries. The risk of significant intra-abdominal injuries is increased almost fourfold in these children. Presence of abdominal wall ecchymosis (AWE) was associated with intra-abdominal injuries in up to 84% of children, with hollow viscus injury being the most common. Likewise, presence of AWE is associated with vertebral fractures, including Chance fractures, in up to 50% of patients. Vertebral fractures were associated with SCI in up to 11%. The presence of AWE in an improperly restrained child should warrant a thorough search for intra-abdominal injuries, vertebral fractures, and SCI.

CONCLUSIONS

Lapbelt injuries and the seatbelt syndrome are often associated with pediatric SCI in improperly restrained children. This injury complex and its associated abdominal injuries are difficult to diagnose unless a high index of suspicion is maintained; delay in diagnosis increases morbidity, and early surgical intervention should be considered.