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Özdülger A. Thoracic trauma in children. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S21-S28. [PMID: 38584786 PMCID: PMC10995687 DOI: 10.5606/tgkdc.dergisi.2024.25746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/24/2023] [Indexed: 04/09/2024]
Abstract
Isolated thoracic trauma is rare in children. Because of their small body size, the trauma often also affects other spaces, such as the abdomen and head, and these coexistences significantly increase the rate of mortality. However, in isolated thoracic traumas, the children can quickly recover if they can survive the initial period of trauma. Pediatric thoracic trauma cases can have a different clinical course compared to adults due to the unique anatomic and physiologic properties of children's thoracic cages. Their ribs are nonossified and are very elastic, and therefore, as their ribs can sustain significant deformation without breaking, some significant intrathoracic injuries can be overlooked. In this review, the most common thoracic injuries, including pulmonary contusion, hemopneumothorax, pulmonary laceration, rib fractures, flail chest, tracheobronchial injuries, traumatic asphyxia, and other less common mediastinal injuries are discussed in detail in regard of clinical presentation and management.
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Affiliation(s)
- Ali Özdülger
- Department of Thoracic Surgery, Mersin University Faculty of Medicine, Mersin, Türkiye
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Komut S, Afşarlar ÇE. A Comprehensive Analysis of the Radiation Exposure and the Diagnostic Benefit of PanCT in Pediatric Cases with Multiple Trauma. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1228. [PMID: 37512040 PMCID: PMC10384405 DOI: 10.3390/medicina59071228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: The primary objective of this study was to obtain quantitative data, taking into account the amount of radiation exposure, about the clinical and diagnostic benefit obtained from panCT in pediatric trauma cases. Thus, we aim to create greater awareness in all physicians and primarily emergency medicine physicians regarding correct selection in terms of the patient group where this effective radiological method is to be applied, and to protect children from the adverse effects of radiation. Materials and Methods: The computed tomography (CT) images were retrieved from the hospital radiological archive system (PACS). The effective dose (Ed) was calculated using the standardized method including the tissue weighted parameters. The radiological pathologies determined as a result of CT imaging of the cases were categorized according to clinical significance in accordance with the Modified CT Colonography Reporting and Data System (C-RADS). Results: The data for a total of 268 patients were analyzed, comprising 89 (33.2%) females and 179 (66.8%) males with a mean age of 8.81 ± 5.21 years. The mean Ed was determined to be 18.14 ± 10.44 mSv. The Ed was determined to be statistically significantly higher in the 1-5 years age group than in the 15-18 years age group (p = 0.024). A statistically significant difference was determined between the age groups in terms of the pathologies determined (p = 0.028). Conclusions: In order to prevent performing unnecessary CT imaging, trauma teams in Emergency Departments (ED) should work in harmony and individual decision-making should be based on the severity of the trauma mechanism, the severity of the predicted injury, and the clinical status of the injured child.
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Affiliation(s)
- Seval Komut
- Department of Emergency Medicine, Faculty of Medicine, Hitit University, Çorum 19040, Turkey
| | - Çağatay Evrim Afşarlar
- Department of Pediatric Surgery, Faculty of Medicine, Hitit University, Çorum 19040, Turkey
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Sweet AAR, de Bruin IGJ, Peek J, IJpma FFA, van Baal MCPM, Leenen LPH, Houwert RM. Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands. Eur J Pediatr 2023; 182:1887-1896. [PMID: 36807757 PMCID: PMC10167109 DOI: 10.1007/s00431-023-04828-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 02/21/2023]
Abstract
UNLABELLED Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7-14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2-8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%. CONCLUSION Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution. WHAT IS KNOWN • Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality. • Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures. WHAT IS NEW • The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death. • The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma.
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Affiliation(s)
- Arthur A R Sweet
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ivar G J de Bruin
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jesse Peek
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mark C P M van Baal
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Floan GM, Calvo RY, Prieto JM, Krzyzaniak A, Patwardhan U, Checchi KD, Beth Sise C, Sise MJ, Bansal V, Ignacio RC, Martin MJ. Pediatric penetrating thoracic trauma: Examining the impact of trauma center designation and penetrating trauma volume on outcomes. J Pediatr Surg 2023; 58:330-336. [PMID: 36402592 DOI: 10.1016/j.jpedsurg.2022.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION We analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI). METHODS PTI patients <18 years were identified from the National Trauma Data Bank (2013-2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance. RESULTS We identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers. DISCUSSION Adult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Gretchen M Floan
- Rady Children's Hospital San Diego, 3020 Children's Way, San Diego, CA 92123, USA; Naval Medical Center San Diego Department of General Surgery, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | - Richard Y Calvo
- Scripps Cercy Hospital, 4077 Fifth Ave, San Diego, CA 92103, USA
| | - James M Prieto
- Naval Medical Center San Diego Department of General Surgery, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | | | - Utsav Patwardhan
- Naval Medical Center San Diego Department of General Surgery, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | - Kyle D Checchi
- Naval Medical Center San Diego Department of General Surgery, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | - C Beth Sise
- Scripps Cercy Hospital, 4077 Fifth Ave, San Diego, CA 92103, USA
| | - Michael J Sise
- Scripps Cercy Hospital, 4077 Fifth Ave, San Diego, CA 92103, USA
| | - Vishal Bansal
- Scripps Cercy Hospital, 4077 Fifth Ave, San Diego, CA 92103, USA
| | - Romeo C Ignacio
- Rady Children's Hospital San Diego, 3020 Children's Way, San Diego, CA 92123, USA; University of California-San Diego, Division of Pediatric Surgery, 3020 Children's Way, San Diego, CA 92123, USA
| | - Matthew J Martin
- Scripps Cercy Hospital, 4077 Fifth Ave, San Diego, CA 92103, USA.
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Factors Associated With Successful Video-Assisted Thoracoscopic Surgery for Traumatic Hemothorax in Children: A Cross-Sectional Study. J Surg Res 2022; 279:748-754. [PMID: 35940051 DOI: 10.1016/j.jss.2022.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 06/13/2022] [Accepted: 06/29/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Due to the rarity of traumatic hemothorax in children, no studies have evaluated factors associated with successful video-assisted thoracoscopic surgery (VATS) as definitive management. METHODS We conducted an exploratory cross-sectional analysis of pediatric patients in the Trauma Quality Programs database from 2008 to 2017 with traumatic hemothorax managed with primary VATS. Those with early resuscitative thoracotomy for cardiac arrest were excluded. We stratified patients by blunt or penetrating mechanism and estimated absolute differences (ADs) and 95% confidence intervals (CIs) to identify factors associated with successful VATS without conversion to thoracotomy or reoperation. RESULTS A total of 293 patients were eligible. Among 184 penetrating injuries, 150 (82%) underwent successful VATS, 6 (3%) required reoperation, and 28 (15%) converted to thoracotomy. Diaphragmatic injuries (AD = -28, 95% CI = -46 to -10) and rib fractures (AD = 12, 95% CI = 1 to 23) had the strongest negative and positive associations (respectively) with successful VATS. There were 109 blunt injuries: 86 (79%) underwent successful VATS, 6 (6%) required reoperation, and 17 (16%) converted to thoracotomy. Moderate or severe head injury (AD = -15, 95% CI = -32 to 2), injury severity score >15 (AD = -19, 95% CI = -33 to -5), and the presence of diaphragmatic injury (AD = -38, 95% CI = -71 to -4) had the strongest negative associations with successful VATS. CONCLUSIONS Some children with traumatic hemothorax can be successfully managed with VATS. For penetrating mechanism, diaphragmatic injuries were associated with less success, while rib fractures were associated with more success. For blunt mechanism, diaphragmatic injuries, injury severity score >15, or moderate or severe head injury were associated with less success.
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Benhamed A, Ndiaye A, Emond M, Lieutaud T, Boucher V, Gossiome A, Laumon B, Gadegbeku B, Tazarourte K. Road traffic accident-related thoracic trauma: Epidemiology, injury pattern, outcome, and impact on mortality—A multicenter observational study. PLoS One 2022; 17:e0268202. [PMID: 35522686 PMCID: PMC9075643 DOI: 10.1371/journal.pone.0268202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries.
Methods
We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome.
Results
A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25–58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70–79 years age group, while this was observed in the 20–29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7]).
Conclusion
Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups.
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Affiliation(s)
- Axel Benhamed
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
- INSERM U1290 (RESHAPE), Université de Lyon 1, Lyon, France
- Département d’urgences, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
- * E-mail:
| | - Amina Ndiaye
- IFSTTAR, Université Gustave Eiffel, Bron, France
| | - Marcel Emond
- Département d’urgences, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
| | | | - Valérie Boucher
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Amaury Gossiome
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
| | | | | | - Karim Tazarourte
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
- INSERM U1290 (RESHAPE), Université de Lyon 1, Lyon, France
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Osuchukwu O, Lopez J, Weaver KL, Waddell VA, Aguayo P, St Peter SD, Juang D. Asymptomatic non-occult pneumothorax in pediatric blunt chest trauma: Chest tube versus observation. J Pediatr Surg 2021; 56:2333-2336. [PMID: 33648730 DOI: 10.1016/j.jpedsurg.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/19/2021] [Accepted: 02/05/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory. METHODS A retrospective chart review of patients < 17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed. RESULTS Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p < 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed. CONCLUSIONS CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.
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Affiliation(s)
- Obiyo Osuchukwu
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Joseph Lopez
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Katrina L Weaver
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Valerie A Waddell
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Baud C, Crulli B, Evain JN, Isola C, Wroblewski I, Bouzat P, Mortamet G. Traumatic brain injury in children with thoracic injury: clinical significance and impact on ventilatory management. Pediatr Surg Int 2021; 37:1421-1428. [PMID: 34232362 PMCID: PMC8260569 DOI: 10.1007/s00383-021-04959-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without associated moderate-to-severe traumatic brain injury (TBI). METHODS All children admitted to our level-1 trauma center from February 2012 to December 2018 following chest trauma were included in this retrospective study. RESULTS A total of 75 patients with a median age of 11 [6-13] years, with thoracic injuries were included. Most patients also had extra-thoracic injuries (n = 71, 95%) and 59 (79%) had TBI. A total of 52 patients (69%) were admitted to intensive care and 31 (41%) were mechanically ventilated. In patients requiring mechanical ventilation, there was no difference in tidal volume or positive end-expiratory pressure in patients with moderate-to-severe TBI when compared with those with no-or-mild TBI. Only one patient developed Acute Respiratory Distress Syndrome. A total of 6 patients (8%) died and all had moderate-to-severe TBI. CONCLUSION In this small retrospective series, most patients requiring mechanical ventilation following chest trauma had associated moderate-to-severe TBI. Mechanical ventilation to manage TBI does not seem to be associated with more acute respiratory distress syndrome occurrence.
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Affiliation(s)
- Caroline Baud
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, La Tronche, France
| | - Benjamin Crulli
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Jean-Noël Evain
- Department of Anesthesiology and Critical Care, Grenoble Alps University Hospital, La Tronche, France
| | - Clément Isola
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, La Tronche, France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, La Tronche, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, Grenoble Alps University Hospital, La Tronche, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, La Tronche, France
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Elsamadicy AA, Sandhu MR, Freedman IG, Koo AB, Hengartner AC, Reeves BC, Havlik J, Sarkozy M, Hong CS, Kundishora AJ, Tuason DA, DiLuna M. Racial Disparities in Health Care Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries. World Neurosurg 2021; 156:e307-e318. [PMID: 34560297 DOI: 10.1016/j.wneu.2021.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to investigate the impact of race on hospital length of stay (LOS) and hospital complications among pediatric patients with cervical/thoracic injury. METHODS A retrospective cohort was performed using the 2017 admission year from 753 facilities utilizing the National Trauma Data Bank. All pediatric patients with cervical/thoracic spine injuries were identified using the ICD-10-CM diagnosis coding system. These patients were segregated by their race, non-Hispanic white (NHW), non-Hispanic black (NHB), non-Hispanic Asian (NHA), and Hispanic (H). Demographic, hospital variable, hospital complications, and LOS data were collected. A linear and logistic multivariate regression analysis was performed to determine the risk ratio for hospital LOS as well as complication rate, respectively. RESULTS A total of 4,125 pediatric patients were identified. NHB cohort had a greater prevalence of cervical-only injuries (NHW: 37.39% vs. NHB: 49.93% vs. NHA: 34.29% vs. H: 38.71%, P < 0.001). While transport accident was most common injury etiology for both cohorts, NHB cohort had a greater prevalence of assault (NHW: 1.53% vs. NHB: 17.40% vs. NHA: 2.86% vs. H: 6.58%, P < 0.001) than the other cohorts. Overall complication rates were significantly higher among NHB patients (NHW: 9.39% vs. NHB: 15.12% vs. NHA: 14.29% vs. H: 13.60%, P < 0.001). Compared with the NHW cohort, NHB, NHA, and H had significantly longer hospital LOS (NHW: 6.15 ± 9.03 days vs. NHB: 9.24 ± 20.78 days vs. NHA: 9.09 ± 13.28 days vs. H: 8.05 ± 11.45 days, P < 0.001). NHB race was identified as a significant predictor of increased LOS on multivariate regression analysis (risk ratio: 1.14, 95% confidence interval: 0.46, 1.82; P = 0.001) but not hospital complications (P = 0.345). CONCLUSIONS Race may significantly impact health care resource utilization following pediatric cervical/thoracic spinal trauma.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Mani R Sandhu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chris S Hong
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dominick A Tuason
- Department of Orthopedics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Farzaneh C, Schomberg J, Sullivan B, Yu PT, Loudon W, Duong WQ, Gibbs D, Guner YS. Analysis of Unintentional Falls in Pediatric Population and Predictors of Morbidity. J Surg Res 2021; 267:48-55. [PMID: 34130238 DOI: 10.1016/j.jss.2021.04.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Unintentional falls are a leading cause of pediatric traumatic injury. This study evaluates clinical outcomes of fall-related injuries in children under the age of 10. METHODS The National Trauma Database was queried for children who experienced an unintentional fall. Patients were stratified by age in two groups: 1-5 and 6-10 years old. The primary outcome was post discharge extension of care, defined as transfer to skilled nursing facility or rehabilitation center after discharge from the hospital. Descriptive statistics and a multivariable logistic regression analysis were used to compare the two groups. RESULTS From 2009 to 2016, a total of 8,277 pediatric patients experienced an unintentional fall, with 93.6% of patients being discharged home. Falls were more common in younger children, with greater odds of post discharge extension of care. Predictors of increased associated risk of extended medical care included intracranial hemorrhage (OR 1.05, 95% CI 1.03-1.06) and thoracic injuries (OR 1.03, 95% CI 1.00-1.1.05) (P< 0.05). Mortality in pediatric patients suffering unintentional falls was a rare event occurring in 0.7% of cases in children 1-5 years old and 0.4% of children 6-10 years old. CONCLUSION The majority of children experiencing an unintentional fall are discharged home, with mortality being very rare. However, younger age is prone to more severe and serious injury patterns. Intracranial hemorrhage and thoracic injury were a predictor of need for extended medical care.
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Affiliation(s)
- Cyrus Farzaneh
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California Irvine, Orange, California.
| | - John Schomberg
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - Brittany Sullivan
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California Irvine, Orange, California
| | - Peter T Yu
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - William Loudon
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - William Q Duong
- Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, University of California Irvine, Orange, California
| | - David Gibbs
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
| | - Yigit S Guner
- Division of Pediatric Surgery, Children's Hospital of Orange County, Orange, California
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Ugalde IT, Prater S, Cardenas-Turanzas M, Sanghani N, Mendez D, Peacock J, Guvernator G, Koerner C, Allukian M. Chest x-ray vs. computed tomography of the chest in pediatric blunt trauma. J Pediatr Surg 2021; 56:1039-1046. [PMID: 33051082 DOI: 10.1016/j.jpedsurg.2020.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Chest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR. METHODS This retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR. RESULTS In 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p < .0001), pneumothorax (23% vs 9%; p < .0001), rib fracture (18% vs 7%; p < .0001), other fracture (20% vs 10%; p < .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p < .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5-61.2) and 90.2% (95% CI: 86.8-93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively. CONCLUSION CXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children. LEVEL OF EVIDENCE Level III, diagnostic test.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX.
| | - Samuel Prater
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Marylou Cardenas-Turanzas
- School of Biomedical Informatics and McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Nipa Sanghani
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Donna Mendez
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - John Peacock
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Grace Guvernator
- Department of Anesthesiology, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Christine Koerner
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery and the Trauma Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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12
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Boserup B, Sutherland M, Paloka R, McKenney M, Elkbuli A. The Effects of Body Mass Index and Seatbelt Use on Pediatric Chest and Abdominal Injuries after Motor Vehicle Collisions. Am Surg 2021; 88:2913-2922. [PMID: 33870738 DOI: 10.1177/00031348211011106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Motor vehicle collisions (MVCs) are a major cause of pediatric morbidity and mortality. However, the effect of body mass index (BMI) and seatbelt use on thoracic injuries and outcomes in pediatric patients with rib fractures remains unexplored. We aim to assess how seatbelt use and BMI affect thoracic injuries and outcomes in pediatric patients who sustained ≥3 rib fractures following an MVC. METHODS The Trauma Quality Improvement Program (TQIP) database (2013-2017) was queried for pediatric patients (8-17 years and >4 feet 9 inches tall) admitted secondary to MVCs, with ≥3 rib fractures and all non-thoracic Abbreviated Injury Scale ≤2. Patients were then divided by Injury Severity Score (ISS) into low (<15) and intermediate-severe (≥15) groups, which were further subdivided according to seatbelt use and BMI. Logistic and linear regression was performed to assess the effects of seatbelt use and BMI on outcomes. RESULTS Seatbelt compliance varied from 39.6 to 50.7%. Belted patients (intermediate-severe ISS) had a reduced hospital length of stay (HLOS), intensive care unit length of stay(ICU-LOS), and mechanical ventilation time but had increased odds of splenic laceration vs. unbelted patients (aOR = 2.46, 95% CI: 1.03-5.93, P = .044). Obese patients (low ISS) had lower incidences of hemothorax, pneumothorax, pulmonary contusion, splenic laceration, and liver injury compared to normal-weight patients. Overweight patients (intermediate-severe ISS) had a significantly reduced ICU-LOS vs. normal-weight patients (β = -.17, 95% CI: -.33,-.01, = .041). CONCLUSIONS Seatbelt use may improve outcomes for pediatric MVC patients with ≥3 rib fractures. Higher BMI may be associated with reduced thoracic injury and decreased ICU-LOS. Effective educational initiatives are needed to increase pediatric seatbelt compliance.
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Affiliation(s)
- Brad Boserup
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Rinald Paloka
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
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13
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Rezazadeh A, Samady Khanghah A. Successful Treatment of GSW to the Intrapericardial Inferior Vena Cava wall: Case Report. Int J Surg Case Rep 2021; 82:105864. [PMID: 33866305 PMCID: PMC8060578 DOI: 10.1016/j.ijscr.2021.105864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Penetrating traumas to the thorax could be potentially serious. Vena caval wounds are highly lethal, so that half of the patients die before reaching the hospital, and another 50% may die perioperatively. Although rare, most of them are the result of gunshot wounds. PRESENTATION OF CASE We report a 13-year-old boy shot by an air gun through his right hemithorax. During surgery, an air gun bullet appeared right within the wall of the intrapericardial inferior vena cava (IVC). DISCUSSION Traumas to the thoracic contents as vena cava are inevitable, presenting mostly with haemo or pneumothorax. If the victim reaches the operating room alive, the approach to his or her vena cava rupture remains a challenge in the hands of surgeons. In this case, the surgeon, following the bullet removal, repaired the penetration immediately by direct suturing because clamping the inferior vena for its thin wall can expand the rupture, also blocking systemic venous return. CONCLUSION The surgeon in a general trauma center that is almost lacking cardiopulmonary pump can repair the vital injuries to the IVC with the technique of direct suturing.
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Affiliation(s)
- Amin Rezazadeh
- Department of Surgery, Fatemi Hospital, Ardabil University of Medical Sciences, Ardabil, Iran.
| | - Ali Samady Khanghah
- Department of Surgery, Fatemi Hospital, Ardabil University of Medical Sciences, Ardabil, Iran.
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14
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Jung PY, Chung JS, Youn Y, Kim CW, Park IH, Kim OH, Byun CS. Characteristics of pediatric thoracic trauma: in view of before and after the establishment of a regional trauma center. Eur J Trauma Emerg Surg 2021; 48:195-204. [PMID: 33813596 PMCID: PMC8019336 DOI: 10.1007/s00068-021-01658-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/21/2021] [Indexed: 12/31/2022]
Abstract
Purpose Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center.
Methods Data of 168 patients’ ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed. Results Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods. Conclusions Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01658-4.
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Affiliation(s)
- Pil Young Jung
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Republic of Korea.,Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Sik Chung
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Republic of Korea.,Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Youngin Youn
- Department of Thoracic and Cardiovascular Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon, 26426, Republic of Korea
| | - Chang Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon, 26426, Republic of Korea
| | - Il Hwan Park
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon, 26426, Republic of Korea
| | - Oh Hyun Kim
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Republic of Korea.,Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Chun Sung Byun
- Department of Thoracic and Cardiovascular Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon, 26426, Republic of Korea.
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Piastra M, De Bellis A, Morena TC, De Luca D, Pezza L, Pizza A, Genovese O, Mancino A, Picconi E, Conti G. Noninvasive Ventilation in a Pediatric Trauma Center: A Cohort Study. J Intensive Care Med 2021; 37:177-184. [PMID: 33461370 DOI: 10.1177/0885066620983744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury. STUDY DESIGN A single center observational cohort study. SETTING Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre). POPULATION During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV. INCLUSION/EXCLUSION CRITERIA Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation. MEASUREMENTS AND RESULTS Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated. CONCLUSIONS AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.
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Affiliation(s)
- Marco Piastra
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
| | - Andrea De Bellis
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Plastic Surgery and Burn Unit, S. Eugenio Hospital, Rome, Italy
| | - Tony C Morena
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniele De Luca
- Centre Antoine Beclere, Paris-Saclay University Hospitals APHP, Division of Pediatrics and Neonatal Critical Care, Paris, Ile-de France, France
- Université Paris-Saclay APHP, Physiopathology and Therapeutic Innovation Unit INSERUM U999, Paris, Ile-de France, France
| | - Lucilla Pezza
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pizza
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Orazio Genovese
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aldo Mancino
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enzo Picconi
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
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16
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Weber B, Lackner I, Braun CK, Kalbitz M, Huber-Lang M, Pressmar J. Laboratory Markers in the Management of Pediatric Polytrauma: Current Role and Areas of Future Research. Front Pediatr 2021; 9:622753. [PMID: 33816396 PMCID: PMC8010656 DOI: 10.3389/fped.2021.622753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/19/2021] [Indexed: 11/13/2022] Open
Abstract
Severe trauma is the most common cause of mortality in children and is associated with a high socioeconomic burden. The most frequently injured organs in children are the head and thorax, followed by the extremities and by abdominal injuries. The efficient and early assessment and management of these injuries is essential to improve patients' outcome. Physical examination as well as imaging techniques like ultrasound, X-ray and computer tomography are crucial for a valid early diagnosis. Furthermore, laboratory analyses constitute additional helpful tools for the detection and monitoring of pediatric injuries. Specific inflammatory markers correlate with post-traumatic complications, including the development of multiple organ failure. Other laboratory parameters, including lactate concentration, coagulation parameters and markers of organ injury, represent further clinical tools to identify trauma-induced disorders. In this review, we outline and evaluate specific biomarkers for inflammation, acid-base balance, blood coagulation and organ damage following pediatric polytrauma. The early use of relevant laboratory markers may assist decision making on imaging tools, thus contributing to minimize radiation-induced long-term consequences, while improving the outcome of children with multiple trauma.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany.,Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, Center of Surgery, University of Ulm, Ulm, Germany
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17
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Azari S, Hoover T, Dunstan M, Harrison TJ, Browne M. Review, monitor, educate: A quality improvement initiative for sustained chest radiation reduction in pediatric trauma patients. Am J Surg 2020; 220:1327-1332. [PMID: 32928539 DOI: 10.1016/j.amjsurg.2020.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We hypothesize that in pediatric trauma patients, CT scans after normal chest x-rays do not add information that alters clinical decision making. METHODS A retrospective review of trauma patients < 15 years with chest imaging evaluated at a pediatric trauma center between 1/2013 and 6/2019 was performed. Imaging was reviewed for significant findings that could affect care. A guideline was established in January 2017 which emphasized x-rays prior to CTs and no CTs after normal x-rays. A prospective review was performed from 1/2017-6/2019. Pre and post guideline groups were compared. RESULTS From 2013 to 2016, 246 patients met inclusion. 29.5% had a chest CT after a normal x-ray, only 1.8% (1/57) had a significant result. From 2017 to 2019, 188 patients were reviewed post guideline; only 9.4% received a CT after normal x-ray, of which 6.3% (1/16) were significant. Neither changed clinical management. CONCLUSIONS Chest CT following normal chest x-ray does not change clinical management in pediatric trauma patients. Monitoring and education following guideline implementation improves long term outcomes.
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Affiliation(s)
- Sarah Azari
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Travis Hoover
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Michele Dunstan
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Timothy J Harrison
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Lehigh Valley Reilly Children's Hospital, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA.
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18
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Affiliation(s)
- Gal Barbut
- Maimonides Children's Hospital, Brooklyn, NY
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19
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Störmann P, Weber JN, Jakob H, Marzi I, Schneidmueller D. [Thoracic injuries in severely injured children : Association with increased injury severity and a higher number of complications]. Unfallchirurg 2019; 121:223-229. [PMID: 28105481 DOI: 10.1007/s00113-017-0312-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Severely injured children and adolescents in clinical practice are rare. For adequate treatment of these patients, detailed knowledge of anatomical and physiological peculiarities, as well as abundant injury patterns, are indispensable. Traumatic brain injuries are known to lead to an unfavorable outcome. In addition, thoracic trauma is regarded as prognostically unfavorable. OBJECTIVES This study depicts epidemiology and injury patterns of severely injured children and adolescents focusing on peculiarities in the severely injured with associated thoracic injuries. MATERIALS AND METHODS A retrospective analysis of underaged patients with suspicion of severe injuries who obtained emergency-room treatment in our level-one trauma center during a four-year time period was performed. The data was collected prospectively using the TraumaRegister® of the German Trauma Society as well as an extended house-internal dataset including data of daily clinical routine. The patients were divided into subgroups with (TT) and without (KT) thoracic trauma based on whether a thoracic injury was present or not. For further analysis, four age groups were established. RESULTS In all, 256 patients younger than 18 years were eligible. Of these, 46 patients revealed thoracic injuries. The mean age of patients with thoracic trauma (12.4 ± 4.9 years) was significantly higher than for patients without thoracic trauma (8.0 ± 5.2 years). In both subgroups, most patients were male (TT: 69.9%, KT: 64.8%). Patients with concomitant thoracic trauma showed a significantly higher injury severity score (ISS) than patients without thoracic trauma (ISS: TT: 26.7 ± 15.8 vs. KT: 8.1 ± 6.8 points). Mortality was higher for TT as well (TT: 6.9% vs. KT: 1.9%). For both groups, traffic accidents were the most common cause of injury. Of patients with thoracic injuries, 52.2% developed at least one complication during their hospital stay (KT: 12.9%). CONCLUSIONS Thoracic trauma is a relevant factor in children with regard to the severity of total injury and complications. Particular attention should therefore be paid to early diagnosis and treatment.
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Affiliation(s)
- Philipp Störmann
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
| | - Julia Nadine Weber
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Heike Jakob
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.,Klinik für Chirurgie, Abteilung Unfall- und Wiederherstellungschirurgie, Kreiskrankenhaus St. Ingbert, Klaus-Tussing-Str. 1, St. Ingbert, 66386, Deutschland
| | - Ingo Marzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Dorien Schneidmueller
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.,Abtl. für Unfallchirurgie, Sportorthopädie und Kindertraumatologie der BGU Murnau und des Klinikums Garmisch-Partenkirchen, Auenstr. 6, Garmisch-Partenkirchen, 82467, Deutschland
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20
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de Roulet A, Burke RV, Lim J, Papillon S, Bliss DW, Ford HR, Upperman JS, Inaba K, Jensen AR. Pediatric trauma-associated acute respiratory distress syndrome: Incidence, risk factors, and outcomes. J Pediatr Surg 2019; 54:1405-1410. [PMID: 30041860 DOI: 10.1016/j.jpedsurg.2018.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/28/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND/PURPOSE Acute Respiratory Distress Syndrome (ARDS) results in significant morbidity and mortality in pediatric trauma victims. The objective of this study was to determine risk factors and outcomes specifically related to pediatric trauma-associated ARDS (PT-ARDS). METHODS A retrospective cohort (2007-2014) of children ≤18 years old from the American College of Surgeons National Trauma Data Bank (NTDB) was used to analyze incidence, risk factors, and outcomes related to PT-ARDS. RESULTS PT-ARDS was identified in 0.5% (2660/488,381) of the analysis cohort, with an associated mortality of 18.6% (494/2660). Mortality in patients with PT-ARDS most commonly occurred in the first week after injury. Risk factors associated with the development of PTARDS included nonaccidental trauma, near drowning, severe injury (AIS ≥ 3) to the head or chest, pneumonia, sepsis, thoracotomy, laparotomy, transfusion, and total parenteral nutrition use. After adjustment for age, injury complexity, injury mechanism, and physiologic variables, PT-ARDS was found to be independently associated with higher mortality (adjusted OR 1.33, 95% CI 1.18-1.51, p < 0.001). CONCLUSIONS PT-ARDS is a rare complication in pediatric trauma patients, but is associated with substantial mortality within 7 days of injury. Recognition and initiation of lung-protective measures early in the postinjury course may represent the best opportunity to change outcomes. LEVEL OF EVIDENCE Level 3 - Epidemiologic.
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Affiliation(s)
- Amory de Roulet
- Keck School of Medicine of the University of Southern California; Division of General Surgery, New York-Presbyterian Queens, Flushing, NY 11355.
| | - Rita V Burke
- Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Joanna Lim
- Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | | | - David W Bliss
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Henri R Ford
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Jeffrey S Upperman
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Kenji Inaba
- Keck School of Medicine of the University of Southern California; Division of Acute Care Surgery and Surgical Critical Care, LAC+USC Medical Center Los Angeles, CA 90027.
| | - Aaron R Jensen
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
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21
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Characterization of all-terrain vehicle-related chest injury patterns in children. Emerg Radiol 2019; 26:373-379. [PMID: 30790115 DOI: 10.1007/s10140-019-01679-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/05/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate chest injury patterns in pediatric patients involved in all-terrain vehicle (ATV) accidents. METHODS Retrospective review of patients 0-18 years old admitted to a level I trauma institute following an ATV-related incident from 2004 to 2013 was performed. Chest injury type, accident mechanism, driver/passenger status, and demographic and clinical data were compared between patients with and without chest injury. RESULTS Chest injury was present in 102 (22%) of total 455 patients. The most common chest injuries were pulmonary contusion (61%), pneumothorax (45%), and rib fracture (34%). There were no cardiac, esophageal, or tracheobronchial injuries. Pulmonary lacerations, hemothoraces, and scapular fractures were predominantly not detected on radiography and recognized on CT only (86-92%). Patients with chest injury had longer median hospital stays (3 days vs 2 days, p = 0.0054). There was no significant difference in admission to intensive care after controlling for injury severity scores in patients with chest injury compared to those without (17 vs 9). Eight patients with chest injury died (8%) compared to 2 patients without chest injury (0.6%) (p = 0.0002). CONCLUSIONS Chest injuries are common in children following ATV accidents and may be a marker of more severe trauma. Increased public awareness of these potentially devastating injuries and continuing safety efforts are needed.
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Braun CK, Schaffer A, Weber B, Huber-Lang M, Kalbitz M, Preßmar J. The Prognostic Value of Troponin in Pediatric Polytrauma. Front Pediatr 2019; 7:477. [PMID: 31824896 PMCID: PMC6879657 DOI: 10.3389/fped.2019.00477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/30/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction: Severe trauma accounts for a great number of deaths among children and adolescents. The diagnostic value of troponin serum levels of severely injured patients has been reported for adults, but data on pediatric polytrauma (PT) are scarce. Therefore, we conducted a retrospective monocentered study analyzing the prognostic value of troponin T (TnT) in pediatric trauma patients at the time point of hospital admission. Methods: Data of 88 polytraumatized pediatric patients admitted to the emergency room of the University Hospital of Ulm, Germany, between 2007 and 2016 were analyzed retrospectively. The data source was the written and digital patient records. Interleukin-6 (IL-6), creatine kinase activity (CK activity), and lactate and TnT levels were measured by a certified clinical diagnostic laboratory; and patients were stratified for the Injury Severity Score (ISS). The prognostic value for lung contusion, organ dysfunction, and fatal outcome was statistically explored. The study was approved by the independent ethical committee of the University of Ulm (#44/18). Results: TnT levels were significantly increased in patients after severe PT compared with mild or moderate trauma severity as assessed by ISS values. Patients with TnT levels above the cutoff showed significantly increased levels of IL-6 and CK activity and a significantly prolonged stay in the intensive care unit. However, TnT levels did not correlate with absolute ISS values. TnT levels were significantly increased in patients with chest trauma and lung contusion. The incidence of lung contusion was associated with elevation of TnT. So was the onset of organ dysfunction, defined as a Sequential Organ Failure Assessment (SOFA) score ≥ 2 and fatal outcome, with a significant enhancement of plasma levels in children with organ dysfunction and in non-survivors. Conclusion: These descriptive data suggest that evaluation of TnT on admission of multiply injured children may help in predicting severity of injury and mortality in the clinical course after trauma and thus may be a useful addition to established prognostic parameters in the future.
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Affiliation(s)
- Christian Karl Braun
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Annika Schaffer
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma-Immunology, University Hospital of Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
| | - Jochen Preßmar
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University Hospital of Ulm, Ulm, Germany
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Lodwick DL, Cooper JN, Gonzalez DO, Lawrence AE, Lee C, Krishnamurthy R, Minneci PC, Deans KJ. Disparities in Radiation Burden from Trauma Evaluation at Pediatric Versus Nonpediatric Institutions. J Surg Res 2018; 232:475-483. [DOI: 10.1016/j.jss.2018.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/13/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
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Murach MM, Kang YS, Bolte JH, Stark D, Ramachandra R, Agnew AM, Moorhouse K, Stammen J. Quantification of Skeletal and Soft Tissue Contributions to Thoracic Response in a Dynamic Frontal Loading Scenario. STAPP CAR CRASH JOURNAL 2018; 62:193-269. [PMID: 30608996 DOI: 10.4271/2018-22-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Thoracic injuries continue to be a major health concern in motor vehicle crashes. Previous thoracic research has focused on 50th percentile males and utilized scaling techniques to apply results to different demographics. Individual rib testing offers the advantage of capturing demographic differences; however, understanding of rib properties in the context of the intact thorax is lacking. Therefore, the objective of this study was to obtain the data necessary to develop a transfer function between individual rib and thoracic response. A series of non-injurious frontal impacts were conducted on six PMHS, creating a loading environment commensurate to previously published individual rib testing. Each PMHS was tested in four tissue states: intact, intact with upper limbs removed, denuded, and eviscerated. Following eviscerated thoracic testing, eight individual mid-level ribs from each PMHS were removed and loaded to failure. A simplified model in which ribs of each thorax are treated as parallel springs was utilized to evaluate the ability of individual rib response data to predict each subject's eviscerated thoracic response. On average across subjects, denuded thoraces retained 89% and eviscerated thoraces retained 46% of intact force. Similarly, denuded thoraces retained 70% and eviscerated thoraces retained 30% of intact stiffness. The rib model did not adequately predict eviscerated thoracic response but provided a better understanding of the influence of connective tissue on a rib's behavior with-in the thorax. Results of this study could be used in conjunction with the database of individual rib test results to improve thoracic response targets and help assess biofidelity of current anthropomorphic test devices.
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Affiliation(s)
| | - Yun-Seok Kang
- Injury Biomechanics Research Center, The Ohio State University
| | - John H Bolte
- Injury Biomechanics Research Center, The Ohio State University
| | - David Stark
- Injury Biomechanics Research Center, The Ohio State University
| | | | - Amanda M Agnew
- Injury Biomechanics Research Center, The Ohio State University
| | - Kevin Moorhouse
- National Highway Traffic Safety Administration, Vehicle Research and Test Center
| | - Jason Stammen
- National Highway Traffic Safety Administration, Vehicle Research and Test Center
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Agnew AM, Murach MM, Dominguez VM, Sreedhar A, Misicka E, Harden A, Bolte JH, Kang YS, Stammen J, Moorhouse K. Sources of Variability in Structural Bending Response of Pediatric and Adult Human Ribs in Dynamic Frontal Impacts. STAPP CAR CRASH JOURNAL 2018; 62:119-192. [PMID: 30608995 DOI: 10.4271/2018-22-0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Despite safety advances, thoracic injuries in motor vehicle crashes remain a significant source of morbidity and mortality, and rib fractures are the most prevalent of thoracic injuries. The objective of this study was to explore sources of variation in rib structural properties in order to identify sources of differential risk of rib fracture between vehicle occupants. A hierarchical model was employed to quantify the effects of demographic differences and rib geometry on structural properties including stiffness, force, displacement, and energy at failure and yield. Three-hundred forty-seven mid-level ribs from 182 individual anatomical donors were dynamically (~2 m/s) tested to failure in a simplified bending scenario mimicking a frontal thoracic impact. Individuals ranged in age from 4 - 108 years (mean 53 ± 23 years) and included 59 females and 123 males of diverse body sizes. Age, sex, body size, aBMD, whole rib geometry and cross-sectional geometry were explored as predictors of rib structural properties. Measures of cross-sectional rib size (Tt.Ar), bone quantity (Ct.Ar), and bone distribution (Z) generally explained more variation than any other predictors, and were further improved when normalized by rib length (e.g., robustness and WBSI). Cortical thickness (Ct.Th) was not found to be a useful predictor. Rib level predictors performed better than individual level predictors. These findings moderately explain differential risk for rib fracture and with additional exploration of the rib's role in thoracic response, may be able contribute to ATD and HBM development and alterations in addition to improvements to thoracic injury criteria and scaling methods.
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Affiliation(s)
- Amanda M Agnew
- Injury Biomechanics Research Center, The Ohio State University
| | | | | | | | - Elina Misicka
- Injury Biomechanics Research Center, The Ohio State University
| | - Angela Harden
- Injury Biomechanics Research Center, The Ohio State University
| | - John H Bolte
- Injury Biomechanics Research Center, The Ohio State University
| | - Yun-Seok Kang
- Injury Biomechanics Research Center, The Ohio State University
| | - Jason Stammen
- National Highway Traffic Safety Administration, Vehicle Research and Test Center
| | - Kevin Moorhouse
- National Highway Traffic Safety Administration, Vehicle Research and Test Center
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Evaluation of factors affecting prognosis in penetrating thoracic injuries. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:598-605. [PMID: 32082802 DOI: 10.5606/tgkdc.dergisi.2018.15734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/23/2018] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the prognostic factors affecting survival and clinical outcomes in patients exposed to pediatric penetrating thoracic injury. Methods A t otal o f 2 67 p ediatric p enetrating t horacic injury patients (217 males, 50 females; mean age 10.8 years; range, 3 to 17 years) who were treated at our hospital during the recent 20 years were analyzed retrospectively. Penetrating thoracic injuries were divided into three groups: incisive/stabbing injuries, gunshot injuries, explosive injuries. Patients" age, gender, New Injury Severity Score, injury type, injuries accompanying thoracic trauma, types of treatment applied, length of hospital stay, and morbidity and mortality outcomes were examined. Their prognostic characteristics were compared to their injury types, New Injury Severity Scores, lengths of hospital stay and complications. Results Of the patients, 103 were exposed to gunshot injuries, 128 to incisive/stabbing injuries, and 36 to explosive injuries. Of the penetrating thoracic injuries, while 211 (79%) were isolated injuries, 56 (21%) were accompanying non-thoracic injuries. Mean New Injury Severity Score was 13±10. Of the patients, 50 (18.6%) were treated with medical therapy alone, 199 (74.5%) with tube thoracostomy, and 18 (6.7%) with thoracotomy. Fiftyone patients (19%) developed complications. Length of hospital was 9±2.7 days. Twenty-one patients (7.9%) died. New Injury Severity Scores, rates of combined injuries, complications, length of hospital stay, and mortality were higher in explosive injuries (p<0.05). Conclusion Pediatric penetrating thoracic injuries may be observed in all age groups in children, the most severe type being explosive injuries. Prognostic factors may vary according to injury type, complications, treatment approach, and presence of accompanying non-thoracic injuries.
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Abstract
Thoracic injuries account for less than one-tenth of all pediatric trauma-related injuries but comprise 14% of pediatric trauma-related deaths. Thoracic trauma includes injuries to the lungs, heart, aorta and great vessels, esophagus, tracheobronchial tree, and structures of the chest wall. Children have unique anatomic features that change the patterns of observed injury compared with adults. This review article outlines the clinical presentation, diagnostic testing, and management principles required to successfully manage injured children with thoracic trauma.
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Affiliation(s)
- Stacy L Reynolds
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, 3rd Floor Medical Education Building, Charlotte, NC 28203, USA.
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Factors Predicting Lung Contusions in Critically Ill Trauma Children: A Multivariate Analysis of 330 Cases. Pediatr Emerg Care 2018; 34:198-201. [PMID: 27261955 DOI: 10.1097/pec.0000000000000756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of the study was to identify factors predicting lung contusion in trauma children. METHODS Retrospective study conducted for a period of 8 years (January 01, 2005-December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared: those with lung contusions (C+ group) and those without lung contusions (C- group). RESULTS We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in 43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1; 95% CI, 1.1-1.2; P = 0.017), hepatic contusion (OR, 4.8; 95% CI, 1.3-17.1; P = 0.017), and pelvic ring fracture (OR, 3.5; 95% CI, 1.1-10.5; P = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C+ group (OR, 2.5; 95% CI, 1.2-5.4; P = 0.021). However, mortality was not different between the 2 groups after adjusting for PRISM score (OR, 1.2; 95% CI, 0.5-2.9; P = 0.752) or after adjusting for Injury Severity Score (OR, 0.7; 95% CI, 0.3-2.1; P = 0.565). CONCLUSIONS Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patients with road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture.
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Sharma S, Mishra B, Gupta A, Soni KD, Aggarwal R, Kumar S. Challenges in Management of Pediatric Life-threatening Neck and Chest Trauma. J Indian Assoc Pediatr Surg 2018; 23:10-15. [PMID: 29386758 PMCID: PMC5772087 DOI: 10.4103/jiaps.jiaps_49_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Introduction: Neck and thoracic trauma in children pose unforeseen challenges requiring variable management strategies. Here, we describe some unusual cases. Patients and Methods: Pediatric cases of unusual neck and thoracic trauma prospectively managed from April 2012 to March 2014 at a Level 1 trauma center were studied for management strategies, outcome, and follow-up. Results: Six children with a median age of 5.5 (range 2–10) years were managed. Mechanism of injury was road traffic accident, fall from height and other accidental injury in 2, 3 and 1 patient respectively. The presentation was respiratory distress and quadriplegia, exposed heart, penetrating injury in neck, dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases respectively. Injuries included lung laceration, open chest wall, vascular injury of the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis. One patient had a flare of miliary tuberculosis. Immediate management included chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal stapling, and feeding jejunostomy (followed by gastric pull-up 8 months later). Chest tube insertion and total parenteral nutrition was required in one each. 2 and 4 patients required tracheostomy and mechanical ventilation. The patient with gastric pull-up developed a stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. At follow-up of 40–61 months, five patients are well. One patient with penetrating neck injury suffered from blindness due to massive hemorrhage from the vascular injury in the neck and brain ischemia with only peripheral vision recovery. Conclusion: Successful management of neck and chest wall trauma requires timely appropriate decisions with a team effort.
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Affiliation(s)
- Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Intensive and Critical Care, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Richa Aggarwal
- Department of Intensive and Critical Care, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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30
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Figaji AA. Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care. Front Neurol 2017; 8:685. [PMID: 29312119 PMCID: PMC5735372 DOI: 10.3389/fneur.2017.00685] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/30/2017] [Indexed: 01/08/2023] Open
Abstract
General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.
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Affiliation(s)
- Anthony A Figaji
- Neuroscience Institute, Division of Neurosurgery, University of Cape Town, Red Cross Children's Hospital, Rondebosch, Cape Town, South Africa
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31
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Abstract
Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. The combination of anatomic, physiologic, and metabolic factors leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups. This article is intended for community, nonpediatric trauma centers, and emergency physicians who are frequently required to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.
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Affiliation(s)
- Angelo Mikrogianakis
- Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail Northwest, Calgary, Alberta T3B 6A8, Canada; Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Vincent Grant
- Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail Northwest, Calgary, Alberta T3B 6A8, Canada; Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
The management of critically ill pediatric patients with trauma poses many challenges because of the infrequency and diversity of severe injuries and a paucity of high-level evidence to guide care for these uncommon events. This article discusses recent recommendations for early resuscitation and blood component therapy for hypovolemic pediatric patients with trauma. It also highlights the specific types of injuries that lead to severe injury in children and presents challenges related to their management.
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Affiliation(s)
- Omar Z Ahmed
- Department of General and Thoracic Surgery, Division of Trauma and Burn Surgery, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Randall S Burd
- Department of General and Thoracic Surgery, Division of Trauma and Burn Surgery, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA.
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Piccolo CL, Ianniello S, Trinci M, Galluzzo M, Tonerini M, Zeccolini M, Guglielmi G, Miele V. Diagnostic Imaging in pediatric thoracic trauma. Radiol Med 2017; 122:850-865. [PMID: 28674910 DOI: 10.1007/s11547-017-0783-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/16/2017] [Indexed: 12/17/2022]
Abstract
Thoracic trauma accounts for approximately 14% of blunt force traumatic deaths, second only to head injuries. Chest trauma can be blunt (90% of cases) or penetrating. In young patients, between 60 and 80% of chest injuries result from blunt trauma, with over half as a consequence of impact with motor vehicles, whereas in adolescents and adults, penetrating trauma has a statistically more prominent role. Pulmonary contusions and rib fractures are the most frequent injuries occurring. Chest X-ray is the first imaging modality of choice to identify patients presenting with life-threatening conditions (i.e., tension pneumothorax, huge hemothorax, and mediastinal hematoma) and those who require a CT examination. Multi-Slice Computed Tomography is the gold standard to evaluate chest injuries. In fact, the high spatial resolution, along with multiplanar reformation and three-dimensional (3D) reconstructions, makes MDCT the ideal imaging method to recognize several chest injuries such as rib fractures, pneumothorax, hemothorax, lung contusions and lacerations, diaphragmatic rupture, and aortic injuries. Nevertheless, when imaging a young patient, one should always keep into account the ALARA concept, to balance an appropriate and low-dose technique with imaging quality and to reduce the amount of ionizing radiation exposure. According to this concept, in the recent years, the current trends in pediatric imaging support the rising use of alternative imaging modalities, such as US and MRI, to decrease radiation exposure and to answer specific clinical questions and during the observation period also. As an example, ultrasound is the first technique of choice for the diagnosis and treatment of pleural and pericardial effusion; its emerging indications include the evaluation of pneumothoraces, costocondral and rib fractures, and even pulmonary contusions.
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Affiliation(s)
| | | | | | - Michele Galluzzo
- Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy
| | - Michele Tonerini
- Department of Emergency Radiology, Cisanello Hospital, Pisa, Italy
| | - Massimo Zeccolini
- Department of Radiology, Santobono Pediatric Hospital, Naples, Italy
| | | | - Vittorio Miele
- Department of Radiology, University Hospital Careggi, L.go Giovanni Alessandro Brambilla, 3, 50134, Florence, Italy.
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Abstract
Pediatric thoracic trauma is relatively uncommon but results in disproportionately high levels of morbidity and mortality when compared with other traumatic injuries. These injuries are often more devastating due to differences in children׳s anatomy and physiology relative to adult patients. A high index of suspicion is of utmost importance at the time of presentation because many significant thoracic injuries will have no external signs of injury. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.
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Affiliation(s)
- Erik G Pearson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Matthew T Santore
- Section of Pediatric Surgery, Department of Surgery, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Third Floor Surgical Offices, 1405 Clifton Rd, Atlanta, Georgia 30322.
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35
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Abstract
Damage control is a surgical strategy that has evolved and expanded considerably over the past 25 years. The approach was initially developed as a "bail out" procedure to control bleeding with severe abdominal injuries in the setting of unmitigated hemorrhagic shock. Damage control is now more broadly applied as a comprehensive management plan for the resuscitation and surgical treatment of injured patients with exhausted physiologic and metabolic reserve. This article reviews the most current concepts in damage control that are important and relevant to the practicing pediatric surgeon. It also provides evidence-based recommendations about how damage control principles can be pragmatically applied to severely injured children. This review focuses specifically on the fundamentals of damage control with respect to resuscitation and the operative treatment of children with severe abdominal, thoracic, and extremity injuries.
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Affiliation(s)
- Anthony Tran
- Pediatric Surgery and Injury Prevention Center, Connecticut Children's Medical Center, Hartford, Connecticut 06106
| | - Brendan T Campbell
- Pediatric Surgery and Injury Prevention Center, Connecticut Children's Medical Center, Hartford, Connecticut 06106.
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36
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McNamara C, Mironova I, Lehman E, Olympia RP. Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations. J Emerg Med 2016; 52:793-800. [PMID: 27998635 DOI: 10.1016/j.jemermed.2016.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/10/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure. OBJECTIVE To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature. METHODS We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation. RESULTS Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%). CONCLUSIONS Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness.
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Affiliation(s)
| | | | - Erik Lehman
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA
| | - Robert P Olympia
- Department of Emergency Medicine, Penn State Hershey Medical Center, Hershey, PA
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37
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Gettig K, Lawson KA, Garcia NM, Fox KA. Penetrating knitting needle through the mediastinum in a child. J Trauma Nurs 2016; 22:132-5; quiz E1-2. [PMID: 25961479 DOI: 10.1097/jtn.0000000000000123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thoracic injuries are second only to central nervous system injuries as the leading cause of traumatic death in patients of all ages. Penetrating chest injury is very uncommon in children, but it comes with significant morbidity and mortality. Presentation of penetrating thoracic injury in the child is unique with inherent opportunities for learning. The purpose of this case report was to disseminate information regarding rare thoracic trauma in the pediatric patient.
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Affiliation(s)
- Kelly Gettig
- Trauma Services (Ms Gettig and Drs Lawson and Garcia) and Pediatric Cardiothoracic Surgery (Dr Fox), Dell Children's Medical Center of Central Texas, Austin
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38
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Tatli O, Kurt NBK, Karaca Y, Sahin A, Aygün A, Sahin E, Katipoglu B, Eryigit U, Turkmen S. The diagnostic value of serum pentraxin 3 levels in pulmonary contusion. Am J Emerg Med 2016; 35:425-428. [PMID: 27955970 DOI: 10.1016/j.ajem.2016.11.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To investigate the difference in pentraxin 3 (PTX 3) levels between patients with pulmonary contusion and healthy volunteers. MATERIALS AND METHODS This study was conducted with a group of 20 trauma patients diagnosed with pulmonary contusion and 30 healthy individuals enrolled as a control group in a tertiary university hospital. RESULTS Median PTX 3 levels were 7.05 (3.29-13.1), ng/ml in the contusion group and 1.03 (0.7-1.58) ng/ml in the control group. PTX 3 titers were significantly higher in patients with pulmonary contusion compared to those of the control group (p<0.001). An area under the curve (AUC) value of 0.968 investigated using ROC analysis to determine the diagnostic value of the PTX-3 in pulmonary contusion patients was measured. A PTX-3 cut-off value of 2.06 produced 95.5% sensitivity and 86.7% specificity. CONCLUSION PTX 3 levels in pulmonary contusion increased significantly compared to the healthy control group. If supported by wider series, PTX 3 may be expected to be capable of use as a marker in pulmonary contusion.
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Affiliation(s)
- Ozgur Tatli
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey.
| | - Nur Banu Keha Kurt
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Yunus Karaca
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Aynur Sahin
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Ali Aygün
- Ordu University, Training and Research Hospıtal, Turkey; Department of Emergency Medicine, Ordu, Turkey
| | - Elif Sahin
- Karadeniz Technical University, Faculty of Medicine, Department of Medical Biochemistry, Trabzon, Turkey
| | - Burak Katipoglu
- Ankara Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
| | - Umut Eryigit
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Suha Turkmen
- Acıbadem University, Faculty of Medicine, Department of Emergency Medicine, İstanbul, Turkey
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Age and sex alone are insufficient to predict human rib structural response to dynamic A-P loading. J Biomech 2016; 49:3516-3522. [PMID: 27717546 DOI: 10.1016/j.jbiomech.2016.09.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/24/2016] [Accepted: 09/19/2016] [Indexed: 11/22/2022]
Abstract
Thoracic injuries from motor vehicle crashes (MVCs) are common in children and the elderly and are associated with a high rate of mortality for both groups. Rib fractures, in particular, are linked to high mortality rates which increase with the number of fractures sustained. Anthropomorphic test devices (ATDs) and computational models have been developed to improve vehicle safety, however these tools are constructed based on limited physical datasets. To-date, no study has explored variation of rib structural properties across the entire age spectrum with data obtained using the same experimental methodology to allow for comparison. One-hundred eighty-four ribs from 93 post mortem human subjects (PMHS) (70 male, 23 female; ages 4-99) were subjected to dynamic bending tests simulating a frontal impact to the thorax. Structural mechanical properties were calculated and a multi-level statistical model quantified the sample variance as explained by age and sex. Displacement (δX), peak force (Fpeak), linear structural stiffness (K), energy absorption to fracture (Utot), and plastic properties including post-yield energy absorption (UPl), plastic displacement (δPl), and the ratio of elastic to secant stiffness (K-ratio) all showed negative relationships with age, while only Fpeak, K, and Utot were dependent on sex. Despite these relationships being statistically significant, only 7-39% of variance is explained by age and only 3-17% of variance is explained by sex. This demonstrates that variability in bone properties is more complex than simply chronological age- and sex-dependence and should be explored in the context of biological mechanisms instead.
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41
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Limiting chest computed tomography in the evaluation of pediatric thoracic trauma. J Trauma Acute Care Surg 2016; 81:271-7. [DOI: 10.1097/ta.0000000000001110] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pandharikar N, Sachdev A, Gupta N, Gupta S, Gupta D. Chest trauma: A case for single lung ventilation. Indian J Crit Care Med 2016; 20:248-50. [PMID: 27303142 PMCID: PMC4906333 DOI: 10.4103/0972-5229.180050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Chest trauma is one of the important causes of mortality and morbidity in pediatric trauma patients. The complexity, magnitude, and type of lung injury make it extremely challenging to provide optimal oxygenation and ventilation while protecting the lung from further injury due to mechanical ventilation. Independent lung ventilation is used sporadically in these patients who do not respond to these conventional ventilatory strategies using double-lumen endotracheal tubes, bronchial blocker balloons, etc. However, this equipment may not be easily available in developing countries, especially for pediatric patients. Here, we present a case of severe chest trauma with pulmonary contusion, flail chest, and bronchopleural fistula, who did not respond to conventional lung protective strategies. She was successfully managed with bronchoscopy-guided unilateral placement of conventional endotracheal tube followed by single lung ventilation leading to resolution of a chest injury.
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Affiliation(s)
- Nagaraj Pandharikar
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Sachdev
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Gupta
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Suresh Gupta
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Dhiren Gupta
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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Zreik NH, Francis I, Ray A, Rogers BA, Ricketts DM. Blunt chest trauma: bony injury in the thorax. Br J Hosp Med (Lond) 2016; 77:72-7. [DOI: 10.12968/hmed.2016.77.2.72] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nasri H Zreik
- Orthopaedic Registrar in the Department of Trauma and Orthopaedics, Aintree University Hospital, Liverpool L9 7AL
| | - Irene Francis
- Medical Student in the Department of Medicine and Dentistry, Brighton University, Brighton
| | - Arun Ray
- Orthopaedic Registrar in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| | - Benedict A Rogers
- Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
| | - David M Ricketts
- Consultant Orthopaedic Surgeon in the Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex
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Abstract
BACKGROUND Rib fracture number correlates with mortality in adult trauma patients, sharply rising above six fractured ribs. Because of the pliability of younger ribs, pediatric ribs are believed to require more energy to fracture. We hypothesized this will result in a different rib fracture-associated pediatric mortality rate. METHODS We queried the National Trauma Data Bank (American College of Surgeons, Chicago, Illinois) for patients younger than 21 years with and without rib fractures (2002-2009), abstracting the number of rib fractures, diagnoses, procedures, and outcomes. Univariable and multivariable analyses were performed with logistic regression to adjust for age and concomitant injury. RESULTS We identified 729,240 pediatric patients, 19,442 with rib fractures. Mortality doubled from 1.79% without rib fracture to 5.81% for one rib fracture and then nearly linearly increased to 8.23% for seven fractures unlike the pattern in adults. This pattern persisted irrespective of the age group evaluated. Ventilator days also increased with increasing number of rib fractures. Adjusted odds of mortality increased up to six rib fractures for all age groups. Penetrating injury, concomitant injury, and hemothorax all predicted mortality on multivariable analysis. More than two rib fractures also predicted chest tube placement (odds ratio [OR], thoracostomy 11.89 (11.37-12.44), thoracotomy 5.89 (5.17-6.84), thoracoscopy (6.28-12.03), laparotomy 2.68 (2.49-2.89). CONCLUSION Mortality increased nearly linearly for increasing numbers of pediatric rib fractures without an inflection. Odds of mortality increases with each additional rib fractured in all pediatric age groups. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Thoracic epidural analgesia in a child with multiple traumatic rib fractures. J Clin Anesth 2015; 27:685-91. [DOI: 10.1016/j.jclinane.2015.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 01/06/2015] [Accepted: 05/21/2015] [Indexed: 02/09/2023]
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Abstract
Thoracic injury in children deserves special attention because, although it accounts for less than 10% of traumatic injuries in children, there is a significant associated morbidity and mortality. This review discusses the anatomic and physiologic factors resulting in such injury severity with blunt thoracic trauma in children. Specific organ injuries, including most common chest wall injuries, hemo- and pneumothoraces, and pulmonary parenchymal injuries, are discussed, encompassing epidemiology, presentation, diagnosis, and management. Rare injuries including tracheobronchial tree injuries, cardiovascular injuries, esophageal injuries, and diaphragmatic injuries are also briefly discussed.
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Affiliation(s)
- Hanna Alemayehu
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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Okonta KE. Traumatic chest injury in children: A single thoracic surgeon's experience in two Nigerian tertiary hospitals. Afr J Paediatr Surg 2015; 12:181-6. [PMID: 26612123 PMCID: PMC4955435 DOI: 10.4103/0189-6725.170193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study was to determine the extent and outcome of childhood chest injury in Nigeria, and to compare results with that of other literatures. PATIENTS AND METHODS A Prospective study of all children under 18 years of age with chest trauma in two tertiary hospitals in Southern Nigeria from January 2012 to December 2014 was reviewed. The aetiology, type, associated injury, mechanism, treatment and outcome were evaluated. The patients were followed up in the clinic. The data were analysed using SPSS version 20.0 with a significant P < 0.05. RESULTS Thirty-one patients (12.1%) under 18 years of age of 256 chest trauma patients were managed in the thoracic units. The mean age was 9.78 ± 6.77 years and 27 (87.1%) were male. The aetiology in 13 was from falls, 10 from automobile crashes, 3 from gunshots, 4 from stabbing and 1 from abuse. The highest peak of chest injury was on Saturday of the week and April of the year. The pleural collections are as follows: 15 (71.4%) was haemothorax, 4 (19.1%) pneumothorax, 2 (9.5%) haemopneumothorax and 18 patients had lung contusion in combination or alone with the pleural collections. Seven patients who presented >12-h versus 2 who presented <12-h and 6 of children between 0 and 9 years versus 3 at 10-18 years of age had empyema thoracis (P value not significant). One death was recorded. CONCLUSION Chest trauma in children is still not common, and blunt chest injury from falls and automobile accidents are more common than penetrating chest injury. Treatment with tube thoracostomy is the major management modality with empyema thoracis as the most common complication.
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Affiliation(s)
- Kelechi Emmanuel Okonta
- Thoracic Unit,Department of Surgery, University of Port-Harcourt Teaching Hospital, Port-Harcourt, Rivers State; Federal Medical Center, Owerri, Imo State, Nigeria
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Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital. Eur J Trauma Emerg Surg 2015; 41:279-85. [PMID: 26037974 DOI: 10.1007/s00068-014-0413-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/10/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children. METHODS A total of 176 consecutive children below the age of 15 years and having Glasgow Coma Scale score greater than 12, who presented to the emergency department of a tertiary care hospital with a history of recent trauma, were retrospectively reviewed. All the children had undergone a thorough clinical examination followed by complete trauma series radiographs, according to the American College of Surgery guidelines. RESULTS A total of 558 radiographs were reviewed by a consultant pediatric radiologist including 528 trauma series radiographs and 30 additional radiographs. Among the trauma series radiographs, 35 (6.63 %) had evidence of injury; 24 (4.54 %) and 11 (2.08 %) involving the chest and pelvic regions, respectively. All children with normal physical examination had normal cervical spine and chest radiographs. Among the 11 positive pelvic X-rays, only two had radiological signs of injury in the absence of localizing physical signs, and all these children were less than 3 years of age. In all the remaining cases, children had localizing signs on physical examination. Out of the 30 additional X-rays, 27 (90 %) had radiological evidence of injury. CONCLUSIONS The routine use of entire radiological trauma series in alert pediatric patients with a normal physical examination has a very low yield. In these children, the localizing signs and symptoms can help us in determining the specific radiological examination to be utilized.
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Choi PM, Farmakis S, Desmarais TJ, Keller MS. Management and outcomes of traumatic hemothorax in children. J Emerg Trauma Shock 2015; 8:83-7. [PMID: 25949037 PMCID: PMC4411582 DOI: 10.4103/0974-2700.155500] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 10/31/2014] [Indexed: 11/30/2022] Open
Abstract
Background: Adult guidelines for the management of traumatic hemothorax are well established; however, there have been no similar studies conducted in the pediatric population. The purpose of our study was to assess the management and outcomes of children with traumatic hemothorax. Materials and Methods: Following Institutional Review Board approval, we conducted a retrospective cross-sectional study of all trauma patients diagnosed with a hemothorax at a Level-1 pediatric trauma center from 2007 to 2012. Results: Forty-six children with hemothorax were identified, 23 from blunt mechanism and 23 from penetrating mechanism. The majority of children injured by penetrating mechanisms were treated with tube thoracostomy while the majority of blunt injury patients were observed (91.3% vs. 30.4% tube thoracostomy, penetrating vs. blunt, P = 0.00002). Among patients suffering from blunt mechanism, children who were managed with chest tubes had a greater volume of hemothorax than those who were observed. All children who were observed underwent serial chest radiographs demonstrating no progression and required no delayed procedures. Children with a hemothorax identified only by computed tomography, after negative plain radiograph, did not require intervention. No child developed a delayed empyema or fibrothorax. Conclusion: The data suggest that a small-volume hemothorax resulting from blunt mechanism may be safely observed without mandatory tube thoracostomy and with overall low complication rates.
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Affiliation(s)
- Pamela M Choi
- Division of Pediatric Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
| | - Shannon Farmakis
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
| | - Thomas J Desmarais
- Division of Pediatric Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
| | - Martin S Keller
- Division of Pediatric Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
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Agnew AM, Schafman M, Moorhouse K, White SE, Kang YS. The effect of age on the structural properties of human ribs. J Mech Behav Biomed Mater 2015; 41:302-14. [DOI: 10.1016/j.jmbbm.2014.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/28/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022]
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