Management of paediatric liver trauma

Of all the intra-abdominal solid organs, the liver is the most vulnerable to blunt abdominal trauma. The majority of liver ruptures present in combination with other abdominal or extra-abdominal injuries. Over the last three decades, the management of blunt liver trauma has evolved from obligatory operative to non-operative management in over 90% of cases. Penetrating liver injuries more often require operative intervention and are managed according to adult protocols. The greatest clinical challenge remains the timely identification of the severely damaged liver with immediate and aggressive resuscitation and expedition to laparotomy. The operative management can be taxing and should ideally be performed in a dedicated paediatric surgical centre with experience in dealing with such trauma. Complications can occur early or late and include haemobilia, intrahepatic duct rupture with persistent biliary fistula, bilaemia, intrahepatic haematoma, post-traumatic cysts, vascular outflow obstruction, and gallstones. The prognosis is generally excellent.

Modified sandwich vacuum pack technique for temporary closure of abdominal wounds: an african perspective

INTRODUCTION

South Africa has very high levels of accidental trauma as well as interpersonal violence. There are more admissions for trauma in South Africa than for any other disease; therefore it can be regarded as the Number 1 disease in the country. Complex abdominal injuries are common, requiring specific management techniques. The aim is to document our experience with the Modified Sandwich Vacuum Pack technique for temporary closure of abdominal wounds.

METHODS

After providing a short historical overview, we will demonstrate the technique which we carefully adapted over the last decade to the present Modified Sandwich Vacuum Pack technique.

RESULTS

In the last 5 years we utilized our Modified Sandwich Vacuum Pack technique 153 times in 69 patients. Five (5) patients were under the age of 12 years. In the patient group over 12 years the most common indication for using our technique were penetrating injuries (40), abdominal sepsis (28), visceral edema (10), abdominal compartment syndrome (9), abdominal packs (6), Abdominal wall defects (2). In the group under 12-years the 2 children had liver ruptures (posttraumatic) and 3 liver transplantations. The average cost for the materials used with our technique was ZAR 96. (10 Euro and 41 cents).

CONCLUSION

In our experience the Modified Sandwich Vacuum Pack technique is an effective, cheap methodology to deal with open abdomens in the African setting. A drawback may be the technical expertise required, particular in centers dealing with low numbers of complex abdominal trauma.

Management of physical child abuse in South Africa: literature review and children's hospital data analysis

BACKGROUND

The reason for this review is the lack of data on the management of physical abused children in Africa. The primary goal of the first part is to outline the management of physical child abuse in (South) Africa and provide suggestions for other governments in Africa on which to base their management of physical child abuse, at both governmental and hospital management level. The main aim of the second part is to outline the extent of the problem as seen at the Red Cross Memorial Children's Hospital (RCH) in Cape Town.

MATERIAL AND METHODS

The National Library of Medicine's PubMed database was searched for articles specifically about the management of physical child abuse. Hospital data were analysed in two phases: one addressed various types of assault in order to assess the number of patients admitted to the trauma unit of RCH between 1991 and 2009, and the other to identify all children with suspected non-accidental injury (NAI) presenting to the trauma unit at RCH from January 2008 until December 2010.

RESULTS

Information on physical abuse of children in Africa in the English scientific literature remains disappointing with only two articles focusing on its management. RCH data for the period 1991-2009 recorded a total number of 6415 children hospitalised with injuries following assault, who accounted for 4.2% of all trauma admissions. Types of abuse included assault with a blunt or sharp instrument, rape/sexual assault and human bite wounds. Over the last 2 decades, there has been a minor decline in the number of cases of severe abuse requiring admission; admissions for other injuries have remained stable. More detailed analysis of hospital data for 2008-2010, found that boys were far more commonly assaulted than girls (70.5% vs 29.5%). Physical abuse appeared to be the most common cause of abuse; 89.9% of all boys and 60.5% of all girls presented after physical abuse.

CONCLUSION

In order to eradicate child abuse, awareness of it as to be promoted in the community at large. Because the types of child abuse vary between countries, each requires its own research in order to develop a policy tailored to their particular requirements. In summary, an increased focus on the prevention of violence against children is urgently needed in order to curb the increasing trend of assaults on children. As the causes and risk factors for violence against children vary, multi-disciplinary and multi-sectoral co-operation and collaboration will be required. It is hoped that this report will help raise awareness among health-care practitioners of NAI and its complexities.

Dog bite injuries in children--a review of data from a South African paediatric trauma unit

BACKGROUND AND OBJECTIVE

Dog bites are a major cause of preventable traumatic injury in the paediatric population. We aimed to determine the epidemiology of dog bite injuries in a group of South African children with a view to developing potential preventive strategies.

DESIGN, SETTING, SUBJECTS

A retrospective review was done of patients presenting with dog bite injuries to the trauma unit at the Red Cross War Memorial Children's Hospital in Cape Town over a 13.5-year period.

RESULTS

We identified 1,871 children treated for 2,021 dog bite injuries during the study period. Dog bites accounted for 1.5% of all trauma unit presentations. Male children accounted for 68% of the patients. Children under 6 years of age were more likely to have sustained injuries to the head, face or neck, while children older than 6 years more commonly received injuries to the perineum, buttocks, legs or feet. Younger children were more likely to be attacked at home and older children outside the home. The most frequent injuries were superficial, and the majority of patients were treated with simple medication, dressing or suturing. There were no dog bite-related fatalities.

CONCLUSION

The relationship between the geographical location of dog attacks on children and the age groups attacked suggests that strategies to prevent dog bites should target both parents supervising younger children at home, and older children who encounter dogs outside the home.

Modified sandwich vacuum pack technique for temporary closure of abdominal wounds: an African perspective

INTRODUCTION

South Africa has very high levels of accidental trauma as well as interpersonal violence. There are more admissions for trauma in South Africa than for any other disease; therefore it can be regarded as the Number 1 disease in the country. Complex abdominal injuries are common, requiring specific management techniques. The aim is to document our experience with the Modified Sandwich Vacuum Pack technique for temporary closure of abdominal wounds.

METHODS

After providing a short historical overview, we will demonstrate the technique which we carefully adapted over the last decade to the present Modified Sandwich Vacuum Pack technique.

RESULTS

In the Last 5 years we utilized our Modified Sandwich Vacuum Pack technique 153 times in 69 patients. Five (5) patients were under the age of 12 years. In the patient group over 12 years the most common indication for using our technique were penetrating injuries (40), abdominal sepsis (28), visceral edema (10), abdominal compartment syndrome (9), abdominal packs (6),Abdominal wall defects (2). In the group under 12-years the 2 children had liver ruptures (posttraumatic) and 3 liver transplantations. The average cost for the materials used with our technique was ZAR 96. (10 Euro and 41 cents).

CONCLUSION

In our experience the Modified Sandwich Vacuum Pack technique is an effective, cheap methodology to deal with open abdomens in the African setting.A drawback may be the technical expertise required, particular in centers dealing with low numbers of complex abdominal trauma.

Causes and distribution of facial fractures in a group of South African children and the value of computed tomography in their assessment

The cases of 107 paediatric patients aged 0-12 years were retrospectively reviewed. The patients presented with facial trauma and both plain radiographs and computed tomography (CT) scans had been ordered. Sixty-five per cent of facial fractures were missed in radiography, but revealed on CT; fractures of the maxilla, the zygoma and the orbit were most frequently missed in radiography. Pedestrian motor vehicle accidents were the most frequent cause of facial fractures (37%), followed by passenger motor vehicle accidents (22%). In contrast with other studies reporting the mandible as the most frequent facial fracture site, the most common fracture sites in this study, in descending order of frequency, were the orbit, the frontal bone and the maxilla.

Pediatric coin ingestion and aspiration

OBJECTIVE

To determine the relationship between physical characteristics of the coin (size), age of the victim, the amount of coins in circulation, and the frequency and outcome of pediatric coin ingestion and aspiration injuries.

METHODS

Records of coin related ingestion and aspiration injuries occurring to children 14 years of age or younger were acquired from the US Consumer Product Safety Commission (CPSC). Logistic regression was conducted to control for mutual confounding among variables.

RESULTS

From 1994 to 2003, an estimated 252,338 children were treated in hospital emergency departments for non-fatal coin-related ingestion or aspiration, and additional 20 fatalities were reported during the same time span. Children 4 years of age or younger were at the highest risk. It is also observed that younger children are the most vulnerable victims of ingestion and/or aspiration of small coins (e.g., pennies), while older children are more likely to be treated due to ingestion and/or aspiration of larger coins (e.g., quarters). Pennies were involved in more incidents than all other coins combined. The hospitalization rate exhibited a negative correlation with the measure of the diameter and the weight of the coins. The overwhelming majority (94%) of the incidents were ingestion, whereas aspiration victims were more likely to encounter hospitalization.

CONCLUSIONS

We hope that this study will raise public and health practitioners' awareness of the risk, and increase supervision, particular of the most vulnerable young children.

Liver injuries in children: the role of selective non-operative management

INTRODUCTION

This review article on the management of blunt liver injury in children is based on the authors' experience of 311 patients over a 22-year period.

MATERIAL AND METHODS

All children presenting to our institution with confirmed blunt liver trauma were studied retrospectively. Hospital folders of 311 patients were analysed. Information was gathered about the clinical presentation, associated injuries, grade of injury, transfusion requirements and haemodynamic stability to examine factors influencing outcome.

RESULTS

The age of patients ranged between 3 weeks and 12 years (mean of 7 years). Injuries as a result of motor vehicle accidents (MVAs) were the most common (268; 232 pedestrian and 36 passenger), other causes were falls (26) assaults or child abuse(15), bicycle handle bar injury (2). One hundred and thirty-six patients sustained an isolated hepatic injury and 175 had multiple injuries. Associated injuries included 147 head injuries, 131 fractures, 66 thoracic and 143 intra-abdominal (74 spleen, 45 renal, 4 pancreatic and 4 hollow viscus). Two patients died soon after arrival, 21 underwent laparotomy, 13 of which were liver related, while 288 were treated non-operatively. One hundred and six patients required blood transfusion (mean of 21.3 ml/kg); 30% of the nonoperative group and 100% of the operative group. There were three fatalities from the operative group (1% total mortality), one secondary to a severe, head injury, one liver haemorrhage and one from multi-organ failure

DISCUSSION

The vast majority (93%) was successfully treated non-operatively with only 4% coming to liver related laparotomy, complications were lower, transfusions less and the in-hospital occupancy was shorter. Complication rate was 8% and mortality was 1%.

CONCLUSION

We confirm the success selective non-operative management of blunt liver trauma as adopted by this institution 20 years ago. It is now proven treatment in an appropriate centre. However, the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy when indicated.

Profile of children with head injuries treated at the trauma unit of Red Cross War Memorial Children's Hospital, 1991 - 2001

OBJECTIVE

To describe the profile of childhood head injury patients treated in a trauma unit.

DESIGN

A retrospective record-based study.

SETTING

The trauma unit of the Red Cross War Memorial Children's Hospital.

SUBJECTS

Children (under 13 years of age) presenting with head injuries between January 1991 and December 2001.

RESULTS

Of the almost 94 000 records, more than one-third were children presenting with head injuries. Fifty-nine per cent were boys, with more than half the sample under 5 years of age. The majority of children presented with superficial lacerations and abrasions, mostly affecting the scalp and skull. Injuries were mainly caused by falls from a variety of heights, and traffic-related injuries. Almost two-thirds of traffic-related injuries involved children as pedestrians being struck by a motor vehicle. More than 60% of injuries occurred in or around the child's own home.

CONCLUSIONS

Head injuries in children are a significant cause of morbidity. Prevention, especially in the home and on the streets, needs urgent attention.

Inhuman shields--children caught in the crossfire of domestic violence

BACKGROUND

Child abuse is a worldwide scourge. One of its most devastating manifestations is non-accidental head injury (NAHI).

METHODS

This is a retrospective chart review of children presenting to the Red Cross Children's Hospital trauma unit with a diagnosis of NAHI over a 3-year period.

RESULTS

Sixty-eight children were included in the study and 2 different groups were identified. Fifty-three per cent of the children were deliberately injured (median age 2 years), while 47% were allegedly not the intended target of the assailant (median age 9 months). The assailant was male in 65% of the intentional assaults and male in 100% of the unintentional assaults, with the intended adult victim female in 85% of the latter cases. Overall, 85% of the assaults were committed in the child's own home.

CONCLUSIONS

The high proportion of cases in which a young child was injured unintentionally suggests that these infants effectively become shields in assaults committed by adults. In this context any attempts to deal with child abuse must also address the concurrent intimate partner violence.

The South African experience with ingestion injury in children

INTRODUCTION

The Red Cross Children's Hospital is the only children's hospital in South Africa. It has a dedicated trauma unit for all children under the age of 13 and serves a population of approximately 2 million inhabitants. As part of the Child Accident Prevention Foundation program we have kept a database of all children treated for trauma in our hospital since 1991. Presently, we have over 88,000 entries in our database.

AIM

To study our experience with ingested foreign bodies in children.

MATERIALS AND METHODS

A retrospective study was performed using the CAPFSA database of a total of 3677 patients presenting with foreign bodies. The hospital folders were searched using a standardised data extraction form. Only foreign bodies aspirated or ingested were included.

RESULTS

To date, 241 folders have been analysed.

DEMOGRAPHICS

Both sexes were equally affected (boys 49%). Age ranged between 0 and 12 years, although there was only one child under the age of 1. At the age of 3 years there was a peak in incidence (24% of all cases). Nature of ingested object: Although the objects were from a range of materials, most were metal (40%) or plastic (23%). The most commonly ingested object was a coin (28%), a ball (20%) or bone (8%). The size ranged from 0.1 to 3 cm (as measured by virtual ring), the most common size of an ingested foreign body was 0.5 cm. Anatomical site: The most common anatomical site of impaction was the nose (41%), followed by the oesophagus (20%), the stomach (14%) and bowel (11%). Other anatomical sites included hypopharynx, nasopharynx, bronchus, larynx and oral cavity. Severity of symptoms: Only 0.4% of our cases were assessed as being severe, 14% as moderate, and 44% as mild. Forty-two percent (42%) had no symptoms. Removal: Fifty-seven percent (57%) of ingested foreign bodies were removed surgically, 19% were left in situ, 14% spontaneously dislodged and only 1% was removed by Foley catheter manipulation.

CONCLUSION

A presentation with a foreign body is quite common in our patient population, representing approximately 4.2% of all our cases. The majority of ingested foreign bodies produced mild or no symptoms, needed surgical removal and had no complications.

Evisceration through multiple abdominal wall defects following blunt abdominal injury

We report an unusual case of a posttraumatic evisceration of small and large bowel through 2 holes in the anterior abdominal wall after a motor vehicle accident. Prompt adequate management consists of reestablishing the perfusion of the eviscerated organ if the blood supply is compromised, performing a full laparotomy to exclude intra-abdominal organ injury and meticulous cleaning of the eviscerated organs before reducing them in the abdomen and closing the abdomen in layers.

The effects of war on children in Africa

There is no doubt that the effects of war extend to the most vulnerable members of society, including children. Although armed conflicts occur throughout the world, the African continent seems to be a particular background for civil and international wars. The aim of this study was to identify causes of conflict in Africa and to evaluate the effect of war on children and their health in order to make practical recommendations to health care workers dealing with children in the setting of war. All articles written in the past 5 years concerning "war" and "children" were identified by means of a literature search and internet review. Contrary to common belief, the causes of conflict are complicated and multi-factorial. The effects of war on childhood are disastrous and include severe negative effects on general paediatric health status. Short-term recommendations for health care workers working with children in war include supply of emergency medical infrastructures, basic health care, rehabilitation and education. Long-term recommendations include orchestrating the relief and support efforts from both national governments and international non-profit organisations and speeding up of economic recovery. The causes of conflict in Africa are complex and unlikely to be resolved soon. The effects of war on children are horrendous in many ways, but can be limited by providing timely and appropriate health care.

Gunshots to the neck: selective angiography as part of conservative management

Trauma units all over the world are faced with an ever-increasing number of gunshot injuries. While the traditional view is that exploration is mandatory for all gunshot wounds to the neck, this issue is now often debated amongst trauma surgeons. The aim of this particular study was to assess the outcome of gunshot wounds to the neck using a selective conservative approach. Haemodynamically stable patients were investigated with angiography. Only when this proved to be positive, the patient was surgically explored. The records of 116 patients presenting with a gunshot to the neck to our trauma unit over a 3-year-period were reviewed. We studied demographics, bullet track, clinical findings, diagnostic investigations, methods of treatment, time in hospital and outcome. Seventy of the 116 patients sustained a direct hit to the neck, in 46 patients the bullet traversed the face or chest first. Eighty-five patients presented with vascular injury, 61 with an injury to the airway, 32 with an injury to the pharynx or oesophagus, and 12 with sustained neurological damage. Angiography was performed in 89 patients and was positive in 12 patients. Lesions occurred in the common carotid artery (seven), the internal carotid artery (three), the external carotid artery (three), the vertebral artery (two) and the subclavian artery (one). Five patients had more than one lesion. In total 18 patients were treated operatively by performing a neck exploration. Four patients had emergency surgery for exsanguinating bleed. Fourteen had surgery after a positive diagnostic study; 12 after angiography, 2 after another positive investigation. Ten (8.6%) patients died; three during resuscitation, three during emergency exploration, two due to respiratory failure, one postoperative and one from the adult respiratory distress syndrome (ARDS). Our results suggest that selective conservative management is a good treatment for gunshot wounds of the neck. In our experience angiography plays a key role in the detection of a major vascular injury requiring surgical exploration. Careful clinical assessment enhanced with the appropriate investigations is the cornerstone for deciding to explore a gunshot wound to the neck.

Impact of Celsior solution on hepatocellular, reperfusion and endothelial cell injury after liver transplantation

BACKGROUND

Initially, preservation solutions were developed to maintain cell function of the transplanted organs. However, recently developed preservation solutions also contain a variety of substances to reduce the reperfusion injury.

AIM

To study the effect of three different preservation solutions on the liver cell injury, endothelial cell function and reperfusion injury after liver transplantation.

MATERIAL AND METHODS

Large White X Landrace pigs of either sex were subjected to orthotopic liver transplantation. Donor livers were flushed and stored in University of Wisconsin Solution, Eurocollins Solution or Celsior Solution for 3 hours. Blood samples were taken at various times post transplantation for assessment of aspartate aminotransferase, hyaluronic acid, malondialdehyde and Vitamin A levels.

RESULTS

Serum aspartate aminotransferase levels were lower in the livers preserved in the Wisconsin solution. Plasma malondialdehyde levels were lower and serum Vitamin A levels were higher in the livers preserved in Celsior solution. Serum hyaluronic acid levels increased after liver transplantation but were similar with all three solutions.

CONCLUSIONS

There was less hepato-cellular injury in the livers preserved in Wisconsin solution and less reperfusion injury with the Celsior solution. The endothelial cell injury was similar with all three solutions.

Effect of early arterialization of the porcine liver allograft on reperfusion injury, hepatocellular injury, and endothelial cell dysfunction

The conventional technique of liver transplantation involves the initial perfusion of the graft with portal blood. However, recent evidence suggests that initial arterialization of the graft may be better. The aim of this study is to evaluate the timing of arterialization on reperfusion injury, hepatocellular injury, and endothelial cell function after liver transplantation. Large white X Landrace pigs (n = 24) were subjected to orthotopic liver transplantation. The animals were randomly assigned to 4 groups, ranging from late arterialization (60 minutes after portal reperfusion) to early rearterialization (20 minutes before portal reperfusion). Aspartate aminotransferase levels continued to increase 4 hours posttransplantation in group 1 (late arterialization), but remained stable after 1 hour posttransplantation in group 4 (early rearterialization). Levels of malondialdehyde doubled in all groups after portal reperfusion with the exception of group 4, in which the liver received arterial blood before portal reperfusion. Vitamin A levels decreased in all groups after revascularization, but the decrease was more pronounced and prolonged in groups 1 and 2 (late arterialization) compared with groups 3 and 4 (early rearterialization). Hyaluronic acid levels continued to increase in all groups until 1 hour posttransplantation except in group 4, in which the level decreased from 20 minutes posttransplantation. Results of this study show that early rearterialization is associated with less hepatocellular damage, less reperfusion injury, and improved liver endothelial cell function. In conclusion, our results indicate that early rearterialization of the graft is beneficial to the transplanted liver.

Do diets enriched with oil prevent multiple organ failure in mice?

OBJECTIVE

To examine the effects of various diets supplemented with fat in an experimental model of multiple organ failure in mice.

DESIGN

Two randomised laboratory studies.

SETTING

University hospital.

MATERIAL

177 female Swiss mice (weight 20-30 g).

INTERVENTIONS

Experiment I: 59 mice; 20 received no dietary supplement, 20 received 15% palm oil, and 19 received 14% fish oil plus 1% corn oil, eight weeks before injection of 100 mg zymosan/100 g in 4 ml liquid paraffin; 5 mice in each group killed after 1.5 hours, and the rest on day 12. Experiment II: 118 mice; 29 received no dietary supplement, 30 received 15% palm oil, 30 1% corn oil, and 29 14% fish oil, 12 weeks before injection with zymosan. 20 mice in each group received streptomycin 5 g/l in drinking water starting five days before injection of zymosan and continued until the end of the experiment. All mice killed on day 12.

MAIN OUTCOME MEASURES

Mortality, body and organ weights, and culture of peritoneal fluid. Detection of tumour necrosis factor-alpha (TNF-alpha) in plasma.

RESULTS

Experiment I: only 5 control mice, 2 in the fish oil, and 7 in the palm oil, groups survived to day 12. Spleens in mice given fish oil were significantly heavier than those that had had palm oil (p = 0.03). Experiment II: 108/118 mice survived until day 12, and most had macroscopic signs of multiple organ failure. Liver weights in the fish oil group were lower than in the control (p = 0.04) and palm oil (p = 0.03) groups, and kidney weights higher than in the corn oil group (p = 0.007); there were no differences in the amounts of TNF-alpha detected in the blood. One culture in each experiment grew bacteria.

CONCLUSION

Diets supplemented with fish oil did not prevent multiple organ failure or reduce plasma concentrations of TNF-alpha. Decontamination of the gut did not alter these results.