Deaths from falls in children: How far is fatal?

Deaths from falls in children: How far is fatal?

522 Editor’s Comment: This case review does a nice job of elucidating the symptomatology and metabolic disorders associated with AKA. While 54% of pa...

133KB Sizes 0 Downloads 71 Views

522

Editor’s Comment: This case review does a nice job of elucidating the symptomatology and metabolic disorders associated with AKA. While 54% of patients were admitted, the criteria for admission or the suitability of some patients for an observation unit was not discussed.

0 PNEUMATIC ANTISHOCK GARMENT DECREASES HEMORRHAGE AND MORTALITY FROM SPLENIC INJURY. Ali J, Duke K. Can J Surg. 1991;34: 496-501. The use of the pneumatic antishock garment (PASG) in prehospital care has been controversial. The PASG has been shown to decrease intra-abdominal arterial blood flow and therefore could potentially play a role in reducing mortality after splenic hemorrhage. A controlled study of 12 dogs was done in order to evaluate the use of the PASG after splenic injury. The PASG was applied to 6 animals and was left off of the other 6. The PASG was inflated to 60 torr as this was the pressure necessary to normalize carotid blood pressure after a drop of 30 torr in blood pressure from hemorrhagic hypotension. All dogs that did not have the PASG died within 58 minutes of hemorrhage. Those dogs with the PASG survived for the 2 hours of the study. Baseline carotid artery blood pressures were 120 f 10 torr. After one hour, the blood pressure in the animals with the PASG had dropped to 102 f 14 torr, and after 2 hours it had dropped to 99 + 12 torr. At 15 minutes, there was a larger drop in splenic artery blood flow in the animals with the PASG than in those without the PASG. The authors felt that this data indicated that hemorrhage from intra-abdominal splenic injuries may be significantly decreased by use of the PASG. The PASG did not stop hemorrhage completely, but did decrease hemorrhage enough to possibly allow time for surgical intervention. The authors also warn that prolonged application of the PASG for more than 4 hours can result in complications such as compartment syndrome and neurovascular damage. [Eric H. Gilbert, MD] Editor’s Comment: While these results are provocative, prospective studies in humans do not bear out the authors’ conclusions.

0 DEATHS FROM FALLS IN CHILDREN: HOW FAR IS FATAL? Chadwick DL, Chin S, Salerno C, et al. J Trauma. 1991;31:1353-5. This is a retrospective review of 3 17 patients presenting to a pediatric trauma center with a history of a fall. With a reported fall of 0 to 4 feet, there were 7 deaths in 100 children. No deaths occurred in 64 children who fell 5 to 9 feet, and in 118 children who fell 10 to 45 feet, one death occurred. Head injury was the cause of all deaths. Fatal short distance falls were described as follows: standing fall, 2; fall from bed or table, 2; fall down stairs, 1; fall in arms of adult, 2. All 7 had fresh subdural bleeding and cerebral edema, but only one had a skull fracture. Of the 7, 5 had

The Journal

of Emergency

Medicine

“associated injuries” of old fractures, bruising on the trunk and extremities, genital injury, or more than one impact site of the head. The authors note that by their data, the risk of death is 8 times greater in children who fall 1 to 4 feet than for those who fall lo-45 feet. They find this conclusion absurd and state that the best explanation is that in the 7 children who died following short falls the history was falsified. They note the difficulty of diagnosing abuse in children with a single inconsistent injury as compared to the presenceof multiple injuries in differing stages of healing. It is important to interview all witnesses soon after the event to determine the facts. [Laurie Vande Krol, MD] Editor’s Comment: Injuries suggestive of child abuse were seen more often in the fatal caseswho fell lessthan 4 feet. However, such associated injuries were not described for the nonfatal cases.

0 TRAUMA DURING PREGNANCY. Esposito T, Gens D, Gerber Smith L, Scorpio R, Buchman T. Arch Surg. 1991;126:1073-8. This is a retrospective study of 79 pregnant patients who were injured and admitted to a trauma center during a 9-year period. Maternal mortality rate was 10% compared to a nonpregnant control group with mortality of 7%. Fetal loss occurred in 34% and was not changed if the mother showed evidence of shock or hypoxia. Compensatory processesmay be occurring at the expense of the fetus. Maternal serum bicarbonate levels were shown to have a significant correlation with fetal outcome in comparison with other variables reflective of shock and hypoxia. The use of bicarbonate level in the pregnant trauma patient regardless of the hemodynamic status is recommended. Liberal use of fluid and supplemental O2 should be implemented even in the “minimally injured” apparently stable pregnant patient. Fetal monitoring for 12 to 24 hours regardless of degree of injury severity is considered essential to allow detection of fetal distress and appropriate intervention. No differences were shown in fetal or maternal outcomes based on seatbelt use. The authors recommend use of seatbelts in pregnancy in the absence of contrary evidence. Diagnostic peritoneal lavage was 95% accurate and safe in the gravid patient using supraumbilical open technique. [Jacques Blanchet, MD] Editor’s Comment: This study serves to remind us of the aggressiveapproach required to adequately manage the two patients that present in these trauma scenarios.

Cl OBESITY AND INCREASED MORTALITY IN BLUNT TRAUMA. Choban PS, Weireter LJ, Maynes C. J Trauma. 1991;31:1253-7. A retrospective review of 184 blunt trauma patients sought to evaluate the specific problems of obesity in trauma victims. Patients were defined as average, overweight (120%-140% of ideal body weight), or severely