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Emergency endotracheal intubation in pediatric trauma
INTERNATIONAL
115
ABSTRACTS
Detection of Neuroblastoma Cells in Blood........ Immunoscintigraphic Imaging of MIBG-Negative Metastases in Neuroblastoma .................... Prognosis in Children With Rhabdomyosarcoma ... ...................................................... .......... Soft-Tissue Sarcoma of the Perineal Region in Childhood ....... ..._..........................................._... Prognostic Correlation of P-Glycoprotein in Soft Tissue Sarcoma of Childhood ....... ..... ............... Problems in Diagnosis and Management of Desmoid Tumors . ....... ........_.................................... Carcinoma of the Colon and Rectum in Patients Less Than 20 Years of Age ......___...................... Long-Term Follow-Up of Children With Renal Carcinoma ....... ....... ......... .................................. Significance of Viridans Streptococcal Septicemia in Pediatric Oncology Patients ... ...............
GENERAL
120 120 120 120 121 121 121 121 121
CONSIDERATIONS
Continuous Hemodialysis in Children. N.A. Bishof; T.R. Welch, CF. Strife, et al. Pediatrics 85:819-823, (May), 1990. Four critically ill pediatric patients who underwent continuous arteriovenous hemoliltration (CAVHD) are reported. Indications for CAVHD included multiorgan failure secondary to perinatal asphyxia, sepsis, and Burkitt lymphoma with tumor lysis. The technique of hemofiltration is described. The authors note that CAVHD is an effective method of correcting fluid overload and, to some extent, azotemia. In a number of instances CAVHD may be preferred to peritoneal dialysis or hemodialysis.-Jefiq L. Zitsman Recommendations on Extracorporeal Membrane Oxygenation. Committee on Fetus and Newborn. Pediatrics 85:618-619. (April). 1990. Recognizing the evident effectiveness of ECMO for certain neonates, the lack of prospective studies, and the enthusiasm surrounding ECMO, the committee makes several recommendations to groups that are contemplating the development of a center. These recommendations include demonstration of regional need for a center, standing regional neonataliperinatal program, adequate personnel and hospital support, research and educational programs, and institutional review.-Jefiq L. Zitsman Percutaneous Catheterization of the Axillary Vein in Infants and Children. R.I. Metz, S.E. Lucking, F.C. Chaten, etal. Pediatrics 85:531-533. (April), 1990. The axillary vein may be used for catheterization when more familiar sites such as femoral, subclavian, internal jugular, and external jugular veins are not practical. The authors report 41 successful placements of axillary vein catheters in 52 attempts (79%). The patients ranged in age from 4 days to 12 years, and weighed from 3.0 kg to 59 kg. The catheters lasted from 2 to 22 days (median, 8 days). The indications for catheter removal were completion of therapy (21) patient death (6), catheter dislodgement with infiltration (4) catheter occlusion (3) venous thrombosis (1). venous stasis (l), and suspected sepsis (1). Two complications occurred: one patient had a small pneumothorax; another had an
axillary hematoma.
Inadvertent
puncture
of the axillary artery was
easily managed by direct pressure; no sequelae were noted. Four complications occurred during therapy; single cases of venous stasis of the extremity, venous thrombosis of the subclavian vein, infiltration secondary to catheter dislodgement. and catheter sepsis were recorded.-Jeffrey L. Zirsman
Management of Alarming Hemangiomas in Infancy: A Review of 25 Cases. 0. Enjolras, M.C. Riche, J.J. Merland, et al. Pediatrics 85:491-498,
(April),
1990.
Twenty-five cases of massive and life-threatening (“alarming”) hemangiomas are reviewed, with a single case presented in detail. Seventeen infants had lesions detected at birth; 22 were cervicocephalic. All patients were treated with corticosteroids, most for 5 months or longer. Liver involvement in three infants resulted in fatal cardiac failure despite the use of steroids, embolization, and irradiation. Although all of the hemangiomas underwent regression, malocclusion, skin sequelae, and ocular changes were present to some degree
in all of the survivors.
-Jefiey
L. Zitsman
Emergency Endotracheal lntubation in Pediatric Trauma. D.K. Nakayama, M.J. Gardner, and M.I. Rowe. Ann Surg 211:218-223, (February), 1990. Early endotracheal
intubation
is the mainstay
of cardiopulmo-
nary resuscitation in patients with severe trauma. Airway management in children is particularly difficult because of normal anatomic variations from the adult. This study analyzes 605 children admitted during a l-year trauma experience at a tertiary care center. Injuries included head (90%) abdomen (12%). face (11%) chest (6%) neck (3%) orthopedic (19%), and multiple injuries (40%). Indications for endotracheal intubation included coma (74%). shock (28%) apnea (22%) and airway obstruction (3%). Ten percent of children arrived with an endotracheal tube placed at the scene or at a referring institution. All but five of these patients were head-injured. Six of eight scene intubations required more than one attempt. The only unsuccessful intubations were at the scene of injury. Airway-related complications occurred in 16 patients (6 from the scene, 6 from referring hospital. and 4 at tertiary institution). Thirteen complications were immediately lifethreatening and included right mainstem bronchus intubation (5). massive barotrauma (2). failure of adequate preoxygenation (2). massive aspiration (1) esophageal intubation (1) nasotracheal intubation in an open facial fracture (l), and extubation during transport (1). Fifteen children died (23.8%). Four deaths involving scene intubations were each complicated by major airway mishap. No statistically significant difference was found in mortality rates between children who experienced airway or respiratory difficulties and those free from airway complication. In comparing patients with airway complications, a PO: less than 90 or a PCO, greater than 45 indicated a mortality rate double that of cases free from respiratory difficulties (P < .05). Two attempts at cricothyroidotomy ended fatally, probably because of associated severe head injuries. Pediatric airway difficulties arise from unique anatomic features of the pediatric patient. Children account for 10% of all ambulance runs, but comprise 32% of the population. On-the-job training and experience in acute management of the child with airway difficulty are limited. This study underscores the necessity for continuing education of those individuals providing acute care for injured children in the field and at community hospitahEdward G. Ford
115
ABSTRACTS
Detection of Neuroblastoma Cells in Blood........ Immunoscintigraphic Imaging of MIBG-Negative Metastases in Neuroblastoma .................... Prognosis in Children With Rhabdomyosarcoma ... ...................................................... .......... Soft-Tissue Sarcoma of the Perineal Region in Childhood ....... ..._..........................................._... Prognostic Correlation of P-Glycoprotein in Soft Tissue Sarcoma of Childhood ....... ..... ............... Problems in Diagnosis and Management of Desmoid Tumors . ....... ........_.................................... Carcinoma of the Colon and Rectum in Patients Less Than 20 Years of Age ......___...................... Long-Term Follow-Up of Children With Renal Carcinoma ....... ....... ......... .................................. Significance of Viridans Streptococcal Septicemia in Pediatric Oncology Patients ... ...............
GENERAL
120 120 120 120 121 121 121 121 121
CONSIDERATIONS
Continuous Hemodialysis in Children. N.A. Bishof; T.R. Welch, CF. Strife, et al. Pediatrics 85:819-823, (May), 1990. Four critically ill pediatric patients who underwent continuous arteriovenous hemoliltration (CAVHD) are reported. Indications for CAVHD included multiorgan failure secondary to perinatal asphyxia, sepsis, and Burkitt lymphoma with tumor lysis. The technique of hemofiltration is described. The authors note that CAVHD is an effective method of correcting fluid overload and, to some extent, azotemia. In a number of instances CAVHD may be preferred to peritoneal dialysis or hemodialysis.-Jefiq L. Zitsman Recommendations on Extracorporeal Membrane Oxygenation. Committee on Fetus and Newborn. Pediatrics 85:618-619. (April). 1990. Recognizing the evident effectiveness of ECMO for certain neonates, the lack of prospective studies, and the enthusiasm surrounding ECMO, the committee makes several recommendations to groups that are contemplating the development of a center. These recommendations include demonstration of regional need for a center, standing regional neonataliperinatal program, adequate personnel and hospital support, research and educational programs, and institutional review.-Jefiq L. Zitsman Percutaneous Catheterization of the Axillary Vein in Infants and Children. R.I. Metz, S.E. Lucking, F.C. Chaten, etal. Pediatrics 85:531-533. (April), 1990. The axillary vein may be used for catheterization when more familiar sites such as femoral, subclavian, internal jugular, and external jugular veins are not practical. The authors report 41 successful placements of axillary vein catheters in 52 attempts (79%). The patients ranged in age from 4 days to 12 years, and weighed from 3.0 kg to 59 kg. The catheters lasted from 2 to 22 days (median, 8 days). The indications for catheter removal were completion of therapy (21) patient death (6), catheter dislodgement with infiltration (4) catheter occlusion (3) venous thrombosis (1). venous stasis (l), and suspected sepsis (1). Two complications occurred: one patient had a small pneumothorax; another had an
axillary hematoma.
Inadvertent
puncture
of the axillary artery was
easily managed by direct pressure; no sequelae were noted. Four complications occurred during therapy; single cases of venous stasis of the extremity, venous thrombosis of the subclavian vein, infiltration secondary to catheter dislodgement. and catheter sepsis were recorded.-Jeffrey L. Zirsman
Management of Alarming Hemangiomas in Infancy: A Review of 25 Cases. 0. Enjolras, M.C. Riche, J.J. Merland, et al. Pediatrics 85:491-498,
(April),
1990.
Twenty-five cases of massive and life-threatening (“alarming”) hemangiomas are reviewed, with a single case presented in detail. Seventeen infants had lesions detected at birth; 22 were cervicocephalic. All patients were treated with corticosteroids, most for 5 months or longer. Liver involvement in three infants resulted in fatal cardiac failure despite the use of steroids, embolization, and irradiation. Although all of the hemangiomas underwent regression, malocclusion, skin sequelae, and ocular changes were present to some degree
in all of the survivors.
-Jefiey
L. Zitsman
Emergency Endotracheal lntubation in Pediatric Trauma. D.K. Nakayama, M.J. Gardner, and M.I. Rowe. Ann Surg 211:218-223, (February), 1990. Early endotracheal
intubation
is the mainstay
of cardiopulmo-
nary resuscitation in patients with severe trauma. Airway management in children is particularly difficult because of normal anatomic variations from the adult. This study analyzes 605 children admitted during a l-year trauma experience at a tertiary care center. Injuries included head (90%) abdomen (12%). face (11%) chest (6%) neck (3%) orthopedic (19%), and multiple injuries (40%). Indications for endotracheal intubation included coma (74%). shock (28%) apnea (22%) and airway obstruction (3%). Ten percent of children arrived with an endotracheal tube placed at the scene or at a referring institution. All but five of these patients were head-injured. Six of eight scene intubations required more than one attempt. The only unsuccessful intubations were at the scene of injury. Airway-related complications occurred in 16 patients (6 from the scene, 6 from referring hospital. and 4 at tertiary institution). Thirteen complications were immediately lifethreatening and included right mainstem bronchus intubation (5). massive barotrauma (2). failure of adequate preoxygenation (2). massive aspiration (1) esophageal intubation (1) nasotracheal intubation in an open facial fracture (l), and extubation during transport (1). Fifteen children died (23.8%). Four deaths involving scene intubations were each complicated by major airway mishap. No statistically significant difference was found in mortality rates between children who experienced airway or respiratory difficulties and those free from airway complication. In comparing patients with airway complications, a PO: less than 90 or a PCO, greater than 45 indicated a mortality rate double that of cases free from respiratory difficulties (P < .05). Two attempts at cricothyroidotomy ended fatally, probably because of associated severe head injuries. Pediatric airway difficulties arise from unique anatomic features of the pediatric patient. Children account for 10% of all ambulance runs, but comprise 32% of the population. On-the-job training and experience in acute management of the child with airway difficulty are limited. This study underscores the necessity for continuing education of those individuals providing acute care for injured children in the field and at community hospitahEdward G. Ford