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Fatal bicycle accidents in children: A plea for prevention
ABSTRACTS
FROM POSTER SESSIONS
reviewed our experience of the past four years to establish a safe and cost-effective protocol for their management. From January 1987 to December 1990,57 children were managed for esophageal coins in this institution. Nineteen children were managed endoscopically under general anesthesia. with a median patient cost of $1,982 (excluding the surgeon and anesthesiologist charge). Thirtyeight children were managed with Foley balloon extraction or esophageal bougienage in the emergency department with a mean patient cost of $149 (excluding surgeon charge). Both methods were 100% effective, and there were no complications in either group. Rigid criteria were used in selecting patients for balloon extraction and bougienage. These are: (1) duration less than 24 hours, (2) no respiratory distress, and (3) no history of esophageal disease or surgery. Using these criteria, 15 of the 19 patients managed endoscopically could have safely and effectively been managed in the emergency department with a net savings of $1,833 per patient. We conclude that Foley balloon extraction and bougienage of esophageal coins in selected children is both safe and costeffective. Fatal Bicycle Accidents in Children: A Plea for Prevention. Laura J. Spence, Eve@ Dykes, Desmond Bohn. and David E. Wesson, Hospital for Sick Children and Kiwanis Injury Prevention and Research Program and University of Toronto, Toronto, Ontario.
We reviewed the coroner’s records of all fatal pediatric (0 to 15 years) bicycle accidents in a region of North America with a population of approximately 9 million between January 1, 1985 and December 31. 1989. The causes and circumstances were documented from police accident reports. The injuries sustained were documented and scored using anatomical injury scores (AIS 1985 and ISS) and categorized as survivable or unsurvivable according to objective definitions which we have previously reported. There were 81 deaths (annual mortality, 1.44 per 100,000 children at risk). This represents 15% of all injury deaths among children in this population. The mean age of the children was 9 2 4 years. Seventy-eight (96%) of the deaths resulted from collisions with motor vehicles. A majority of the accidents occurred during the daylight hours in summer. According to police reports the child was responsible for the collision in 70% of the cases. No victim was wearing a helmet at the time of injury. In 74 cases (91%) the injuries were deemed unsurvivable. Eighty-nine percent of these were head injuries. Bike helmets have been shown to reduce the risk of severe head injury in cycling accidents by 8.5%. On this basis, we have estimated that at least 60 of the 81 children who died in this study might have survived if they had been wearing a helmet. We feel that approved helmets should be mandatory for all child cyclists. Pediatric Abdominal Visceral Injury Associated With Seat Belts. Bonnie L. Beaver, Elizabeth Tso, and J. Alex Hailer, Jr, The Johns Hopkins Hospital and The University of Maryland Hospital, Baltimore. MD.
A state-wide experience with pediatric abdominal visceral injury associated with seat belt use was compiled from the trauma registries of two academic institutions. A retrospective analysis of motor vehicle passenger injuries from 1987 to 1990, included age, sex, mechanism of iniurv, nrehosnital care, type of iniurv, therapeutic interventions, complications: and ultimate outcome. Over-2000 patients with blunt trauma were reviewed, with 30 children fulfilling the following inclusion criteria: 16 years of age or younger, wearing seat belt or other passive restraint, and documented seat belt-related abdominal visceral injury.
1163
In the 30 patients studied, the male-female ratio was 1:2 with a mean age of 7.02 years (range, 2 months to 16 years). Forty percent of the patients required extrication from thevehicle at the accident scene. Twenty-one were noted to have abdominal wall bruising or erythema only. The specific blunt visceral injuries sustained were as follows: splenic 5, hepatic 4, distal small bowel 4, renal 3, other 6 (stomach, diaphragm, colon, pancreas). Two or more visceral injuries existed in 10 patients (24%). Operative intervention was necessary in 7 of the 21 (25%). A delay in diagnosing the visceral injury occurred in 50% of the cases. In one case the patient developed abdominal symptoms 72 hours after the accident. Length of hospital stay was 1.5 to 45 days. There were 2 deaths. Although solid visceral abdominal injury is more frequent than hollow visceral injury, it is a source of significant morbidity, and its presence should be sought out carefully. A high index of suspicion should exist in those wearing seat belts during motor vehicle accidents. External signs of seat belt-associated trauma and extrication from the vehicle are harbingers of significant visceral injury. Innominate Artery Compression of the Trachea and Gastroesophageal Reflux. Allen L. Milewicz. David W Tuggle, and William P. Tunnell, lJni,~ersiy of Oklahoma Health Sciences Center and the Children :s Hospital of Oklahoma, Oklahoma Ciy, OK.
Innominate artery compression of the trachea (IACT). an uncommon cause of airway obstruction in newborns, has been noted most often in infants with esophageal atresia. Gastroesophageal reflux (GER) in association with IACT has not been previously described. Between 1986 and 1991,lO patients with IACT, confirmed by bronchoscopy, were treated with aortic suspension (aortopexy). The mean age was 5 months (range, 1 to 1I months). All patients had stridor, 8 had cyanosis and apnea, and 6 presented with respiratory arrest requiring cardiopulmonary resuscitation. Three patients suffered multiple arrests before being referred for bronchoscopy. Two-dimensional Doppler echocardiography of the mediastinum was performed in all patients and failed to detect IACT. Seven patients (70%) had associated GER, confirmed by barium swallow and 24-hour pH monitoring. Four patients had had previous repair of esophageal atresia and had GER. Three of six patients without esophageal atresia had symptomatic GER. Three patients underwent fundoplication prior to aortopexy with persistence of apnea. Four patients had successful medical therapy for reflux following aortopexy without further airway obstruction. Postaortopexy bronchoscopy showed relief of airway obstruction in all patients. This experience suggests that: (1) GER commonly occurs in association with innominate artery compression of the trachea whether or not esophageal atresia was present; (2) IACT can occur in the absence of esophageal atresia and its diagnosis requires a high index of suspicion; and (3) in the presence of IACT and GER, aortopexy should be performed prior to considering an antireflux procedure. A Better Incision for Pectus Excavatum Repair: Avoiding the Keloid Triangle. Brian R. West, Hany Applebaum, and Bradford W Edgerton. Departments of Pediatric Surgery and Plastic and Reconstructive Surgery, Kaiser Permanente Medical Center, Los Angeles. C.4.
Pectus excavatum is surgically repaired primarily for its psychosocial symptoms, although evidence of true physiological benefit is accumulating. Currently used techniques give excellent chest wall configurations, but many patients are dissatisfied with the subsequent hypertrophic or keloid scar and its suprasternal location. For
FROM POSTER SESSIONS
reviewed our experience of the past four years to establish a safe and cost-effective protocol for their management. From January 1987 to December 1990,57 children were managed for esophageal coins in this institution. Nineteen children were managed endoscopically under general anesthesia. with a median patient cost of $1,982 (excluding the surgeon and anesthesiologist charge). Thirtyeight children were managed with Foley balloon extraction or esophageal bougienage in the emergency department with a mean patient cost of $149 (excluding surgeon charge). Both methods were 100% effective, and there were no complications in either group. Rigid criteria were used in selecting patients for balloon extraction and bougienage. These are: (1) duration less than 24 hours, (2) no respiratory distress, and (3) no history of esophageal disease or surgery. Using these criteria, 15 of the 19 patients managed endoscopically could have safely and effectively been managed in the emergency department with a net savings of $1,833 per patient. We conclude that Foley balloon extraction and bougienage of esophageal coins in selected children is both safe and costeffective. Fatal Bicycle Accidents in Children: A Plea for Prevention. Laura J. Spence, Eve@ Dykes, Desmond Bohn. and David E. Wesson, Hospital for Sick Children and Kiwanis Injury Prevention and Research Program and University of Toronto, Toronto, Ontario.
We reviewed the coroner’s records of all fatal pediatric (0 to 15 years) bicycle accidents in a region of North America with a population of approximately 9 million between January 1, 1985 and December 31. 1989. The causes and circumstances were documented from police accident reports. The injuries sustained were documented and scored using anatomical injury scores (AIS 1985 and ISS) and categorized as survivable or unsurvivable according to objective definitions which we have previously reported. There were 81 deaths (annual mortality, 1.44 per 100,000 children at risk). This represents 15% of all injury deaths among children in this population. The mean age of the children was 9 2 4 years. Seventy-eight (96%) of the deaths resulted from collisions with motor vehicles. A majority of the accidents occurred during the daylight hours in summer. According to police reports the child was responsible for the collision in 70% of the cases. No victim was wearing a helmet at the time of injury. In 74 cases (91%) the injuries were deemed unsurvivable. Eighty-nine percent of these were head injuries. Bike helmets have been shown to reduce the risk of severe head injury in cycling accidents by 8.5%. On this basis, we have estimated that at least 60 of the 81 children who died in this study might have survived if they had been wearing a helmet. We feel that approved helmets should be mandatory for all child cyclists. Pediatric Abdominal Visceral Injury Associated With Seat Belts. Bonnie L. Beaver, Elizabeth Tso, and J. Alex Hailer, Jr, The Johns Hopkins Hospital and The University of Maryland Hospital, Baltimore. MD.
A state-wide experience with pediatric abdominal visceral injury associated with seat belt use was compiled from the trauma registries of two academic institutions. A retrospective analysis of motor vehicle passenger injuries from 1987 to 1990, included age, sex, mechanism of iniurv, nrehosnital care, type of iniurv, therapeutic interventions, complications: and ultimate outcome. Over-2000 patients with blunt trauma were reviewed, with 30 children fulfilling the following inclusion criteria: 16 years of age or younger, wearing seat belt or other passive restraint, and documented seat belt-related abdominal visceral injury.
1163
In the 30 patients studied, the male-female ratio was 1:2 with a mean age of 7.02 years (range, 2 months to 16 years). Forty percent of the patients required extrication from thevehicle at the accident scene. Twenty-one were noted to have abdominal wall bruising or erythema only. The specific blunt visceral injuries sustained were as follows: splenic 5, hepatic 4, distal small bowel 4, renal 3, other 6 (stomach, diaphragm, colon, pancreas). Two or more visceral injuries existed in 10 patients (24%). Operative intervention was necessary in 7 of the 21 (25%). A delay in diagnosing the visceral injury occurred in 50% of the cases. In one case the patient developed abdominal symptoms 72 hours after the accident. Length of hospital stay was 1.5 to 45 days. There were 2 deaths. Although solid visceral abdominal injury is more frequent than hollow visceral injury, it is a source of significant morbidity, and its presence should be sought out carefully. A high index of suspicion should exist in those wearing seat belts during motor vehicle accidents. External signs of seat belt-associated trauma and extrication from the vehicle are harbingers of significant visceral injury. Innominate Artery Compression of the Trachea and Gastroesophageal Reflux. Allen L. Milewicz. David W Tuggle, and William P. Tunnell, lJni,~ersiy of Oklahoma Health Sciences Center and the Children :s Hospital of Oklahoma, Oklahoma Ciy, OK.
Innominate artery compression of the trachea (IACT). an uncommon cause of airway obstruction in newborns, has been noted most often in infants with esophageal atresia. Gastroesophageal reflux (GER) in association with IACT has not been previously described. Between 1986 and 1991,lO patients with IACT, confirmed by bronchoscopy, were treated with aortic suspension (aortopexy). The mean age was 5 months (range, 1 to 1I months). All patients had stridor, 8 had cyanosis and apnea, and 6 presented with respiratory arrest requiring cardiopulmonary resuscitation. Three patients suffered multiple arrests before being referred for bronchoscopy. Two-dimensional Doppler echocardiography of the mediastinum was performed in all patients and failed to detect IACT. Seven patients (70%) had associated GER, confirmed by barium swallow and 24-hour pH monitoring. Four patients had had previous repair of esophageal atresia and had GER. Three of six patients without esophageal atresia had symptomatic GER. Three patients underwent fundoplication prior to aortopexy with persistence of apnea. Four patients had successful medical therapy for reflux following aortopexy without further airway obstruction. Postaortopexy bronchoscopy showed relief of airway obstruction in all patients. This experience suggests that: (1) GER commonly occurs in association with innominate artery compression of the trachea whether or not esophageal atresia was present; (2) IACT can occur in the absence of esophageal atresia and its diagnosis requires a high index of suspicion; and (3) in the presence of IACT and GER, aortopexy should be performed prior to considering an antireflux procedure. A Better Incision for Pectus Excavatum Repair: Avoiding the Keloid Triangle. Brian R. West, Hany Applebaum, and Bradford W Edgerton. Departments of Pediatric Surgery and Plastic and Reconstructive Surgery, Kaiser Permanente Medical Center, Los Angeles. C.4.
Pectus excavatum is surgically repaired primarily for its psychosocial symptoms, although evidence of true physiological benefit is accumulating. Currently used techniques give excellent chest wall configurations, but many patients are dissatisfied with the subsequent hypertrophic or keloid scar and its suprasternal location. For