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Frostbite: Pathogenesis in treatment
452
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 19, Number 5 • September 2001
fatalities occurred in unrestrained pediatric patients with a drinking driver. The driver transporting the child was usually not old enough to be a legal purchaser of alcohol. Interestingly, in the final editorial written by Guohua, the author calls for zero tolerance policy similar to the established aviation policy which states that no person may act as an operator of a plane after the consumption of alcohol within 12 hours. This policy has been established successfully for both the airlines and private aviation, and it presumably would have a similar effect on the ground as well.
Pediatric Restraint Use in Motor Vehicle Collisions. Tyroch MH, Kaups KL, Sue LP, et al. JAMA 2000;135:1173-1176. The use of restraint devices has contributed to appreciably to the decrease in fatalities as a result of motor vehicle crashes. The authors performed this study to investigate the injury patterns in restrained and pediatric passengers, and found that unrestrained children were more severely injured, required more services, and had higher mortality rates. With the exception of back fractures, the restrained group showed a reduction in severe injuries for every anatomic site. The spleen was the most frequently injured abdominal organ, followed by the liver and kidney. Restrained children had a lesser incidence of solid organ injuries, and a statistically-significant difference in the incidence of hollow organ injuries, Moreover, restrained children were less likely to suffer head, facial, cervical, thoracic and extremity injuries. The authors did not find injuries that were restraint-related in the pediatric population. The importance of child restraints to reduce pediatric injury and mortality needs continued emphasis.
Risk Factors and Predictors of Mortality in Children After Ejection From Motor Vehicle Crashes. Scheidler MG, Schultz BL, Schall L, et al. J Trauma 49:864-868. This study was designed to analyze the risk factors and predictors of mortality in children after ejection from a motor vehicle crash. A total of 2,414 children were involved in motor vehicle crashes and formed the basis of this study. The authors fotmd that that the mortality rate for children ejected from a motor vehicle crash was nearly triple that for nonejected children. The authors found that only 39% of the children in this study were using safety restraints. The most common cause of death was head injury. Ejection was associated with a higher mortality particularly in the yotmger child.
Pediatric Falls: Is Height a Predictor of Injury and Outcome? Murray JA, Chen D, Velmahos GC, et al. Am Surgeon 2000; 66:863-5. The authors of this paper wished to evaluate the commonly used triage criterion of "fall greater than 15 feet." From a retrospective review of 164 patients aged 0 to 14 years old admitted to the LA County and USC Medical Center over five years, they found that patients who fell less than 15 feet had a higher incidence of intracranial injuries, and a lower incidence of extremity fracture, than patients who fell more than 15 feet! This finding is of course the result of selective triage of patients with altered neurologic status to the trauma center, but it does highlight the fact that 15 feet is not a magic height, and it's use as a triage criterion is highly suspect.
Focused Abdominal Sonography for Trauma (FAST) in Children With Blunt Abdominal Trauma. Coley BD, Mutabagani KH, Moore LC, et al. J Trauma 2000;48:902-906. All emergency physicians should be aware of this interesting report. The authors have done a prior study which failed to show any benefits using ultrasonography (US) to diagnose free intraperitoneal fluid in children. The present study was done to develop
more knowledge of the sensitivity and accuracy of abdominal US in children. Interestingly, the authors found US to be very inaccurate in predicting free intraperitoneal fluid: its sensitivity and negative predictive value was poor. This is the first study that I have read that would downplay the benefits of ultrasonography in diagnosing free intraperitoneal fluid.
BURNS Long-Term Outcome of Children Surviving Massive Burns. Sheridan RL, Hinson MI, Liang MH, et al. J A M A 2000;283: 69-74. This excellent article reviews the contemporary management of children with severe burn injuries, and reports the Boston Shriners' Hospital Pediatric Burn Center's recent results. The Shriners' Burns Institute is a philanthropic organization, where all acute and rehabilitation care is provided to patients free of charge. Patients with massive burn injuries of greater than 75% of total body surface area require very long hospitalizations rehabilitative care. One as yet unanswered question has been what is the long-term outcome and reassimilation into society: what is the quality of life after massive bum? The authors performed such a study, which to their knowledge this was the first description of the long-term outcome in survivors of massive pediatric bums. They found that a large percentage of these individuals were married, gainfully employed, and assumed roles in society which were quite normal. With the assistance of physical and cosmetic rehabilitation, these patients are able to live a satisfying and productive life. The data support the authors' strong clinical impression that a supportive family is of enormous benefit to severely injured children. This study provides important data that support aggressive and vigorous management of patients who have suffered severe bums.
Frostbite: Pathogenesis in Treatment. Murphy JV, Branwell PE, Roberts AHN, et al. J Trauma 2000;48:171-178. The frequency of frostbite in the civilian population has increased. This article is a good review of the epidemiology, clinical presentation, and appropriate therapy for frostbite injuries. Frostbite is defined as the acute freezing of tissues when exposed to temperatures below the freezing point of impact skin. Contrary to popular opinion, adults between the ages of 30 and 49 years of age are commonly affected. Men outnumber women 10 to 1. The most commonly injured areas are the extremities. Alcohol, psychiatric illness, drug abuse, and vehicular trauma or failure are common risk factors. Frostbite is categorized into 4 degrees. In first degree, there is a numb central white plaque with surrounding erythema. Second degree injury causes blister formation. Third degree frostbite is characterized by hemorrhagic blisters that evolve into hard black eschar 2 weeks later. Fourth degree injury produces complete necrosis and tissue loss. The treatment of cold injury can be divided into 3 phases, (1) field care phase, (2) immediate hospital rewarming phase and (3) postthaw care phase. In the field, protection of the involved part from mechanical trauma, and the avoidance of thawing until definitive rewarming can occur is essential. Rubbing the affected tissue with warm hand or snow is not recommended. In phase 2 in the hospital, rewarming should occur promptly but not overrapidly. The ideal temperature to be used is approximately 40 ° centigrade. Once the injured extremity has been completely rewarmed, various methods of improving blood flow to the extremity are under consideration, including aspirin, low molecular weight dextran, and heparin. Prevention of edema is also of importance. Amputation should be performed if at all long after the acute injury: "frostbite in January, amputate in July."
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 19, Number 5 • September 2001
fatalities occurred in unrestrained pediatric patients with a drinking driver. The driver transporting the child was usually not old enough to be a legal purchaser of alcohol. Interestingly, in the final editorial written by Guohua, the author calls for zero tolerance policy similar to the established aviation policy which states that no person may act as an operator of a plane after the consumption of alcohol within 12 hours. This policy has been established successfully for both the airlines and private aviation, and it presumably would have a similar effect on the ground as well.
Pediatric Restraint Use in Motor Vehicle Collisions. Tyroch MH, Kaups KL, Sue LP, et al. JAMA 2000;135:1173-1176. The use of restraint devices has contributed to appreciably to the decrease in fatalities as a result of motor vehicle crashes. The authors performed this study to investigate the injury patterns in restrained and pediatric passengers, and found that unrestrained children were more severely injured, required more services, and had higher mortality rates. With the exception of back fractures, the restrained group showed a reduction in severe injuries for every anatomic site. The spleen was the most frequently injured abdominal organ, followed by the liver and kidney. Restrained children had a lesser incidence of solid organ injuries, and a statistically-significant difference in the incidence of hollow organ injuries, Moreover, restrained children were less likely to suffer head, facial, cervical, thoracic and extremity injuries. The authors did not find injuries that were restraint-related in the pediatric population. The importance of child restraints to reduce pediatric injury and mortality needs continued emphasis.
Risk Factors and Predictors of Mortality in Children After Ejection From Motor Vehicle Crashes. Scheidler MG, Schultz BL, Schall L, et al. J Trauma 49:864-868. This study was designed to analyze the risk factors and predictors of mortality in children after ejection from a motor vehicle crash. A total of 2,414 children were involved in motor vehicle crashes and formed the basis of this study. The authors fotmd that that the mortality rate for children ejected from a motor vehicle crash was nearly triple that for nonejected children. The authors found that only 39% of the children in this study were using safety restraints. The most common cause of death was head injury. Ejection was associated with a higher mortality particularly in the yotmger child.
Pediatric Falls: Is Height a Predictor of Injury and Outcome? Murray JA, Chen D, Velmahos GC, et al. Am Surgeon 2000; 66:863-5. The authors of this paper wished to evaluate the commonly used triage criterion of "fall greater than 15 feet." From a retrospective review of 164 patients aged 0 to 14 years old admitted to the LA County and USC Medical Center over five years, they found that patients who fell less than 15 feet had a higher incidence of intracranial injuries, and a lower incidence of extremity fracture, than patients who fell more than 15 feet! This finding is of course the result of selective triage of patients with altered neurologic status to the trauma center, but it does highlight the fact that 15 feet is not a magic height, and it's use as a triage criterion is highly suspect.
Focused Abdominal Sonography for Trauma (FAST) in Children With Blunt Abdominal Trauma. Coley BD, Mutabagani KH, Moore LC, et al. J Trauma 2000;48:902-906. All emergency physicians should be aware of this interesting report. The authors have done a prior study which failed to show any benefits using ultrasonography (US) to diagnose free intraperitoneal fluid in children. The present study was done to develop
more knowledge of the sensitivity and accuracy of abdominal US in children. Interestingly, the authors found US to be very inaccurate in predicting free intraperitoneal fluid: its sensitivity and negative predictive value was poor. This is the first study that I have read that would downplay the benefits of ultrasonography in diagnosing free intraperitoneal fluid.
BURNS Long-Term Outcome of Children Surviving Massive Burns. Sheridan RL, Hinson MI, Liang MH, et al. J A M A 2000;283: 69-74. This excellent article reviews the contemporary management of children with severe burn injuries, and reports the Boston Shriners' Hospital Pediatric Burn Center's recent results. The Shriners' Burns Institute is a philanthropic organization, where all acute and rehabilitation care is provided to patients free of charge. Patients with massive burn injuries of greater than 75% of total body surface area require very long hospitalizations rehabilitative care. One as yet unanswered question has been what is the long-term outcome and reassimilation into society: what is the quality of life after massive bum? The authors performed such a study, which to their knowledge this was the first description of the long-term outcome in survivors of massive pediatric bums. They found that a large percentage of these individuals were married, gainfully employed, and assumed roles in society which were quite normal. With the assistance of physical and cosmetic rehabilitation, these patients are able to live a satisfying and productive life. The data support the authors' strong clinical impression that a supportive family is of enormous benefit to severely injured children. This study provides important data that support aggressive and vigorous management of patients who have suffered severe bums.
Frostbite: Pathogenesis in Treatment. Murphy JV, Branwell PE, Roberts AHN, et al. J Trauma 2000;48:171-178. The frequency of frostbite in the civilian population has increased. This article is a good review of the epidemiology, clinical presentation, and appropriate therapy for frostbite injuries. Frostbite is defined as the acute freezing of tissues when exposed to temperatures below the freezing point of impact skin. Contrary to popular opinion, adults between the ages of 30 and 49 years of age are commonly affected. Men outnumber women 10 to 1. The most commonly injured areas are the extremities. Alcohol, psychiatric illness, drug abuse, and vehicular trauma or failure are common risk factors. Frostbite is categorized into 4 degrees. In first degree, there is a numb central white plaque with surrounding erythema. Second degree injury causes blister formation. Third degree frostbite is characterized by hemorrhagic blisters that evolve into hard black eschar 2 weeks later. Fourth degree injury produces complete necrosis and tissue loss. The treatment of cold injury can be divided into 3 phases, (1) field care phase, (2) immediate hospital rewarming phase and (3) postthaw care phase. In the field, protection of the involved part from mechanical trauma, and the avoidance of thawing until definitive rewarming can occur is essential. Rubbing the affected tissue with warm hand or snow is not recommended. In phase 2 in the hospital, rewarming should occur promptly but not overrapidly. The ideal temperature to be used is approximately 40 ° centigrade. Once the injured extremity has been completely rewarmed, various methods of improving blood flow to the extremity are under consideration, including aspirin, low molecular weight dextran, and heparin. Prevention of edema is also of importance. Amputation should be performed if at all long after the acute injury: "frostbite in January, amputate in July."