MINOR PEDIATRIC INJURIES

PEDIATRIC SURGERY FOR THE PRIMARY CARE PEDIATRICIAN, PART I

0031-3955/98 $8.00

+ .OO

MINOR PEDIATRIC INJURIES Shahid Shafi, MB, BS, MPH, and James C . Gilbert, MD

Trauma is the leading cause of death and disability in children over the age of 1 year.69The incidence of injuries sustained by children in the United States is estimated to be approximately 30 episodes per 100 children per year, resulting in a loss of 28 school days per 100 children per year? With an estimated 60,000 admissions per year, injuries are the second leading cause of hospitalization in children (20%) after respiratory illnesses (2370),~ In addition, almost 16 million children are evaluated for injuries in emergency departments around the country every year.79It is estimated that unintentional childhood injuries resulted in a cost to the society of at least $7.5 billion in 1982.37So far, the focus of trauma care has been on early identification of major inj~ries.4~ However, minor injuries account for the majority of trauma admissions and A population-based study in Massachusetts found that for every child dying of an injury, 45 are hospitalized and 1300 require treatment in an emergency de~artment.3~ The number of children treated in doctor’s offices and those who never received medical attention remains unknown. The objective of this article is to provide a brief overview of minor pediatric injuries that may be managed safely and effectively in an office setting, and also to provide a guideline for referral for advanced care. ORIGIN The National Pediatric Trauma Registry (NPTR), located at New England Medical Center-Tufts University School of Medicine, Boston, Massachusetts, provides the best overview of pediatric trauma in North America based upon information collected from 78 participating centers. Some of its findings from

From the Division of Pediatric Surgery, Department of Surgery, School of Medicine and Biomedical Sciences, State University of New York at Buffalo; and Pediatric Trauma, Kiwanis Pediatric Trauma Center, Department of Pediatric Surgery, Children’s Hospital of Buffalo, Buffalo, New York

PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 45 * NUMBER 4 * AUGUST 1998

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Table 1. INJURY EPIDEMIOLOGY AND CIRCUMSTANCES Age:

(1 year 1-4 years 5-9 years 10-1 4 years 15 years Sex: Male Female Unknown Time of Injury: AM PM Unknown Circumstances of Injury: Unintentional Intentional Others Mechanism of Injury: Falls Motor-vehicle Pedestrian Bicycle sports Gun-shot wounds Stabbing Struck (accident) Assault Animal bites Motor-cycle All terrain vehicleshecreation vehicle Others Site of Injury: Road Home Recreational place Public place School Farm Workplace Other Unknown

4.4% 25.2% 29% 24.9% 16.6% 65.6% 33.9% 0.5% 16.7% 66.8% 16.5% 89.3% 9.7% 1 Yo 26.3% 18.9% 14.5% 8.5% 6.2% 5.1% 4.7% 4% 3.5% 1.4% 1.3% 1.2% 4.4% 42.5% 34.6% 6.8% 5.2% 3.5% 0.7% 0.2% 0.7% 5.9%

From DiScala C: National Pediatric Trauma Registry Biannual Repoft. Boston, National Pediatric Trauma Registry, 1996; with permission.

53,113 cases reported in October 1996 are summarized in Table l.19 The most common mechanisms of injury in children involve motor-vehicles, falls, sports, and bicycles. Majority of these injuries occur in the everyday environment of the children (i.e., home, school, roads, and playgrounds). The mechanism of injury is a strong determinant of the severity of inj~ry.4~8 50 Motor-vehicle acci-

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dents, pedestrian injuries, and falls more than 15 feet are associated with severe injuries, while minor falls and bicycle and sports-related injuries are likely to result in minor injuries. Data from our pediatric trauma center based upon a review of almost 2000 inpatient admissions indicate that the mechanism of injury of falls is an independent predictor of a minor injury (unpublished data). DIAGNOSIS

In vast majority of instances, the history of a traumatic event is obvious and volunteered by the child's care-givers. In certain situations, such as child abuse, the patient may present without a history of trauma.6,74 All children presenting with a history of trauma must be presumed to have significant injuries until proven 0therwise.5~The most common symptoms of an injury are pain and hemorrhage, while the signs may range from none to ecchymosis, contusion, laceration, deformity, and hemodynamic or neurologic impairment. The initial evaluation should follow the ABCs of trauma based upon the findings in the history and physical e~amination.5~,~~ The objective of this evaluation is to identify patients who can be managed safely and effectively in the office, as opposed to those who need to be referred. Any child with hemodynamic or neurologic compromise should be referred to an appropriate pediatric trauma center. In addition, we believe that all extremity fractures should be referred to trained specialists, as extremity injuries are the leading cause of long-term disability. The most common pediatric injuries include minor soft tissue injuries, minor head injuries, fractures, and open/superficial wounds (Table 2). Several quantitative scales have been developed oxer the years to grade injury severity and are based upon the anatomic definition of the injuries and the physiologic status of the child. The most commonly used measures of injury severity include: 1. Injury Severity Score (ISS)? 49 which, in its most recent form, is the sum of the squares of the three highest Abbreviated Injury Scores (AIS). AIS is an anatomic definition of injury severity, developed by the Association for the Advancement of Automotive Medicine (AAAM).

Table 2. DISTRIBUTION OF INJURIES (CHILDREN'S HOSPITAL OF BUFFALO, 1993 TO 1995)

Injuries

Minor soft tissue Minor head (concussion, others) Extremities/clavicle Major head (fracture, bleed, contusion) Burns Abdomen Facelneck Eye Chest Spine (column,cord) Others

All Number of Patients

Minor Injury (ISS6) Number of Patients

("/.I

("/.I

873 (44%) 626 (32%) 491 (25%) 286 (15%) 214 (11'Yo) 123 (So/,) 117 (6%) 75 (4%) 68 (3%) 57 (3%) 102 (5%)

661 (46%) 505 (35%) 297 (21%) 125 (9%) 136 (9%) 52 (4%) 68 (5%) 64 (4%) 4 (.3%) 25 (2%) 74 (5%)

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Table 3. PEDIATRIC TRAUMA SCORE Component

Category +1

Category + 2

Size Airway Systolic Blood Pressure Neurologic Status

20 kg Normal 90 mm Hg Awake

Open Wound Skeletal

None None

Sum Total Points

Best Score = 12

10-20 kg Maintainable 90-50 rnm Hg Obtunded/Loss of Consciousness Minor Closed Fracture

Category - 1 10 kg Unmaintainable 50 mm Hg Coma/ Decerebrate Major/Penetrating Open/Multiple Fractures Worst Score = - 6

From Tepas JJ, 111, Mollitt DL, Talbert JL, et al: The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg 22:14, 1987; with permission.

2. Pediatric Trauma Score (PTS, Table 3),” which is based upon the physiologic status of the child. 3. Glasgow Coma Score (GCS, Table 4):4 and its pediatric and neonatal modifications, Children’s Coma (CCS, Table 5), and Neonatal Arousal Scale” (NAS, Table 6), respectively, all of which are based upon the level of consciousness of the patient. Several studies have correlated survival with various measures of injury severity. In the NPTR data base, no deaths were seen with ISS9, which is also consistent with the experience at our pediatric trauma center over the last 3

Table 4. GLASGOW COMA SCALE Component Best Motor Response Obeys commands Localizes pain Withdraws from pain Abnormal flexion (decorticate) Extensor response (decerebrate) No response Best Verbal Response Oriented Confused conversation Inappropriatewords Incomprehensible sounds No response Best Ocular Response Spontaneous eye opening Eye opening to speech Eye opening to pain No eye opening Sum Total Points

Score

4 3

2 1 Best score = 15 Worst score = 3

From Ghajar J, Hariri RJ: Management of pediatric head injury. Pediatr Clin North Am 39:1093, 1992, with permission.

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Table 5. CHILDREN’S COMA SCALE Component Best Motor Response Flexes & extends Withdraws from pain Hypertonic Flaccid Best Verbal Response Cries Spontaneous respirations Apneic Best Ocular Response Pursuit Extraocular muscles intact/reactive pupils Extraocular muscles impaired/fixed pupils Extraocular muscles paralyzed/fixed pupils Sum Total Points

Score 4 3 2 1

3 2 1 4

3 2 1 Best score = 11 Worst Score = 3

From Raimondi AJ, Hirschauer J: Head injury in the infant and toddler: Coma scoring and outcome scale. Child Brain lf:12, 1984, with permission.

Table 6. NEONATAL AROUSAL SCALE ComDonent Best Response to Bell Facial and extremity movements Grimaces/ blinks Increase in respiratory and heart rate Seizurelextensor posturing No response Best Response to Light Blink and faciaVextremity movements Blink Seizure/extensor posturing No response Best Motor Response Spontaneous periods of activity Occasional spontaneous movements Extremity movements with sternal rub Grimace/facial movements with sternal rub Seizurelextensor posturing with sternal rub No response with sternal rub Sum Total Points

Score

4

3 2 1

Best Score = 15 Worst Score = 3

From Duncan CC, Ment LR, Smith B, et al: A scale for the assessment of neonatal neurologic status. Child Brain 8:299, 1981, with permission.

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Table 7. INJURY SEVERITY AND MORTALITY Injury Severity Score

Mortality

9 10-19

0 0.8 32

20

("/I

Pediatric Trauma Score

Mortality

9 5-8 4

0.1 2.1 34.3

("/.I

From DiScala C: National Pediatric Trauma Registry Biannual Report. Boston, National Pediatric Trauma Registry, 1996;with permission.

years (Table 7). PTS6 and 8 have been suggested as critical points beyond which injury severity and mortality increase precipitously.n,96 Head injuries associated with a GCS13 are generally defined as mild, and are associated with almost zero mortality and excellent long-term functional outcome.3z,44 The normal NAS ranges from 12 to 15.2zSimilar data for CCS are not available but a general principle of referring young children who measure less than two points from the maximum on their respective scales appears to be a safe and effective strategy. Based on these principles, the office-based pediatrician can identify children with minor injuries who can be managed at the office. MANAGEMENT

The outpatient management of minor injuries depends upon the final definition of all injuries, and may range from reassuring the parents and the patients, to wound care, to referral to an appropriate center or specialist. The principles of wound care are: adequate hemostasis, removal of foreign bodies and nonviable tissues, and an appropriate closure or coverage of the wound to optimize healing. The skills required include ability to use local/regional anesthesia, cleaning and irrigation, identification and removal of foreign bodies, sharp and blunt debridement of nonviable tissue, suture closure of wound, and appropriate dressings for open wounds. The wound and the surrounding area are initially prepared with an antiseptic solution, the most common of which is povidone iodine solution (Betadine, Ethicon, Somerville, NJ) and chlorhexidine (Hibiclens, Ethicon, Somerville, NJ). This is followed by injection of local anesthetic. The most commonly used local anesthetic for minor procedures is lidocaine. It has a rapid onset of action, and lasts for 90 to 200 minutes.67The maximum dose is 4.5 mg/kg when using lidocaine without epinephrine, and up to 7 mg/kg when using it with epinephthin ~ i n eA. ~ ~ needle (27 to 30 gauge) mounted on a 5 to 10 mL syringe is used to infiltrate lidocaine in and around the wound. When treating wounds with end blood vessels, epinephrine should not be used as the associated vasoconstriction may cause damage to terminal tissue, such as a digit, ear lobe, tip of the nose, or penis. Also, the vasoconstriction may impair wound healing by interfering with the normal inflammatory response.23Topical anesthetics may be used for superficial skin wounds, and offer the advantage of being less painful and causing less distortion of the wound. An example is a combination of tetracaine (0.5%), epinephrine (1:2000), and cocaine (11.8%) (TEC). Although useful in children, the intense vasoconstriction may interfere with local wound defenses, and in one study led to an increase in infecti~ns?~ Again, its use should be avoided in terminal organs. Exposure of mucous membranes to

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excessive local anesthetics can lead to systemic toxicity and death.67Other anesthetic techniques involve local and regional nerve blocks. After induction of adequate local anesthesia, the wound should be examined in detail to define the extent of injury, and to identify presence of devitalized tissue and foreign bodies. A wound involving significant underlying structures, such as the bones, joints, and tendons, should be referred to an appropriate specialist. Hemostasis of minor injuries is best secured by direct pressure and rarely requires suture ligation of the bleeding vessel. Devitalized tissue is then debrided using a blade or a pair of sharp scissors. Foreign bodies must be removed. If a wound is heavily contaminated, or if any suspicion exists about retained foreign bodies, referral to a pediatric surgeon is required. A radiograph should be individualized to rule out associated bony injury or radio-opaque foreign bodies if there is any doubt. The wound is then irrigated with copious volumes of warm saline. The optimal balance between appropriate decontamination and irrigation-induced inflammation is at pressures between 5 and 8 psi, which is easily generated by using a 30 mL syringe and an 18 to 20 gauge plastic catheter or needle.13Although in common use, irrigation using an antiseptic solution, such as povidone iodine, should be avoided as it has been shown to interfere with wound healing and increase the risk of systemic absorption and t0xi~ity.l~ All wounds should be closed primarily, unless there is infection, gross contamination, or a delay of several hours. In this situation, delayed primary closure is used or the wound is allowed to heal by secondary intention. In delayed primary closure, the wound is left open for 3 to 4 days prior to closure. This delay allows the opportunity to determine the presence of infection, to establish tissue viability, or to provide repeated surgical debridement.I8 In almost all other circumstances, the wound can be closed primarily using sutures, tapes, staples, or tissue glue. Lacerations to the face are an exception as they should be closed primarily in virtually all situations. There are two broad categories of sutures: absorbable and nonabsorbable. Absorbable sutures include plain gut, chromic gut, and polyglactin (Vicryl, Ethicon, Somerville, NJ). Nonabsorbable sutures may be constructed using a single filament (i.e., Prolene, Ethicon, Somerville, NJ) or multiple braided filaments (i.e., silk). Monofilaments are generally preferred over braided sutures. Recently monofilament absorbable sutures have been developed, such as polydioxanone (PDS) and polyglyconate (Maxon).Vicryl generally loses its strength in 4 weeks, while PDS retains approximately 70% of its strength at that time.55 Absorbable sutures on tapered needles are used for deep layers and mucosal surfaces, while nonabsorbable sutures on cutting needles are used on the skin. For deep wounds, a layered closure is desirable as it produces better cosmetic result by taking the tension off the skin sutures and by providing better approximation of wound edges. The appropriate curve of the needle needed depends on the shape and depth of the wound. Several different suture techniques are available for different wounds. Simple interrupted sutures are used most commonly (Fig. 1). The major disadvantage is the potential of cutting through the skin with increased tension or swelling. Simple running and running locked sutures save time and distribute the tension evenly,, but are contraindicated in wounds under tension (Fig. 2). Horizontal and vertical mattress sutures are ideal for wounds under tension, and these sutures evert the skin naturally (Figs. 3 and 4). The disadvantage is the potential for prominent suture marks. For layered closure, subcutaneous and intradermal inverted sutures with buried knots are ideal (Fig. 5 ) . Running subcuticular sutures provide excellent cosmetic results, but should only be used in wounds under minimal tension (Fig. 6). Summary recommendations for suture repair of soft tissue injuries is given in Table 8.55

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Table 8. SUTURES ~

Location

Anesthetic

Suture Material

Scalp

Lidocaine 1% with epinephrine

Face

Lidocaine 1% with epinephrine or use field block

Pinna (ear)

Lidocaine 1% (field block)

3-0 or 4-0 Nonabsorbable monofilament 4-0 or 5-0 Synthetic absorbable or 6-0 nonabsorbable monofilament 6-0 Nonabsorbable monofilament or 5-0 synthetic absorbable

Lip

Lidocaine 1% with epinephrine or use field block

Oral Cavity

Lidocaine 1% with epinephrine or IV sedation (in children) Lidocaine 1% with epinephrine

Neck, Chest, Back, Abdomen Extremity

Lidocaine 1% with epinephrine 1%

Hands, Feet

Lidocaine 1% (if field block with 2% lidocaine or 0.25% bupivacaine) Lidocaine 2% or bupivacaine 0.25% digital nerve block

Nailbeds

Technique of Closure and Dressing

Suture Removal

(d)

Interrupted in galea, single tight layer in scalp or horizontal mattress If full-thickness laceration, layered closure is desirable

7-12

Close perichondrium with 5-0 synthetic absorbable; close skin with nonabsorbable interrupted sutures-stint dressing Three layers (mucosa, muscle, and skin) if through and through; otherwise, two layers

4-6

3-5

4-0 or 5-0 Synthetic absorbable in mucosa, muscle, and intradermal layer; 6-0 nonabsorbable monofilament 4-0 Synthetic absorbable

Simple interrupted or horizontal mattress

Allow to dissolve

4-0 Synthetic

Single layered closure

6-12

Single-layered closure is adequate, although layered or running SQ closure may give better cosmetic result; apply splint if wound is over a joint Single-layered closure only with simple or horizontal mattress interrupted suture

6-1 4

absorbable; 4-0 or 5-0 nonabsorbable monofilament 3-0 or 4-0 Synthetic absorbable (muscle fascia); 4-0 Or 5-0 nonabsorbable monofilament 4-0 Or 5-0

Nonabsorbable monofilament

5-0 Synthetic absorbable

Gentle, meticulous placement to obtain even edges, stint dressing with original nail

3-5

7-1 2

Allow to absorb

Adapted from Markovchick V: Suture materials and mechanical aftercare. Emerg Clin North Am 10(4):673-689, 1992; with permission.

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/

/ Figure 1. The simple interrupted suture. Since there is a broad base to the suture loop, the edges of the wound approximate without inversion. (Adapted from Zukin DD, Simon RR: Emergency Wound Care: Principles and Practice. Rockville, MD, Aspen, 1987, p 290; with permission.)

Figure 2. The locked running suture. A, The stitch is begun the same way as for a conventional running suture. B and C, The needle is then looped through the preceding surface suture. (Adapted from Zukin DD, Simon RR: Emergency Wound Care: Principles and Practice. Rockville, MD, Aspen, 1987, p 291 ; with permission.)

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Figure 3.The horizontal mattress suture. The two lines of suture lie parallel to one another in the horizontal plane of the skin surface. The suture is tied approximating and everting the wound edge. (Adapted from Zukin DD, Simon RR: Emergency Wound Care: Principles and Practice. Rockville, MD, Aspen, 1987, p 291; with permission.)

Paper tapes (Steri-strips) have a lower incidence of infection, compared to sutures, and are considerably easier to use and are pain-free.23,55 They are used only on small linear wounds that are under minimal tension. Staples are a rapid method of closure for linear lacerations on scalp, trunk, and extremities, but for cosmetic reasons should be avoided in the hands, face, breasts, and in any area of the body that will be exposed to computed tomography or magnetic resonance imaging.55Tissue glues derived from cyanoacrylate have also been used with less pain, decreased time for wound repair, and good cosmetic results in selected wounds.'l, 70 PROGNOSIS

Overall, pediatric trauma patients enjoy a good prognosis. When selected appropriately, the outcome of children with minor injuries should be excellent, with zero mortality and minimal long-term disability. The data to establish norms in this area do not exist at the present time. Most of the registries, including the NPTR, are based upon in-patients, but are the best sources of information available. NPTR collects data on functional status at discharge from the trauma center in the following area: vision, hearing, speech, self-feeding, bathing, dressing, walking, toileting, cognition, and behavior. Overall, 56% of children did not suffer any functional impairment. Of those who did, 78% of children with ISS9 and 67% of those with PTS8 had only one to three impairments, primarily related to fractures, open wounds, and head injuries. Of the

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Figure 4. The vertical mattress suture. The two lines of suture lie in the same vertical plane within the wound. The wound is re-entered and exited about 1 to 2 mm from the edge to evert the wound edges. (Adapted from Zukin DD, Simon RR: Emergency Wound Care: Principles and Practice. Rockville, MD, Aspen, 1987, p 292; with permission.)

children with 1 to 3 functional impairments, 95% were discharged home, and only 1.7% required transfers to rehabilitation centers or extended care facilities. PREVENTION

Injury prevention is the single most important aspect of trauma care. We are reaching a critical point in the history of trauma care where most of the deaths seen are due to unsurvivable injuries, and hence the only way to decrease trauma-related mortality further is to prevent the injuries from occurring in the first place. Injuries are not random events, but follow predictable patterns, and hence are susceptible to preventive interventions. Parental knowledge and atti-

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C

Figure 5. The buried knot suture. The loop is constructed so that the knot lies at the bottom, leaving the upper surface that the skin will rest dn smooth and flat. (Adapted from Zukin DD, Simon RR: Emergency Wound Care: Principles and Practice. Rockville, MD, Aspen, 1987, p 293; with permission.)

tude are crucial determinants of injury prevention, and there is a continuing need for programs to increase parental knowledge of childhood injuries and Preventive strategies can be broadly classified into three categories: education, legislation, and cost subsidization. These approaches have met variable success in different communities. Experience from bicycle helmet interventions suggests that an integrated approach, combining all three types of strategies, is essential for success of preventive measures.53The most common places of injury

Figure 6. The subcuticular suture. The suture travels in the subcuticular plane on alternating sides of the wound. (Adapted from Zukin DD, Simon RR: Emergency Wound Care: Principles and Practice. Rockville, MD, Aspen, 1987, p 293; with permission.)

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Table 9. SPECIFIC PREVENTIVE STRATEGIES Examples of Preventive Strategies Road Motor-Vehicle Accidents Pedestrians

Bicycle Homes Burns

Falls Suffocation Entrapment Strangulation Poisoning Violence/Abuse

Recreational Areas Drowning Playground injuries sports

Child seat, Seatbelt, Rear passenger seating Training street crossing skills to children, Crossing guards, Well marked crosswalks, Mandatory sidewalks, Restricted parking near intersections, Modification of driving behavior, Well lit streets, Roadway barriers, Pedestrian crossing sign, Schoolzone measures, Pedestrian indicator lights at traffic signals, Restricting right-turn on red signal Helmets, Reflectors, Bicycle lanes Smoke detectors, Non-flammablesleepwear, Fire-safe cigarettes, Child-resistant cigarette lighters, Sprinkler systems, Lower water heater thermostat temperature, Antiscald devices on faucets and showerheads Window guards, Stair guards, Side rails for beds, Carpeted floors, Avoiding bunk beds for children under 6 years of age, Avoiding baby walkers Restricted access to plastic bags and sheets Narrow space between side rails of cribs and beds, Restricted access to refrigerator, oven, washer and dryer, and other appliances Restricted access or removal of cords hanging from pacifiers, windows, clothing, and straps Closet locks, Poison preventive packages Handgun control, Conflict resolution teaching, Interventions directed at alcohol and drug abuse prevention, Teaching parenting skills, Community support groups, Child care, Social services, Early identification of victims, CiviMCriminal justice system interventions, Suicide prevention centers, Restricted access to medicationdpoisons Pool fencing, Life guards with CPR training Playground surfacing, Equipment design and maintenance Helmets and other protective devices (as appropriate for the sport), Elimination of trampolines, Prohibiting dangerous practices such as head-butting in football

occurrence are road, home, and recreational areas. Several options are available to minimize injuries in all these places* (Table 9). SPECIAL TOPICS

Mild Head Injuries Head injuries constitute the single most common injury seen in the pediatric age group.9 It is also the most common cause of death in pediatric t r a ~ m a . 9A~ minor head injury is usually defined as one with a Glasgow Coma Score of 13, and constitutes the vast majority of head i n j ~ r i e sThe . ~ estimates of minor head ‘References 3, 36, 38, 58, 65, 73, 77, 78, 80, 88, 92, 93, and 98.

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injury patients with clinically significant intracranial injury are usually around 3% to 4%.17,69,91 Mortality associated with head injuries of AIS 1 to 2, and GCS of 13 is almost nonexistent in the pediatric age group^.^',^^ A large series of 28,000 pediatric head injuries revealed the incidence of intracranial bleeding to be only 0.13?'0.~ All patients with acute bleeding had symptoms and signs to indicate a need for continued observation within the first 6 hours. The authors concluded that observation of an uncomplicated case of head injury for more than 6 hours, when there were no residual signs or symptoms, would not have increased the detection of intracranial hemorrhage. Still, a large proportion of these patients are routinely admitted for observation for 1 to 2 days.63There is experimental and clinical evidence that a certain proportion of these patients develop neurologic problems in the long run4,35* 76 Of the 2238 children admitted to our trauma center from 1993 to 1995 with GCS13, only one child died. Thus, it seems that a GCS of 13 to 15 in an asymptomatic child may be used as an indicator for minor injury. Child Abuse

Because abused children may present with relatively minor injuries, when abuse is suspected, these injuries should be considered harbingers of major trauma with an etiologic spectrum of physical, psychological, and social factors. Child abuse is hard to recognize, because the very people trusted to care for the child are the perpetrators of the injury, which significantly compromises the well-being of the child. They may present with hernodynamic compromise owing to delay in seeking medical care for the injured child.I4There are characteristic patterns of injury associated with child abuse, including the well-recognized shaken baby syndrome.', 6, 39, 42, 47, 68, 74 However, it is important to recognize that injuries may be inflicted upon any body region, with no outward signs.30,42 Skeletal surveys, while useful in locating specific fractures, infrequently identify 48, 62 The cutaneous manifestations of child abuse include unsuspected bruises, lacerations, abrasions, burns, bites, and traumatic alopecia.= Any suspicion of physical child abuse should prompt an evaluation for severe injuries. The injuries sustained by an abused child are very similar in distribution to the other common mechanisms of trauma, and include a high incidence of head, extremity, and abdominal injuries. The spectrum of injuries associated with child abuse includes injuries to the the the the pharynx;' the especially rib fractures,3', 87 the abdomen?O the orofacial area:], 66 the genitourinary the perineum: the and the spine.I5 Head A treatise on the injuries are the leading cause of death in abused children.',60'89 diagnosis and management of child abuse is beyond the scope of this article and the reader is referred to the above references that cover this topic in more detail. Like all other injuries, primary prevention is the best strategy to protect the children of our communities from abuse. A high incidence of repeat offenses in the abused children and their siblings makes them specially amenable to prevention, by early identification, close monitoring, removal from dangerous homes, and legal and punitive actions against the perpetrators. Unfortunately, the longterm outcome of abused children cannot be measured by mortality rate or reinjury rate only. Issues pertaining to the child's emotional, behavioral, and intellectual development must also be addressed, but are very difficult to m e a s ~ r e . ~It~ is , ~imperative ' that physicians taking care of the injured children recognize child abuse as a severe mechanism of injury, and take extreme measures to treat these children, and to prevent subsequent injuries.64

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Dog Bites

I

Dog bites account for over 80% of 1 to 2 million animal bites treated each year in the United Statesz0The majority of the victims are children, and the injuries range from trivial to fatal.10,84*97 In a majority of instances, the dog belongs to neighborhood families and friends.*O,97 The risk factors associated with biting dogs include the predominant breed (German Shepherd, Chow Chow), male, unneutered, residing in a house with children, and chained in the yard. Pitbulls are the most commonly reported breed in fatal dog bites, followed by Rotweilers and German Shepherds.% The wounds related to dog bites may include contusions, lacerations, avulsions, punctures, crushed tissue, and fractures. Referrals to appropriate surgical specialists should be made in cases of facial wounds, wounds located elsewhere which require extensive reconstruction, those associated with fractures, or those with retained foreign bodies. Minor wounds on the trunk or extremities may be managed easily in the office. The issues related to management of these children include: wound care, use of antibiotics, and assessment of the risk of tetanus and rabies. The principles of wound care remain the same, i.e., hemostasis, removal of foreign bodies, debridement of nonviable tissue, copious irrigation, and closure or coverage as appropriate. Bite wounds are grossly contaminated wounds. The risk of infection can be minimized by the above measures, but the cosmetic benefit of closure must always be balanced against the risk of infection associated with primary closure. As with all contaminated wounds, time lapse between the injury and treatment is of crucial significance, with wound infection A meta-analysis of eight rates increasing after a delay of 6 to 8 randomized trials of prophylactic oral antibiotic therapy to prevent infections in patients with dog bites showed that the risk of wound infection was reduced by almost half (9.8% in treated versus 16% in untreated patients, p<.05).I6 The choice of antibiotic is much less clear, and includes penicillin, oxacillin, cloxacillin, dicloxacillin, erythromycin, trimethoprim/sulfamethoxazole, amoxicillin/ clavulanic acid, and cephalexin. Broad-spectrum antibiotics, such as cloxacillin, dicloxacillin, or cephalexin, are all reasonable choices, and dicloxacillin is generally preferred to cloxacillin or oxacillin because it produces highest serum concentrations and is by far the cheapest.1z,16The risk of tetanus remains the same as with other open wounds, and depends upon the characteristics of the wound and the immunization status of the child. Increased risk of tetanus is associated with a delay in wound care > 6 hours, depth > 1 cm, contamination, infection, compromised neurovascular status, and a stellate, avulsed, or crushed wound.%The recommendations for tetanus prophylaxis are summarized in Table lo.% Routine recommendations should be followed. The risk of rabies depends upon the geographic location of the event, the type and immunization status of the dog involved, and the extent of injury. Rabies develops in 5% to 60% of untreated humans bit by a rabid animal, and in 0.1% to 2% of those exposed to a rabid animal but not bitten." Treatment recommendations are given in Table 11. Minor Burns

Bums afflict approximately 2 million people in the United States each year. Most of the victims are children and young adults, and the vast majority are treated as outpatients in emergency departments or physician's 0ffices.3~Most common mechanisms of bums in children are scalding from hot water and flame burns. While scalds are more common among children under the age of 5 years,

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Table 10. TETANUS PROPHYLAXIS Nontetanus Prone Wound History of Adsorbed Tetanus Toxoid

Tetanus-Prone Wound

DTP/DT/Td* 0.5 m U M

TIG 250 U IM

DTP/DT/Td* 0.5 mUlM

TIG 250 U IM

Yes' No2

No No

Yes' 3

Yes No

No No

Yes' 5

Yes No

Age less than 7 years: Unknown or less than 3 doses Three or more doses Age more than 7 years: Unknown or less than 3 doses Three or more dosest

Yes' ~

0

4

~

~

0

0

DTP = diptheria-tetanus-pertussis vaccine, TIG = tetanus immune globulin, DT = diphtheriatetanus vaccine, Td = tetanus and diphtheria vaccine. 'Use DT if pertussis is contraindicated, and use Td for children over 7 years old. t l f three doses of fluid rather than adsorbed toxin are used, give a fourth dose, preferably adsorbed. 'Primary immunization series should be completed. 2Yes, if the routine immunization schedule has lapsed (i.e., to make up for missed doses). 3Yes, if the routine immunization schedule has lapsed, or if more than 5 years since last dose of tetanus toxoid. 'Yes, if more than 10 years since last dose. 5Yes, if more than 5 years since last dose. From Annals of Emergency Medicine

flame bums are the predominant cause of thermal injury in older children.28The criteria for referral to a specialized facility include hemodynamic instability, electric and chemical burns, severe burns (second and third degree burns involving > 10% body surface area, third degree bums involving > 5% body surface area, second and third degree bums involving the face, hands, feet, genitalia, perineum, or major joints), presence of associated injuries (inhalation injury, other blunt or penetrating injuries), presence of pre-existing medical conditions, and social issues (unsafe home environment, suspected abuse).z8The body surface area in children varies with the age, and hence the extent of burn injury should be estimated and documented by standardized charts.Z8The office management of minor bum wounds follows the broad principles of wound care, i.e., pain control, tetanus prophylaxis, debridement of nonviable tissue, removal of Table 11. RABIES TREATMENT RECOMMENDATIONS ~

~~

~~~

~~

Geographic Area Group 1: Rabies endemic or suspected (dogs in most developing countries and in the United States along Mexican border). Group 2: Rabies not endemic in dogs, but endemic in other terrestrial animals in the area.' Group 3: Rabies not endemic in dogs or in other terrestrial animals in the area.

~~

Recommendation Treat Obsetve or consult2 Consult or do not treatz

'A healthy domestic dog should be observed for 10 days. An illness should be reported immediately to the local health department. If the dog is stray or unwanted, it should be killed immediately and brain tissue examined for evidence of rabies. 2"Consult" denotes consultation with a state or local health department. Adapted from Fishbein DB, Robinson LE: Rabies. N Engl J Med 329:1632,1993; with permission.

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foreign bodies, thorough cleansing, and appropriate coverage. Burn wounds should be cleaned with a mild soap and copiously irrigated with warm saline or tap water. Blisters that are intact may be left alone as they provide a sterile biologic coverage, while blisters which are broken should be debrided to prevent bacterial g r o ~ t h . 3Topical ~ antibacterials are the major modality for preventing bum wound infections. The most commonly used agents are 0.5% to 1%silver sulfadiazine, 0.5% silver nitrate, mafenide acetate, bacitracin, and combination antibiotic ointments. Of these, the agent of choice is silver sulfadiazine?,28 Burn wounds should be covered with sterile nonadherent fine mesh gauze, followed by plain absorbent gauze and nonconstricting gauze roll. Bum wounds involving the face, neck, or perineum may be left open, after treatment with a clear antibiotic such as ba~itracin.3~ Initially, the dressing changes are done every 24 hours, which also provide an opportunity to examine the wound for signs of infection. Once the wound has epithelialized it is appropriate to leave the dressing on for 48 to 72 hours. With detailed instructions and close follow-up, home care by parents may be instituted, as appropriate. The ultimate goal is to return the child to his/her normal functional status, and may require physical and occupational therapy. Foreign Bodies

A wide variety of foreign bodies embedded in soft tissue are a frequent occurrence in children. Although not all foreign bodies need removal, the ones left behind may lead to inflammation, infections, and toxic or allergic reactions.45,46 The decision to remove a foreign body depends upon its nature, size, location, and anticipated problems assdciated with it, and must be weighed against the risks of damage to underlying tissue associated with exploration. The child may present acutely with a history of trauma and foreign body lodging in the tissues or with a chronic complaint of draining sinuses, recurrent abscesses, and granulomas. The diagnosis is based upon history and a good examination of the wound. Plain radiographs can detect radio-opaque objects, such as metal, bone, teeth, pencil graphite, some plastics, glass, and gravel, which constitute 80% to 90% of all foreign bodies.%An important exception is wood. The visualization of these objects on a plain radiograph also depends upon the orientation of the object to the radiographs, the size of the object (2 mm and over can be detected with 100% accuracy), and proximity to calcified bones (which may obscure the image of the foreign body).45, 46 Other imaging modalities, such as ultrasound, computed tomography, and magnetic resonance imaging, may be necessary to locate the foreign object. An accurate clinical history guiding a specific request to the radiologist regarding the foreign body in question will aid in the identification of radiopaque objects. Indications for the removal of a foreign body include reactivity and toxicity, gross contamination, impairment of neurovascular or mechanical functions, potential for migration, proximity to fractured bone or open joint, persistent pain, inflammation or infection, allergic reaction or cosmesis, and psychological distress.46Foreign bodies that are superficial and are not associated with a vital structure may be removed in the office using local anesthesia and a combination of sharp and blunt dissection. A superficial incision over the foreign body, followed by undermining of the edges of the wound will usually expose the foreign body in the middle of the wound for easy removal. Alternatively, en bloc removal of the foreign body along with the surrounding contaminated tissue may be required. If not easily apparent, or if located close to a vital structure, the child should

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be referred to the appropriate surgical service for removal using localization techniques, such as ultrasonography, fluoroscopy, or radiography in multiple projections. Caution should be used for foreign bodies of the sole of the foot. Because of the multiple tissue plains present, even the most obvious foreign body of the foot should be referred to a pediatric surgeon to avoid failed or incomplete removal. After removal, the wound should be copiously irrigated and is generally allowed to heal by secondary intention.

CONCLUSION

Injuries are a common source of childhood morbidity and mortality. Most common pediatric injuries include minor soft tissue injuries, minor head injuries, fractures, and open/superficial wounds. The initial evaluation should follow the ABCs of trauma to obtain an overview of the airway, hemodynamic and neurologic status of the child based upon the history, and physical findings. Several quantitative scales, based upon the anatomic definition of the injuries and the physiologic status of the child, can be used to grade injury severity. Minor injuries can be treated safely and cost effectively in an office setting. The principles of wound care include adequate hemostasis, removal of foreign bodies and nonviable tissues, and an appropriate closure or coverage of the wound to optimize healing. The skills required include the ability to use local/regional anesthesia, cleaning and irrigation, identification and removal of foreign bodies, sharp and blunt debridement of nonviable tissue, sufure closure of wound, and appropriate dressings for open wounds. Appropriate use of antibiotics, tetanus prophylaxis, and rabies immunization will minimize complications. With proper selection and treatment, the outcome of children with minor injuries should be excellent, with zero mortality and minimal long-term disability. A registry, based upon inexpensive and user-friendly database software, is essential for this purpose. Finally, primary prevention remains the single most important strategy to minimize childhood injuries.

References 1. Anonymous: American Academy of Pediatrics Committee on Child Abuse and Neglect: Shaken baby syndrome-inflicted cerebral trauma. Pediatrics 92872, 1993 2. Anonymous: Vital and health statistics: Current estimates from the national health interview survey, 1990. Hyattsville, Maryland, National Center for Health Statistics, Centers for Disease Control, Public Health Service, US Department of Health and Human Services, 1991 3. Baker SP: Advances and adventures in trauma prevention. J Trauma 42369, 1997 4. Barth JT, Macciocchi SN, Giordani B, et al: Neuropsychological sequelae of minor head injury. Neurosurg 13:529, 1983 5. Baxter CR, Waeckerle J F Emergency treatment of bum injury. Ann Emerg Med 171305,1988 6. Berkowitz C D Pediatric abuse: New patterns of injury. Emerg Med Clin North Am 13:321, 1995 7. Biros M H Minor head trauma, revisited. Acad Emerg Med 3:4, 1996 8. Black CT, Pokomy WJ, McGill CW, et al: Ano-rectal trauma in children. J Pediatric Surg 17501, 1982 9. Breaux CW, Jr, Smith G, Georgeson KE: The first two years’ experience with major trauma at a pediatric trauma center. J Trauma 30:37, 1990

MINOR PEDIATRIC INJURIES

849

10. Brogan TV, Bratton SL, Dowd MD, et a1 Severe dog bites in children. Pediatrics 96947, 1995 11. Bruns TB, Simon HK, McLario DJ, et a1 Laceration repair using a tissue adhesive in a children’s emergency department. Pediatrics 98:673, 1996 12. Callaham M Controversies in antibiotic choices for bite wounds. Ann Emerg Med 171321, 1988 13. Chisholm CD. Wound evaluation and cleansing. Emerg Med Clin North Am 10:665, 1992 14. Cooper A, Floyd T, Barlow B, et a1 Major abdominal trauma due to child abuse. J Trauma 281483, 1988 15. Cullen JC: Spinal lesions in battered babies. J Bone Joint Surg 57:364, 1975 16. Cummings F: Antibiotics to prevent infections in patients with dog bite wounds: A meta-analysis of randomized trials. Ann Emerg Med 23525, 1994 17. Dacey RG Jr, Alves WM, Rimel RW, et al: Neurosurgical complications after apparently minor head injury. J Neurosurg 65203, 1986 18. Dimick AR Delayed wound closure: Indications and techniques. Ann Emerg Med 17:1303, 1988 19. DiScala C: National Pediatric Trauma Registry Biannual Report, October 1996. Boston, National Pediatric Trauma Registry, 1996 20. Dos Santos LM, Abramo TJ, Schunk JE, et al: Dog bites. Pediatr Emerg Care 11:313,1995 21. Dowel1 HPM, Fielding DW Traumatic perforation of the hypopharynx: An unusual form of abuse. Arch Dis Child 59:88, 1984 22. Duncan CC, Ment LR, Smith B, et al: A scale for the assessment of neonatal neurologic status. Child Brain 8299, 1981 23. Edlich RF, Rodeheaver GT, Morgan RF, et a1 Principles of emergency wound management. Ann Emerg Med 171284, 1988 24. Eichelberger MR, Gotschall CS, Feely HB, et al: Parental attitudes and knowledge of child safety: A national survey. Am J Dis Child 144.714, 1990 25. Ellerstein NS: The cutaneous manifestations of child abuse and neglect. Am J Dis Child 133906, 1979 26. Ellerstein NS, Norris KJ: Value of radiologic skeletal survey in assessment of abused children. Pediatrics 741075, 1984 27. Ervin-Mulvey LD, Nelson LB, Freeley DA: Pediatric eye trauma. Pediatr Clin North Am 30:1167, 1983 28. Finkelstein JL, Schwartz SB, Madden MR, et a l Pediatric bums: An overview. Pediatr Clin North Am 39:1145, 1992 29. Fishbein DB, Robinson LE: Rabies. N Engl J Med 329:1632, 1993 30. Fossum RM, Descheneaux KA: Blunt trauma of the abdomen in children. J Forensic Sci 36:47, 1991 31. Garcia VF, Gotschall CS, Eichelberger MR, et a1 Rib fractures in children: A marker of severe trauma. J Trauma 30695, 1990 32. Ghajar J, Hariri RJ: Management of pediatric head injury. Fed Clin North Am 39:1093, 1992 33. Griglak MJ: Thermal injury. Emerg Med Clin North Am 10369, 1992 34. Groleau G: Tetanus. Emerg Med Clin North Am 10351, 1992 35. Gronwall D, Wrightson P: Delayed recovery of intellectual function after minor head injury. Lancet 2:605, 1974 36. Grossman DC,Neckerman HJ, Koepsell TD, et a1 Effectiveness of a violence prevention curriculum among children in elementary school A randomized controlled trial. J A M 277:1605, 1997 37. Guyer B, Ellers B: Childhood injuries in the United States: Mortality, morbidity and cost. Am J Dis Child 144649, 1990 38. Holinger PC: The causes, impact, and preventability of childhood injuries in the United States: Childhood suicide in the United States. Am J Dis Child 144:670, 1990 39. Hyden PW, Gallagher TA Child abuse intervention in the emergency room. Pediatr Clin North Am 391053, 1992 40. Jane JA, Rimel RW Prognosis in head injury. Clin Neurosurg 29:346, 1982

850

SHAH & GILBERT

41. Jessee S A Orofacial manifestations of child abuse and neglect. Am Fam Physician 52:1829, 1995 42. Johnson C F Inflicted injury versus accidental injury. Pediatr Clin North Am 37791, 1990 43. Knopp R, Yanagi A, Kallsen G, et a 1 Mechanism of injury and anatomic injury as criteria for prehospital trauma triage. Ann Emerg Med 17895, 1988

44. Kraus JF, Nourjah-P: The epidemiAogy of mild,-mcomplicated brain injury. J Trauma 283637, 1988 45. Lammers R L Soft tissue foreign bodies. Ann Emerg Med 171336, 1988 46. Lammers RL, Magill T Detection and management of foreign bodies in soft tissue. Emerg Med Clin North Am 10767, 1992 47. Lenoski EF, Hunter KA: Specific patterns of inflicted bum injuries. J Trauma 17:842, 1977 48. Leonidas JC: Skeletal trauma in the child abuse syndrome. Pediatr Ann 122475, 1983 49. Linn S The injury severity score: Importance and uses. Ann Epidemiol 5 4 0 , 1995 50. Lowe DK, Oh GR, Neely KW, et al: Evaluation of injury mechanism as a criteria in trauma triage. Am J Surg 152:6, 1986 51. Luerssen TG, Klauber MR, Marchall L F Outcome from head injury related to patient’s

age: A longitudinal prospective study of adult and pediatric head injury. J Neurosurg 68:409, 1988 52. MacKenzie EJ, Morns JA, Smith G S Acute hospital costs of trauma in the United States: Implications for regionalized systems of care. J Trauma 30:1096, 1990 53. Macknin ML, Medendorp SV: Association between bicycle helmet legislation, bicycle safety education, and use of bicycle helmets in children. Arch Pediatri Adolesc Med 148:255, 1994 54. Manning SC, Casselbrandt M, Lammers D. Otolaryngologic manifestations of child abuse. Int J Pediatr Otorhinolaryngol20:7, 1990 55. Markovchick V: Suture materials and mechanical after care. Emerg Med Clin North Am 10673, 1992 56. McAleer IM,Kaplan G W Pediatric genitourinarfr trauma. Urol Clin North Am 22:177, 1995 57. McCarty DL, Surpure J S Pediatric trauma: Initial evaluation and stabilization. Ped Ann 19:584, 1990 58. McLoughlin E, McGuire A: The causes, cost, and prevention of childhood bum injuries. Am J Dis Child 1M677, 1990 59. Meller JL, Little AG, Shermeta DW Thoracic trauma in children. Pediatrics 74:813,1984 60. Merten DF, Osbome DRS Craniocerebral trauma in the child abuse syndrome. Pediatr Ann 12882, 1983 61. Merten DF, Osbome DRS, Radkowski MA, et al: Craniocerebral trauma in the child abuse syndrome: Radiological observations. Pediatr Radio1 14:272, 1984 62. Merten DF, Radkowski MA, Leonidas JC: The abused child: A radiological reappraisal. Radiology 146377, 1983 63. Miller EC, Derlet RW, Kinser D: Minimal head trauma: Is computed tomography always necessary? Ann Emerg Med 27290, 1996 64. Morse T S Child abuse, a neglected form of trauma. J Trauma 15:620, 1975 65. National Committee for Injury Prevention and Control Injury prevention: Meeting the challenge. New York, Oxford University Press, 1989 66. Needleman HL: Orofacial trauma in child abuse: Types, prevalence, management, and the dental profession’s involvement. Pediatr Dent 8:71, 1986 67. Norris RLJ: Local anesthetics. Emerg Med Clin North Am 10:707, 1992 68. ONeill JA, Jr, Meacham WF, Griffin PP, et al: Patterns of injury in the battered child svndrome. T Trauma 13:332. 1973 69. iolhgeers A, Ruddy RM: update on pediatric trauma. Emerg Med Clin North Am 13:267, 1995

70. Quinn J, Wells G, Sutcliffe T, et al: A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 277:1527, 1997 71. Raimondi AJ, Hirschauer J: Head injury in the infant and toddler: Coma scoring and outcome scale. Child Brain 11:12, 1984

MINOR PEDIATRIC INJURIES

851

72. Ramenofsky ML, Ramenofsky MB, Jurkovich GJ, et al: The predictive value of pediatric trauma score. J Trauma 28:1038, 1988 73. Rauchschwalbe R, Mann C: Pediatric window-cord strangulations in the United States, 1981-1995. JAMA 2771696, 1997 74. Reese RM, Grodin MA. Recognition of nonaccidental injury. Pediatr Clin North Am 3241, 1985 75. Riffenburgh RS, Sathyavagiswaran L: Ocular findings at autopsy on child abuse victims. Ophthalmology 98:1519, 1991 76. Rime1 RW, Giordani B, Barth JT, et a1 Disability caused by minor head injury. Neurosurg 9:221, 1981 77. Rivara FP: Child pedestrian injuries in the United States: Current status of the problem, potential interventions, and future research needs. Am J Dis Child 144:692, 1990 78. Rivara FP: Epidemiology of violent deaths in children and adolescents in the United States. Pediatrician 123, 1983-1985 79. Rodriguez JG: Childhood injuries in the United States. Am J Dis Child 144:627, 1990 80. Rosenberg ML, Powell KE, Hammond R Applying science to violence prevention. JAMA 2771641, 1997 81. Rosenbloom L, Hensey OJ: Outcome for children subject to non-accidental injury. Arch Dis Child 60191, 1985 82. Rouse TM, Eichelberger MR: Trends in pediatric trauma management. Surg Clin North Am 721347,1992 83. Rutledge R The goals, development, and use of trauma registries and trauma data sources in decision making in injury. Surg Clin North Am 75:305, 1995 84. Sacks JJ, Lockwood R, Homeicht J, et al: Fatal dog attacks, 1989-1994. Pediatrics 97891, 1996 85. Sainsbury CPQ, Sibert J R How long do we need to observe head injuries in hospital? Arch Dis Child 59:856, 1984 86. Sapien RE, Olson LM, Home-Lucero LC, et al: Retrospective vs. concurrent review on the quality of care of pediatric trauma patients.’Ped Emerg Care 11:162, 1995 87. Schweich P, Fleisher G: Rib fractures in children. Pediatr Emerg Care 1:187, 1985 88. Selbst SM, Baker D, Shames M Bunk bed injuries. Am J Dis Child 144:721, 1990 89. Showers J, Apolo J, Thomas J, et a1 Fatal child abuse: A two-decade review. Pediatr Emerg Care 1:66, 1985 90. Sivit CJ, Taylor GA, Eichelberger MR Visceral injury in battered children: A changing perspective. Radiology 173:659, 1989 91. Snoek JW, Minderhoud JM, Wilmink JT Delayed deterioration following mild head injury in children. Brain 107:15, 1984 92. Spence LJ, Dykes EH, Bohn DJ, et a1 Fatal bicycle accidents in children: A plea for prevention. J Pediatr Surg 28:214, 1993 93. Stylianos S, Eichelberger MR Pediatric trauma: Preventive strategies. Ped Clin North Am 401359, 1993 94. Teasdale G, Jennet B: Assessment of coma and impaired consciousness: A practical scale. Lancet 281, 1974 95. Tepas JJ, 111, DiScala C, Ramenofsky ML, et al: Mortality and head injury: The pediatric perspective. J Pediatr Surg 25:92, 1990 96. Tepas JJ, 111, Mollitt DL, Talbert JL, et a1 The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg 22:14, 1987 97. Tuggle DW, Taylor DV, Stevens RJ: Dog bites in children. J Pediatr Surg 28:912, 1993 98. Wintemute GJ: Childhood drowning and near-drowning in the United States. Am J Dis Child 144663, 1990 I

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