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Background Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers. Material and methods A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed. Results A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed. Conclusion In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0–10 day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index – Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.

Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery. To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20–40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion. Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p

Computed tomography scans of the abdomen/pelvis (CTAP) in the adult population may reveal findings unrelated to the injury, such as a mass; the occurrence of incidental findings in pediatric patients remains unknown. This study aims to determine the percentage of pediatric trauma patients with incidental findings. Data regarding consecutive 250 patients who underwent CTAP during their evaluation were retrieved from our level 1 pediatric trauma center trauma registry. Interpretations were reviewed for mention of incidental findings. Records for patients with incidental findings were examined to determine what further evaluation occurred. Nine patients were excluded due to incomplete records. Of the remaining 241 patients, 114 incidental findings were identified among 86 (35.7%) patients. There were 47 clinically significant incidental findings, occurring in 41 (17%) patients. Seven patients (8.1%) had further workup of their findings; Three (3.5%) went on to have an operation (two patients with ureteropelvic junction obstruction and one with high-riding testicle). No potential tumors were found in this population. Incidental findings were mentioned in 25.5% of discharge summaries. Pediatric trauma CTAP reveals incidental findings at a lower rate than in their adult counterparts. Documentation of findings should be improved for optimal care of the injured child.

Trauma systems improve survival by directing severely injured patients to trauma centers. This study analyzes the impact of trauma systems on pediatric triage and injury mortality rates. Population-based data were collected on injured children less than 15 years who were admitted to any hospital in New England from 1996 to 2006. Data from three trauma system states were compared to three non-trauma system states. The percentages of injured children, severely injured children, and brain-injured children admitted to trauma centers were determined as well as injury hospitalization and death rates. Time trend analysis examined the pace of change between the groups. A total of 58,583 injured children were hospitalized during the study period. Injury hospitalization rates were initially similar between the two groups (with and without trauma systems) and decreased over time in both. Rates decreased more rapidly in trauma system states compared to those without, (P = 0.003). Injury death rates decreased over time in both groups with no difference between the groups, (P = 0.20). A higher percentage of injured children were admitted to trauma centers in non-trauma system states throughout the study period, and this percentage increased in both groups of states. A higher percentage of severely injured children and brain-injured children were admitted to trauma centers in non-trauma system states and both percentages increased over time. The increase was more rapid in trauma system states for children with severe injuries (P

Enteric duplication cysts are rare congenital anomalies of unclear etiology. While they can occur anywhere in the gastrointestinal tract, they typically occur in the ileum or ileocecal region and very rarely in the duodenum. Here, we report a case of a periampullary duodenal duplication cyst in a 13-year-old male who presented with clinical and laboratory evidence of small bowel obstruction, hepatitis, and pancreatitis. Based on radiologic imaging, the patient was thought to have a type III choledochal cyst (choledochocele) within the duodenal lumen. Intraoperative findings and postoperative pathological evaluation, however, revealed that the lesion was a duodenal duplication cyst masquerading as a choledochal cyst. Interestingly, the duplication cyst was communicating with the common bile duct, simultaneously causing biliary and small bowel obstruction.

The American Pediatric Surgical Association Trauma Committee proposed the use of a clinical practice guideline (CPG) for the non-operative management of isolated splenic injuries in 1998. An analysis was conducted to determine the financial impact of CPGs on the management of these injuries. The Pediatric Health Information System database, which contains data from 44 children's hospitals, was used to identify children who sustained a graded isolated splenic injury between June 2005 and June 2010. Demographics, length of stay (LOS), readmission rates, and laboratory, imaging, procedural, and total cost data were determined for all hospitals verified as a pediatric trauma center by the American College of Surgeons and/or designated by their local authority. Comparisons were made between facilities self-identifying as having a splenic injury management CPG and those without a CPG. Children (1,154) with isolated splenic injuries (grades 1–4) were cared for in 26 pediatric trauma centers: 20 with a CPG and 6 without (non-CPG). Median costs were significantly lower at CPG than non-CPG centers for imaging (US $163 vs. US $641, P

Eleven patients with Yersinia enterocolitica infections were identified in the Upper Valley of New Hampshire and Vermont during October and November of 1995. Three children presented with an appendicitis-like picture. Two underwent appendectomy, one of whom was the outbreak's index case. Both appendectomy patients presented with lower abdominal pain, fever, vomiting, and a right lower quadrant mass associated with leukocytosis. Both had terminal ileitis, and in both, cultures of peritoneal fluid and a mesenteric lymph node grew Y. enterocolitica. Even during an outbreak there is no consistently reliable nonoperative way to separate a sporadic case of appendicitis from one whose appendicitis-like symptoms are due to Yersinia. In addition, a small percentage of Yersinia patients will present with true appendicitis as a complication of their disease.

The radiologic evaluation of neonatal chest masses may be carried out with a number of different imaging modalities, each with distinct advantages and disadvantages. While it is necessary clinically to rapidly and accurately diagnose these lesions, this may be difficult when the neonate is critically ill. We report the use of spiral (helical) CT (SCT) scanning with reconstructed images to diagnose chest masses in two critically ill neonates undergoing oscillating ventilation. We describe the technique used to image the masses and compare this technique with other available imaging modalities.