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ABSTRACT: Children and adolescents with injuries resulting in facial fractures are a population that is potentially at risk for suffering concomitant concussion. Concussion results in a variety of physical symptoms and often affects cognition, emotion, and sleep. These effects can have a significant impact on academics and social functioning. Early recognition of concussion and active management have been shown to improve outcomes. The goal of this study was to describe the occurrence of concussion in patients sustaining facial fractures and to determine whether certain fracture types are associated with concussion.
We performed a retrospective review of patients aged 0 to 18 years who were evaluated in the emergency department of the Children's Hospital of Pittsburgh from 2000 to 2005 with an International Classification of Diseases, Ninth Revision code indicative of facial fractures. Data included demographics, documentation of concussion, and facial fracture type. Patients with intracranial injury were excluded from the study. Univariate χ analysis and logistic regression were performed to determine characteristics associated with concussion.
Facial fracture was diagnosed in 782 patients. Ninety-one patients had an intracranial injury and were excluded, leaving 691 patients for evaluation. The mean age was 11.1 (SD, 4.6) years. Males made up 69.6% of patients, and 80.6% of patients were white. Concussion was diagnosed in 31.7% of patients. Age, sex, and race were not associated with concussion. Univariate analysis demonstrated that skull and orbital fractures were associated with higher rates of concussion, whereas maxillary fractures showed a trend toward higher rates of concussion, and nasal and mandible fractures showed a trend toward lower rates of concussion. Logistic regression analysis demonstrated the odds of having a concussion were higher in those with skull fractures (odds ratio, 2.3; confidence interval, 1.5-3.7).
Nearly one third of pediatric patients with facial fractures in this retrospective series were diagnosed with a concomitant concussion. Our data suggest that a higher index of suspicion for concussion should be maintained for patients with concomitant skull fractures and potentially orbital and maxillary fractures. Given the possibility of a worse outcome with delayed concussion diagnosis, patients with facial fractures may benefit from more active early concussion screening.
The Journal of craniofacial surgery 09/2012; 23(5):1270-3. · 0.81 Impact Factor
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Lorelei Grunwaldt,
Darren M Smith, Noel S Zuckerbraun,
Sanjay Naran,
S Alex Rottgers,
Michael Bykowski,
Christopher Kinsella,
James Cray,
Lisa Vecchione,
Richard A Saladino,
Joseph E Losee
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ABSTRACT: Pediatric craniofacial fractures are anatomically distinct from their adult counterparts and must be managed with respect for future growth and development. These injuries must be approached as entities fundamentally different from adult craniofacial fractures. Here, the authors aim to provide context for practitioners managing pediatric facial fractures by augmenting presently available demographic, diagnostic, and treatment data.
This is a retrospective review of demographics, diagnosis, and treatment of patients under 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with facial fractures. Patients were included regardless of treating specialty, treatment modality, or inpatient status.
A total of 772 consecutive patients met inclusion criteria. A significant majority (p < 0.001) of patients (68.9 percent) were male; older children were significantly more likely to sustain a facial fracture (p < 0.001). Fracture pattern, level of care, and cause of injury varied by age; 55.6 percent of patients had severe associated injuries. Male subjects, older patients, and patients of lower socioeconomic status were significantly more likely to sustain facial fractures secondary to violence (p ≤ 0.001).
Pediatric facial fractures may be associated with severe concomitant injuries. Injury patterns are significantly correlated with socioeconomic metrics.
Plastic and reconstructive surgery 08/2011; 128(6):1263-71. · 2.74 Impact Factor
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ABSTRACT: This study examines the epidemiologic data of pediatric craniofacial fractures secondary to violence, comparing these data to craniofacial fractures sustained from all other causes.
A retrospective review was completed on all patients who presented to the emergency department of a major urban children's hospital from 2000 to 2005 with a craniofacial fracture. Data were compared between patients with fractures due to violent and nonviolent mechanisms. Socioeconomic analysis was performed using Geographic Information System mapping and 2000 US Census data by postal code.
One thousand five hundred twenty-eight patients were diagnosed with skull and/or facial fractures. Isolated skull fractures were excluded, leaving 793 patients in the study. Ninety-eight children were injured due to violence, and 695 were injured from a nonviolent cause. Patients with violence-related fractures were more likely to be older, male, and nonwhite and live in a socioeconomically depressed area. A greater number of patients with violence-related injuries sustained nasal and mandible angle fractures, whereas more patients with non-violence-related injuries sustained skull and orbital fractures. Those with violence-related craniofacial fractures had a lower percentage of associated multiorgan system injuries and a lower rate of hospital admissions and intensive care unit admissions. The rate of open reduction and internal fixation for craniofacial fractures was similar in both groups.
Patients with violence-related fractures had fewer associated serious injuries and lower morbidity and lived in a more socioeconomically depressed area. The information gained from this descriptive study improves our ability to characterize this population of pediatric patients and to identify the associated constellation of injuries in such fractures.
The Journal of craniofacial surgery 07/2011; 22(4):1342-7. · 0.81 Impact Factor
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ABSTRACT: This study of concussed adolescents sought to determine if a computer-based neurocognitive assessment (Immediate Postconcussion Assessment and Cognitive Test [ImPACT]) performed on patients who present to the emergency department (ED) immediately following head injury would correlate with assessments performed 3 to 10 days postinjury and if ED neurocognitive testing would detect differences in concussion severity that clinical grading scales could not.
A prospective cohort sample of patients 11 to 17 years of age presenting to the ED within 12 hours of a head injury were evaluated using two traditional concussion grading scales and neurocognitive testing. ED neurocognitive scores were compared to follow-up scores obtained at least 3 days postinjury. Postconcussive symptoms, outcomes, and complications were assessed via telephone follow-up for all subjects.
Sixty patients completed phone follow-up. Thirty-six patients (60%) completed follow-up testing a median of 6 days postinjury. Traditional concussion grading did not correlate with neurocognitive deficits detected in the ED or at follow-up. For the neurocognitive domains of verbal memory, processing speed, and reaction time, there was a significant correlation between ED and follow-up scores trending toward clinical improvement. By 2 weeks postinjury, 23 patients (41%) had not returned to normal activity. At 6 weeks, six patients (10%) still had not returned to normal activity.
Immediate assessment in the ED can predict neurocognitive deficits seen in follow-up and may be potentially useful to individualize management or test therapeutic interventions. Neurocognitive assessment in the ED detected deficits that clinical grading could not and correlated with deficits at follow-up.
Academic Emergency Medicine 03/2011; 18(3):246-54. · 1.86 Impact Factor
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ABSTRACT: To describe injuries due to golf-related activities among pediatric patients requiring hospital admission.
We conducted a retrospective analysis of all sports-related injuries from 2000 to 2006 using a level 1 trauma center database.
Of 1005 children admitted with sports-related injuries, 60 (6%) had golf-related injuries. The mean injury severity score was significantly higher for golf-related injuries (11.0) than that for all other sports-related injuries (6.8). Most golf-related injuries occurred in children younger than 12 years (80%), at home (48%), and by a strike from a club (57%) and resulted in trauma to the head or neck (68%).
Golf-related injuries, although an infrequent cause of sports-related injuries, have the potential to result in severe injuries, especially in younger children. Preventive efforts should target use of golf clubs by younger children in the home setting.
Pediatric emergency care 01/2011; 27(1):11-2. · 0.92 Impact Factor
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ABSTRACT: To measure adolescents' perceived overall satisfaction with health care in a pediatric emergency department (PED), identify key factors that contributed to satisfaction, and determine how these factors interacted with length of stay (LOS) and triage acuity.
Prospective observational design with a convenience sample of 100 adolescents 13 to 21 years old recruited from the PED between February and June 2007. Participants completed a self-administered 27-item written survey with closed and open-ended items.
Survey response rate was 99%. Respondents completed the survey in a mean time of 6.6 minutes (range, 3-12 minutes; SD, 2.0 minutes). Most (95%) reported being satisfied with their overall PED experience, and 91% would recommend the PED to other adolescents. Interpersonal communication and respect correlated significantly with respondents' overall satisfaction. There were no statistically significant differences in overall satisfaction rates by sex, age, socioeconomic status, or ethnicity, or by LOS, triage acuity score, or hospital admission. Most (94%) answered a qualitative survey item that asked how their PED care could be improved with 4 distinct responses: no changes necessary, enhance interpersonal communication, improve comfort of stay, and shorten LOS.
Adolescents expressed high levels of satisfaction with their overall PED experience at our institution. Interpersonal communication and respect highly correlated with overall satisfaction. A multicenter study using a similar self-administered survey would further support the relationship between key factors and PED adolescent satisfaction. Utilization of a self-administered survey for adolescent research is feasible in the PED and could be used to improve quality control measures for adolescent care.
Pediatric emergency care 04/2010; 26(4):257-73. · 0.92 Impact Factor
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ABSTRACT: Digital anesthesia in the pediatric population has traditionally been accomplished using a ring block that requires multiple injections. A modified transthecal digital nerve block is a single-injection technique of the midproximal phalanx that has been shown to be technically simple and highly effective in adults.
To describe the success rate of the modified transthecal digital nerve block in children.
: A convenience sample of children requiring digital anesthesia for minor surgical procedures on the fingers or thumb at an urban tertiary-care pediatric emergency department were prospectively enrolled into the study. A transthecal digital nerve block was performed by injecting a 1:1 mixture of 1% lidocaine and 0.5% bupivicaine into the flexor tendon sheath at the midpoint between the proximal digital and the proximal interphalangeal joint creases. The volume of anesthetic was based on age. All nerve blocks were performed by 3 investigators trained in the procedure. Successful digital anesthesia was defined as complete loss of pinprick sensation on both the dorsal and palmar aspects of the digit and the ability to complete the anticipated minor surgical procedure without pain. Primary outcome measures were anesthesia success rate and pain score. Age-appropriate pain scale scores (Face, Legs, Activity, Cry, Consolability Scale, 0-3 years; Faces Scale, 4-7 years; and visual analog scale, > or =8 years) were recorded 5 minutes after injection. All patients were followed up for 6 months to assess for adverse events.
Between November 2003 and March 2004, 48 patients (50 digits) requiring digital anesthesia were enrolled into the study. The mean age of patients was 8.3 years (median, 7.6 years; range, 0.7-17.5 years). Twenty-four (50%) were boys and 30 whites (62.5%). Overall, the transthecal digital nerve block technique was successful in 47 (94%) of the 50 digits (95% confidence interval [CI], 83%-98%), including 37 (97%) of 38 fingers (95% CI, 85%-99%) and 10 (83%) of 12 thumbs (95% CI, 54%-96%). Forty-seven (94%) of the 50 digits had a recorded pain score of 0 five minutes after injection. Mean (SD) procedure time was 113 (24.8) seconds, and mean (SD) anesthetic volume was 2.13 (0.61) mL. No adverse events were reported.
The single-injection modified transthecal digital nerve block is a safe and effective method for digital anesthesia in children. These data confirm the applicability of transthecal digital nerve block for children with finger and thumb injuries that require minor surgical procedures.
Pediatric emergency care 02/2010; 26(3):177-80. · 0.92 Impact Factor
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ABSTRACT: Current theories suggest that all children in a home are at risk for physical abuse, when one child is abused. However, little evidence exists to guide decisions regarding the medical management of siblings of physically abused children (contact children [CC]). This study sought to compare child protective services (CPS) caseworkers' and child abuse physicians' (CAP) recommendations regarding the need for medical evaluation of CC in case scenarios of unequivocal physical abuse. In all cases, caseworkers and physicians disagreed on which CC warranted a medical evaluation. In addition, 25% of caseworkers did not think that physicians should make recommendations on the need for medical evaluation of CC. The findings of the authors suggest that the home visit is a critical part of the decision-making process for caseworkers and that it often acts as a substitute for a medical evaluation. Caseworkers indicated that visible injury to the contact child and severity of injury to the index child were among the most important factors in deciding which CC need a medical evaluation. Although caseworkers and physicians disagree on certain issues related to the evaluation of CC, it is clear that limited resources should be directed at CC at highest risk for physical abuse.
Child Maltreatment 02/2010; 15(2):144-51. · 2.77 Impact Factor
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Plastic & Reconstructive Surgery 09/2009; 124(4S):6-7. · 3.38 Impact Factor
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ABSTRACT: Mycoplasma pneumoniae is a common cause of community-acquired respiratory illness in the adolescent population. Stevens-Johnson syndrome is an extrapulmonary manifestation that has been associated with M. pneumoniae infections. Three adolescent males presented within a 1-month period with M. pneumoniae respiratory illnesses and severe mucositis but without the classic rash typical of Stevens-Johnson. Diagnosis was facilitated by the use of a polymerase chain reaction-based assay. This case series highlights the potential for M. pneumoniae-associated Stevens-Johnson syndrome to occur without rash and supports the use of polymerase chain reaction for early diagnosis.
PEDIATRICS 05/2007; 119(4):e1002-5. · 4.47 Impact Factor
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ABSTRACT: Although etomidate is widely used for rapid sequence intubation (RSI), there is no consensus on the optimal induction agent and no prospective pediatric emergency department (ED) study exists. The objective of this study was to assess the effectiveness and safety of etomidate as an induction agent for RSI in the pediatric ED.
Data on RSI conditions and complications were collected prospectively on patients undergoing RSI in a tertiary pediatric ED from January 2003 to December 2003. ED hemodynamic data and inpatient data were collected retrospectively via chart review.
Seventy-seven of 101 patients requiring intubation underwent RSI with etomidate. The mean (+/- SD) age was 8.2 (+/- 6.2) years. All 77 patients were successfully intubated. Intubation condition data were available for 69 of 77 patients (89.6%). Conditions were good in 68 of 69 (99%; 95% confidence interval = 92.2% to 99.9%). The mean (+/- SD) maximal percent decrease in systolic blood pressure was 10% (+/- 13.6%). A greater than 20% maximal percent decrease in systolic blood pressure occurred in 12 of 69 patients (17.4%; 95% confidence interval = 9.3% to 28.4%). There was no relationship between seizures after etomidate administration and prior seizure history (p = 0.25). Corticosteroids were given to 29 of 77 patients post-RSI for varying diagnoses. All eight patients given corticosteroids for shock were in shock at the time of intubation.
In the pediatric ED setting, etomidate as an induction agent provided successful RSI conditions and resulted in varied hemodynamic changes that were especially favorable in those patients presenting in decompensated shock. Hypotension and seizures were uncommon and occurred in patients with confounding diagnoses. Until the significance of a single dose of etomidate on adrenal dysfunction is further clarified, caution should be used in those patients at risk for adrenal insufficiency.
Academic Emergency Medicine 07/2006; 13(6):602-9. · 1.86 Impact Factor
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ABSTRACT: Patients with severe spasticity are frequently encountered in the pediatric emergency department. Intrathecal baclofen therapy is being used increasingly to treat these patients. The purpose of this case series is to illustrate the importance of early recognition and treatment of intrathecal baclofen withdrawal, a potentially life-threatening complication of intrathecal baclofen therapy. Four cases of intrathecal baclofen withdrawal are presented.
Pediatric emergency care 12/2004; 20(11):759-64. · 0.92 Impact Factor
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ABSTRACT: To describe the use of an emergency department (ED)-based injury surveillance model to determine the incidence and mechanisms of nonfatal injuries among children living in Cabrini Green, a poor urban community.
Using ED records and census data, population-based injury rates were determined for a retrospective cohort of children, 0 to 14 years old, (N = 3908) with nonfatal injuries resulting in ED treatment between January 1994 and December 1998.
There were 1950 nonfatal injuries during the 5-year study period (annual injury incidence of 998/10,000). Age-specific rates (per 10,000 per year) were 899 among 0- to 4-year olds, 616 among 5- to 9-year olds, and 435 among 10- to 14-year olds. Sixty-three percent were male. The most common injury mechanisms were falls (339/10,000 per year), being struck by/against an object (201/10,000 per year), and being cut/pierced by an object (87/10,000 per year). Falls from a building window (2/10,000 per year) were infrequent. The incidence of housefire-related burns was 1.5/10,000 per year. Intentional injuries included alleged child abuse, 43/10,000 per year, and assaults, 30/10,000 per year. The assault rate among 10- to 14-year-old males was 100/10,000 per year. One hundred thirty-four children were admitted to the hospital (average annual rate of 69/10,000). The most frequent admission diagnoses were falls (22/10,000) among 0- to 9-year olds and assaults (13/10,000) among 10- to 14-year olds.
An ED-based injury surveillance system can provide an efficient and useful way to determine injury incidence in a defined urban community. The data suggest that rates of violence-related injuries were high, while rates of window falls and housefires were low. These data have allowed targeted injury prevention efforts in Cabrini Green, and future surveillance will allow the evaluation of injury prevention activities.
Pediatric emergency care 07/2004; 20(6):361-6. · 0.92 Impact Factor
