The spectrum of liver and spleen injuries in children: failure of the pediatric trauma score and clinical signs to predict isolated injuries

High serum interleukin-6 concentration upon admission is predictive of disease severity in paediatric trauma patients

BACKGROUND

Trauma is the leading cause of death among children worldwide. The inflammatory response of paediatric patients to multiple injuries can be monitored using serum interleukin-6 (IL-6) levels. This study aimed to assess the value of IL-6 levels in predicting the severity of paediatric trauma and its clinical association with disease activity.

METHOD

We prospectively tested serum IL-6 levels and evaluated the Paediatric Trauma Score (PTS) and other clinical data among 106 paediatrics trauma patients from January 2022 to May 2023 at the Emergency Department of the Xi'an Children's Hospital in China. The relationship between IL-6 and trauma severity levels by PTS was analyzed statistically.

RESULTS

IL-6 levels were elevated in 76 (71.70%) of the 106 paediatric patients with trauma. Spearman's test showed a significant negative linear correlation between IL-6 and PTS (rs = - 0.757, p < 0.001). IL-6 levels were moderate positively correlated with alanine aminotransferase, aspartate aminotransferase, white blood cells, blood lactic acid and interleukin 10 (rs = 0.513, 0.600, 0.503, 0.417, 0.558, p < 0.01). IL-6 levels were positively correlated with hypersensitive C-reactive protein and glucose (rs = 0.377, rs = 0.389, respectively, p < 0.001). IL-6 levels were negatively correlated with fibrinogen and PH (rs = - 0.434, p < 0.001; rs = - 0.382, respectively, p < 0.001). Binary scatter plots further demonstrated higher levels of IL-6 correlated with lower PTS scores.

CONCLUSION

Serum IL-6 levels significantly increased with increasing severity of paediatric trauma. Serum levels of IL-6 can function as important indicators for predicting disease severity and activity in paediatric trauma patients.

Field triage of children with abdominal trauma

Objective

Identify physical findings in children with abdominal trauma to inform prehospital providers regarding appropriate hospital destinations.

Methods

This is a secondary analysis of the Pediatric Emergency Care Applied Research Network Abdominal Trauma Public Use Dataset. Children involved in motor vehicle collisions; struck by motor vehicles at >20 mph; involved in all-terrain vehicle, motorcycle, or scooter accidents; or who fell from >10 ft ( n = 5575) were included. Stepwise multivariable multinomial logistic regression was used to compare clinical findings at presentation between children with no intra-abdominal injury, intra-abdominal injury without intervention, and intra-abdominal injury with intervention (laparoscopy/laparotomy, embolization, red blood cell transfusion, or admission >48 h on intravenous fluids).

Results

Compared to children with no intra-abdominal injury, children with intra-abdominal injury (with and without intervention) were more likely to have evidence of abdominal wall trauma, abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and evidence of thoracic trauma. Children with intra-abdominal injury requiring intervention were more likely to have evidence of abdominal wall trauma (OR 3.32, 95% CI 2.03–5.44) and be intubated (OR 4.93, 95% CI 3.17–7.65) when compared to children with intra-abdominal injury without intervention.

Conclusions

The findings of abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and thoracic trauma may be used to identify children who warrant evaluation at any trauma center because of increased risk of intra-abdominal injury, whereas intubation and evidence of abdominal wall trauma help identify children with intra-abdominal injury in need of transport to a pediatric trauma center due to risk of undergoing intervention.

Elevated white blood cell count, decreased hematocrit and presence of macrohematuria correlate with abdominal organ injury in pediatric blunt trauma patients: a retrospective study

Introduction

Computerized tomography (CT) has become an important diagnostic modality in trauma patients. Pediatric patients are particularly susceptible to ionized radiation making liberal CT use in this age group unacceptable. We aimed to identify parameters that might predict abnormal findings on abdominal CT leading to patient management changes.

Methods

Data on blunt trauma patients up to 15 years of age admitted to Assaf Harofeh Medical Center from January 2007 to October 2014 was retrospectively collected. All patients with abdominal CT scan as part of initial assessment were included. Medical and surgical data were extracted from the medial charts. Patients were divided into two groups. Group I: patients whose management was changed solely based on abdominal CT findings and Group II: patients with normal abdominal CT. The groups were compared by all the data parameters.

Results

Overall, 182 patients were included in the study. The groups were comparable by age and mechanism of injury. Management changes based on CT findings were found in 68 (37.4 %) patients. White blood cell count >14000, abnormally low hematocrit level and macrohematuria were associated with a diagnosis of intra-abdominal injury requiring patient management changes (p < 0.05). Group I patients had longer LOS. Fifteen patients (22 %) required active intervention based solely on CT findings. Physical examination, arterial blood gases and initial radiology examinations results did not correlate with abdominal CT findings.

Conclusions

Elevated WBC, decreased hematocrit and presence of macrohematuria strongly correlate with abdominal CT findings and lead to changes in patient management.

Nuances in pediatric trauma

Pediatric trauma evaluation mimics adult stabilization in that it is best accomplished with a focused and systematic approach. Attention to developmental differences, anatomic and physiologic nuances, and patterns of injury equip emergency physicians to stabilize and manage pediatric injury.

Investigating moderate to severe paediatric trauma in the Auckland region

OBJECTIVE

To investigate differences between paediatric patients with moderate to severe trauma admitted from two paediatric ED, with respect to: demographics, patterns of presentation, mechanism of injury, injury severity scores (ISS), interventions and outcome.

METHOD

Retrospective cohort study. Moderate to severe trauma was defined as ISS>9. Paediatric patients admitted to hospital via Starship Children's Emergency or KidzFirst ED, with trauma from 1 May 2003 to 30 April 2004, with ISS>9 were identified using multiple databases. The charts were reviewed and data collected included: demographics, hospital of first presentation, diagnoses, ISS, Paediatric trauma score (PTS), Glasgow coma score (GCS), ventilator hours, length of admission, survival and discharge destination. Descriptive statistics with 95% confidence intervals, Mann-Whitney U-test, chi2-test and Fisher's exact test were used as appropriate.

RESULTS

A total of 393 children with moderate to severe trauma were identified using initial search strategies. Of these, 82 children met the inclusion and exclusion criteria for the study; 42 children were admitted via KidzFirst ED and 40 via Starship Children's ED. There was no statistically significant difference in ISS (P=0.86), PTS (P=0.11), GCS (P=0.62), hours on a ventilator (P=0.28) and length of stay (P=0.87) between children admitted from Starship or KidzFirst ED.

CONCLUSION

This study suggests that there are no differences in the numbers or severity of paediatric trauma patients admitted from the Starship and KidzFirst ED. This indicates triage is to the closest ED despite having a tertiary referral centre for paediatric trauma available in Auckland City.

Pediatric major trauma: an approach to evaluation and management

Trauma is the leading cause of death in children nationwide. Proper management of the pediatric trauma patient involves many of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences in the pediatric population, clinicians will be assured the best possible outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.

Blunt abdominal trauma: back to clinical judgement in the era of modern technology

BACKGROUND AND METHODS

Abdominal trauma poses a diagnostic challenge to most trauma surgeons. This study evaluates a clinical scoring system in 476 blunt abdominal trauma patients treated by the author over a period of 92 months. Patients were sorted into three groups according to the score results. Priority I group (160 patients) was subjected to an immediate laparotomy. Priority II group (200 patients) was treated according to the results of auxiliary investigations. Priority III group (116 patients) was kept under observation. The treatment outcome was used as a gold standard for the evaluation of the results.

RESULTS

In priority I and III groups (276 cases) the management was only dependent on the proposed clinical score with a 100% specificity, 88% sensitivity, 90% positive predictive value, 100% negative predictive value and an overall accuracy of 94%.

CONCLUSIONS

This scoring system (CASS) is helpful in ensuring rapid diagnosis and treatment, reduces time, costs and mortality that may result from improper and/or delayed diagnosis.

The use of routine laboratory studies as screening tools in pediatric abdominal trauma

BACKGROUND

Standard laboratory panels were shown to play an important role in the evaluation of pediatric blunt abdominal trauma before the routine use of computed tomography (CT) scan. Recently, only a few relatively limited studies have evaluated the use of these "trauma panels."

OBJECTIVE

To evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of routine "trauma panels" for evaluating intra-abdominal injury in pediatric blunt trauma patients.

METHOD

We undertook a retrospective medical record review of all children with potential major blunt abdominal trauma who entered the Children's Hospital (Boston, MA) trauma registry from July 1996 to August 1999. Routine laboratory tests during those years included sodium, glucose, white blood cell count, hematocrit, platelets, prothrombin time, activated partial thromboplastin time, aspartate aminotransferase (AST), alanine aminotransferase, amylase, lipase, and urinalysis. Individual findings were considered abnormal if they fell out of the laboratory's respective reference range. We determined sensitivity, specificity, PPV, NPV, and the 95% confidence interval for each test, using abdominal pathology identified by CT scan as the gold standard.

RESULTS

Three hundred eighty-two patients were included. Of that, 68% were men. Median age was 115 months (intraquartile range, 60-159 months). In total, 241 of the patients (63%) had an abdominal CT scan performed, 83 of which (33%) had abnormal findings. Abnormal values for glucose, AST, urinalysis, and white blood cell count were the most frequently observed abnormalities (67%, 47%, 43%, and 43%, respectively). Among the 83 patients with abdominal pathology, glucose and AST had the highest sensitivity (75% and 63%, respectively). Lipase had the highest PPV at 75%, and AST had the highest negative predictive at 71%. No routine laboratory test had excellent sensitivity, specificity, PPV, and NPV.

CONCLUSIONS

Routine "trauma panels" should not be obtained as a screening tool in children with blunt trauma being evaluated for intra-abdominal injury.

The utility of clinical and laboratory data for predicting intraabdominal injury among children

BACKGROUND

The initial assessment of the child with blunt injury should lead ideally to a low rate of missed intraabdominal injury (IAI) while avoiding unnecessary imaging among children without IAI. The purpose of this study was to determine the utility of clinical and laboratory data for predicting the risk for IAI.

METHODS

Among 351 children evaluated for possible blunt abdominal trauma, 23 variables potentially associated with IAI were determined retrospectively. Logistic regression and recursive partitioning were used to identify variables and develop predictive models.

RESULTS

Logistic regression identified four positive predictors (abdominal tenderness, abrasion, ecchymoses, and alanine aminotransferase) and two negative predictors (injury caused by a motor vehicle crash and hematocrit) for IAI. The recursive partitioning model predicted the absence of IAI with a sensitivity of 100% (95% CI confidence interval, 86-100%) and a specificity of 87% (95% CI confidence interval, 81-91%) using abdominal examination and aspartate aminotransferase as discriminating variables.

CONCLUSIONS

Physical examination combined with selected laboratory studies can be used to predict the risk of IAI accurately among children who sustain blunt trauma. Application of these findings may be useful in reducing costs and improving the accuracy of diagnosing IAI among children.

Identification of children with intra-abdominal injuries after blunt trauma

STUDY OBJECTIVE

We sought to determine the utility of laboratory testing after adjusting for physical examination findings in the identification of children with intra-abdominal injuries after blunt trauma.

METHODS

The study was a prospective observational series of children younger than 16 years old who sustained blunt trauma and were at risk for intra-abdominal injuries during a 2(1/2)-year period at an urban Level I trauma center. Patients were examined by faculty emergency physicians and underwent standardized laboratory testing. Clinical and laboratory findings were recorded on a standardized data sheet. Intra-abdominal injury was considered present if an injury was documented to the spleen, liver, pancreas, kidney, adrenal glands, or gastrointestinal tract. We performed multiple logistic regression and binary recursive partitioning analyses to identify which physical examination findings and laboratory variables were independently associated with intra-abdominal injury.

RESULTS

Of 1,095 enrolled patients, 107 (10%, 95% confidence interval [CI] 8% to 12%) had intra-abdominal injuries. The mean age was 8.4+/-4.8 years. From both analyses, we identified 6 findings associated with intra-abdominal injury: low systolic blood pressure (adjusted odds ratio [OR] 4.1; 95% CI 1.1 to 15.2), abdominal tenderness (adjusted OR 5.8; 95% CI 3.2 to 10.4), femur fracture (adjusted OR 1.3; 95% CI 0.5 to 3.7), serum aspartate aminotransferase concentration more than 200 U/L or serum alanine aminotransferase concentration more than 125 U/L (adjusted OR 17.4; 95% CI 9.4 to 32.1), urinalysis with more than 5 RBCs per high-powered field (adjusted OR 4.8; 95% CI 2.7 to 8.4), and an initial hematocrit of less than 30% (adjusted OR 2.6; 95% CI 0.9 to 7.5).

CONCLUSION

After adjusting for physical examination findings, laboratory testing contributes significantly to the identification of children with intra-abdominal injuries after blunt trauma.

Pediatric trauma. Anesthesia management

Prevention of childhood injury remains the cornerstone of reducing the number of children who present for post-traumatic surgical intervention. Beyond prevention, the next best step is the accurate diagnosis and treatment of traumatic injury. Anesthesiologists contribute to this step by providing timely resuscitation and optimal care to avoid secondary injury. This article classifies trauma in children into different categories depending on the location of the injury. Trauma, of course, is rarely focal, and is often a multisystem entity. With knowledge in management for each subset of trauma, one may be efficient in prioritizing injury and have a good understanding of the appropriate management of the pediatric patient with multiple traumatic injuries.

Prognostic value of trauma scores in pediatric patients with multiple injuries

BACKGROUND

For the quantification of multiple injuries in children, a range of different trauma scores are available, the actual prognostic value of which has, however, not so far been investigated and compared in a group of patients.

METHODS

In 261 polytraumatized children and adolescents, 11 trauma scores (Abbreviated Injury Scale [AIS], Injury Severity Score [ISS], Glasgow Coma Scale [GCS], Acute Trauma Index [ATI], Shock Index [SI], Trauma Score [TS], Revised Trauma Score [RTS], Modified Injury Severity Score [MISS], Trauma and Injury Severity Score [TRISS]-Scan, Hannover Polytrauma Score [HPTS], and Pediatric Trauma Score [PTS]) were calculated, and their prognostic relevance in terms of survival, duration of intensive care treatment, hospital stay, and long-term outcome analyzed.

RESULTS

With a specificity of 80%, physiologic scores (TS, RTS, GCS, ATI) showed a greater accuracy (79-86% vs. 73-79%) with regard to survival prediction than did the anatomic scores (AIS, HPTS, ISS, PTS); combined forms of these two types of score (TRISS-Scan, MISS) did not provide any additional information (76-80%). Overall, the TRISS-Scan was the score that showed the highest correlation with duration of treatment and long-term outcome. Trauma scores specially conceived for use with children (PTS, MISS) failed to show any superiority vis-à-vis trauma scores in general.

CONCLUSION

With regard to prognostic quality and ease of use in the practical setting, TS and the TRISS-Scan are recommended for polytrauma in children and adolescents. Special pediatric scores are not necessary.

Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management

Evaluation of children with suspected abdominal trauma could be a difficult task. Unique anatomic and physiologic features render vital sign assessment and the physical examination less useful than in the adult population. Awareness of injury patterns and associations will improve the early diagnosis of abdominal trauma. Clinicians must have a complete understanding of common and atypical presentations of children with significant abdominal injuries. Knowledge of the utility and limitations of available laboratory and radiologic adjuncts will assist in accurately identifying abdominal injury. While other obvious injuries (eg, facial, cranial, and extremity trauma) can distract physicians from less obvious abdominal trauma, an algorithmic approach to evaluating and managing children with multisystem trauma will improve overall care and help to identify and treat abdominal injuries in a timely fashion. Finally, physicians must be aware of the capabilities of their own facility to handle pediatric trauma. Protocols must be in place for expediting the transfer of children who require a higher level of care. Knowledge of each of these areas will help to improve the overall care and outcome of children with abdominal trauma.

ED evaluation of the pediatric trauma patient by ultrasonography

The purpose of this study was to determine the accuracy of ultrasound examination of pediatric trauma patients by emergency physicians. Pediatric (age less than 18 years) trauma patients presenting to the emergency department of a level I trauma center were prospectively examined with bedside ultrasound during the secondary survey of their trauma resuscitation. Examinations were performed by emergency medicine residents and attending physicians who had completed an 8-hour course on trauma ultrasonography. Trauma physicians providing care to the patient were blinded to the results of the examination. In 47 children (median age 9 years) computed tomography of the abdomen/pelvis or laparotomy were also performed and served as gold standards to verify the presence or absence of free fluid in the abdomen. Sensitivity, specificity, and accuracy of the ultrasound examination for the detection of free fluid in the abdominal cavity was 75% (95% confidence interval [CI] 36% to 95%), 97% (95% CI 81% to 100%), and 92% (95% Cl 77% to 98%). Positive and negative predictive values were 90% (95% CI 46% to 100%) and 92% (95% CI 74% to 99%), respectively. Ultrasound examinations took an average of 7 minutes and 36 seconds, although this did not take into consideration delays created by interruptions for other diagnostic tests or procedures. An emergency physician and radiologist agreed on blinded interpretations of 83% of the examinations (kappa = 0.56). Bedside ultrasonography is a reliable and rapid method for screening traumatized children for the presence or absence of free fluid in the peritoneum even in the hands of novice sonographers.

Blunt abdominal trauma in children

Blunt abdominal trauma is the commonest cause of intra-abdominal injuries in children. The use of computerized axial tomography and non-operative management of haemoperitoneum are two significant developments in the last two decades in the management of blunt abdominal trauma in children. The concept of non-operative management was introduced in late 1979 and wherever possible remains the optimum treatment. Computerized tomography scan for paediatric abdominal trauma was first described in 1980 and remains the investigation of choice. There is no substitute, however, for a good history, astute physical examination, and strict adherence to the principles of primary and secondary survey, prompt resuscitation, vigilant monitoring and repeated evaluation.

Prehospital triage in the injured pediatric patient

BACKGROUND/PURPOSE

Identifying major trauma patients in the prehospital setting is essential in determining management, destination, and best utilization of emergency department resources. Few methods of trauma triage have been accepted unanimously. This study prospectively evaluates the efficacy of comprehensive field triage using 12 criteria (simplified version of the American College of Surgeon's guidelines) in 1,285 pediatric trauma patients.

METHODS

Major trauma was defined as occurring in those who died in the emergency room, had major surgery (penetrating injury involving surgery of the head, neck, chest, abdomen, or groin), or were admitted directly to the intensive care unit. The correlation between trauma triage criteria, hospital disposition, and triage accuracy were determined prospectively and compared in the pediatric patients (36 months) with an adult cohort of patients (12 months).

RESULTS

A total of 1,285 pediatric trauma patients were evaluated and compared with 1,326 adult trauma patients. The most accurate trauma triage criterion for major injury was a blood pressure < or = 90 mmHg (systolic) with an accuracy of 86%. This was followed by burn greater than 15% total body surface area (79%), Glasgow Coma Scale score < or = 12 (78%), respiratory rate less than 10/min or greater than 29/min (73%), and paralysis (50%). Less accurate criteria included a fall from greater than 20 feet (33%); penetrating injury to head, neck, chest, abdomen, or groin (29%); ejection from vehicle (24%); pedestrian struck at greater than 20 mph (16%); paramedic judgement (12%); rollover (3%); and extrication (0%). The Glasgow Coma Scale score was a more accurate indicator of major injury in children than adults, and paramedic judgement was less accurate in children when compared with adults. Of the 379 major pediatric trauma victims, the Revised Trauma Score and Pediatric Trauma Score missed 36% and 45% of these major trauma victims, respectively. The overtriage rate for children was 71% with a sensitivity of 100% (no missed major trauma patients).

CONCLUSIONS

Physiological variables, anatomic site, and mechanism of injury provide a sensitive and safe system of triage. Continued education of prehospital personnel regarding pediatric trauma and stratification of the current triage tools are necessary to minimize overtriage in an era of shrinking resources.

Identification of intra-abdominal injuries in children hospitalized following blunt torso trauma

OBJECTIVE

To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra-abdominal injuries (IAIs).

METHODS

The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a four-year period. Patients were considered high-risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for LAI. The authors compared moderate-risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED.

RESULTS

Of 1,040 children with blunt trauma, 559 (54%) were high-risk and 481 (46%) were moderate-risk for IAI. 126 (23%) of the high-risk and 22 (4.6%) of the moderate-risk patients had IAIs. Among moderate-risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm3 vs 12.8 K/mm3, p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate-risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations.

CONCLUSION

In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.

Evaluation and management of pediatric major trauma

Proper management of the pediatric trauma patient involves most of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences among the pediatric population, the clinician will be assured the best outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.

Superman play and pediatric blunt abdominal trauma

Two pediatric patients with life-threatening intra-abdominal injuries associated with Superman play are presented. The cases illustrate the importance of knowing the mechanism of injury in the assessment of children with blunt abdominal trauma. The diagnostic value of liver enzymes and the controversies surrounding the radiographic assessment of pediatric blunt abdominal trauma are presented.

Disaster triage: START, then SAVE--a new method of dynamic triage for victims of a catastrophic earthquake

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of time, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49-72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage. The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of "Simple Triage and Rapid Treatment" (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, "Secondary Assessment of Victim Endpoint" (SAVE). The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology. Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources-both personnel and equipment-and would be triaged to an "expectant area." Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a "treatment" area. The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.

Abdominal injuries in restrained pediatric passengers

A statewide experience with pediatric abdominal visceral injury in restrained automobile passengers was compiled from the trauma registries of two academic institutions. Retrospective analysis of motor vehicle passenger injuries from 1987 to 1991 included age, sex, mechanism of injury, prehospital care, type of injury, therapeutic interventions, complications, and ultimate outcome. The records of over 2,000 patients evaluated for blunt trauma were reviewed, with 42 children fulfilling the following inclusion criteria: 15 years of age or younger, restrained in an automobile at the time of the accident, and diagnosed with an abdominal injury. Of the 42 patients studied, there were 20 boys and 22 girls; ages ranged from 2 months to 15 years (mean, 7.02 years). Six of 42 patients (14%) required extrication from the vehicle at the scene. Nineteen of 42 patients (45%) sustained belt-related abdominal wall bruising or erythema. The specific blunt visceral injuries noted were as follows: splenic 5, hepatic 5, bowel 6, renal 3, combined 6 (stomach, diaphragm, pancreas, or retroperitoneum). Twenty-three children (55%) had abdominal visceral injuries without external seat belt marks. Operative intervention was necessary in seven patients. A delay in diagnosing visceral injury occurred in 4 of 42 (10%) cases. One patient developed abdominal symptoms 72 hours after the accident. Length of hospital stay ranged from 1 to 45 days. Complications occurred in 4 (10%) of patients. There were two deaths due to injuries. Hollow and solid visceral injuries can occur in belted pediatric passengers during vehicular accidents. Both are a source of significant morbidity, and the patient should be evaluated carefully.(ABSTRACT TRUNCATED AT 250 WORDS)