Patient and injury characteristics in abusive abdominal injuries

OBJECTIVE

To identify patient and injury characteristics associated with suspected child abuse in the setting of blunt abdominal trauma.

PATIENTS

We extracted from the National Pediatric Trauma Registry phases 2 and 3 (October 1995 to April 2001; N = 106,135) all cases of blunt abdominal injury, excluding motor vehicle injuries, in patients aged 0 to 4 years.

MAIN OUTCOME MEASURES

Independent variables included age, mortality, nutritional status, and injury type. The dependent variable was suspected child abuse.

RESULTS

Six hundred sixty-four cases were analyzed. The median age of patients was 2.6 years; 11.4% were undernourished. The 3 most common mechanisms of injury were suspected child abuse (40.5%), fall (36.6%), and struck-not child abuse (9.7%). Hepatic injury (46.1%) was the most common intra-abdominal injury, followed by splenic (26%), hollow viscous (17.9%), and pancreatic (8.6%) injuries. Eighty-four percent of deaths were related to suspected child abuse. There was a greater proportion of children with suspected child abuse in every patient and injury characteristics studied than all other mechanisms combined. In a regression model including age, undernourishment, pancreatic injury, hollow viscous injury, traumatic brain injury, and mortality, all variables were significantly associated with suspected abuse. Hollow viscous injury had the highest odds ratio (OR, 9.5; confidence limits, 5.7, 15.8), whereas traumatic brain injury had the lowest (OR, 3.6; confidence limits, 2.4, 5.6).

CONCLUSIONS

Young children with severe pancreatic or hollow viscous injuries or severe abdominal injuries in the context of either brain injury or undernourishment should be evaluated for the possibility that these injuries resulted from abuse. Increasing the awareness of the possibility of child abuse associated with a set of injury characteristics may allow for more consistent and complete medical evaluation.

Management of Blunt Pediatric Hepatic and Splenic Injury: Similar Process, Different Outcome

Though nonoperative management of stable children with blunt solid organ injury has been shown to be effective, we hypothesize that hepatic injuries represent a higher mortality risk than splenic injuries and that combination hepatosplenic injury is a marker of even greater mortality potential. A multi-institutional pediatric trauma registry was queried for all children with blunt injuries to the liver (H) or spleen (S), excluding those with severe brain injury. Incidence and mortality of H, S, and all combinations of H/S were compared. The mortality rate for patients with H was significantly higher (2.5%) than in patients with S (0.7%), and the overall mortality of H/S (8.6%) was significantly higher than both. Furthermore, the mortality of H/S injuries was associated with increasing severity of either the hepatic or splenic injury. In childhood injury, H and S occur with almost equal frequency but with different mortality, and H/S is less common but associated with increased mortality.

Management of blunt pediatric hepatic and splenic injury: similar process, different outcome

Though nonoperative management of stable children with blunt solid organ injury has been shown to be effective, we hypothesize that hepatic injuries represent a higher mortality risk than splenic injuries and that combination hepatosplenic injury is a marker of even greater mortality potential. A multi-institutional pediatric trauma registry was queried for all children with blunt injuries to the liver (H) or spleen (S), excluding those with severe brain injury. Incidence and mortality of H, S, and all combinations of H/S were compared. The mortality rate for patients with H was significantly higher (2.5%) than in patients with S (0.7%), and the overall mortality of H/S (8.6%) was significantly higher than both. Furthermore, the mortality of H/S injuries was associated with increasing severity of either the hepatic or splenic injury. In childhood injury, H and S occur with almost equal frequency but with different mortality, and H/S is less common but associated with increased mortality.

DBcat: a catalog of 500 biological databases

The DBcat (http://www.infobiogen.fr/services/dbcat ) is a comprehensive catalog of biological databases, maintained and curated at Infobiogen. It contains 500 databases classified by application domains. The DBcat is a structured flat-file library, that can be searched by means of an SRS server or a dedicated Web interface. The files are available for download from Infobiogen anonymous ftp server.

DBcat: a catalog of biological databases

The DBcat (http://www.infobiogen.fr/services/dbcat) is a comprehensive catalog of biological databases, maintained and curated on a daily basis at GIS Infobiogen. It contains more than 400 databases classified by application domains. The DBcat is a structured flat file library, that can be searched by means of an SRS server or a dedicated Web interface. The files are available for downloading from Infobiogen anonymous ftp server.

Pediatric risk indicator: an objective measurement of childhood injury severity

INTRODUCTION

The Pediatric Risk Index (PRI) uses established measures of physiologic derangement (Pediatric Trauma Score and Glasgow Coma Scale) and anatomic severity (Injury Severity Score) to identify those patients at risk of death, impairment, or extensive resource utilization.

METHODS

The PRI was evaluated by analysis of 5,345 patients entered into a multi-institutional pediatric trauma registry during 1993. PRI was calculated for each patient, and its distribution for survivors compared with those of fatalities. Analysis of this distribution identified a risk discriminant which was used to compare resulting cohorts by mortality, intensive care unit stay, and discharge impairment as measured by Functional Independence Measure. To evaluate the PRI's ability to identify unexpected outcome the records of 7,319 children injured in 1992 were then compared to the "standards" developed from the 1993 data.

RESULTS

Mortality distribution analysis identified a PRI > 1 as an indication of injury related risk. For mortality, intensive care unit stay, and discharge Functional Independence Measurement, there was a statistically significant difference (chi2, p < 0.001) between the at-risk and no-risk populations. Comparison of 1992 experience demonstrated at least one potentially preventable death.

CONCLUSIONS

The PRI effectively identifies injured patients at risk for dying, impairment, or extensive intensive care unit care.

Blunt hepatic injury in adolescents: age makes a difference

This analysis of mortality from blunt hepatic injury was performed to define outcome in the adolescent age group in relation to that recorded for children and adults. Children (age 0-10 years) were selected from a multi-institutional trauma registry, adults (age > or = 21 years) from the registry of a Level I trauma center, and adolescents (age 11-20 years) from both. Groups were compared by injury frequency, proportion of severe hepatic injuries (code 864.03 or 864.04 in the International Classification of Diseases, Adapted for Use in the United States 9-CM), immediate laparotomy, mortality, and cause of death. Children had the lowest proportion of severe injury and overall mortality. Torso trauma was the primary cause of death in only three children. Adolescent injury patterns were similar to those of adults in the proportion of severe visceral disruption and incidence of fatal torso trauma. Immediate laparotomy was employed almost twice as commonly in adults as in adolescents. The 64 per cent of adolescents who did not undergo laparotomy had a lower mortality than those who did. Conversely, the 36 per cent of adults without exploration had a significantly higher mortality, which usually occurred before laparotomy could be initiated. Increasing hepatic injury severity brought increasing mortality; however, the cause of death differed with age. Although the incidence of severe liver injury did not differ between adolescents and adults, management and outcome did. These data indicate that individualized management based on overall patient status remains the best approach to care of these injuries.