Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

For many years, pediatricians have realized that accidents are a primary source of morbidity and mortality among children. The American Academy of Pediatrics has placed a high priority on the prevention of accidents, poison control centers have been established throughout the country, numerous articles have been published for the laity as well as for the profession, and the recognition of child abuse as an important entity has brought added awareness in diagnosing the cause of injuries. Pediatric Annals has devoted a complete issue to childhood accidents and another to child abuse. The present issue deals with another aspect of the same problem; it is a discussion of traumatic injuries of children, presenting modern methods of diagnosing the extent of the injuries and present-day means of treatment.

We practicing pediatricians are constantly treating or advising about children who have suffered some traumatic injury. Fortunately, most of the injuries are minor or at least not potentially lethal - lacerations, abrasions, minor burns, fractures of the long bones or clavicles, sprains, and simple concussions.

Occasionally, however, all of us have seen children who have had severe traumatic injuries, which require not only quick diagnoses but skilled judgment in directing and following through in treatment. Among these are head injuries with potential intracranial bleeding and cerebral edema, abdominal injuries with signs indicative of internal bleeding, fractured ribs with pneumothorax or hemothorax, and, of course, shock.

A great many pediatricians in the United States practice in small communities, where the burden of diagnosis and direction of treatment falls primarily or entirely on their shoulders. Roentgenograms can almost always be obtained without difficult blood studies, urinalyses, and intravenous pyelograms.

All pediatricians must decide when to consult or call in a surgeon or neurosurgeon. In addition, in the case of pediatricians in small communities, the decision must be made when to transport a child to a large center where a well-equipped and well-organized intensive-care unit is available or where better diagnostic facilities, such as computerized brain scans and intracranial pressure readings, may be obtained.

In this issue of Pediatric Annals, Dr. Martin W. Abrams, the Guest Editor, has brought together a group of surgeons experienced in the modern approach to the diagnosis of the damage incurred in traumatic incidents during childhood and the most effective methods of treatment.

Dr. Hugh R. Lynn, Professor of Surgery at the University of Alabama, opens the symposium with an editorial on present-day concepts concerning splenectomy, in which he emphasizes the important function of the spleen in the prevention of infections and the potential danger if the spleen is removed. He recommends splenectomy only in the very rare cases where preservation of the spleen is impossible.

This is followed by an article on the "Emergency Management of the Injured Child," by Dr. William T. Brown, pediatric surgeon at the University of Miami School of Medicine. This is an excellent review in which priorities of treatment are emphasized. Included in this article are the advised amounts of intravenous solutions to be used in such conditions as shock, respiratory acidosis, and the restoration of blood volume. This article should be of special value to pediatricians in whose hands the burden of treatment falls.

The next three contributions deal with acute traumatic injuries of specific body areas - the abdomen, the thorax, and the head.

Dr. James L. Talbert, pediatric surgeon at the University of Florida School of Medicine, discusses acute abdominal injuries in children, a subject that often presents numerous and difficult diagnostic problems. Means of diagnosis are very well covered in a methodical description of the various procedures. Injuries of all the abdominal…

For many years, pediatricians have realized that accidents are a primary source of morbidity and mortality among children. The American Academy of Pediatrics has placed a high priority on the prevention of accidents, poison control centers have been established throughout the country, numerous articles have been published for the laity as well as for the profession, and the recognition of child abuse as an important entity has brought added awareness in diagnosing the cause of injuries. Pediatric Annals has devoted a complete issue to childhood accidents and another to child abuse. The present issue deals with another aspect of the same problem; it is a discussion of traumatic injuries of children, presenting modern methods of diagnosing the extent of the injuries and present-day means of treatment.

We practicing pediatricians are constantly treating or advising about children who have suffered some traumatic injury. Fortunately, most of the injuries are minor or at least not potentially lethal - lacerations, abrasions, minor burns, fractures of the long bones or clavicles, sprains, and simple concussions.

Occasionally, however, all of us have seen children who have had severe traumatic injuries, which require not only quick diagnoses but skilled judgment in directing and following through in treatment. Among these are head injuries with potential intracranial bleeding and cerebral edema, abdominal injuries with signs indicative of internal bleeding, fractured ribs with pneumothorax or hemothorax, and, of course, shock.

A great many pediatricians in the United States practice in small communities, where the burden of diagnosis and direction of treatment falls primarily or entirely on their shoulders. Roentgenograms can almost always be obtained without difficult blood studies, urinalyses, and intravenous pyelograms.

All pediatricians must decide when to consult or call in a surgeon or neurosurgeon. In addition, in the case of pediatricians in small communities, the decision must be made when to transport a child to a large center where a well-equipped and well-organized intensive-care unit is available or where better diagnostic facilities, such as computerized brain scans and intracranial pressure readings, may be obtained.

In this issue of Pediatric Annals, Dr. Martin W. Abrams, the Guest Editor, has brought together a group of surgeons experienced in the modern approach to the diagnosis of the damage incurred in traumatic incidents during childhood and the most effective methods of treatment.

Dr. Hugh R. Lynn, Professor of Surgery at the University of Alabama, opens the symposium with an editorial on present-day concepts concerning splenectomy, in which he emphasizes the important function of the spleen in the prevention of infections and the potential danger if the spleen is removed. He recommends splenectomy only in the very rare cases where preservation of the spleen is impossible.

This is followed by an article on the "Emergency Management of the Injured Child," by Dr. William T. Brown, pediatric surgeon at the University of Miami School of Medicine. This is an excellent review in which priorities of treatment are emphasized. Included in this article are the advised amounts of intravenous solutions to be used in such conditions as shock, respiratory acidosis, and the restoration of blood volume. This article should be of special value to pediatricians in whose hands the burden of treatment falls.

The next three contributions deal with acute traumatic injuries of specific body areas - the abdomen, the thorax, and the head.

Dr. James L. Talbert, pediatric surgeon at the University of Florida School of Medicine, discusses acute abdominal injuries in children, a subject that often presents numerous and difficult diagnostic problems. Means of diagnosis are very well covered in a methodical description of the various procedures. Injuries of all the abdominal organs are described and modern methods of treatment recommended.

The acute thoracic injuries of children are next covered by Dr. J. Alex Haller, Jr., Professor of Pediatric Surgery, and Dr. Dennis W. Shermeta, Associate Professor of Pediatric Surgery, both of Johns Hopkins University. Although not so common as abdominal injuries, traumatic damage to the lungs, heart, and trachea does occasionally occur. The authors divide such injured children into three categories depending on whether the injury is life threatening, serious but not immediately life threatening, or localized to the thorax without pulmonary injury. They recommend that a single experienced physician have the primary responsibility for decision making in the evaluation and management of the injured child.

The next contribution presents another of the very difficult problems of pediatrics - the evaluation of children with head injuries. It was written by Dr. Luis Schut, chief of the Neurological Services of the Children's Hospital of Philadelphia, and Dr. Derek A. Bruce, associate neurosurgeon at the same hospital. This article is of special importance not only because it is an excellent review of the subject but also because it presents some of the most recent diagnostic advances, notably computerized tomography scanning and continuous intracranial pressure monitoring. These new approaches have been invaluable in the care of children with severe head injuries and should reduce not only the mortality but also the serious sequelae in children who survive severe brain injury.

The final article, on "Surgical Aspects of Child Abuse," once again reminds pediatricians of the need for increased awareness of this entity when treating children with traumatic injuries. The authors - Dr. Jay L. Grosfeld, Professor of Pediatric Surgery, and Dr. Thomas V. N. BaIlantine, Assistant Professor of Pediatric Surgery - are both from the Indiana University School of Medicine. Six cases of child abuse are reported in detail, with comments on the cooperation of the Child Advocacy Consultant Team (Child Abuse Team). Following this is a general discussion of the subject, with suggestions on approaches to diagnosis. The authors include one aspect of child abuse that is rarely discussed - child abuse by siblings. Seven months ago we published a full issue of Pediatric Annals devoted to the subject of child abuse. This article by Drs. Grosfeld and Ballantine is an excellent addition to that symposium. It is important that pediatricians be reminded frequently of this entity so that they are not only aware of but also alert to the possibility of this condition. It cannot be overemphasized.

10.3928/0090-4481-19761001-03

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