PubMed Health⌕ Search

Biomedical subjects

C S Gotschall

Publications and source records attributed to C S Gotschall.

At least 19 recordsLinked to original sources
PubMed1997

Blunt abdominal trauma in children: impact of CT on operative and nonoperative management.

OBJECTIVE: The purpose of this study was to evaluate the impact of CT on operative management of children examined after blunt abdominal trauma. SUBJECTS AND METHODS: Fifteen-hundred consecutive children who sustained blunt abdominal trauma were prospectively examined with CT. CT findings and the decision for operative or nonoperative management were recorded prospectively. In the children who underwent laparotomy, indications for operative intervention as determined by the attending trauma surgeon and surgical findings were also recorded. RESULTS: Three hundred eighty-eight (26%) of the CT scans had abnormal findings: solid viscus injury, 286; other CT abnormality, 102. Twenty (7%) of 286 children with a solid viscus injury and 25 (83%) of 30 children with a hollow viscus injury underwent therapeutic laparotomy. Abnormalities seen on CT were noted in all 20 children with solid viscus injury and 24 of 25 children with hollow viscus injury who underwent therapeutic laparotomy. The decision for laparotomy was based on CT findings in five (25%) of 20 children with solid viscus injury and 17 (68%) of 25 children with hollow viscus injury. Eleven hundred twelve children (74%) had normal findings on CT. Only one of these children later required laparotomy. CONCLUSION: CT rarely influenced the decision for operative intervention in children who sustained blunt abdominal trauma. CT findings affected the decision for operative intervention in most children with hollow viscus injury; however, CT findings affected such a decision in only a small subset of children with solid viscus injury. Normal abdominal CT findings strongly predicted a lack of subsequent deterioration requiring operative intervention.

Abdominal Injuries↗
PubMed1996

Helicopter transport of injured children: system effectiveness and triage criteria.

The authors compared air and ground transport to a level I pediatric trauma center to assess the effectiveness of helicopter transport of injured children. They also performed a retrospective assessment of triage criteria and utilization patterns for helicopter transports. The sample comprised 3,861 children who were admitted (consecutively) to an urban level I pediatric trauma center during a 4-year period and who were transported by emergency medical services. TRISS probability of survival (P2),z, and W scores were used to compare outcomes of ground and air transports. An absolute value of z greater than 1.96 indicates a statistically significant difference in mortality rate; the W statistic represents the number of survivors more than expected per 100 patients treated. Receiver operator characteristic (ROC) curves were used to identify optimal triage criteria, using P6 < .95 to define children who potentially could benefit from air transport. The triage criteria were applied to the air transport group to determine overtriage rates. Nearly 75% of the children arrived directly from the scene of injury. Those transported by air were more severely injured, as shown by significant differences in the mean Glasgow Coma Scale (GCS), P6, Injury Severity Score, and mortality rate. The better survival rate for children transported by helicopter was indicated by a TRISS z score of 2.81, compared with a z score of 0.31 for those transported by ambulance. The W statistic for the children transported by air was 1.11. ROC analysis identified GCS < 12 and heart rate > 160 beats per minute as optimal air triage criteria; these yielded 99% sensitivity and 90% specificity. Using these criteria, approximately 85% of air transports would be considered overtriage. The authors conclude that (1) helicopter transport was associated with better survival rates among urban injured children; (2) pediatric helicopter triage criteria based on GCS and heart rate may improve helicopter resource utilization without compromising care; and (3) current air triage practices result in overuse of helicopters in approximately 85% of flights.

Air Ambulances↗
PubMed1996

Nonoperative management of blunt hepatic and splenic injury in children.

OBJECTIVE: The authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991. METHOD: One hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). CONCLUSION: Pediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.

Adolescent↗
PubMed1995

Comparison of three measures of injury severity in children with traumatic brain injury.

Eighty-six traumatically brain-injured children aged 6 to 15 years who were consecutively admitted to a pediatric Level I trauma center were recruited for participation in the study. A comprehensive battery of behavioral, cognitive, communicative, social, motoric, and neurological tests was administered to the children from 12 to 36 months postinjury. The performance of three severity indices, the Glasgow Coma Scale (GCS), the ASCOT probability of survival, and the head injury component of the Anatomic Profile, was compared with respect to their association with long-term outcomes in five neurological domains, as assessed by linear regression models. The ASCOT probability of survival was correlated to test scores in all five domains. The GCS and the head injury component of the Anatomic Profile were each correlated to outcome in only one domain. The ASCOT probability of survival, which includes coded variables for the GCS, systolic blood pressure, and respiratory rates on admission, as well as a measure of multisystem anatomic injury, was the most sensitive indicator of head injury severity and was associated with outcomes beyond survival and death in this population. Probability of survival is a promising brain injury severity index that may be useful in efforts to assess new medical and rehabilitative therapies for children with traumatic brain injury.

Adolescent↗
PubMed1994

Age and outcome in pediatric cervical spine injury: 11-year experience.

Age-related outcome in children with cervical spine injury has not been previously reported. We performed a retrospective chart review of all children with cervical spine injury who presented to a children's hospital during an 11-year period; 73 patients were identified. Their mean age was 8.6 years, with bimodal peaks at 2 to 4 and 12 to 15 years. Sixty-seven percent of the injuries were traffic-related, resulting from motor vehicle crashes affecting passengers, pedestrians, or bicyclists. Distraction and subluxation injuries were the most common injuries in children aged eight years or younger, whereas fractures were more common in older children. Younger children sustained more severe injuries than older children, as measured by the Revised Trauma Score, Injury Severity Score, and Trauma Score-Injury Severity Score estimated probability of survival, and were more likely to sustain injuries to higher levels of the cervical spine. Deaths occurred exclusively in children eight years old or younger, but the rate of occurrence of neurologic disability was similar in both groups: 26% in those eight years old and under, and 25% in those more than eight years old. The mortality in younger patients was not caused exclusively by the higher level of cervical injury, but it occurred more often in the presence of head injury and multiple trauma.

Accidents, Traffic↗
PubMed1993

Significance of periportal low-attenuation zones following blunt trauma in children.

The CT scans of 400 consecutive children evaluated with CT following blunt abdominal trauma were evaluated to determine the frequency of periportal low-attenuation zones, assess patterns of associated intraabdominal injury, and examine clinical outcome. Periportal low-attenuation zones were noted in 60 children (15%). The presence of these zones was associated with a significantly higher incidence of intraabdominal injury (60% versus 11%, p = 0.0001). Injuries most frequently associated with zones of periportal low-attenuation included hepatic (n = 23, 38%), and adrenal (n = 14, 23%). Children who had periportal low-attenuation zones tended to be more physiologically unstable as evidenced by a lower Trauma Score (diffuse, 11.9; focal, 13.4) than children without the zones (15.1, p = 0.0001). The presence of these zones was also associated with a significantly higher mortality rate (13% versus 1%, p = 0.0001). Ten children who had periportal low-attenuation zones and no hepatic injury on CT had a normal appearing liver on gross inspection at surgery or autopsy. In conclusion, periportal low-attenuation zones are common in children who have hepatic injury. These zones may be seen in conjunction with non-hepatic visceral injury or in the absence of intraabdominal injury. The presence of zones of periportal low-attenuation is associated with a higher index of physiologic instability, and higher mortality.

Abdominal Injuries↗
PubMed1993

Pediatric coefficients for TRISS analysis.

We computed regression coefficients for TRISS analysis for all 4271 pediatric patients (aged 1 through 14 years) with complete data from the Major Trauma Outcome Study. We then compared predicted pediatric and adult TRISS survival probability norms. There were no statistically significant differences in the predicted and actual numbers of survivors using either norm. Differences in discrimination and reliability between the two norms were minimal. The study confirmed that the TRISS adult blunt norm is highly discriminating and reliable in predicting survival probabilities for pediatric patients. Given that both norms were equally good predictors, and the importance of a consistent system to evaluate trauma care, the authors recommend the continued use of the adult blunt trauma norm for estimating survival probability in children.

Adolescent↗
PubMed1993

Hepatic injury from blunt trauma in children: follow-up evaluation with CT.

OBJECTIVE: Because CT is now used to assess the extent of abdominal injury after blunt trauma, children with hepatic injury often can be treated nonsurgically. We used a CT grading system to evaluate the frequency of complications and the time course of healing in children with hepatic injury from blunt abdominal trauma. MATERIALS AND METHODS: Forty-five children with CT or surgical evidence of hepatic injury after blunt abdominal trauma were followed up clinically and with serial CT scans. Hepatic injuries were graded as mild (< 25% of one lobe injured), moderate (25-50% of one lobe injured), or severe (> 50% of one lobe injured). Physical activities were limited until healing was verified with follow-up CT scans. RESULTS: All mild hepatic injuries (n = 12) appeared to have healed on follow-up CT studies 1 week to 11 months after the injury. Sixty-seven percent of moderate hepatic injuries (n = 19) showed complete healing on CT scans 1-3 months after injury, and 80% showed complete healing between 3.5 and 6 months. In all 14 children with severe hepatic injuries, residual lesions were seen on CT scans up to 8 months after injury. Residual lesions were seen in seven of 11 children with severe injuries who were reexamined 9-15 months after trauma. Despite this protracted course, no delayed hepatic complications occurred. No difference was seen between unenhanced and IV contrast-enhanced CT findings in 28 of 32 studies. IV contrast material improved the resolution of residual lesions in two cases, and two residual lesions were identified only on unenhanced CT scans. CONCLUSION: CT grading of acute hepatic injuries is useful for estimating the time course of healing. Although mild and moderate hepatic injuries heal relatively quickly, severe hepatic injuries take months to resolve. Follow-up CT scans to verify complete hepatic healing should be obtained 3 months after mild injuries, 3-6 months after moderate injuries, and 9 months after severe injuries.

Abdominal Injuries↗
PubMed1992

Blunt pancreatic trauma in children: CT diagnosis.

The purpose of this study is to determine the efficacy of CT in the diagnosis of pancreatic injury after blunt abdominal trauma in children. Pancreatic injury was diagnosed at surgery, at autopsy, or on the basis of the development of clinical pancreatitis or a pseudocyst on follow-up imaging evaluation in 18 of 1045 consecutive children examined with CT after blunt trauma. Types of pancreatic injury included laceration in 11 children, transection in two, contusion in one, and tumor with hemorrhage in one. Three children had clinical pancreatitis without a pancreatic abnormality noted on CT. The pancreatic injury was prospectively identified on CT in 12 children (67%). The presence of fluid in the lesser sac was a useful marker for injury to the pancreas. This was noted in 13 children with pancreatic injury, whereas it was observed in only six (1%) of 1028 children in the absence of pancreatic injury (sensitivity, 72%; specificity, 99%). Fluid in the anterior pararenal space was less helpful in establishing the diagnosis of pancreatic injury (sensitivity, 44%; specificity, 98%). A pancreatic pseudocyst developed in four of the 11 survivors. Our experience shows that direct signs of pancreatic trauma may be difficult to identify on CT. Recognition of the limitations of CT diagnosis of pancreatic injury is important in helping to reduce errors of interpretation.

Child↗
PubMed1991

Safety-belt injuries in children with lap-belt ecchymosis: CT findings in 61 patients.

We have noted a complex of common injuries in children wearing lap-styled safety belts during vehicular accidents. Sixty-one children who were restrained passengers in motor vehicle crashes had linear ecchymosis across the abdomen and had CT for abdominal trauma. Thirteen children (21%) had a lumbar spine injury, and 14 children (23%) injured a hollow viscus (bowel, 12; bladder, two); five children (8%) had both spine and hollow viscus injuries. Abnormal findings on abdominal CT were recognized retrospectively in three of 13 children with lumbar spinal injury. Lateral radiographs of the spine showed lumbar spinal injury in all cases. Free intraperitoneal air was noted in on three (25%) of 12 children with bowel injury. In eight of those children, CT showed large, unexplained collections of peritoneal fluid. The presence of lap-belt ecchymosis should prompt a careful search for spine, bowel, and bladder injury. Recognition of the limitations of CT diagnosis of these injuries is important to reduce errors in interpretation.

Abdominal Injuries↗
PubMed1991

Predictors of abdominal injury in children with pelvic fracture.

During a 48-month period, 2,248 children (aged less than 15 years) were consecutively admitted to a regional pediatric trauma center with blunt trauma (ICD-9-CM code greater than or equal to 800). Fifty-four children (2.4%) had injury to the pelvic circle, as diagnosed by radiographic examination; 13 of these children had concomitant abdominal or genitourinary (GU) injury. Contingency table analysis and stepwise logistic regression were used to determine the best predictors of abdominal injury. The mean age of the children was 8.6 years. Eighty-nine percent of the injuries were motor-vehicle related (59% pedestrian; 30% crash occupant). Nine children (17%) required transfusions of packed red blood cells; 9 children (17%) required surgery. There were 6 deaths in this group, a mortality rate of 11.1%. The most common fracture sites in the pelvis were the pubic rami (59%), ilium or pelvic rim (17%), and the sacrum (6%). Ten children (19%) had multiple pelvic fractures. Location of fracture was strongly associated with the probability of abdominal injury: 80% of children with multiple pelvic fractures had concomitant abdominal or GU injury, compared with 33% with fracture of the ilium or pelvic rim, and 6% with isolated pubic fractures (p less than 0.001). The variables that best predicted abdominal or GU injury using a backward-elimination, stepwise logistic model were the presence of multiple pelvic fractures (p less than 0.002) and unweighted Revised Trauma Score (p less than 0.05); age of child, systolic blood pressure, respiration rate, Glasgow Coma Scale score, and mechanism of injury were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1990

Parental attitudes and knowledge of child safety. A national survey.

The protection of children from injury ultimately depends on the actions of adults. We conducted a national telephone survey to assess parental attitudes and understanding of child safety. Parents worried more about kidnapping and drug abuse than about childhood injury. Although well informed about potential injuries to automobile occupants, parents knew little about dangers of pedestrian and bicycle injuries, burns, and drowning. Parents frequently mentioned "being careful" when describing precautions to reduce the risk of unintentional injury rather than mentioning proved safety measures. Parents of lower socioeconomic status demonstrated a more limited understanding of child safety. Physicians were cited as the parents' first choice for information on injury control and child safety. The parents' poor showing indicates (1) the importance of passive interventions and (2) the need for programs to increase parental knowledge of childhood injury and safety.

Accident Prevention↗
PubMed1990

Thoracic trauma in children: an indicator of increased mortality.

This study was undertaken to assess the significance of thoracic trauma as a marker of morbidity and mortality in children. During a 34-month period, 2,086 children younger than 15 years old were consecutively admitted to a Level I pediatric trauma center with blunt or penetrating trauma. For each child we prospectively recorded Trauma Score (TS), Injury Severity Score, (ISS), medical, and etiologic data. One hundred four children (4.4%) presented with thoracic trauma. The most common mechanisms of injury were pedestrian injury (36%), motor vehicle crashes (32%), and armed assault (12%). The most common injuries were pulmonary contusion (48%), pneumothorax, hemothorax, or pneumohemothorax (39%), and rib fractures (32%). Multisystem injury was present in 82% of the children. The mean TS and ISS were 11 and 27, respectively, significantly worse than scores for children without thoracic injury (15 and 7; P less than .0001). Seventy-one percent of the children were admitted to the intensive care unit, where they stayed an average of 6 days; 20% required surgery. The mortality rate was 26%. Injuries to the heart or great vessels had the highest mortality rate (75%), followed by hemothorax (53%), lung laceration (43%), and rib fracture (42%). Mortality for children with isolated chest injury was 5%, compared with rates of 20% for abdominal and chest trauma, 35% for head and chest trauma, and 39% for trauma to the head, chest, and abdomen. Less than 5% of the admissions to a pediatric trauma center incurred thoracic injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗
PubMed1990

Patterns of injury in children.

Trauma is the leading cause of death for children over 1 year of age. This study was undertaken to identify the patterns of injury among children admitted to a regional pediatric trauma center. During a 34-month period, 3,472 injured children were consecutively admitted to a regional pediatric trauma center. Data were collected on medical, etiological, and financial aspects of injury. Eight subgroups were defined by mechanism of injury: motor-vehicle crash occupants, pedestrian and cycle injuries, falls, child abuse, gunshot and stab wounds, burns, poisonings, and foreign body ingestions or aspirations. Analysis of variance, Duncan's multiple range test, and contingency table analysis were used to determine differences among subgroups of children. Blunt and penetrating trauma accounted for 64.3% of all admissions. The mean age of injured children was 5.5 years; 64% of the children were boys. Sixty-seven percent of the children were admitted directly from the scene of injury. One-way analysis of variance yielded significant differences in mean age, mean hospital length of stay (LOS), mean intensive care LOS, mean trauma score, mean injury severity, and mean hospital charges by mechanism of injury (P less than .01). The overall mortality rate was 2.4%. Child abuse, gunshot/stab wounds, and drowning had the highest mortality rates, but injuries to motor-vehicle crash occupants and pedestrians accounted for the greatest number of deaths.

Accidental Falls↗
PubMed1990

The lap belt complex: intestinal and lumbar spine injury in children.

The "seatbelt syndrome" describes intestinal and spinal injury caused by lap-style automotive restraints. More than 2,600 children were admitted to Children's National Medical Center with blunt injury in 3 years; 395 were involved in a motor vehicle crash. Ninety-five of the crash occupants (24%) were known to be wearing safety belts. Ten children sustained a "lap belt injury": five with lumbar spine injury, four with combined lumbar spine and intestinal injuries, and one child with intestinal injury. All ten children presented with a characteristic transverse abdominal ecchymosis. The CT scan was unreliable in evaluation of both spinal and intestinal injury. Lateral radiographs were required for definitive diagnosis in eight of nine children with lumbar spinal injury. CT scan was clearly diagnostic in only one of five children with intestinal injury. Children wearing lap belts are at risk of a "lap belt complex." Lateral spine X-rays, peritoneal lavage, and early laparotomy are recommended to establish an accurate diagnosis and to decrease morbidity.

Accidents, Traffic↗
PubMed1990

Rib fractures in children: a marker of severe trauma.

The early recognition of life-threatening injury is paramount to the prompt initiation of appropriate care. This study assesses the importance of multiple rib fractures as a marker of severe injury in children. We analyzed physiologic, etiologic, and injury data for 2,080 children with blunt or penetrating trauma aged 0-14 years consecutively admitted to a Level I pediatric trauma center. Analysis of variance, Student's t-test, and the Chi-square test of independence were used to test for differences between children with rib fractures and other children. Probability of survival was modeled using stepwise logistic regression. There were 14 deaths among 33 children with rib fractures, a mortality rate of 42%. Child abuse accounted for 63% of the injuries to children less than 3 years old, while pedestrian injuries predominated among older children. Children with rib fractures were significantly more severely injured than children with blunt or penetrating trauma but without rib fractures. When compared to children without rib fractures, children with rib fractures had a higher mortality rate, but no statistically significant difference in morbidity. The mortality rate for the 18 children with both rib fractures and head injury was 71%. A logistic model with variables measuring severity of head injury and number of ribs fractured correctly predicted survival in more than 85% of children with thoracic trauma. Although rib fractures are rare injuries in childhood, they are associated with a high risk of death. The risk of mortality increases with the number of ribs fractured. The combination of rib fractures and head injury was usually fatal.

Adolescent↗
PubMed1989

Trauma score versus revised trauma score in TRISS to predict outcome in children with blunt trauma.

We analyzed the accuracy of TRISS and a revised TRISS to predict survival outcome in a group of 1,562 consecutive children less than 15 years old admitted with blunt trauma to a pediatric trauma center. TRISS is an index that computes a probability of survival for each patient based on Trauma Score, Injury Severity Score, and age. R-TRISS uses the Revised Trauma Score instead of the Trauma Score. We used a statistical method based on TRISS and R-TRISS to compare patient outcomes from the pediatric study group with those of an adult baseline control group from the Major Trauma Outcome Study. Both TRISS and R-TRISS have the capability to accurately quantify survival outcome for children with blunt trauma; there was no statistical difference between the two methods to do so.

Adolescent↗