Seminars in pediatric surgery
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Unintentional injury is the leading cause of death for children less than 14 years of age. Optimal injury control includes prevention, acute care, and rehabilitation. When prevention efforts fail, a dedicated well-trained team must be prepared to resuscitate and treat the injured child. ⋯ The secondary survey completes the early resuscitation phase and consists of a systematic and complete physical examination. Resuscitation priorities specific to the multiply-injured child are also discussed. Finally, the importance of rehabilitation and prevention efforts are included.
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Thoracic injury is the second leading cause of death in pediatric trauma, second only to head injury in lethal potential. With the exception of lung contusion, serious injuries to vital thoracic structures are associated with mortality rates in excess of 50%. With blunt chest trauma, approximately 15% of the deaths result directly from intrathoracic injury, but with penetrating chest trauma, nearly 100% of the deaths result from intrathoracic injury. Facility with management of thoracic injuries is therefore vital to optimal outcome in childhood trauma.
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Critical care of the injured child should be an effective extension of aggressive resuscitation, stabilization, and definitive care. In the hours and days after acute injury, initially unnoticed lesions may emerge, secondary organ dysfunction may develop, and complications of primary injury or initial management may occur. ⋯ We follow an organ system, problem oriented protocol, and attempt to anticipate problems before they occur. This article defines our approach in general terms, with specific emphasis on the more common problems encountered in caring for seriously injured children.
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The response to trauma begins in the immune system at the moment of injury. The loci are the wound, with activation of macrophages and production of proinflammatory mediators, and the microcirculation with activation of endothelial cells, blood elements, and a capillary leak. These processes are potentiated by ischemia and impaired oxygen delivery and by the presence of necrotic tissue, each exacerbating the inflammatory response. ⋯ An important part of these expanding concepts is the notion that all noxious stimuli activate the cytokine system as a final common pathway. Sepsis, hemorrhage, ischemia, ischemia-reperfusion, and soft tissue trauma all share an ability to activate macrophages and produce proinflammatory cytokines that may initiate the SIRS. Second-message compounds and effector molecules mediate the observed clinical phenomena.(ABSTRACT TRUNCATED AT 250 WORDS)