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September 20, 1989 Dear Editor: In their article regarding wounds of the colon and their treatment, George and colleagues.' refer to war wounds caused by high-velocity missles and shrapnel. Certainly the missles referred to as shrapnel should be labeled high-explosive fragments. A letter I have written,2 with the replies of two authors regarding the proper terminology for missles, is readily available to the interested surgeon. Data regarding the percentage of wounds caused by the various missles are included in the letter. The error in describing shrapnel has entered standard dictionaries. Webster's Collegiate Dictionary (1946)3 gives the proper definition with an illustration of the shell enclosing the balls; I have seen this same illustration in a multivolume dictionary from the 19 century. Webster's New World Dictionary (1970)4 also includes the erroneous statement that any fragment of an exploding shell is shrapnel.

References 1. George SM Jr, Fabian TC, Voeller SR, et al. Primary repair of colon wounds. Ann Surg 1989; 209:728-733. 2. Sommer GNJ Jr. Injuries from high-explosive fragments. Ann Thorac Surg 1896; 42:723. 3. Neilson WA. Webster's Collegiate Dictionary (Fifth Edition), Springfield, 1946, p. 921. 4. Guralnik DB, ed. Webster's New World Dictionary (Second College Ediction), New York and Cleveland, 1970, p. 1391.

GEORGE N. J. SOMMER, JR., M.D. Trenton, New Jersey

October 30, 1989 Dear Editor: The authors appreciate Dr. Sommer's attempts to point out the original definition of 'shrapnel.' He has reported' that the Germans in World War II referred to steel balls, which were enclosed in the explosive casings of land mines, as shrapnel, this also being the definition in Webster's Collegiate Dictionary of that era.2 However, to place this in accurate historical context, I would like to point out that shrapnel was originally developed by British Lieutenant Henry Shrapnel (1761 to 1842).3 It was an artillery shell containing a number of balls and powder that burst the shell and was first used by the British in Surinam in 1804. This particularly devastating weapon was used extensively against infantry in one of the bloodiest wars humankind has witnessed: the American Civil War. It was referred to as 'grape shot and canister' during that conflict. Since World War II, the term 'shrapnel' has been used to refer to the fragments of the shell casing thrust by an explosive charge. The point is well taken that we should be precise in defining the mechanisms of injury so appropriate comparisons can be made and correct operative management be applied. To that end we would like to recommend that the surgical community continue to refer to high-explosive fragments as 'shrapnel,' and,

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if in future military conflicts steel balls are encased in exploding casings, that we refer to them as 'grape shot and canister.' References 1. Sommer GNJ Jr. Injuries from high-explosive fragments. Ann Thorac Surg 1986; 42:723. 2. Neilson WA. Webster's Collegiate Dictionary (Fifth Edition), Springfield, 1946:921. 3. World Book-Childcraft International, Inc. The World Book Encyclopedia, (1980 Edition), Vol. 17, pp. 359-360.

TIMOTHY C. FABIAN, M.D. Memphis, Tennessee

September 12, 1989 Dear Editor: We commend the leadership in pediatric trauma care provided by Eichelberger and his colleagues from the Children's Hospital National Medical Center in Washington, but were somewhat disconcerted by the conclusions in their recent paper 'Abdominal CT in Children with Neurological Impairment Following Blunt Trauma-Abdominal CT in Comatose Children' (Ann Surg 1989; 210:229-233). In their prospective study examining indications for abdominal CT in 482 consecutive children, they observed that 28% of their study group with a Glascow Coma Scale (GCS) less than 8 had significant intra-abdominal injury compared to 8% of those with a GCS more than 8. This finding correlates with similar previous analyses,1"2 and the authors conclude appropriately that children with severe neurologic impairment are at higher risk for intra-abdominal injury-an important message. They then review the cases of 11 children who had a GCS less than 8 as their only indication for abdominal CT scanning, and noted that the scan was normal in each case. Based on this small sample, they surmise that abdominal CT scanning is unjustified in these high-risk children without corroborative signs of abdominal trauma. To support this contention, they catalog the indications for abdominal CT in children with a GCS less than 8 who had significant abdominal injury. Abdominal distension, absent bowel sounds, and abrasions were the most frequent. But surely the authors recognize that these 'indications' are subjective and nonspecific in the setting of multisystem trauma. Furthermore the authors cite the report by Beaver et al.' documenting the absence of telltale signs in 22% oftheir children in this precise scenario. In addition other groups have reported an increasing rate of intestinal perforation in children after blunt trauma, perhaps due to the wider use of seatbelts.3'4 Delayed recognition of intra-abdominal trauma has the greatest penalty in the critically injured and may be the precipitating event for inexorable multiple-organ failure. Finally recent studies confirm that unrecognized intraperitoneal hemorrhage remains a common cause of preventable death in children.5 Authorities in pediatric trauma have admonished for years that children compensate extremely well for acute blood loss but deteriorate precipitously when this capacity is exceeded.6 Thus, in reflecting on the weight of available literature as well as our experience,7 we submit that diagnostic pursuit ofoccult abdom-

inal injury is mandatory in the multisystem-injured child with neurologic impairment.

The more common issue of debate is the relative merit of abdominal CT scanning versus diagnostic peritoneal lavage. Abdominal CT scanning in the child is not consistently reliable to exclude intestinal perforation or pancreatic fracture.8 Other reports9 and our experience7 continue to demonstrate the extreme sensitivity of DPL in the pediatric age group. We have found the closed-wire technique of peritoneal access particularly valuable in the child, and have been impressed with its simplicity, safety, and sensitivity. Thus we would concur that abdominal CT scanning is not mandatory in the high-risk child but recommend diagnostic peritoneal lavage as a safer and more costeffective alternative. In fact Eichelberger and his colleagues'0"' previously championed DPL as an integral component of the initial evaluation of the critically injured child and have generally embraced an aggressive operative approach.'2 We wonder if they have changed their philosophy or if we have misinterpreted their timely manuscript. References 1. Beaver BL, Colombami PM, Fal A, et al. The efficacy of compared tomography in evaluating abdominal injuries in children with major head trauma. J Ped Surg 1987; 22:1117-1122. 2. Mayer T, Walker ML, Johnson DG, et al. Causes of morbidity and mortality in severe pediatric trauma. JAMA 198 1; 245:719-721. 3. Cobb LM, Vinocur CD, Wagner CW, et al. Intestinal perforation due to blunt trauma in children in a era of increased nonoperative treatment. J Trauma 1986; 26:461-463. 4. Kovacs GZ, Davies MRQ, Saunders W, et al. Hollow viscus rupture due to blunt trauma. Surg Gynecol Obstet 1986; 163:552-555. 5. Dykes EH, Spence LJ, Bohn DJ, et al. Evaluation of pediatric trauma care in Ontario. J Trauma 1989; 29:724-729. 6. Ramenofsky ML, Morse TS. Standards of care for the critically injured pediatric patient. J Trauma 1982; 22:921-932. 7. Rothenberg S, Moore EE, Marx JA, et al. Selective management of blunt abdominal trauma in children-the triage role of peritoneal lavage. J Trauma 1987; 27:1101-1106. 8. Haftel AJ, Lev R, Mahour GH, et al. Abdominal CT scanning in pediatric blunt trauma. Ann Emerg Med 1988; 17:634-689. 9. Bivins BA, Jona JZ, Belin RP. Diagnostic peritoneal lavage in pediatric trauma. J Trauma 1976; 739-744. 10. Eichelberger MR, Randolph JG. Pediatric trauma: an algorithm for diagnosis and therapy. J Trauma 1983; 23:91-97. 11. Eichelberger MR, Randolph JG. Progress in pediatric trauma. World J Surg 1985; 9:222-235. 12. Bass BL, Eichelberger MR, Schisgall R, et al. Hazards of non-operative therapy of hepatic injury in children. J Trauma 1984; 24: 978-982.

RENATO POGGETTI, M.D. ERNEST E. MOORE, M.D. FREDERICK A. MOORE, M.D. CHARLES M. ABERNATHY, M.D. Denver, Colorado

November 2, 1989 Dear Editor:

We thank Dr. Poggetti and colleagues for their interest in our abdominal computed tomography (CT) in neurologically impaired children,' and we welcome the opportunity to respond to their concerns. We undertook this study to evaluate the role of neurologic impairment as an indication for CT expaper on

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LETTERS TO THE EDITOR

Vol. 212.No. I

amination, and to test the hypothesis that children with severe neurologic impairment are at increased risk for intra-abdominal injury than children with little or no neurologic impairment. As a point of clarification, we did not conclude that CT scans were 'unjustified' in children with isolated neurologic impairment, but merely that neurologic impairment, in the absence ofphysical signs of abdominal injury, was 'a low-yield indicator of underlying abdominal injury.' We leave the problem ofjustifying the use of resources to the individual physician. We believe one of the most important findings of our study is that all of the children with both neurologic impairment and abdominal injury (n = 25) presented with two or more physical signs of abdominal injury. Furthermore most of these indicators (hematuria, abrasion, blood per nasogastric tube, and distension) are not 'subjective and nonspecific,' but rather represent objective measures that are reliably recognized. We think that our use of a 'check list' of abdominal signs by physicians requesting CT exams resulted in more accurate documentation of abdominal signs than did previous studies,2 3 4 and underscores the importance of careful physical examination of the injured child. Dr. Poggetti is correct to point out that our study is limited by the small number of neurologically impaired children who had neither abdominal signs nor injury. However these children are from a series of 482 consecutive abdominal CT scans representing more than 4 years of experience. The provision of 'denominator data' represents a significant improvement over previous studies3'4 that give no numerical context for the series they report. Dr. Poggetti and colleagues raise the possibility of missing intestinal perforation after blunt trauma. Recently we reported our experience with bowel injuries occurring in 547 consecutive children with blunt abdominal trauma.5 We detected all six cases of perforated viscus with CT by demonstrating small amounts of free intraperitoneal air (n = 4), and bowel thickening or unexplained peritoneal fluid (n = 2). All children had significant findings on physical examination. The diagnostic utility of CT scans versus peritoneal lavage is a controversial topic, as Dr. Poggetti accurately notes. We did not perform routine peritoneal lavage on this series of patients; therefore we believe that our data may not be used correctly for comparative purposes. We agree that diagnostic peritoneal lavage is appropriate for children at high risk of intestinal perforation or rupture, as in the child with 'lap belt complex' injury.6 Physical examination continues to be an important component of the evaluation of children after blunt trauma. Reliance on radiographic investigation without attention to physical signs will hinder progress in improving care of injured children. References 1. Taylor GA, Eichelberger MR. Abdominal CT in children with neurologic impairment following blunt trauma. Ann Surg 1989; 210: 229-233. 2. Beaver BL, Colombani PM, Fal A, et al. The efficacy of compared tomography in evaluating abdominal injuries in children with major head trauma. J Pediatr Surg 1987; 22:1117-1122. 3. Pietzman AB, Makaroun MS, Slasky S, et al. Prospective study of computed tomography in initial management of blunt abdominal trauma. J Trauma 1986; 26:585-592. 4. Karp MP, Cooney DR, Berger PE, et al. The role of computed tomography in evaluation of blunt abdominal trauma in children. J Pediatr Surg 1981; 16:316-323. 5. Bulas DI, Taylor GA, Eichelberger MR. The value of CT in detecting bowel perforation in children after blunt abdominal trauma. Am J Radiol 1989; 153:561-564.

Abdominal CT in children with neurological impairment following blunt trauma--abdominal CT in comatose children.

R1VdflM:!UrnmWMnIkm - September 20, 1989 Dear Editor: In their article regarding wounds of the colon and their treatment, George and colleagues.' re...
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