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Vice Chair, University of Colorado School of Medicine
Both pain and opioid analgesia can have a negative impact on breastfeeding outcomes; thus, mothers should be encouraged to control their pain with the lowest medication dose that is fully effective. However, when maternal pain 126 is adequately treated, breastfeeding outcomes improve. Especially after cesarean birth or severe perineal trauma requiring repair, mothers should be encouraged to adequately control their pain. Katarina Jankovic breastfeeding because of negligible maternal plasma levels achieved. A randomized study that compared spinal anesthesia for elective cesarean with or without the use of postoperative extradural continuous bupivacaine found that the continuous group had lower pain scores and a higher volume of milk fed to their infants. In general, if treatment of a lactating mother with an analgesic drug is considered necessary, the lowest effective maternal dose should be given. Moreover, infant exposure can be further reduced if breastfeeding is avoided at times of peak drug concentration in milk. As breast milk has considerable nutritional, immunological, and other advantages over formula milk, the possible risks to the infant should always be carefully weighed on an individual basis against the benefits of continuing breastfeeding. Intravenous medications · Pethidine should be avoided because of reported neonatal sedation when given to breastfeeding mothers postpartum, in addition to the concerns of cyanosis, bradycardia, and risk of apnea, which have been noted with intrapartum administration. They may be suitable in individuals with certain opioid allergies or other conditions described in the preceding section on labor. Following a 2-mg intranasal dose, levels in milk were quite low, with a relative infant dose of about 0. This dose is probably too low to affect a breastfeeding infant, but this drug is a strong opioid, and some caution is recommended. If I have no opioids available, do I have any pharmacological options to relieve the discomfort of childbirth in my patients? A variety of different drug classes are used in obstetrics when regional techniques and opioids are not available. While neuroleptics (promethazine) and antihistamines (hydroxyzine) are specifically indicated in nausea and vomiting, other drug classes have a direct effect on the distress of childbirth through their anxiolytic, sedative, and dissociative activity. Above all, a single small dose of benzodiazepines may be used (mainly midazolam or diazepam). In prodromal and early stages of childbirth, barbiturates (secobarbital or pentobarbital) may be a choice, and in experienced hands ketamine or S-ketamine may be helpful. With "analgesic doses," which are only a fraction of the anesthetic dose, cholinergic and central nervous system effects are usually absent. Tramadol, which has some opioid-like effects but acts mostly by a unique mechanism, would be another alternative choice for analgesia. All of these drugs pass the placental barrier and may induce sedation ("sloppy child") Oral medications · Hydrocodone and codeine have been used worldwide in millions of breastfeeding mothers. This history suggests that they are suitable choices, even though there are no data reporting their transfer into milk. Higher doses (10 mg hydrocodone) and frequent use may lead to some sedation in the infant. Therefore, if the use of these drugs is unavoidable, postpartum observation of the neonate (for approximately 812 hours) is required. The Lancet deplored the use of this "unnatural novelty for natural labor"; however, royal sanction helped make anesthesia respectable in midwifery as well as surgery. The inhalation method of analgesia in labor now uses 50% nitrous What is the oldest analgesia method still in use, and can it still be recommended? John Snow provided for her eighth childbirth (Prince Leopold) the newly developed chloroform anesthesia with an open-drop Table 2 Use of analgesics in pregnancy Medication Opioids and Opioid Agonists Meperidine Morphine Fentanyl Hydrocodone Oxycodone Propoxyphene Codeine Hydromorphone Methadone Nonsteroidals Diclofenac Etodolac Ibuprofen Indomethacin Ketoprofen Ketorolac Naproxen Sulindac Aspirin Full-strength aspirin Low-dose (baby) aspirin Salicylates Acetaminophen Salicylate-Opioid Combinations Acetaminophen-codeine Acetaminophen-hydrocodone Acetaminophen-oxycodone Acetaminophen-propoxyphene 1 1 1 2 Widely used for treatment of acute pain 1 Widely used 4 1 Full-strength aspirin can cause constriction of the ductus arteriosus Low-dose (baby) aspirin is safe throughout pregnancy 4 4 2/4 2/4 4 4 4 4 Both ibuprofen and indomethacin have been used for short courses before 32 weeks of gestation without harm; indomethacin is often used to arrest preterm labor Associated with third-trimester (after 32 weeks) pregnancy complications: oligohydramnios, premature closure of ductus arteriosus 1 1 2 1 2 2 1 2 3 Almost all cause respiratory depression in the neonate when used near delivery Used for treatment of acute pain: nephrolithiasis, cholelithiasis, appendicitis, injury, postoperative pain Neonatal narcotic withdrawal is seen in women using long-term opioids Risk Comments 1 = Primary recommended agent 2 = Recommended if currently using or if their primary agent is contraindicated 3 = Limited data to support or prescribe use 4 = Not recommended. It was introduced in clinical practice more than 100 years ago, and it remains a standard analgesia method in obstetrics departments ("anaesthesia de la reine"). Later on, other inhalation ("volatile") agents such as halothane also came into use. The safety of this technique is that the parturient will be unable to hold the mask if she becomes too drowsy, and thus will cease to inhale the anesthetic. The analgesia is considered to be superior to opioids, but less effective than epidural analgesia. Although there are data on maternal desaturation, recent studies have not demonstrated any adverse effects on mothers or neonates.
Anatomical considerations that predispose the younger child to head injuries are a large head to body ratio, a relatively weak neck, a thinner skull, and a larger subarachnoid space in which the brain can move freely (2). The injury directly caused by the mechanical force of the trauma is called primary injury. This type of injury is due to shear force, direct contact, and tissue penetration. However, medical management theoretically attempts to minimize the damage caused by secondary injury. This dramatic rise in pressure impedes cerebral perfusion and results in the herniation of brain tissue across the tentorium, falx or through the foramen magnum causing significant morbidity and often death. Intracranial hypertension, or elevated intracranial pressure is harmful as it can decrease cerebral perfusion, inciting further hypoxia and cell death. The initial clinical assessment is extremely important in determining the clinical management of a victim with head trauma. Verbal response: 5=oriented, 4=confused, 3=inappropriate words, 2=nonspecific sounds, 1=none. If the head injury has been determined to be mild, a history looking for symptoms of possible intracranial injury should be elicited. This would include questions pertaining to loss of consciousness, headache, amnesia, seizures, nausea, vomiting, or focal neurological defects. Skull x-rays have a limited role in children with head injuries, since they do not identify intracranial injury. Magnetic resonance imaging has no role in the initial evaluation of an acute head injury since it is time consuming, expensive, and not usually readily available. In minor head injuries, management is almost always observation and parental education. Hospitalization is utilized if there is concern about proper follow up, since most complications will occur within the first 24 hours following the injury (6). Parents should be instructed on what signs to look for and when to return for further care. Separate practice guidelines have been recommended for the management of minor head injuries in children ages 2-20 years and <2 years of age by the American Academy of Pediatrics (6,7). Infants are especially susceptible to linear skull fractures, because of their thinner skull. Thus, diagnostic imaging is recommended for any infant with an obvious scalp hematoma. A fluid collection cyst can be produced by the pinched meninges, which is called a leptomeningeal cyst. Leptomeningeal cysts (hence, growing skull fractures) are rare complications, but the clinician should still look for them during follow up weeks after a skull fracture is found. It is initially tense, but over the next few days as the hematoma begins resorption, the hematoma becomes very soft, which is often alarming to parents, prompting them to bring the child to a physician. A skull fracture that is pushed in a distance equivalent to the thickness of the skull table is called a depressed skull fracture. A concussion is defined as, "a trauma induced alteration of mental status that may or may not involve a loss of consciousness" (1). Practice guidelines for the return of activity after sustaining a concussion have been recommended in the literature (10). Very often the blood is arterial originating from the middle meningeal artery in association with a parietal skull fracture. However, in younger children, 20% of epidural hematomas are due to venous blood (1). The classic clinical coarse is that of a child who sustains a head injury and may have been rendered unconscious. This is usually not a neurosurgical emergency, since evacuation of the clot will not usually reverse the significant primary damage inflicted on the brain parenchyma. Especially when subdural hematomas are found, the possibility for child abuse must be explored. Thus, the examining clinician should have a low threshold to perform a skeletal survey and attain ophthalmology consultation for suspicious cases of head injuries. This type of acute subdural hematoma is very different from the type of subacute subdural hematoma found in the elderly.
Another area where endovascular management has led to improved outcomes in terms of mortality and paraplegia risk is in patients with blunt injuries to the thoracic aorta. Endovascular injury management may be useful for patients with abdominal and pelvic artery and vein injuries. Stent grafts placement in abdominal vessels would provide a method of repairing the vascular injury and avoiding the exposure of a vascular repair to contamination from a nearby gastrointestinal or genitourinary injury. Arthurs and colleagues cited data indicating that stent graft repairs of injuries to the abdominal aorta, the iliac arteries, the renal arteries, and the popliteal arteries are feasible and associated with an early technical success rate of 94%. The authors stated that patients who can be stabilized after penetrating or blunt abdominal injury with significant retroperitoneal hematoma formation can undergo imaging for diagnosis. Identifying a vascular injury that can safely be occluded with endovascular coils or covered with an endovascular stent offers an opportunity to repair the injury without the risk attendant to placing a vascular suture line and/or conduit adjacent to a gastrointestinal or pancreatic injury. There is not a sufficient number of reported patients to establish an accurate risk-benefit analysis for this approach. Additional data will be helpful in documenting the effectiveness of endovascular approaches for abdominal vascular injuries. It is well known that angiographic coil occlusion of bleeding pelvic branches of the internal iliac system is a valuable approach in patients with pelvic fractures. Boufi and coauthors55 reported data on outcomes of coil embolization and stent graft placement in hemodynamically unstable patients with pelvic bleeding in Annals of Vascular Surgery, 2011. The authors reported a single-center case series of 16 patients who sustained blunt injuries to retroperitoneal vessels. Coil embolization was used in 13 patients with ongoing bleeding from pelvic vessels lacerated by pelvic fractures. Two of these were placed in the proximal common and internal iliac arteries in patients with pelvic fractures who had undergone coil occlusion of the contralateral internal iliac artery. Early hemorrhage control was achieved in all stented patients, with no patient requiring repeat endovascular intervention or open operation for hemorrhage control. The authors concluded that endovascular approaches may be helpful for selected patients with injuries to retroperitoneal arteries. A report on endovascular repairs for major torso vascular injuries was by Gilani and coauthors56 in the Journal of Trauma and Acute Care Surgery, 2012. The authors used endovascular balloon occlusion via an open femoral access approach to facilitate endovascular stent repair of subclavian and axillary artery injuries in eight patients. Technical success was achieved in all patients and oneyear follow-up showed no device-related complications or need for follow-up procedures. The first is fasciotomy, currently used liberally as an intervention before revascularization to prevent compartment syndrome. Compartment syndrome is reviewed in the book chapter by Frykberg and Schinco referenced earlier. Another important component of compartment syndrome observed after a vascular injury is loss of venous outflow. Venous outflow can be lost because of preexisting venous obstruction, a direct venous injury, or loss of venous collaterals from fractures or a soft tissue injury. Compartment syndrome may be encountered independent of ischemic injury to muscle in association with fractures and soft-tissue contusion. Whatever the mechanism, fasciotomy is performed to open up these "tight" compartments and reduce the pressure-related ischemic injury to nerve and muscle that might result. Frykberg and Schinco provided a description of the pathophysiologic events that accompany the subsequent reperfusion of ischemic muscle. The most dangerous consequence of this reperfusion syndrome is the release of potassium and acid metabolic products into the systemic circulation. This life-threatening set of events is associated with, but is distinct from, compartment syndrome. Uptake of the byproducts of ischemic tissue into the systemic circulation on reperfusion can result in cardiac arrest, acidosis, hemoglobinuria, myoglobinuria, and renal failure. Olson and Glasgow57 offered a comprehensive review of the diverse circumstances under which compartment syndrome might occur in the Journal of the American Academy of Orthopaedic Surgeons, 2005. Compartment syndrome is seen most frequently in conjunction with fractures of the tibia, with fracture of the distal radius being the second most common accompanying injury.
An inguinal hernia is non-tender, soft, reducible and can be located in the inguinal canal or may extend into the scrotum (inguinal-scrotal hernia). Of note, retractile testes, a common finding in infants and young children, can resemble an inguinal hernia. An increase in size of the mass would be consistent with a hernia or communicating hydrocele. However, in children, inguinal-scrotal hernias and incarcerated bowel may also brilliantly transilluminate. If an inguinal hernia is present, abdominal contents may be palpated extending through the internal ring (2,3,6). If there is a history suspicious for a hernia but no mass can be demonstrated on examination, it may be helpful to empty the bladder which, when full, can block the internal inguinal ring and mask an inguinal hernia. The spermatic cord is palpated over the pubic tubercle and a "silky sensation" is appreciated when the two layers of peritoneum are rubbed together. A scrotal hydrocele that is sufficiently large and tense may cause ischemic injury to the testis. Strangulation of the hernia can occur and ischemic injury to intestine and testis/ovary may result (3,6). Intestinal obstruction, intestinal gangrene, and gonadal infarction occur more commonly in the first 6 months of life (4). The differential diagnosis of inguinal-scrotal swelling in children (6,7) can be classified based on acuteness of presentation, tenderness, location (intratesticular versus extratesticular), and transillumination. Communicating hydroceles are compressible (that is, they decrease in size with pressure), while non-communicating hydroceles will not change in size. However, scrotal hydroceles are spherical or oval in shape, while an incarcerated inguinal hernia is usually tubular in shape (often shaped like a small banana with a slightly tapered point at the end). Other considerations include epididymal cyst, testicular cancer, peritesticular rhabdomyosarcoma, benign soft tissue tumors, meconium sequestration, testicular torsion (tender), torsion of appendages, epididymitis, trauma, idiopathic scrotal edema, and Henoch-Schonlein purpura. It can also be used to examine both ovaries when an incarcerated ovary is suspected (6). Abdominal x-rays are unnecessary for diagnosis of an incarcerated hernia, although they may be helpful in confirming an intestinal obstruction. However, early surgical repair is recommended for large, tense hydroceles because they rarely disappear spontaneously, they can cause ischemic injury to the testis, and they may be difficult to distinguish from hernias. Communicating hydroceles also require early surgical repair due to the fact that they may progress to symptomatic inguinal-scrotal hernias (6). In fact, inguinal hernia repair is the most common surgical procedure in children (4). In an outpatient setting, if a child presents with an inguinal hernia but is otherwise well (no obstruction or shock), manual reduction should be attempted. If the hernia is easily reducible, referral to a pediatric surgeon should be done for elective surgical repair. If reduction is successful, a pediatric surgeon should be consulted for outpatient follow-up. If reduction is unsuccessful, then a pediatric surgeon must be consulted immediately. While incarcerated bowel is at risk for ischemia and must be surgically corrected immediately, the vascular supply to the incarcerated ovary is usually not compromised, thus, this is often less emergent. Hospitalization may be necessary for children at high risk for postoperative/post-anesthesia complications. Of note, females undergoing surgical correction of a hernia should be evaluated for the possibility of testicular feminization. If the results are inconclusive, the hernia sac must be explored during surgery and the presence of a fallopian tube verified. If neither fallopian tube nor testis is found, an endoscopic examination of the vagina after surgery should be performed to evaluate for a cervix. Bilaterality is more frequent in females, children less than 12 months of age, and children with left-sided inguinal hernias. For this reason, it is recommended that bilateral surgical exploration be done in males less than 12 months of age, females less than 24 months of age, and children at high risk for development of inguinal hernias. Of note, contralateral exploration can be avoided with laparoscopic herniorrhaphy. Premature infants will often develop a symptomatic hernia while remaining hospitalized for prematurity.
