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Your employer must providing they give seriously consider your request Parental responsibility means their employers 21 days and can only refuse for one of that you are a: notice of the expected the business reasons set out in week of childbirth pulse pressure guide purchase generic lopressor canada. If your sample letters can be downloaded employer does not think that the change that you ask for can from Sex discrimination law applies to arrhythmia multiforme buy lopressor 50 mg all the legal help scheme allows employers and all employed parents people on a low income to prehypertension jnc 7 cheap lopressor uk get free with childcare responsibilities heart arrhythmia xanax buy lopressor amex. Full representation is you must write to your employer as an employer must have a good available under legal aid (to those stating your reasons for appealing. Your employer will only know discrimination law and the Tribunals if they have a good reason for right to request? An if disabled), who have not made You must complete the appeal employer must consider each an application within the last procedure and wait for the individual request in order to avoid 12 months, and who have worked decision before you can make discriminating against a woman or for their employer for 26 weeks at a tribunal application. This may be because following the procedure correctly out a more child-friendly option you have made a request under the. It touches our lives at times of basic human need, when care and compassion are what matter most. You have nine responsibilities to keep in mind: is structured and what the responsibilities of. Amniocentesis A test in which a thin needle is inserted into the uterus through the abdominal wall to take a sample of the? An amniocentesis is usually carried out between 15 and 18 weeks into your pregnancy. Antenatal this literally means ?before birth and refers to the whole of pregnancy, from conception to birth. They can be caused by hormone changes, tiredness or discomfort and usually only last a week. More severe depression or anxiety that lasts longer than a week could be postnatal depression (see page 181). Birth plan A written record of what you would like to happen during pregnancy, labour and childbirth. They are also frequently used to allow physicians to access the body with surgical instruments. It is normally almost closed, with just a small opening through which blood passes during monthly periods. During labour, your cervix will dilate (open up) to let your baby move from your uterus into your vagina. Conception the start of a pregnancy, when an egg (ovum) is fertilised and then moves down the fallopian tube to the uterus, where it attaches itself to the uterus lining. It can be very helpful for women who are having a long or particularly painful labour, or who are becoming very distressed. A thin catheter is placed between the vertebrae so that medicine can be delivered to the nerves in the spinal cord. This is done during the last stages of labour and delivery to expand the opening of the vagina to prevent tearing during the birth of the baby. Folic acid One of the B group of vitamins, which is found naturally in foods, including green leafy vegetables, forti? If you are pregnant or trying to get pregnant, you should take a 400 microgram folic acid tablet every day until you are 12 weeks pregnant. Jaundice is common in newborn babies and usually occurs approximately three days after birth. It can last for up to two weeks after birth or up to three weeks in premature babies. Severe jaundice can be treated by phototherapy, where a baby is placed under a very bright light. Meconium is made up of what a baby has ingested during their time in the uterus, including mucus and bile. Symptoms include nausea sickness/nausea or feeling sick, as well as actually being sick. Morning sickness can occur at any time of the day, though it occurs most often in the morning because blood sugar levels are low after a night without food. It takes place in a neonatal unit, which is specially designed and equipped to care for them. Obstetrician A doctor specialising in the care of women during pregnancy and labour and after the birth. It is usually nothing to worry about, but if it gets worse suddenly it can be a sign of pre-eclampsia. Postnatal the period beginning immediately after the birth of a baby until they are about six weeks old. Postnatal depression affects one in 10 women and can be serious if left untreated. Symptoms include high blood pressure, protein in urine, bad headaches, vision problems and the sudden swelling of the face, hands and feet. Premature birth the birth of a baby before the standard period of pregnancy (37 weeks) is completed. This can be harmful to the baby as it may result in a condition called haemolytic disease of the newborn, which can lead to anaemia and jaundice. This means that they have a substance known as D antigen on the surface of their red blood cells. Rubella (German A virus that can seriously affect unborn babies if the mother gets it during the early weeks measles) of pregnancy. The Network can also offer advice and support abuse, mental health problems, learning to women who wish to have a vaginal delivery disabilities and severe? Works to improve awareness including parents rights, the choices available, 10 Parkway and access to treatment. All information childminders, over-7s childminders and nannies Rape Crisis Centre on the website, or email for enquiries should be submitted by email. It offers a information, contraception, pregnancy testing, support and direction to treatment services. Counselling services, abortion pill for children in hospital, at home and in the who support them, including those with a and surgical abortion available. Ongoing support Information, advice and support for women 10am?4pm) given to parents via publications, a helpline, who have had, or who are having, a miscarriage. Support is offered to health Voluntary sector organisation providing professionals by way of training, conferences Stillbirth and Neonatal Death information and advice about spina bi? The helpline 020 7833 4883 Muscular Atrophy and email support are staffed by volunteers who info@clapa. Operates a pregnancy information line staffed by midwives, and publishes books and lea? Inclusion criteria were randomized controlled trial studies, systematic reviews, and meta analyses on the effects of massage therapy on preterm and full-term infants. Several studies have focused on the effects of different pressure massage and various oils to enhance weight gain in preterm newborns. Other conditions that have benefited from massage therapy include hyperbilirubinemia and colic. Mothers have experienced less depression, anxiety, and sleep disturbance after massaging their infants and fathers and couples relationships have benefited as well. Despite the limitations of the literature reviewed here including small sample sizes and the need for more randomized controlled trials on a standard moderate pressure massage protocol, the data suggest that both infants and their parents benefit from massage therapy. These different literature on preterm and full-term Ireview is derived from literature searches of PubMed, infants are reviewed separately here. The weight gain was focused on weight gain and the potential underlying related to increased vagal activity, gastric motility, insulin, mechanisms for massage leading to weight gain. These were followed by studies comparing different and full-term infants [Table 1 for listing of effects]. Mothers of preterm infants have benefited moderate pressure was introduced in 1986. Milleur, Ang, Badr, Fucile, Wang, Li, Ho, Telkgunduz, Ferreira, Niemi Lower incidence infection Salam, Ang, Saeadi Shorter hospital stay Wang, Ferreira, Fucile, Gonzalez, Ho, Niemi Better development Abdallah, Fucile, Procianoy, Hu, AlvarezLower Less parent stress Afand, Holditch? The author tolerance, and earlier discharge in preterm infants given the concluded, however, that the review was based on a small massage. Although 611 articles were retrieved, only 17 experimental studies, one pilot randomized controlled studies met criteria.

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Guidelines for sibling visits should be established to blood pressure chart for child buy cheap lopressor 50mg on-line maximize opportunities for visit ing and to hypertension specialist cheap lopressor 100 mg with visa minimize the risks of transmission of pathogens brought into the hospital by young visitors arteria occipital discount lopressor 100mg visa. Guidelines may need to arteria coronaria c x generic 50mg lopressor with amex be modifed by local nursing, pediatric, obstetric, and infectious diseases staff members to address specifc issues in their hospital settings. These interviews should be documented, and approval for each sibling visit should be noted. No child with fever or symptoms of an acute infection, including upper respiratory tract infection, gastroenteritis, or cellulitis, should be allowed to visit. Siblings who recently have been exposed to a person with a known communicable disease and are susceptible should not be allowed to visit. Before and during infuenza season, siblings who visit should have received infuenza vaccine. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodefciency virus. Adult Visitation Guidelines should be established for visits by other relatives and close friends. Medical and nursing staff mem bers should be vigilant about potential communicable diseases in parents and other adult visitors (eg, a relative with a cough who may have pertussis or tuberculosis; a parent with a cold visiting a highly immunosuppressed child). Before and during infuenza season, it is prudent to encourage all visitors to receive infuenza vaccine. Adherence to these guide lines especially is important for oncology, hematopoietic stem cell transplant units, and neonatal intensive care units. Guidelines for pet visitation should be established to minimize risks of transmission of pathogens from pets to humans or injury from animals. The specifc health care setting and the level of concern for zoonotic dis ease will infuence establishment of pet visitation policies. The pet visitation policy should be developed in consultation with pediatricians, infection-control professionals, nursing staff, the hospital epidemiologist, and veterinarians. Basic principles for pet visitation poli cies in health care settings are as follows :1. No rep tiles (eg, iguanas, turtles, snakes), amphibians, birds, primates, ferrets, or rodents should be allowed to visit. The pet should be free of obvious bacterial skin infections, infections caused by superfcial dermatophytes, and ectoparasitic infec tions (feas and ticks). All contact should be supervised throughout the visit by appropriate personnel and should be followed by hand hygiene performed by the patient and all who had contact with the pet. Supervisors should be familiar with institutional policies for managing animal bites and cleaning pet urine, feces, or vomitus. For patients who are immunodefcient or for people receiving immunosuppressive therapy, the risks of exposure to the microfora of pets may outweigh the benefts of contact. These sites should have dressings that provide an effective barrier to pet contact, including licking, and be covered with clothing or gown. Concern for contamination of other body sites should be considered on a case-by-case basis. These animals are not pets, and separate policies should govern their uses and presence in the hospital according to the American Disabilities Act recommendations. Infection Control and Prevention in Ambulatory Settings Infection control and prevention is an integral part of pediatric practice in ambula tory care settings as well as in hospitals. All health care personnel should be aware of the routes of transmission and techniques to prevent transmission of infectious agents. Written policies and procedures for infection prevention and control should be developed, implemented, and reviewed at least every 2 years. Key principles of infection prevention and control in an outpatient setting are as follows: 1 Centers for Disease Control and Prevention. Guideline for isolation precautions: preventing transmission of infectious agents in health care settings 2007. Policies for children who are suspected of having contagious infections, such as vari cella or measles, should be implemented. Immunocompromised children and neonates should be kept away from people with potentially contagious infections. In health care settings, alcohol-based hand products are preferred for decon taminating hands routinely. Soap and water are preferred when hands are visibly dirty or contaminated with proteinaceous material, such as blood or other body fuids. Alcohol is preferred for skin preparation before immunization or routine venipuncture. Skin preparation for inci sion, suture, or collection of blood for culture requires 70% alcohol, alcohol tinctures of iodine (10%), or alcoholic chlorhexidine (>0. The use of safer medical devices designed to reduce the risk of needle sticks should be implemented. Sharps disposal containers that are impermeable and puncture resistant should be available adjacent to the areas where sharps are used (eg, areas where injections or venipunctures are performed). Sharps containers should be replaced before they become overflled and kept out of reach of young children. Policies should be established for removal and the disposal of sharps containers consistent with state and local regulations. Physicians can prepare patients and families about the need for private time by educating both parents and pre adolescents about the need for confdentiality as adolescence approaches. For adolescent females who are immunosuppressed or immunocompromised, yearly Papanicolaou smears should begin with the initiation of consensual sexual intercourse or with a history of nonconsensual sexual intercourse. Sexually active adolescent females should be screened at least annually for chlamydia and gonorrhea. All adolescents should receive hepatitis B virus immunization if they were not immunized earlier in childhood. Hepatitis A vac cine should be offered to adolescent males who have sex with males (see Recommended Childhood and Adolescent Immunization Schedules, Fig 1. Patients and their partners treated for gonorrhea, Chlamydia trachomatis infection, and trichomoniasis should be advised to refrain from sexual intercourse for 1 week after completion of appropriate treatment. Retesting to detect therapeutic failure (tests of cure) for patients who receive recommended treatment regimens for Neisseria gonorrhoeae or C trachomatis infection is not recommended unless therapeutic adherence is in question or symptoms persist. Repeat testing is recommended for these infections within 3 months because of the likelihood of reinfection as a result of nontreatment of a current sexual partner and/or new infection from a new sexual partner. Therefore, tests that allow for isolation of the organism and have the highest specifcities must be used. Specimens for culture to screen for N gonorrhoeae and C trachomatis should be obtained from the rectum and vagina of girls and from the rectum and urethra of boys. Specimens for culture to screen for N gonorrhoeae also should be obtained from the pharynx, even in the absence of symptoms. Culture and nucleic acid hybridization tests require female endocervical or male urethral swab specimens. Endocervical specimens for culture are not required for prepubertal girls but are required for culture of C trachomatis and N gonorrhoeae if the female is pubertal or postmenarcheal. If vaginal discharge is present, specimens for wet mount for Trichomonas vaginalis and wet mount or Gram stain for bacterial vaginosis may be obtained as well. Completion of the hepatitis B immu nization series should be documented, or the patient should be screened for hepatitis B surface antibody. Anogenital gonorrhea in a prepubertal child indicates sexual abuse in virtually every case. All confrmed cases of gonorrhea in prepubertal children beyond the neonatal period should be reported to the local child protective services agency for investigation. In an infant or toddler in diapers, genital herpes may arise from any of these mechanisms. In a prepubertal child whose toilet-use activities are independent, the new occurrence of genital herpes should prompt a careful investigation, including a child protective services investigation, for suspected sexual abuse. In a perinatally infected infant, vaginal discharge can persist for several weeks; accordingly, intense social investigation may not be warranted. However, a new diagnosis of trichomoniasis in an older infant or child should prompt a careful investigation, including a child protective services investigation, for suspected sexual abuse. Although hepatitis B virus, scabies, and pediculosis pubis may be transmitted sexually, other modes of transmission can occur. The discovery of any of these conditions in a pre pubertal child does not warrant child protective services involvement unless the clinician fnds other information that suggests abuse.

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The extent of disease is relevant in the determination of what kind of therapy will be most efficacious arteria carotida externa cheap lopressor online mastercard. The aims of therapy include the treatment of active disease followed by maintenance of remission hypertension images buy 50 mg lopressor amex. Treatment should successfully suppress active inflammatory disease medically and attempt to pulse pressure 32 order 12.5mg lopressor fast delivery conserve the small bowel pulse pressure 48 buy lopressor cheap. Surgery should be reserved for managing complications (fistulae and abscesses) as well as treating obstruction. Symptoms such as fever, anorexia, crampy pain, and abdominal tenderness should abate within the first few days or weeks of treatment. If symptoms do not respond promptly, the physician must suspect obstruction, abscess, or an error in diagnosis. Aminosalicylates have multiple anti-inflammatory effects that are primarily topical (mucosal), not systemic. The side effects associated with sulfasalazine therapy are common and related to the sulfapyridine component of the drug. These side effects, which include headache, dyspepsia, malaise, nausea, vomiting and anorexia, are often dose related with the exception of osalazine (dipentum), which can cause diarrhea. These drugs have also been evaluated for use in maintenance therapy with inconsistent results. Benefit has been demonstrated, however, with 3 g doses in reducing endoscopicendoscopic and clinical evidence of disease process in postoperative recurrence studies. Metronidazole is the most commonly used antibiotic and its efficacy is comparable to sulfasalazine. Metronidazole has been effective in treatment of perianal disease and has transiently reduced recurrence of the disease process after ileal resection. Patients with predominantly ileal involvement are the most responsive (Figure 20). Significant benefit was noted in a large controlled study in steroid-treated patients for all disease locations. If there is evidence of osteopenia or osteoporosis, therapy with a bisphosphonate or calcitonin is indicated. Weight-bearing exercise, supplemental calcium, and vitamin D are also used, but care must be taken in patients with a history of nephrolithiasis. Topical steroid drugs (budesonide) have been used in oral delayed-release formulations for site-specific delivery of active steroids. Low-dose budesonide has not yet been proven efficacious for the prevention of relapse. These preparations are currently available in Canada and Europe but not in the United States. These drugs are thought to alter the immune response by inhibition of natural killer cell activity and suppression of T-cell function. Immunomodulator therapy has been shown to be more effective than steroids as a maintenance therapy and is generally well tolerated. However, potential side effects include fever, rash, nausea, leukopenia and hepatitis. Pancreatitis may occur in 3?15% of patients with prompt resolution with drug cessation. Immunomodulators are indicated for patients with disease refractory to conventional therapy and as a mechanism for steroid sparing. Another potent T cell inhibitor, cyclosporine, has demonstrated rapid onset of action. The use of this drug remains controversial and requires further investigation and comparison trials. The drug is well tolerated and potential toxicity (hepatic fibrosis and bone marrow suppression) is uncommon with consistent monitoring of liver enzymes and blood counts. Common side effects may include diarrhea, nausea, or vomiting, which can be reduced with folic acid supplementation. In a multicenter trial using weekly intramuscular or subcutaneous injections, clinical remission was maintained during a 16-week trial and half of the patients continued to show sustained responses at one year. Biologic Therapies Infliximab (Remicade) is a potent new biologic agent that offers potential for the treatment of inflammatory bowel disease. For patients with disease refractory to immunomodulators and those with perianal fistulizing disease, benefit may be achieved from therapy with this new chimeric monoclonal antibody that targets tumor necrosis factor-alpha. Preliminary evidence indicates that more than 60% of patients receiving a single infusion will have a clinical response. This drug has also shown utility in sustaining clinical remission with re-infusion at 8-week intervals. Drawbacks include the need for multiple dosing, a concern for developing lymphoma, and limited long-term follow-up information. Enteral nutrition?involving monomeric, oligomeric, or polymeric diets used for 1?2 months may provide short-term remissions in approximately 70% of patients. Total parenteral nutrition therapy instituted for 2?3 weeks in medically refractory patients can induce remission in approximately 60% of cases (although most patients relapse). This improvement, however, must be supported by additional medical therapy such as an immunomodulator; without it, most patients relapse when they resume enteral feeding. Late in the disease, medical treatment may provide patients with partial obstruction a several-month reprieve from surgery, but they will eventually require resection. Surgical results are improved if nutritional deficits and active disease have been managed preoperatively. Laparoscopically assisted surgery may be possible in patients with adequate nutrition repletion and the absence of phlegman fistulae or numerous adhesions. Blood levels should be monitored every 3 months, including white blood cell count to avoid leukopenia and bone marrow suppression. Many clinicians report that the antibiotics used to induce remission continue to maintain remission (although no data are available to support this). Metronidazole (at a rate of 20 mg/kg) administered for 3 months after surgical resection has also been shown to be effective postoperatively for up to 12 months. Infusion of Infliximab at 8-week intervals also has shown promising results in maintaining remission. Patients require surgery earlier if they develop intra-abdominal abscesses or the rare free perforation. Unfortunately, 50?60% of patients who undergo surgery develop recurrent disease within 10 years. Aggressive transmural disease (abscesses or free perforation) tends to recur sooner. Physicians usually delay definitive resection of the involved bowel and fistulous tracts (Figure 21) until they have controlled the inflammatory reaction and corrected malnutrition. In the presence of a severe protein-losing enteropathy, surgery should not be delayed. If the bowel is resected when the disease is active, the recurrence rate (within 3?4 years) approaches 50%. Abscesses and Fistulae Abscesses and fistulae are the products of extension of a mucosal fissure or ulcer through the intestinal wall into another loop of bowel or into extra-intestinal tissue. Abscesses are caused by the leakage of intestinal contents through a tract into the peritoneal cavity. The infection is walled off by surrounding tissue, unlike free perforation, which causes generalized peritonitis. Extension of this tract through adjacent viscera, or through the abdominal wall to the skin, results in a fistula. The typical clinical presentation is fever and abdominal pain, often with tenderness and abdominal mass. Simple drainage of an abscess may not provide adequate therapy because of persistent communication between the abscess cavity and intestinal lumen. In such circumstances, drainage may result in the formation of an enterocutaneous portion of the intestine containing the abscess (see Figure 21). After adequate drainage and reduction of inflammation, often accompanied by bowel rest and total parenteral nutrition, the involved bowel segment is resected.

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The mean age of children with blunt aortic injury is 12 years old hypertension in african americans generic lopressor 12.5 mg with visa, and less than 10% occurs in children younger than 10 years of age blood pressure bottom number low cheap lopressor online amex. Motor vehicle crashes are the most common cause of aortic injury and up to blood pressure herbs buy cheap lopressor 50mg 85% of patients die at the scene hypertension jnc 7 ppt order lopressor amex. The mechanism of thoracic aortic injury is thought to be secondary to sudden deceleration of the mobile aortic arch against the fixed descending aorta at the level of the ligamentum arteriosum, resulting in a sheer injury distal to the left subclavian artery. Thus, high energy blunt trauma with rapid deceleration or multi-system injury should be approached with a high degree of suspicion. A screening chest x-ray for thoracic trauma may identify radiographic findings suggestive of aortic injury, including a widened mediastinum, obscured aortic knob, ?apical capping" or pleural blood above the apex of the lungs, and depression of the left mainstem bronchus. In cases where results are equivocal, catheter-directed angiography may be necessary. Since these patients often have other associated injuries, prioritization in management is essential. Life threatening issues involving airway, breathing, and circulation are addressed first. In the face of intra-abdominal hemorrhage and hemodynamic instability, laparotomy should be performed before any other procedure, including aortography or aortic repair. Stable patients are otherwise admitted to the intensive care unit for further resuscitation and strict heart rate and blood pressure control until definitive care is appropriate. Short acting b-blockers, such as esmolol, are preferred to reduce shear stress on the aortic wall and risk of free rupture. In the pediatric population, open repair for aortic injury is the standard management. The operative procedure of choice for traumatic aortic injury repair is the ?clamp and sew technique. This procedure is performed by occluding the proximal aorta and repairing the aorta without establishing a bypass for distal perfusion. This procedure avoids the need for distal vascular cannulation and, more importantly, anti-coagulation, which would increase the risk of bleeding in a multiply injured patient. Although this procedure is the simplest and fastest technique for aortic repair, it has a higher risk of paraplegia and renal failure. Traumatic Chylothorax Non-iatrogenic traumatic chylothorax is extremely rare in children with only sporadic case reports of chylothorax occurring in children after blunt trauma. The thoracic duct is the main vessel of the lymphatic system that originates from the cisterna chili in the abdominal cavity at the level of the second lumbar vertebrae. It travels on the right anterior surface of the vertebral column in the cephalad direction to enter the posterior mediastinum through the aortic hiatus of the diaphragm. The duct then crosses to the left side of the vertebral column between the fourth and sixth thoracic vertebrae. The duct then terminates at the junction of the left subclavian and internal jugular vein. Due to its proximity to the vertebral column, it is susceptible to traumatic disruption 319 from compressive or acceleration-deceleration forces. Although traumatic chylothorax in children has been described after motor vehicle crashes, it is also seen after child abuse. Traumatic chylothorax usually has a cryptogenic and sometimes delayed presentation, because the development of a clinically significant chylous effusion may take up to 24 hours to accumulate. In the acute setting of trauma, clinical examination may be similar to pleural injury or hemothorax, with findings of respiratory distress or diminished breath sounds on auscultation. Regardless, evaluation remains unchanged, as these findings should prompt further evaluation with a chest x-ray. The identification of a pleural effusion in the acute setting of trauma is a hemothorax, until proven otherwise. Diagnosis of a chylothorax is established with the evacuation of milky-white pleural fluid. Fluid analysis demonstrating triglycerides levels > 110 mg/dL, lymphocytes > 1000cells/mL, presences of chylomicrons, and low cholesterol levels is confirmatory. Due to its association with non-accidental trauma, further evaluation of the child is necessary for concomitant injuries. Chylothorax can result in respiratory, nutritional, and immunologic compromise, due to losses in the pleural space. Management includes chest tube decompression, dietary modification, and nutritional support. The primary goal of therapy is to decrease chyle flow to allow closure of the disrupted thoracic duct. The patient may be trialed on a low-fat diet consisting of only 320 medium-chain triglycerides, which is absorbed directly into the portal system, rather than the lymphatics. If drainage persists or increases, the patient should be made nothing by mouth and total parental nutrition should be initiated. Octreotide is a long-acting somatostatin analog, which acts directly on vascular somatostatin receptors, may also be considered for adjunctive therapy to decrease lymph fluid excretion. Traumatic chylothorax typically resolves with non-operative management within 10 to 14 days. However, when conservative measures fail, operative ligation of the thoracic duct through thoracotomy or video-assisted thoracic surgery may be necessary. Penetrating Lung Injuries Penetrating wounds occur almost exclusively in teenagers in the pediatric population and account for 10% to 15% of pediatric trauma cases. In comparison to blunt chest trauma, penetrating chest injuries are associated with higher rates of operative intervention and mortality. Stab wounds to the chest should be evaluated for penetration into the thoracic cavity. Suggestive physical exam findings include crepitus in the subcutaneous tissue or active air movement through the wound itself. Placement of a three sided occlusive dressing over the wound can be a life-saving maneuver and prevents the precipitation of a tension pneumothorax. Fortunately, the majority of stab wounds to the chest in children do not go beyond the muscle wall. Thoracic bullet penetration injuries can result in significant tissue damage from direct missile penetration or secondary missiles from bone fragments. Furthermore, bullets may travel in an unpredictable trajectory, necessitating complete evaluation of intrathoracic structures, including the mediastinum. A chest X-ray is obtained to assess for pneumothorax, hemopneumothorax, or mediastinal air. Tube thoracostomy should be placed for pneumothorax or hemothorax, and a persistent air leak should prompt further evaluation for tracheobronchial tree injury. Operative criteria for bleeding include > 20 mL/kg blood loss on initial tube placement or persistent bleeding at a rate of 3cc/kg per hour. In cases where significant bleeding occurs from a missile tract through the lung parenchyma, a pulmonary tractotomy should be performed. The entry and exit wounds on the lung are first identified, and a penrose drain is subsequently placed through the tract to assist with retraction. A gastrointestinal anastomosis stapler is then placed into the tract and fired to complete the tractotomy. This 322 allows exposure of the injured lung and hemostasis can be achieved with selective suture ligation of bleeding vessels or tissues. The entry and exit wounds should be left open to allow drainage and the suture line should be tested for leak at the end of procedure. Penetrating Injuries to the heart Penetrating injuries to the heart in children are rare. The right ventricle is the most often injured cardiac chamber, followed by the left ventricle, because of their anterior location in the chest. Clinical manifestations of tamponade physiology include tachycardia, hypotension, distended neck veins, muffled heart sounds, and pulsus paradoxus. In unstable patients with hemodynamic compromise, bedside pericardiocentesis or subxiphoid pericardial window can be life-saving, temporizing maneuvers. Regardless of hemodynamic stability, definitive surgical repair for penetrating cardiac injury is necessary. The chest is entered through a left 323 anterolateral thoracotomy or sternotomy, and the pericardium is opened sharply with scissors taking care not to injure the phrenic nerve. Depending on the size of the cardiac wound, a finger may be used to occlude the laceration. Repair is then performed with nonabsorbable mattress sutures over Teflon pledgets.

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