Pediatric Blunt Abdominal Trauma

Stephen Wegner, MDJames E.Colletti, MDDonald Van Wie, MD

Intern 林士森

Preface

Abdominal trauma is a leading cause of morbidity and mortality in children.

Discussing issues ： Key issues to help for efficiently and successfully

evaluate and manage blunt pediatric abdominal trauma.

Select organ trauma Disposition issues

Mechanisms of injury

Motor vehicle collisions and automobile versus pedestrian accidents and falls are associated with the greatest increased risk.

Children only wearing a lap belt restrains, automobile versus bicycle accidents, all-terrain vehicle accidents, handlebar injuries, sports or nonaccidental trauma.

Abdomen-to-handlebar collisions are associated with a high risk of small bowel and pancreatic trauma.

Past medical history

Medical conditions that affect children’s neurologic or developmental baseline are important. Autism, cerebral palsy, or other medical condition

s that result in mental or physical handicaps. Hemophilia Being anticoagulated or receiving antiplatelet ther

apy EB virus infection

Physical examination

Abnormality in abdominal PE should be considered an indicator of IAI.

Other comorbid injuries or factors predict abdominal injury.

A negative examination and absence of comorbid injuries do not totally rule out

IAI.

Physical examination

Holmes and colleagues ： Abdominal tenderness

Cotton and colleagues ： Abdominal tenderness, ecchymosis, and abrasion

s as positive findings of IAI. Isaacman ：

Abnormal PE findings plus an abnormal urine analysis to be a highly sensitive screen of IAI.

Physical examination

Associated comorbid findings/injuries ： Femoral fracture (Holmes) Low SBP (Holmes) Decreased mental status

GCS<13 ： mild indicator of IAI (Holmes) GCS<10 ： 23% had significant IAI (Beaver)

Laboratory findings

The most valuable lab tast include the CBC, liver function tests ， and urine analysis.

Amylase, lipase, coagulation studies, genaral chemistries.

Laboratory findings

Select organ trauma

Spleen and liver are the most commonly injured organ.

Hepatic trauma Abdominal CT (enhanced) is accurate in localizin

g the site and extent of liver injuries and providng vital information.

Subcapsular, intrahepatic hematoma, contusion, cascular injury, biliary disruption.

American association for the surgery of trauma liver injury scale

Select organ trauma

Grade Description

I Subcapsular hematoma <1cm in maximal thickness, capsular avulsion, superficial laceration<1cm deep, and isolated periportal blood tracking

II Parenchymal laceration 1-3cm deep and parenchymal/subcapsular hematomas 1-3cm thick

III Parenchymal laceration>3cm deep and parenchymal or subcapsular hematoma >3cm in diameter

IV Parenchymal/subcapsular hematoma >10 cm in diameter, lobar destruction, or devascularization

V Global destruction or devascularization of the liver

VI Hepatic avulsion

Select organ trauma

Splenic trauma LUQ abdominal tenderness, l’t lower rib fracture, o

r evidence of l’t lower chest/abdominal contusion. managed with bed rest, frequent examination, ser

ial Hb monitoring. Massive disruption and hemodynamic unstability

– absolute surgical indication. Splenic rupture and EB virus infection.

Select organ trauma

Grade Description

I Subcapsular hematoma < 10% of surface area or capsular tear of < 1cm deep

II Subcapsular hematoma of <10-50% of surface area, intraparenchymal hematoma <5cm in diameter, or laceration of 1-3cm deep and not involve trabecular vesse

III Subcapsular hematoma >50% surface area or expanding and ruptured and subcapsular or parenchumal hematoma, intraparenchymal hematoma >5cm or expanding, or laceration >3cm deep or involving trabecular vessels

IV Laceration involving segmental or hilar vessels with devascularization >25% of the spleen

V Shattered spleen or hilar vascular injury

Select organ trauma

Intestinal trauma Peforation, intestinal hematoma, and mesenteric t

ears with bleeding. Seatbelt sign CT with subtle signs such as bowel wall edema. Abdominal pain that worsens or persists and persi

stent emesis must be investigated with serial examinations.

Select organ trauma

Pancreatic trauma Falls onto handlebar result in a crush force applied to upper

abdomen. Persistent tenderness should indicate further investigation. Overall prognosis is good.

Renal trauma Posterior abdomen and retroperitoneum blunt trauma Significant flank/abdominal pain and hematuria is indication

for CT scan.

Management and disposition

Stabilizing treatment with ATLS and PALS. Immediate fluid resuscitation CBC,LFTs,UA Transfusion Surgical consultation

Hemodynamically stable CBC,LFTs,UA Abnormal lab finding CT scan

Length of hospitalization and return to activity

Spleen or liver injury grade

Hospital day Activity day

Grade I-III Injury grade +1 day

Injury grade+2weeks

Grade IV 1 day intensive care + injury grade

Injury grade+2weeks

Thanks for your attention ！