Abdominal Trauma

Published on 26/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1385 times

Chapter 50 Abdominal Trauma

Ronald A. Furnival, MD

1 What are the most common mechanisms of injury for pediatric patients with abdominal trauma?

Across the United States, more than 85% of pediatric patients with abdominal trauma are injured from blunt mechanisms, most commonly motor vehicle collisions (as passengers or pedestrians), and from falls. In some urban emergency departments (EDs), penetrating injuries from gunshots or stab wounds in adolescents account for up to 40% of pediatric abdominal injuries.

2 Is the age of a patient a factor for some abdominal injuries?

Yes. Young infants have a larger portion of the liver and spleen exposed below a more flexible rib cage, placing those organs at greater risk for injury with upper abdominal and lower thoracic trauma. Infants and preschool children may be victims of child abuse, with liver, pancreatic, and duodenal injuries resulting from a direct blow to the abdomen. In addition, young preschool children involved in auto crashes may have injuries related to lap belts.

3 What is the “lap-belt complex” seen with motor vehicle crash victims?

This complex of injuries results during an automobile crash when the seat belt rides up from the pelvic bones and over the softer abdominal viscera in an improperly restrained child not sitting in a car seat or booster seat. Young children may have some or all of the lap-belt complex. A visible abdominal wall bruise or mark from the lap belt may be present. A perforated or ischemic colon is a unique injury associated with lap belts, and splenic injury as well as associated spinal injury or vertebral fracture (lumbar fracture) also are possible. The lap-belt complex is the most common cause of blunt pediatric bowel injury.

Lutz N, Nance ML, Kallan MJ, et al: Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg 39:972–975, 2004.

Sokolove PE, Kupperman N, Holmes JF. Association between the “seat belt sign” in intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med 2005; 12:808–813.

4 Which injuries may result from a direct blow to the midabdomen, such as from a bicycle handle bar or abuse?

Duodenal hematoma, pancreatic trauma, and injury to the left lobe of the liver have been associated with handle bar injury. Infants and preschool children may also be victims of child abuse, with a potentially delayed presentation of the above injuries from a fist to the upper abdomen.

Gaines BA, Shultz BS, Morrison K, Ford HR: Duodenal injuries in children: Beware of child abuse. J Pediatr Surg 39:600–602, 2004.

Nadler EP, Potoka DA, Shultz BL, et al: The high morbidity associated with handlebar injuries in children. J Trauma 58:1171–1174, 2005.

5 When is it appropriate to assess for abdominal injury in the pediatric patient with multiple trauma?

As outlined by the Advanced Trauma Life Support program, the pediatric patient with multiple injuries must initially have a primary survey of the ABCs to identify and begin therapy for immediately life-threatening injuries. Once the primary survey is completed, the secondary survey to identify any additional injuries, including the abdominal evaluation, should begin. The secondary survey may include laboratory testing and imaging studies for the diagnosis of all injuries.

American College of Surgeons’ Advanced Trauma Life Support program. Available at: www.facs.org/trauma/atls/index.html

6 What physical examination findings are useful for identifying abdominal injuries?

The physical examination during the secondary survey is intended to recognize that an intra-abdominal injury exists, rather than to identify a specific diagnosis. Physical findings, including absent or diminished bowel sounds, evidence of peritoneal irritation with involuntary guarding or rebound, abdominal distention, abdominal wall abrasions or bruising, abdominal or flank tenderness, lower chest wall injury, or unexplained hypotension, may indicate the presence of an intra-abdominal injury. Gently palpate the pelvic bones for tenderness or instability since pelvic fractures have been associated with an increased risk of intra-abdominal injury. Inspect the perineum for injury, including extravasation of blood or urine. Finally, perform a rectal examination for palpable mass, lacerations, pelvic brim fracture, or blood.

Perform serial abdominal examinations to look for evidence of delayed clinical deterioration. (The pediatric patient with a small bowel perforation may develop physical findings 6–24 hours after injury.) Look for increasing abdominal girth and tenderness. Serious abdominal injury is possible even without bruises on the abdomen.

7 What is the appropriate management of a child with a normal abdominal examination who appears to be at low risk for injury?

The patient with stable vital signs, normal mental status, normal results on screening laboratory tests, and a normal abdominal examination on serial evaluations may be discharged from the ED after a period of observation.

Cotton BA, Beckert BW, Smith MK, et al: The utility of clinical and laboratory data for predicting intra-abdominal injury among children. J Trauma 56:1068–1075, 2004.

Holmes JF, Sokolove PE, Brant WE, et al: Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 39:500–509, 2002.

8 Why is gastric distention following abdominal trauma concerning?

Children often develop gastric distention after abdominal trauma from crying and swallowing air. This can interfere with respiration by altering motion of the hemidiaphragm. Young children are primarily diaphragmatic breathers, so this can be serious. Also, gastric dilatation increases the risk of vomiting. Children often have a full stomach when injured, and vomiting could lead to aspiration of stomach contents. Gastric distention also makes abdominal examination difficult. Place a nasogastric tube to decompress the stomach.

9 What is the treatment for the child with an apparent abdominal injury and clinical instability?

The initial care for the unstable pediatric patient with abdominal trauma must begin with the ABCs. Once airway and breathing are secure, circulation is addressed with an initial infusion of an isotonic crystalloid solution (normal saline or lactated Ringer’s solution) of up to 40–60 mL/kg via the IV route. For the patient who continues to be unstable, a transfusion with packed red blood cells is indicated. If the transfusion requirement exceeds 40 mL/kg during the initial resuscitation, or with separate transfusions during the hospital course, surgical exploration must be considered for ongoing bleeding. Intra-abdominal hemorrhage is the primary cause of early death in pediatric abdominal trauma.

10 Which laboratory studies are useful for evaluating patients with abdominal trauma?

An initial hemoglobin/hematocrit (or as part of a complete blood count) can serve as a baseline; subsequent decreases may be evidence of internal bleeding. Hematuria, either gross or microscopic (> 5 red blood cells/high-powered field) on urinalysis, may indicate the presence of genitourinary or other internal organ injury. About 30% of pediatric trauma patients with hematuria have liver or splenic injury, demonstrating the utility of hematuria as a nonspecific marker for intra-abdominal injury. The liver function tests aspartate aminotransferase (AST) and alanine aminotransferase (ALT) have been valuable markers of injury in several studies, with levels exceeding 200 and 100 IU/L, respectively, an indicator of possible liver injury. A serum amylase level may also serve as a marker for pancreatic or bowel injury, but given the low sensitivity and specificity of the initial value, serial levels are more useful as evidence of evolving pancreatic injury.

Additional laboratory studies should include a type and crossmatch for the patient requiring (or who may require) blood transfusion for hemodynamic instability, a serum pregnancy test for the adolescent female trauma patient, blood gases for the patient requiring respiratory support, and coagulation studies for the multiply injured patient with concomitant head injury. Some recommend an alcohol and drug screen for adolescent trauma victims.

Cotton BA, Beckert BW, Smith MK, et al. The utility of clinical laboratory data for predicting intrabdominal injury among children. J Trauma 56:1068–1074, 2004.

11 What is the role of computed tomography (CT) for pediatric abdominal trauma?

For the clinically stable pediatric patient with blunt trauma (those without any of the clinical indications for laparotomy), CT continues to be the gold standard for abdominal injury diagnosis, with sensitivity, specificity, and accuracy all exceeding 95%. Advantages of CT over other imaging modalities include the ability to noninvasively assess anatomic organ injury, perfusion, renal function, and the retroperitoneal space and lower chest. CT seldom affects the decision for laparotomy for solid organ injury, which is usually based upon the patient’s clinical condition, but CT does have a greater role in decision making for hollow viscous injuries, which are often clinically subtle.

Disadvantages of CT include a limited utility for the unstable patient (it is difficult to resuscitate an unstable patient in a CT suite), radiation exposure for the patient (and caregivers), and limited (60–80%) sensitivity for the diagnosis of pancreatic or bowel injury. Some believe CT scans are overused and that better decision rules are needed to limit these studies in children.

Fenton SJ, Hansen KW, Meyers RL, et al. CT scan and the pediatric trauma patient—are we overdoing it. J Pediatr Surg 398:1877–1881, 2004.

Peters E, LoSasso B, Foley J, et al. Blunt bowel and mesenteric injuries in children: Do nonspecific computed tomography findings reliably identify these injuries. Pediar Crit Care Med 7:551–556, 2006.

12 What is the role of ultrasonography (US) for pediatric abdominal trauma?

A number of studies of adults, and a few involving pediatric patients, advocate US over CT for the initial evaluation of blunt abdominal trauma. US is primarily used to identify the presence of intra-abdominal fluid, usually a hemoperitoneum in the patient with blunt trauma, with sensitivity and specificity approaching 90%. The chief advantage of US over CT is the ability to perform an evaluation in the trauma suite during the initial resuscitation, even for the unstable patient, in a rapid (generally < 5 minutes) and noninvasive manner.

Since the presence of hemoperitoneum is an indirect marker of organ injury, and is not an indication for laparotomy in pediatric trauma, most authors recommend follow-up with CT or other imaging for the patient at risk for an intra-abdominal injury. Other disadvantages of US include the need for additional imaging for the patient with multiple injuries (i.e., head or thoracic CT) and a limited ability to diagnose solid organ, hollow viscous, or bony injuries.

Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 42:1588–1594, 2007.

Mutabagani KH, Coley BD, Zumberge N, et al: Preliminary experience with focused abdominal sonography for trauma (FAST) in children: Is it useful? J Pediatr Surg 34:48–54, 1999.

Patel JC, Tepas JJ: The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children. J Pediatr Surg 34:44–47, 1999.

13 So which is better, CT or US?

Good question. If the accurate diagnosis of all intra-abdominal injuries is necessary for nonoperative management of the patient with blunt trauma, as some authors contend, then CT has the clear advantage. However, if the patient is clinically unstable and cannot leave the resuscitation suite, US has the advantage. For the stable patient with a possible intra-abdominal injury, the benefit of US versus CT on clinical decision making, management outcome, and medical cost has yet to be fully defined.

14 What is FAST? Is it useful in children?

FAST is focused abdominal sonography for trauma. The FAST exam is helpful to identify intrabdominal free fluid and parenchymal injury. It is advantageous because it is a rapid, convenient, inexpensive tool that does not expose a child to radiation. It is done at the bedside in some emergency departments, so the patient does not need to be transported. There are few studies to evaluate its utility in children. One study found FAST to be inadequate to independently identify intraabdominal trauma, since free fluid may not be seen in many cases of blunt abdominal trauma. Other studies imply the FAST exam should be used as a screening tool and, if positive, a CT scan is needed to better identify in a hemodynamically stable patient.

Coley BD, Mutabagani KH, Martin LC, et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma 48: 902–906, 2000.

Eppich WJ, Zonfrillo MR. Emergency department evaluation and management of blunt abdominal trauma in children. Curr Opin Pediatr 19: 265–269, 2007.

15 What are the indications for laparotomy for pediatric abdominal trauma?

See Table 50-1.

Table 50-1 Indications for an Emergent Laparotomy for the Pediatric Trauma Patient

image Vital sign instability, despite fluid resuscitation, or blood transfusion requirement totaling > 40 mL/kg during the hospital course

image Peritoneal irritation on physical examination

image Gunshot wound to the lower chest or abdomen

image Stab wound of the abdomen, with vital sign instability, peritoneal irritation, or clinical evidence of organ injury

image Rectal or vaginal laceration

image Evisceration of abdominal contents

image Evidence of intestinal perforation (e.g., pneumoperitoneum on imaging studies, fecal content on diagnostic peritoneal lavage

image Evidence of renal vascular injury on imaging studies (controversial)

16 What is meant by the nonoperative management of blunt abdominal trauma in children?

Despite the long list of indications for laparotomy mentioned above, operative intervention is infrequently required for pediatric blunt abdominal trauma, and nonoperative management is the current standard of care for the majority of patients. With few exceptions, the need for an operation rests entirely with the patient’s clinical condition, rather than with specifics of the intra-abdominal organ injuries or the grade or severity of organ injury. Studies indicate that appropriately selected patients (i.e., those without surgical indications) have excellent overall outcomes, low transfusion rates, and few complications.

However, nonoperative does not mean nonaggressive or nonsurgical management. These patients must be closely monitored, often in the intensive care unit, with surgical supervision and adequate laboratory, blood bank, radiologic, nursing, and medical support. An aggressive and continuing reevaluation of the patient’s clinical condition is mandatory, with surgical exploration for any evidence of deterioration.

Stylianos S. Outcomes from pediatric solid organ injury; role of standardized care guidelines. Curr Opin Pediatr 17:402–406, 2005.

Venkatsh KR, McQuay N Jr. Outcome of management in stable children with intra-abdominal free fluid without solid organ injury after blunt abdominal injury. J Trauma 62:216–220, 2007.

17 How often do pediatric patients require operative versus nonoperative management of blunt abdominal injuries?

A number of studies dating back to the 1980s note that over 90% of pediatric patients with abdominal trauma may be successfully managed with nonoperative care. Delayed laparotomy rates at most centers have been < 1%, usually for recognition of an initially occult bowel injury, or for late intra-abdominal bleeding. Laparoscopic repair of bowel injuries in hemodynamically stable children seems to be less invasive and decreases hospital stay.

Studies show that splenectomy after injury is more likely at general hospitals than children’s hospitals, and more likely in non-trauma centers.

Bowman SM, Zimmerman FJ, Christakis DA, et al. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA 294:2611–2617, 2005.

Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 115:89–94, 2005.

Holmes JH, Wiebe DJ, Tataria M, et al. The failure of non-operative management in pediatric solid organ injury; a multi-institutional experience. J Trauma 59:1309–1313, 2005.

Streck CJ, Lobe TE, Pietsch JB, et al. Laproscopic repair of traumatic bowel injury in children. J Pediatric Surg 41:1864–1869, 2006.

KEY POINTS: ABDOMINAL TRAUMA

1 Nonoperative management is appropriate for > 90% of pediatric patients with an abdominal injury.

2 Clinical instability is the most important indication for an emergent laparotomy in the child with an abdominal injury.

3 Hemoperitoneum in the stable pediatric trauma patient is not an indication for laparotomy.

4 Physical examination findings in the child with a bowel perforation may be clinically silent for 6–24 hours.

5 Laboratory tests (hematocrit, urinalysis, aspartate aminotransferase, alanine aminotransferase) are excellent adjuncts to the physical examination to screen for an abdominal injury in the stable pediatric patient.

18 What is the clinical approach to penetrating abdominal trauma?

Because of their high velocity and penetrating ability, > 90% of gunshot wounds to the abdomen will result in organ injury requiring laparotomy. Stab wounds are typically of lower velocity, with less penetrating ability, and can be managed more selectively. Triple-contrast CT, laparoscopy, clinical observation, or local wound exploration have all been advocated to identify peritoneal penetration or intra-abdominal organ injury in the stable stab wound victim. Evidence of clinical instability, peritoneal irritation, pneumoperitoneum, hematuria, or rectal blood are all absolute indications for laparotomy for either the gunshot or stab wound patient.

Related posts:

Transport Medicine Chemical and Biological Terrorism Shock Apnea Electrical and Lightning Injuries Burns and Smoke Inhalation