AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Characteristics
• Epidemiology
• Initial Assessment and Evaluation
• Specific Considerations
• Multimedia
• References

INTRODUCTION

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• Epidemiology
• Initial Assessment and Evaluation
• Specific Considerations
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Trauma is the leading cause of morbidity and mortality in the pediatric population. Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children. Abdominal trauma can be associated with significant morbidity and may have a mortality rate as high as 8.5%. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children.

Management of abdominal injuries in children has evolved considerably in recent years. Nonoperative treatment of children with blunt abdominal trauma is successful in more than 95% of appropriately selected cases if trauma care providers have a thorough knowledge of the anatomy and physiology of the growing child. This article reviews the typical presenting signs, evaluation, and treatment of children with suspected abdominal injuries following trauma.

For excellent patient education resources, visit eMedicine's Wounds Center and Children's Health Center. Also, see eMedicine's patient education articles Puncture Wound and Bruises and Medscape's Trauma Resource Center.

CHARACTERISTICS

Section 3 of 8  

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• Characteristics
• Epidemiology
• Initial Assessment and Evaluation
• Specific Considerations
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Unique pediatric aspects of the anatomy and physiology of the abdomen contribute to the abdomen's biomechanical response to traumatic loads. The young child's abdomen is square and becomes more rectangular as the child matures. The abdominal wall of a child has thinner musculature than that of an adult, particularly during the first 2 years of life, providing less protection to underlying structures. The ribs are more flexible in the child, which makes them less likely to fracture. However, this increase in compliance makes them less effective at energy dissipation and, therefore, less effective at protecting the upper abdominal structures (eg, spleen, liver).

The solid organs are comparatively larger in the child than in the adult; therefore, more surface area is exposed, making the organ more at risk for injury. A lower fat content and more elastic attachments are typical of the intra-abdominal organs in children. These characteristics reduce the amount of energy absorption and may result in increased motility and vulnerability (eg, kidneys). The child's spleen has a thicker capsule than that of the adult, yet it is among the most commonly injured solid organs in blunt abdominal trauma. In the young child, the intestine is not fully attached within the peritoneal cavity (especially the sigmoid and right colon), potentially making it more vulnerable to injury due to sudden deceleration and/or abdominal compression.

The bladder extends to the level of the umbilicus at birth and is, therefore, more exposed to a direct impact to the lower abdomen. With age, the bladder descends to its retropubic position. The rapid growth of the spine during adolescence influences its anatomy and biomechanical properties, particularly in the lumbar area. In a child with a thin abdominal wall and who is poorly restrained (lap belt only), the fulcrum of a flexion injury would be at the body of the spine, which exposes it to a flexion-distraction injury (Chance fracture). Because of the unique compensatory mechanisms of the injured child, hypotension secondary to hypovolemic shock is a late and ominous event. Early aggressive fluid resuscitation is indicated in injured children. Because young children have a disproportionately larger body surface area and less thermoregulation, preserving core temperature during the care of an injured child is important.

EPIDEMIOLOGY

Section 4 of 8  

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• Epidemiology
• Initial Assessment and Evaluation
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Traumatic injuries continue to be the leading cause of death in children, far surpassing other causes. Abdominal trauma accounts for 8-10% of all trauma admissions to pediatric hospitals. More than 80% of traumatic abdominal injuries in children result from blunt mechanisms and are most commonly motor vehicle related.

Abdominal injuries may also result from falls or direct blows to the abdominal wall (eg, handlebar injury). Penetrating injuries in children are less common and result in 8-12% of the abdominal trauma admissions in most trauma centers. In the United States, firearm injuries are by far the most common cause of penetrating wounds. Patterns of organ injury vary by mechanism and are presented in Table 1.

Table 1. Pattern of Abdominal Organ Injury by Mechanism of Injury

INITIAL ASSESSMENT AND EVALUATION

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Any child with suspected abdominal trauma should be initially evaluated following advanced trauma life support (ATLS) guidelines.¹ A focused primary survey aimed at rapidly assessing the ABCs remains the initial priority. In addition, at the time of the primary survey, performing an abbreviated neurologic assessment (D) and completely exposing (E) the child to thoroughly search for injuries is appropriate. This is followed by a secondary survey, which consists of a head-to-toe physical examination to identify all traumatic injuries. The abdomen is typically evaluated during the secondary survey. A tertiary survey, usually performed 24 hours after admission, is also recommended and includes a follow-up head-to-toe examination to minimize the risk of missed injuries.

Fluid resuscitation is an important component of the management of abdominal injuries in children. An algorithm for volume replacement for the injured child (both hemodynamically stable and unstable) has been taught by the American College of Surgeons as part of the ATLS course and provides a good point of reference for the management of children with abdominal injuries (see Media file 8).¹

The physical examination should include inspection, auscultation, and palpation. Inspection of the abdomen may reveal distention associated with bleeding or intraperitoneal air. When a traumatic diaphragmatic hernia is present, a scaphoid abdomen might be observed. All abrasions and contusions should be documented and may indicate associated intra-abdominal injury. For example, skin ecchymosis from a lap belt injury may indicate a hollow organ injury and spinal fracture. Auscultation is helpful in determining the presence of intra-peritoneal fluid (dull to percussion) or free-air (tympani); however, performing it reliably in the trauma bay may be difficult because of ambient noise. Abdominal palpation reveals tenderness associated with injury in children who are neurologically healthy. Findings may include focal tenderness, which is often a result of abdominal wall contusion, or rebound tenderness, which suggests an intraperitoneal process, such as hemorrhage or perforation.

Laboratory testing is a routine component of the trauma evaluation. The baseline tests performed are typically determined according to the suspected severity of injury and individual institutional guidelines. A CBC count and urinalysis (UA) are the only initial tests routinely performed in most children with suspected intra-abdominal injuries. The CBC count provides a baseline blood count, and the UA has proven useful in screening for injury to the urinary tract. A positive UA for blood should prompt further evaluation because even microscopic hematuria can be associated with significant renal trauma.

Liver function tests (LFTs) and pancreatic enzyme tests have variable sensitivity and specificity for abdominal organ injuries and should not be relied on as screening tools. However, trends in findings from LFTs or pancreatic enzyme tests may be useful to monitor progress in the course of a liver or pancreatic injury. In all cases in which significant abdominal injury is suspected or present, a blood specimen for type and cross-match should be obtained.

CT scanning with double contrast (intravenous and oral) is the criterion standard for the assessment of the abdominal cavity in a hemodynamically stable child. Increasingly rapid scan acquisition times and better quality images make this modality ideal for trauma evaluation. Intravenous contrast is essential for the evaluation and accurate grading of solid organ injuries. Some reports have described the acute extravasation of contrast (blush) as a sign of acute hemorrhage.² Although such a sign has been associated with the need for surgical intervention in the adult, its clinical significance is still under evaluation in children. Oral contrast should be given to increase the sensitivity of CT scan images for the diagnosis of pancreatic, duodenal, and proximal bowel injuries.

The use of oral contrast in the immediate radiologic assessment of abdominal trauma has been questioned.³ Administration of oral contrast may delay the scheduling of the scan and, because it may induce vomiting, poses an aspiration risk. Thus, the use of oral contrast in the immediate assessment of abdominal trauma should be performed selectively and based on institutional best practice guidelines.

The focused assessment by sonography in trauma (FAST) examination has become a standard part of the initial evaluation of bluntly injured abdomens in adult trauma centers.⁴ It allows rapid assessment of the peritoneal cavity and can detect free fluid. In the pediatric population, the role of FAST is still unclear. FAST is highly sensitive for the detection of free intra-peritoneal fluid, but it is operator-dependent and lacks specificity. Detailed information regarding the grade of organ injury is not provided by the FAST examination.

In addition, the FAST examination produces a significant number of false-negative results (eg, solid organ injury without free intraperitoneal fluid), which may lead to inappropriate triage and management. Furthermore, because management protocols for solid organ injury in the pediatric population are highly dependent on accurate grading of the organ injury, FAST currently cannot replace CT scanning. Ongoing evaluation of its usefulness in pediatric trauma centers is necessary to validate and specify its utility.

Before the advent of CT scanning and FAST examination, diagnostic peritoneal lavage (DPL) was the modality of choice for the assessment of the injured abdomen. In current management algorithms, its use is significantly diminished. DPL may still be indicated when CT scanning is unavailable or in a hemodynamically unstable child with a suspected bleed from an intra-abdominal injury. In the ICU, DPL may also be useful in the assessment of the critically ill and traumatized child in whom an evolving intraperitoneal process is present. Although very sensitive for the detection of intra-abdominal blood and hollow visceral injuries, DPL is nonspecific and invasive and has associated morbidity.

SPECIFIC CONSIDERATIONS

Section 6 of 8  

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Penetrating trauma

Despite declining national trends in firearm-related injury, gunshot wounds (GSWs) are the most common cause of penetrating injuries in the pediatric age group and represent the leading cause of death in black males aged 15-24 years. Other causes of penetrating injuries include stab wounds, impalements, dog bites, and machinery-related accidents. The abdomen is injured in 25% of children with GSWs; of these wounds, 14% are fatal.

Because the vast majority of penetrating injuries to the abdomen require surgical intervention, preparation of the operating room should occur simultaneously with patient assessment. Determination of trajectory is imperative when evaluating a patient with a GSW. All entrance and exit wounds should be marked with radiopaque indicators, and plain radiographic films should be obtained. A thorough search for all missiles is important because many children with intra-abdominal injury from a GSW have remote entrance sites, such as the thigh, buttock, or chest. Remember that during exhalation, the diaphragm ascends to the level of the nipple; thus, injuries to the lower thorax may pose a risk to the intra-abdominal contents. Fifteen percent of children with an intra-abdominal injury also have injuries to other body regions; thus, a complete assessment in every child is needed.

In selected cases (eg, isolated right upper quadrant GSW), CT scanning is useful to evaluate the trajectory of a bullet and permits the evaluation of solid organ injury. For penetrating rectal injuries, triple-contrast (intravenous, oral, rectal) CT scanning may also be useful to help define the trajectory and extent of injury prior to intervention. When indicated, laparotomy for penetrating injuries should be expeditious and goal directed. A generous midline incision should be performed to allow evaluation of the entire abdomen. Upon opening, all 4 quadrants should be packed to control hemorrhage. The packing is then systematically removed, and each quadrant is inspected. The bowel should be thoroughly evaluated from esophagus to rectum. The surgeon should also be mindful of the potential injuries that may be present on the basis of trajectory. Management of specific injuries is similar to that in adults and is not covered in this article.

As a tool for both assessment and treatment of penetrating injuries to the abdomen, laparoscopy has proven use in several select clinical situations.⁵ In a hemodynamically stable child with a possible diaphragmatic injury, laparoscopy may help clarify the integrity of the diaphragm. In the setting of a tangential GSW when violation of the parietal peritoneum is unknown, laparoscopy allows excellent visualization of the entire peritoneal wall with minimal morbidity.

Blunt trauma

Blunt mechanisms of abdominal trauma predominate in the pediatric population. The management approach to injuries of the abdominal solid organs (liver, spleen, kidney, pancreas) has evolved from routine operative exploration to cautious observation. Solid organ injury pathways are now available to facilitate and optimize their management and have resulted in successful outcomes in more than 90% of cases. The American Association for the Surgery of Trauma (AAST) has established grading classifications for all solid organs based on anatomic descriptive criteria (see AAST Injury Scaling and Scoring System). These classifications should be used to describe all blunt injuries.

The decision to intervene operatively for a solid organ injury should be based on the physiologic response to the identified injury rather than the anatomic severity of injury. However, management guidelines, including postdischarge activity limitations, are based on the anatomic grade of the injury. This management approach is one that accepts the risk of potential missed injury for the benefit of avoiding laparotomy and potential organ loss. This strategy has been used successfully in children with multiple solid organ injuries, as well as those with concomitant head injuries. The decision not to operate, just as a decision to operate, should be made by the treating surgeon.

A pathway based on injury grade is used to evaluate blunt trauma in children (see Table 2). Each child should be carefully evaluated for suitability to undergo expectant management. Children with grade 1 or 2 injuries require no ICU stay and a hospitalization of 2 days. Children with a grade 3 injury or higher require a minimum of 24 hours in the ICU followed by 3 days of observation in the hospital. A deviation from the expected course (eg, hemoglobin drop, increased pain) may warrant follow-up imaging. Transfusion is occasionally necessary and should be based on guidelines established by the trauma care providers. Transfusion volumes of up to 40 mL/kg may be necessary before a course of observation is considered a failure.

Overall, the number of CBC counts should be minimized to that which is necessary to adequately assess the clinical condition, usually every 12 hours for the first 36 hours followed by daily thereafter. An alternative management pathway has been proposed by the Trauma Committee of the American Pediatric Surgical Association for isolated liver or spleen injuries (see Table 3).

After discharge from the hospital, to avoid contact and reinjury, activities should be limited to house arrest, which is defined as limited, non–peer-related, housebound activity. The duration of house arrest is determined by the injury grade (see Table 2). Outpatient follow-up care is scheduled to coincide with the completion of the house arrest period. At that time, an assessment is made to determine suitability to return to school.

Limitations on contact activities are based on injury grade (see Table 2). Children are reevaluated in the outpatient clinic upon completion of this prohibition period. A healthy child can typically return to all activities with no anticipated increase in risk for rebleed. Follow-up imaging may be useful for renal or pancreatic injuries but is not routinely obtained because it has been proven not to be beneficial or to modify the treatment in asymptomatic children with blunt splenic or liver injuries.

Although the nonoperative approach has been successfully used for all solid organs, the pancreas and kidney have historically been more problematic. As adjunctive measures have improved, even high-grade complicated injuries to the kidney or pancreas can be managed without laparotomy in the selected stable pediatric patient. These adjunctive measures include endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drainage for management of pseudocyst or duct disruption complicating pancreatic injuries and cystoscopy and stent placement or percutaneous nephrostomy for kidney injuries with urinoma. Selective embolization and endovascular stent placement for renovascular injuries have been reported.

One of the original reasons to pursue nonoperative management and avoidance of splenectomy in children with splenic injuries was to preclude the possibility of overwhelming postsplenectomy infection (OPSI). This entity was recognized as a significant risk in those children who were functionally or anatomically asplenic. The true prevalence of OPSI remains unclear, but it has been estimated to have a lifetime risk of 5%. Patients who have undergone a splenectomy should generally receive routine vaccination against those organisms responsible for OPSI (encapsulated bacteria), including Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis. The authors' current practice is to also recommend daily prophylaxis with oral penicillin until the age of 18 years; however, this should be guided by institutional best practice guidelines.

Table 2. Clinical Pathway for Solid Organ Injury

Table 3. APSA Guidelines for Management of Isolated Liver or Spleen Injuries in Children

*Return to full-contact competitive sports (eg, football, wrestling, hockey, lacrosse, mountain climbing) should be at the discretion of the individual pediatric trauma surgeon. The proposed guidelines for return to unrestricted activity include typical age-appropriate activities.

Hollow viscus injuries

Viscus injuries to hollow organs (eg, stomach, intestine, bladder) remain the nemesis of the trauma surgeon and are a risk of the nonoperative management strategies adopted for solid organ injuries. Repeat clinic examinations, a high index of suspicion, and follow-up imaging help detect these injuries early to minimize associated morbidity. Increasing abdominal pain or distention may indicate a hollow visceral injury. Free intraperitoneal fluid on CT scan without evidence of an associated solid organ injury may be the result of a hollow organ injury. The presence of a handlebar mark or lower abdominal wall ecchymosis in a lap belt–restrained child (seat belt sign) should raise concerns for hollow viscus injury.

Overall, hollow viscus injuries are present in 3% of abdominal injuries. The risk for hollow visceral injuries significantly increases with pancreatic injury or when multiple intra-abdominal organs (eg, liver, spleen) are affected. The vast majority of detected hollow organ injuries require operative intervention, with the exception of some intestinal wall hematomas (ie, duodenal), which can be first treated nonoperatively.

Duodenal hematoma

In children, the management of duodenal hematoma is nonoperative and involves decompression of the stomach until normal passage through the duodenum can be observed. Most intramural duodenal hematomas resolve over the course of 1-3 weeks with gastric decompression alone. Surgical evacuation described for hematomas that fail to resolve is rarely necessary. Serial imaging can be performed to monitor the resolution of the hematoma. Concomitant pancreatic or biliary tract morbidity due to direct trauma to or obstruction of the ampulla must be considered. In many cases, a nasoenteric feeding tube can be advanced beyond the hematoma to provide nutritional support during the hospital course.

Child abuse

Children with abdominal trauma secondary to assault or abuse have the highest mortality rate out of all causes of abdominal trauma. Abdominal trauma related to child abuse also carries a particularly high risk of hollow viscus injury. In all children with suspected inflicted injury, the abdomen must be thoroughly evaluated. This investigation may include laboratory assessment (LFTs, amylase test, lipase test, CBC count, UA) and/or imaging (CT scanning) to help detect abdominal injury. In the obtunded patient with inflicted injury, CT scanning should be performed to exclude concomitant abdominal injury. The possibility of inflicted abdominal injury should also be considered in the child with unexplained or unusual clinical history or physical findings.

MULTIMEDIA

Section 7 of 8  

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• Introduction
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• Epidemiology
• Initial Assessment and Evaluation
• Specific Considerations
• Multimedia
• References

Media file 1:  CT image of a grade 4 splenic laceration from an auto-pedestrian accident.
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Media file 2:  CT image of a grade 4 renal laceration from a handlebar injury. Reprinted with permission from Pryor JP, Stafford PW, Nance ML. Severe blunt hepatic trauma in children. J Pediatr Surg, 36:7, 2001, Elsevier Science.
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Media type:  CT

Media file 3:  CT image of a grade 5 liver laceration in an unrestrained passenger in a motor vehicle accident.
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Media type:  CT

Media file 4:  CT image of a duodenal hematoma from a blow to the abdomen. (Large arrow, hematoma; small arrow, lumen of duodenum.)
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Media type:  CT

Media file 5:  Abdominal wall findings from a handlebar injury.
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Media file 6:  Abdominal wall findings in a passenger who was restrained with only a lap belt during a motor vehicle accident.
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Media type:  Photo

Media file 7:  Penetrating injury to the abdomen from a shotgun wound.
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Media file 8:  Volume management algorithm for the pediatric trauma patient.
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REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Characteristics
• Epidemiology
• Initial Assessment and Evaluation
• Specific Considerations
• Multimedia
• References

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Article Last Updated: Jan 11, 2008