Chapter 50 Abdominal Trauma
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.
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