Trauma is the most common cause of death in children. Abdominal trauma accounts for close to 200,000 visits to US emergency departments each year.¹ Serious abdominal injuries account for approximately 8% of admissions to pediatric trauma centers. Only 15% of these injuries require surgery and the majority of these are for penetrating wounds.

Abdominal trauma is the third leading cause of traumatic death, behind head and thoracic injuries in children. Blunt trauma accounts for 85% of pediatric abdominal trauma. Penetrating abdominal trauma accounts for approximately 15% of the total cases and 6% of these will die primarily from the penetrating wound.

Children are susceptible to different injury patterns than adults. Blunt trauma from motor vehicle collisions (MVCs) causes more than half of the abdominal injuries and is the most lethal. Penetrating injuries in the pediatric population are increasing, particularly in young adolescents. Accidental impalement occurs more often in children younger than 13 years and may involve such diverse items as scissors or picket fences.

Management of pediatric abdominal trauma requires a coordinated effort between the emergency physician, trauma surgeon, and pediatric referral center. Immediate stabilization and transfer of the most severely injured children to an appropriate trauma center when indicated will result in greatly improved outcomes.^2,3

MOTOR VEHICLE COLLISIONS

Multisystem trauma, along with abdominal injury, is common when an automobile strikes a child (Table 27-1). Waddell’s triad (Fig. 27-1) demonstrates a pattern of pediatric pedestrian injury with impact first to the upper leg, then chest and abdomen, followed by head. The head and extremity components of Waddell’s triad should not divert attention from intra-abdominal injury that may include life-threatening hemorrhage. In countries in which motorists drive on the right side of the road, the most common injuries are on the left side, as children are often struck crossing the street, and frequently result in splenic injuries.

Vehicle restraint systems greatly increase survival from a motor vehicle collision but can also themselves cause injury. In the restrained child, the lap belt complex is characterized by ecchymosis, abrasion, or erythema in the pattern of a lap belt (“seat belt sign”) across the abdomen (Figs. 27-2 and 27-3) and flanks (Grey–Turner sign) and occurs in up to 10% of restrained children. The injury is thought to occur because of an improperly applied restraint that allows the lap belt to ride up and compress the abdomen as the child slides forward under the belt. Presence of the seat belt sign always warrants further evaluation and has been associated with increased risk of gastrointestinal injury.^4,5

BICYCLE CRASHES, SPORTS INJURIES, AND FALLS

Head trauma remains the predominant injury in bicycle crashes, although abdominal injury can occur. Handlebar injuries (Fig. 27-4) are particularly obscure, as most children show no serious sign of injury for hours to days after the impact. The mean elapsed time to onset of symptoms is almost 24 hours and as many as one-third are discharged home initially. The ability of modern handlebars to rotate allows a focused force to be directed into the abdomen and can cause significant damage.⁶ The seriousness is illustrated by a mean length of stay exceeding 3 weeks for children who require admission for a handlebar injury. Traumatic pancreatitis, often with pseudocyst formation, is the most common handlebar injury followed by injuries to the kidneys, spleen, and liver, duodenal hematoma, and bowel perforation. Consult a trauma surgeon and observe children with a suspicion for this injury.

Sports-related trauma typically produces isolated organ injury because of a direct blow to the abdomen. The spleen, kidney, and gastrointestinal tract are particularly vulnerable. Injury is more common in contact sports but has been reported in noncontact sports as well.⁷ Falls rarely cause isolated serious abdominal injury unless there is a direct blow to the abdomen or fall from great height, usually twice the child’s height.

CHILD ABUSE

Significant abdominal injury occurs in approximately 5% of child abuse cases. The diagnosis can be obscured by the inherent delay in seeking treatment, the surreptitious nature of the visit, and the lack of abdominal bruising in up to 80% of these patients. Common patterns of injury are to the liver and spleen with associated rib fractures, though any organ can be injured. Abusive blunt abdominal trauma tends to affect younger children and has significantly higher morbidity and mortality when compared to accidental blunt abdominal trauma.⁸

Certain anatomic features predispose children to multiple rather than single injuries. Proportionally larger solid organs, poorly muscled protuberant abdomen, and flexible thin ribs contribute to the increased incidence of significant abdominal injury and potential for hemorrhage. The diagnosis of a major intra-abdominal hemorrhage may be delayed because children have the capacity to maintain normal blood pressure and pulse rate for age, even in the face of significant blood loss. External signs of injury, abdominal tenderness, and absence of bowel sounds seldom give clues to the ultimate need for surgery. Abdominal distention may be because of hemoperitoneum, peritonitis, or most commonly, gastric distention from crying, and air swallowing. This can confound the examination by masking or mimicking serious abdominal injury or bleeding. Severe dilation can result in respiratory compromise because of interference with diaphragm motion, gastric aspiration, or vagal dampening of the normal tachycardic response. Vagal dampening can lead to precipitous circulatory collapse in the presence of unrecognized hypovolemia, as increasing the heart rate is the primary response to decreased cardiac output in children.

GENERAL PRINCIPLES

A team approach in the evaluation and treatment of abdominal injuries, that includes the emergency physician, trauma surgeon, anesthesiologist, and surgical subspecialists, is ideal. In reality, many emergency physicians find themselves as the only physician initially and must approach the injured child in a systematic way, utilizing consultants expeditiously. Blunt abdominal injuries rarely require surgical intervention, whereas penetrating injuries frequently do. Nevertheless, all unstable patients need immediate surgical consultation.

Follow the basic principles of trauma evaluation and resuscitation in all cases of abdominal trauma. Evaluation of the abdomen is included in both the primary and secondary surveys. The following interventions are particularly important:

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  Insert a nasogastric or orogastric tube if the abdomen is distended to decompress the stomach and to check for blood or bile. Insert an orogastric tube if there is any suspicion of head trauma or basilar skull fracture.

  
  
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  If the patient cannot urinate, consider placing a urinary catheter to check for blood and urinary retention, if there is no gross blood at the meatus. Obtain a urinalysis.

  
  
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  Complete a rectal examination to check for blood, prostate position in males, and rectal tone.

  
  
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  Keep the child NPO because of the possibility of surgery or development of paralytic ileus.

  
  
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  Obtain blood for type and crossmatch, electrolytes, CBC, serum amylase, and liver transaminases.

The mechanism of injury is important and guides the secondary survey and the ordering of specific tests or procedures. It is always important to log roll the patient to inspect the posterior torso for additional wounds. External injuries such as abrasions, lacerations, bruising, and characteristic markings such as tire tracks and seat belt marks should be noted.

Children respond differently to trauma and stress. A traumatized child may be more difficult to examine and may not show the familiar signs of impending demise as seen with adults. History may be limited and the child’s reaction to pain may be difficult to assess. Designate a team member or the parent or caregiver at the bedside to take care of the child’s emotional needs and to comfort them through the ordeal of trauma evaluation and treatment. Over the past decade, many pediatric trauma centers have instituted policies to encourage family member presence for trauma and pediatric resuscitation.^9–11

PENETRATING ABDOMINAL TRAUMA

The diagnosis and treatment of penetrating abdominal injuries in children does not differ greatly from that for adults, and initial management is not dependent on identifying any specific injury. The hollow organs, because of their large volume, are most commonly injured, followed by the liver, kidney, spleen, and major vessels.

In children, the abdomen begins at the nipples, so penetrating wounds between the nipples and the groin potentially involve the peritoneal cavity and should be considered contaminated. Location, size, and possible trajectory of entrance and exit wounds help to identify potential underlying injuries. Surgical evaluation, wound debridement, and possible exploration, along with broad-spectrum intravenous antibiotics, are necessary in all but the most minor of wounds. At a minimum, perform the following for significant penetrating abdominal trauma: placement of a nasogastric or orogastric tube; placement of a urinary catheter; upright and lateral (if possible) chest radiograph; supine, upright, and cross-table abdominal radiographs; obtain a computed tomography (CT) scan of the abdomen with IV contrast for deep-penetrating stab wounds and all gunshot wounds unless the child’s clinical condition is unstable and they need exploration in the operating room. Most gunshot wounds to the abdomen enter the peritoneal cavity and injure organs directly or indirectly through kinetic energy dissipation. The associated morbidity and mortality is high due to the destructive force of the missile and its fragments, rapid blood loss, complicated surgical repair, and postoperative complications. Gunshot wounds to the abdomen require immediate exploration.