Paediatric Abdominal Trauma
UPDATE ON BURNS MANAGEMENT IN
CHILDREN
LA Hodsdon
Oct 09
Considerations
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Incidence
Type
Anatomical Considerations
History & Examination
Diagnostic Modalities
Suggested Investigative Approaches
Incidence:
• Abdominal Trauma:
– 8-10% admissions to Paediatric Trauma Centres
– 3rd most frequent cause of death ()
– MOST COMMON UNRECOGNIZED FATAL INJURY
– NAI – 5% admitted with Abdominal Trauma
Type of Injury:
• Blunt Abdominal Trauma:
– 85% of paeds abdo trauma (US/UK)
– > 50 due to MVA’s
– Other common causes bicycles, sports, falls, NAI
• RSA ?% Penetrating Trauma
– Likely to be >15%
Anatomical Considerations:
• Solid Organs: proportionally larger & more
anterior
• Kidneys: larger, more mobile +/- foetal
lobulations
• Subcutaneous Fat: ↓
• Abdominal Musculature: ↓
• AP Diameter: ↓
• Flexible Cartilaginous Ribcage
• Increased Solid Organ Injury
– Both Blunt & Penetrating Injury
• GIT Trauma not uncommon
– Duodenal & Small Bowel haematomas &
perforation
– Pancreatic injuries
– Mesenteric lacerations
History & Examination:
• Age dependant
• Often difficult for kids to localise / verbalise
• FEAR
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Often hard to reassure
Fear of unknown / vague concepts
Separation
Fear of Medical Personnel
• Haemodynamically stable child
- who is alert and co-operative
- able to communicate effectively
history and examination approach reliability
rates of adults
 2004 Poletti et al:
Awake, haemodynamically stable (adults):
abdo pain, tenderness & peritoneal signs
more reliable physical signs & can be found
in 90%
 BUT significant injuries can be missed
 No physical signs ≠ exclude intra-abdominal
injury
 7.1% pts with normal physical examination =
intra-abdominal injuries on CT
 Multiple small studies suggest normal
examination excludes the need for
Plain X-Rays
• Free Air
– Gastric, duodenal bulb & colonic perforation
– Only 25-33% of jejunal & ileal perforations have
FA
– Better viewed on CT
• Foreign Bodies
• Projectory Paths
FAST
• Advantages:
– Rapid ID of Intraperitoneal Haemorrhage
– Non Invasive
– Portable
– Rapid (5min FAST)
– Widespread (US) therefore not rely on
Radiologists
– Serial examinations possible
– No side effects
FAST
• Disadvantages:
– Not able to image extent of organ damage
– Not able to visualise retroperitoneum
– Operator dependant
– Patient dependent
– Can’t differentiate blood from ascites
– Can’t pick up contained bleeding
FAST in ABDO Trauma
• Most studies:
– sensitivity for haemoperitonium 86-89%
– Depends on required end point (Intra-abdominal
Injury / Intra-abdominal Injury requiring ø /
Potentially Fatal intra-abdominal Injury)
• Ollerton et al: U/S & Trauma Management
– Changed Mx decisions 32.8% of time
– ↓ CT (4734%) & ↓ DPL (91%)
• Branay et al: U/S key pathway
– ↓CT (5626%) & ↓DPL (17-4%)
FAST: Reliability in Kids:
• Holmes: 224 kids (mean age 9 yrs)
– Prospective
– Hypotension (13): 100% sens, 100% spec
– All Patients (244): 82% sens, 95% spec
• Soudack: 313 kids (2months – 17yrs)
– Retrospective
– 275 Negative FASTs
– 73 of Negative FASTs had abdominal signs & CTs:
• 3 Positive – Parenchymal Injuries, none requiring ø
– 92.5% sens, 97.% spec
CT Scan
• Advantages
– Define extent of injury & organ involvement
– Non Invasive
– Most Accurate S/I for Solid Organ injury
– Evaluates retroperitoneum
• 3 Contrast Studies have 97% sens, 98% spec
• Velmahos et al achieved similar rates with IVI
contrast alone.
CT Scan
• Disadvantages
– Time consuming & unable to monitor patients
– Requires IVI Contrast
– Requires Sedation in most kids
– Can’t visualise pancreas, diaphragm, small bowel
or mesentery
– Radiation Dose – Brenner et al
1 yr old child: lethal malignancy risk of 1
abdominal CT was ± 1 in 550
CT Scan in Kids
• High Sensitivity & Specificity for the solid
organ pattern common in kids
• Radiation dose and need for sedation major
drawback in kids, so CT scans should be
considered not just ordered as ‘routine’
DPL
 Rapidly reveals/excludes the abdomen as the
source of hypotension
 Advantages
 May detect Bowel Injury (GIT matter)
 Disadvantages
 Invasive with complication rate of 0.3%
 Operator dependant
 Comparatively time consuming (vs. FAST)
Widespread replacement by FAST
Other Diagnostic Modalities
• Local Wound Exploration:
– Bedside surgical exploration of tract
– Determine whether Peritoneal Violation has taken
place
– Patient Factors
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Contrast Studies
Angiography
ERCP
Laparoscopy
Management Questions:
Blunt Abdominal Trauma
– Trauma vs. Medical component
– Single vs. Multisystem trauma
– Emergency Laparotomy vs. Dx workup
– Single vs. Multiple Intraperitoneal Injury
– Expectant vs. Necessary Laparotomy
Paediatric patients tolerate expectant management
better than adults.
If paediatric patient is stable and adequate
monitoring is available: normally follow expectant
management.
Management Questions:
Penetrating Trauma
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Trauma vs. Medical component
Single vs. Multisystem trauma
Emergency Laparotomy required?
Peritoneal Violation?
Intraperitoneal Injury?
Stab Wounds – 70% have peritoneal violation
but only 25-33% of those require surgery.
Expectant: Shaftan 1960’s
Operative vs. Non-operative
Management.
 Successful: mod – high grade liver / spleen
trauma
 Failures  considerable morbidity /
mortality
 Balance between avoiding unnecessary
laparotomy & preventing significant
morbidity or mortality by waiting too long.
 Requirements:
 Patient – alert & co-operative, mild-mod MOA
 Institution - experienced nursing staff, trauma
• Pitfalls:
1) Hollow Viscera Injuries: missed
2) Increased use of blood products
3) Approach will fail if haemorrhage ≠ respond to Rx
angiography + embolization or not abate from
solid organs.
Time from injury  operation: increase
morbidity and mortality.
Resources:
 Advances in Abdominal Trauma; J.L . Isenhour,
MD, J Marx, MD; Emerg Med Clin N Am 25
(2007) 713–733
 Pediatric Major Trauma: An Approach to
Evaluation and Management; J.T. Avarello, MD,
FAAP, R.M. Cantor, MD, FAAP, FACEP; Emerg
Med Clin N Am 25 (2007) 803–836
 Rosen’s Emergency Medicine
 Emergency Medicine Manual, 6th Ed; O.John Ma
& Davis M Kline
 Oxford Handbook of Trauma for Southern
Africa; A Nicol & E Steyn