Abdominal Trauma
Abdominal Trauma
Etiology:
– Blunt injuries: 90%
• Automobile injuries - 60%
• ≥90% = survive
• 22% = death
– Penetrating abdominal trauma: 10%
• Gunshot or stab wound
Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON
Factors that make children vulnerable to
abdominal injury:
• Abdominal wall and lower rib cage are thin in
children
• Liver and kidneys lie relatively lower in the
abdomen
• Kidneys and pancreas lie only a short distance
away from the abdominal wall in thin children
• Liver occupies a large percentage of the
abdominal cavity
Key Components of Abdominal Assessment
• INSPECTION
• AUSCULTATION
• PALPATION
• PAIN ASSESSMENT
• RESPIRATION
Diagnostic Procedures
• Laboratory Tests:
– CBC
• Hemoglobin and hematocrit
• maintain Hct >30%
– Serum Amylase
– Urinalysis
– Transaminase
– Blood typing and crossmatching
– Peritoneal Lavage
Radiological Studies
• Supine and Upright abdominal films (Upright
CXR)
– free air in the abdomen (pneumoperitoneum)
– extent of injury in penetrating trauma
• CT Scan
– diagnostic test of choice
– solid organ injuries
– grade of injury
Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON
Conservative Approach
• Assessment should include determination:
– level of consciousness (GCS)
– Vital signs
– palpation and auscultation of the abdomen
– accurate intake and output measurement
• Patient Stabilization: aggressive volume
expansion
Surgical Intervention
• Indications for surgery:
– blood transfusions of 40 ml/kg or 50% of
circulating blood volume is required
– most penetrating injuries
– inability to achieve hemodynamic stability even
after aggressive fluid and blood replacement
– severe abdominal distention accompanied by
hypotension
Types of Abdominal Injuries
1. Solid Organ Injury
•
•
Liver
Spleen
2. Pancreatic Injury
3. Stomach and Intestinal Injury
LIVER INJURY
• Most fatal due to the potential for massive
hemorrhage
• Signs and Symptoms:
– Pain in right upper shoulder
– Pain and tenderness in right upper quadrant of
abdomen
– Bruising, abrasions and seatbelt marks
– Vital Signs: hypotension with major bleeding
Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON
Management
• Conservative
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–
–
–
Standard practice for stable pediatric patients
monitored for at least 48 hours
Strict bedrest for 7 days with serial H and H
Limit activity for 2-3 months after discharge
• Surgical
– control of massive bleeding or liver resection
– Indications:
• Child continues to deteriorate
• more than 50% of the circulating blood volume requires
replacement within 24 hours
Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON
SPLENIC INJURY
• Blow to the LUQ/epigastric region of the
abdomen
• Signs and Symptom:
•
•
•
•
•
•
Abdominal tenderness and pain
Kehr’s Sign (pain in the left shoulder)
Pain in left part of chest with respirations
Decreased breath sounds
Turner sign (ecchymoses in the left flank)
Cullen sign (ecchymoses around the umbilicus)
Management
• Preservation of the spleen to prevent the occurrence of
postsplenectomy sepsis
• Conservative
– Standard practice for stable pediatric patients
– Receives ≤ 50% blood volume replacement
– Monitored in the ICU for at least 48 hours
• Surgical (splenorrhaphy or splenectomy)
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Hemodynamic instability after aggressive fluid resuscitation
Continued blood loss
Separation of the spleen from its blood supply
Severe head injury that cannot tolerate volume
resuscitation
The decision to operate for spleen or liver injury,
which should always be made by a surgeon, is
best based on clinical signs of continued blood
loss such as:
– low blood pressure,
– elevated heart rate,
– decreased urine output, and
– falling hematocrit
PANCREATIC INJURY
• uncommon in children
• difficult to diagnose
Management
• Conservative
– complete gastrointestinal rest
• Surgery
– pancreatic duct is transected requiring a partial or
total pancreatectomy
STOMACH AND INTESTINAL TRAUMA
• contusions, lacerations, hematomas or
perforation
• Signs of hollow organ injury:
– abdominal tenderness, ecchymosis of the upper
and lower abdomen, bloody gastric drainage
Management
• Surgery