Pediatric Blunt Abdominal Trauma (PowerPoint)

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					Pediatric Blunt Abdominal Trauma
                   Stephen Wegner, MD
                   James E.Colletti, MD
                   Donald Van Wie, MD

                           Intern 林士森

   Abdominal trauma is a leading cause of
    morbidity and mortality in children.
   Discussing issues:
       Key issues to help for efficiently and successfully
        evaluate and manage blunt pediatric abdominal
       Select organ trauma
       Disposition issues
Mechanisms of injury

   Motor vehicle collisions and automobile
    versus pedestrian accidents and falls are
    associated with the greatest increased risk.
   Children only wearing a lap belt restrains,
    automobile versus bicycle accidents, all-
    terrain vehicle accidents, handlebar injuries,
    sports or nonaccidental trauma.
   Abdomen-to-handlebar collisions are
    associated with a high risk of small bowel and
    pancreatic trauma.
Past medical history

   Medical conditions that affect children’s
    neurologic or developmental baseline are
       Autism, cerebral palsy, or other medical
        conditions that result in mental or physical
       Hemophilia
       Being anticoagulated or receiving antiplatelet
       EB virus infection
Physical examination

   Abnormality in abdominal PE should be
    considered an indicator of IAI.
   Other comorbid injuries or factors predict
    abdominal injury.
   A negative examination and absence of
    comorbid injuries do not totally rule out
Physical examination

   Holmes and colleagues:
       Abdominal tenderness
   Cotton and colleagues:
       Abdominal tenderness, ecchymosis, and
        abrasions as positive findings of IAI.
   Isaacman:
       Abnormal PE findings plus an abnormal urine
        analysis to be a highly sensitive screen of IAI.
Physical examination

   Associated comorbid findings/injuries:
       Femoral fracture (Holmes)
       Low SBP (Holmes)
       Decreased mental status
           GCS<13:mild indicator of IAI (Holmes)
           GCS<10:23% had significant IAI (Beaver)
Laboratory findings

   The most valuable lab tast include the CBC,
    liver function tests,and urine analysis.
   Amylase, lipase, coagulation studies, genaral
Laboratory findings
Select organ trauma

   Spleen and liver are the most commonly
    injured organ.
   Hepatic trauma
       Abdominal CT (enhanced) is accurate in
        localizing the site and extent of liver injuries and
        providng vital information.
       Subcapsular, intrahepatic hematoma, contusion,
        cascular injury, biliary disruption.
       American association for the surgery of trauma
        liver injury scale
Select organ trauma

Grade                         Description

  I     Subcapsular hematoma <1cm in maximal thickness,
        capsular avulsion, superficial laceration<1cm deep, and
        isolated periportal blood tracking
  II    Parenchymal laceration 1-3cm deep and
        parenchymal/subcapsular hematomas 1-3cm thick
  III   Parenchymal laceration>3cm deep and parenchymal or
        subcapsular hematoma >3cm in diameter
  IV    Parenchymal/subcapsular hematoma >10 cm in diameter,
        lobar destruction, or devascularization
  V     Global destruction or devascularization of the liver

  VI    Hepatic avulsion
Select organ trauma

   Splenic trauma
       LUQ abdominal tenderness, l’t lower rib fracture,
        or evidence of l’t lower chest/abdominal contusion.
        managed with bed rest, frequent examination,
        serial Hb monitoring.
       Massive disruption and hemodynamic unstability –
        absolute surgical indication.
       Splenic rupture and EB virus infection.
Select organ trauma
Grade                         Description

  I     Subcapsular hematoma < 10% of surface area or
        capsular tear of < 1cm deep

  II    Subcapsular hematoma of <10-50% of surface area,
        intraparenchymal hematoma <5cm in diameter, or
        laceration of 1-3cm deep and not involve trabecular vesse
  III   Subcapsular hematoma >50% surface area or expanding
        and ruptured and subcapsular or parenchumal hematoma,
        intraparenchymal hematoma >5cm or expanding, or
        laceration >3cm deep or involving trabecular vessels

  IV    Laceration involving segmental or hilar vessels with
        devascularization >25% of the spleen
  V     Shattered spleen or hilar vascular injury
Select organ trauma

   Intestinal trauma
       Peforation, intestinal hematoma, and mesenteric
        tears with bleeding.
       Seatbelt sign
       CT with subtle signs such as bowel wall edema.
       Abdominal pain that worsens or persists and
        persistent emesis must be investigated with serial
Select organ trauma

   Pancreatic trauma
       Falls onto handlebar result in a crush force applied to upper
       Persistent tenderness should indicate further investigation.
       Overall prognosis is good.
   Renal trauma
       Posterior abdomen and retroperitoneum blunt trauma
       Significant flank/abdominal pain and hematuria is indication
        for CT scan.
Management and disposition

   Stabilizing treatment with ATLS and PALS.
       Immediate fluid resuscitation
       CBC,LFTs,UA
       Transfusion
       Surgical consultation
   Hemodynamically stable
       CBC,LFTs,UA
       Abnormal lab finding  CT scan
Length of hospitalization and return to
 Spleen or liver   Hospital day      Activity day
 injury grade
 Grade I-III       Injury grade +1   Injury
                   day               grade+2weeks

 Grade IV          1 day intensive   Injury
                   care + injury     grade+2weeks
Thanks for your attention!

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