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 Injury3. 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

• Conservative – 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

Management

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)– 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

• Conservative– complete gastrointestinal rest

• Surgery– pancreatic duct is transected requiring a partial or

total pancreatectomy

Management

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