Tummy Trauma: Evaluation and Management

of the Injured Child

Catherine J. Goodhue, CPNP

Pediatric Nurse Practitioner

Trauma Program/Division of Pediatric Surgery

Objectives

1. Discuss common mechanisms of injury in

pediatric blunt abdominal trauma and likely

subsequent injuries

2. Review common traumatic injuries and their

management of both solid and hollow viscera

3. List 5 signs or symptoms that should warrant

high index of suspicion for abdominal injury in

a child

4. Describe return to sports guidelines for solid

organ injury

2

3

Joy

3

• 4 year old

• Flipped over

handlebars

• Abrasions to face

• Bruising on abdomen

4

Brittany

4

• 7 year old

• Auto vs. peds

• Deformity left

femur

• Crying

5

Helen

5

• 15 year old

• Kicked in abdomen

• Continued playing

• Now nauseous and

dizzy

• Bruise on abdomen

6

Isaac

6

• 4 year old

• Motor vehicle crash

• Altered mental

status

Epidemiology –

Abdominal Trauma

• 90% blunt• 10% penetrating

– Impalement

– Gunshot

– Stabbing

7

Pediatric Differences

8

Assessing the Pediatric

Trauma Patient

9

In the Trauma Bay

10

HistoryMechanism of injury

GCS/AVPU on scene

Any death on scene (MVA)

Illicit substances/ETOH involved

Interventions in field

ABCs

11

Mechanism of Injury

External Forces

Internal Forces

Blunt vs. Penetrating Forces

1212

Waddell’s Triad

- Bumper vs

femur and

torso on same

side

- Child is

thrown, lands

on opposite

side of head

13

Restraint Devices & Injuries

In the Trauma Bay

14

HistoryMechanism of injury

GCS/AVPU on scene

Any death on scene (MVA)

Illicit substances/ETOH involved

Interventions in field

ABCs

In the Trauma Bay

15

ABCDE

Pediatric Abdominal Exam

Inspection

Auscultation

Percussion

Palpation

16

Benign Abdominal Exam

- No outward signs

- Soft, NTND

17

Concerning Abdominal Exam

- Tenderness

- Ecchymosis

- Distension

- Rebound

- Guarding

- Kehr’s sign

- Blood urethral

meatus or rectum

- Pelvic instability

18

Hemodynamics

19

20

Hollow Organs (<10%)

Solid Organs (>90%)

Kidneys

Liver

Spleen

Pancreas?

Stomach

Small Intestine

Colon

Intraperitoneal Bladder

Intra-Abdominal Injuries

21

Ult

raso

un

d

• Able to identify fluid

• Unable to localize or identify solid organ injury

• Portable and Fast

CT

Scan

• Excellent identification of solid organ injury

• Questionable sensitivity for hollow viscusinjury

• Takes time

Pla

in F

ilm

• Free Air

• Pelvic Fracture

• Portable and Fast

Imaging the Belly

Also remember:

Serial abdominal exams…NPO…observation…

22

With permission

To Scan or Not to Scan??Streck et al 2012 – High-risk Clinical Variables

– Hypotension

– Abnormal abdominal exam

– AST > 200 U/L

– Microhematuria

– HCT < 30%

– Amylase > 100 U/L

CLINICAL PREDICTION MODEL

– Normal systolic

– Normal abdominal exam

– AST < 200 U/L

– HCT > 30%

– Normal CXR

23

Trauma Bay Study

24

• Multi-center study

• Data points collected from

Trauma Bay

• Data points collected 1-2

months after injury

25

• 3819 patients with normal

CT scan results

•16 (0.4%) subsequently

diagnosed with intra-

abdominal injury

•Physical exams, labs

Re-imaging?

Hollow Viscus Injury

26

Diagnosis

Free air

Unexplained free

fluid on CT

PeritonitisSerial Exams

Fever

Oliguria

Tachycardia in

absence of bleeding

Management

Operate

Grading of Splenic Injury

27

American Association for the Surgery of Trauma (AAST) 1994

Grading of Liver Injuries

28

American Association for the Surgery of Trauma (AAST) 1994

29

Solid Organ Injury Management

Operative

Management

- Refractory

hemorrhagic

shock

- Concomitant

TBI

Non-Operative

Management

- ICU, serial

exams (bowel

injury), serial

Hct

- APSA

Guidelines

Grade plus 1

day

APSA Guidelines –

Isolated Spleen or Liver

CT GRADE I II III IV

ICU stay (days) None None None 1

Hospital stay (days) 2 3 4 5

Pre-discharge imaging None None None None

Post-discharge imaging None None None None

Activity restriction (weeks) 3 4 5 6

30

From Stylianos S, and APSA Trauma Committee: Evidence-based

guidelines for resource utilization in children with isolated spleen or

liver injury. J Pediatr Surg 35:164-169, 2000

31

Protocol

• Grade I/II – One night bedrest

• Grade III-V – Two nights bedrest

• Ambulate after bedrest

• Hgb/Hct after 4 hours

• Discharge

Revised bedrest: spleen & liver

Follow up bedrest protocol

32

• 249 patients

• 199 bedrest: mean grade of injury 2.7

• 28 required transfusion due to solid organ

injury

• Mean bedrest 1.6 days vs 3.6 if had

followed current guidelines

J Pediatric Surg, 2013

APSA Guidelines –

Activity Restriction

CT GRADE I II III IV

ICU stay (days) None None None 1

Hospital stay (days) 2 3 4 5

Activity restriction (weeks)

3 4 5 6

33

From Stylianos S, and APSA Trauma Committee: Evidence-based

guidelines for resource utilization in children with isolated spleen or

liver injury. J Pediatr Surg 35:164-169, 2000

3434

Joy

34

• 4 year old

• Flipped over

handlebars

• Abrasions to face

• Bruising on abdomen

35

Brittany

35

• 7 year old

• Auto vs. peds

• Deformity left

femur

• Crying

36

Helen

36

• 15 year old

• Kicked in abdomen

• Continued playing

• Now nauseous and

dizzy

• Bruise on abdomen

37

Isaac

37

• 4 year old

• Motor vehicle crash

• Altered mental

status

38

References• Acker SN, Stewart CL, Roosevelt GE, Partrick DA, Moore EE,

Bensard DD. When is it safe to forgo abdominal CT in blunt-injured

children? Surgery. 2015;158:408-12.

• Adelgais KM, Kuppermann N, Kooistra J, Garcia M, Monroe DJ,

Mahajan P, Menaker J, Ehrlich P, Atabaki S, Kent Page M, Kwok M,

Holmes JF on behalf of Intra-Abdominal Injury Study Group of

PECARN. Accuracy of the abdominal examination for identifying

children with blunt intra-abdominal injuries. J Pediatr.

2014;265:1230-35.

• Dodgion CM, Gosain A, Rogers A, St. Peter SD, Nichol PF, Ostlie DJ.

National trends in pediatric blunt spleen and liver injury

management and potential benefits of an abbreviated bed rest

protocol. J Pediatr Surg. 2014;49:1004-1008.

39

References

• Golden J, Dossa A, Goodhue CJ, Upperman JS, Gayer CP. Admission

hematocrit predicts the need for transfusion secondary to

hemorrhage in pediatric blunt trauma patients. J Trauma Acute

Care Surg. 2015;79:555-562.

• Kerry BT, Rogers AJ, Lee LK, Adelgais K, Tunik M, Blumberg SM,

Quayle KS, Sokolove PE, Wisner DH, Miskin ML, Kuppermann N,

Holmes JF, PECARN. A multicenter study of the risk of intra-

abdominal injury in children after normal abdominal computed

tomography scan results in the emergency department. Ann Emerg

Med. 2013;62:319-326.

40

References• Le TV, Baaj AA, Deukmedjian A, Uribe JS, Vale FL. Chance fractures

in the pediatric population. J Neurosurg Pediatrics. 2011;8:189-

197.

• LeeVan, E, Zmora O, Cazzulino F, Burke RV, Zagory J, Upperman JS.

Management of pediatric blunt renal trauma: a systematic review.

J Trauma Acute Care Surg. In Press.

• Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M,

Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N, Holmes

JF, for the Intra-abdominal Injury Study Group of PECARN. Use of

the focused assessment with sonography for trauma (FAST)

examination and its impact on abdominal computed tomography

use in hemodynamically stable children with blunt torso trauma. J

Trauma Acute Care Surg. 2014;77:427-432.

41

References• Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA,

Champion HR. Organ injury scaling: spleen and liver (1994

revision). J Trauma. 1995;38;333-334.

• Notrica DM. Pediatric blunt abdominal trauma: current

management. Curr Opin Crit Care. 2015;21:531-537.

• Notrica DM, Eubanks III JW, Tuggle DW, Maxson RT, Letton RW,

Garcia NM, Alder AC, Lawson KA, St. Peter SD, Megison S, Garcia-

Filion P. Nonoperative management of blunt liver and spleen injury

in children: evaluation of the ATOMAC guideline using GRADE. J

Trauma Acute Care Surg. 2015;79:683-693.

• Safavi A, Skarsgard ED, Rhee P, Zangbar B, Kulvatunyou, Tang A,

O’Keeffe T, Friese RS, Joseph B. Trauma center variation in the

management of pediatric patients with blunt abdominal solid organ

injury: a national trauma data bank analysis. J Pediatr Surg. 2015

42

References

• Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr

Opin Pediatr. 2012;24:314-318.

• St. Peter SD, Sharp SW, Snyder CL, Sharp RJ, Andrews WS, Murphy

JP, Islan S, Holcomb GW, Ostlie DJ. Prospective validation of an

abbreviated bedrest protocol in the management of blunt spleen

and liver injury in children. J Pediatr Surg. 2011;46:173-177.

• St. Peter SD, Aguayo P, Juang D, Sharp SW, Snyder CL, Holcomb

GW, Ostlie DJ. Follow up of prospective validation of an

abbreviated bedrest protocol in the management of blunt spleen

and liver injury in children. J Pediatr Surg. 2013;48:2437-2441.

• Streck CJ, Jewett BM, Wahlquist AH, Gutierrez PS, Russell WS.

Evaluation for intra-abdominal injury in children after blunt torso

trauma: can we reduce unnecessary abdominal computed

tomography by utilizing a clinical prediction model? J Trauma

Acute Care Surg. 2012;73:371-376.

43

References• Stylianos and the APSA Trauma Committee. Evidence-based

guidelines for resource utilization in children with isolated spleen

or liver injury. J Pediatr Surg. 2000;35:164-169.

• Wisner DH, Kuppermann N, Cooper A, Menaker J, Ehrlich P,

Kooistra J, Mahajan P, Lee L, Cook LJ, Yen K, Lillis K, Holmes JF.

Management of children with solid organ injuries after blunt torso

trauma. J Trauma Acute Care Surg. 2015;79:206-214.

44