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<< Evaluation And Management Of Pediatric Abdominal Trauma
Emergency Department Evaluation
Initial Evaluation And History
A favorable outcome for any pediatric trauma depends upon rapid and accurate diagnosis with prompt treatment of potential life-threatening injuries. Evaluation and management of the injured child should follow the paradigm of the Advanced Trauma Life Support protocols with assessment of airway, breathing, circulation, neurological status, and complete exposure during the primary survey with management of immediate life threats as soon as they are identified. The first step consists of assessment of airway patency and quality of breathing. Once the airway has been secured, evaluate the quality of the circulation. The heart rate is the most sensitive indicator of intravascular volume status in infants and young children. It should be emphasized that hypovolemic shock is heralded by tachycardia long before hypotension is apparent. A child with multiple injuries should undergo placement of two large-bore intravenous catheters. If intravenous access proves to be difficult, insertion of an intraosseous catheter can be life saving in any age group. An intraosseous catheter can be used for fluid resuscitation and administration of medications.79 The most common location is at least one finger breadth below the tibial tuberosity to make certain the physis is avoided. After the initial resuscitation has been performed using an intraosseous catheter, intravenous attempts are often successful.
Obtaining as much information as possible about a child’s past medical history is always worthwhile even in the abbreviated trauma history and examination. Medical conditions that affect a child’s neurological or developmental baseline are important to obtain. A few examples that may make evaluation more difficult include autism, cerebral palsy, or other medical conditions that result in mental or physical handicaps. Hemophilia patients or patients with recent or concurrent Epstein-Barr virus infection may have delayed splenic rupture and massive bleeding from minor abdominal trauma.80
Fear and pain can complicate the management of serious abdominal trauma in children. Children tend to distend the stomach greatly with ingested air and this can significantly decrease the diaphragmatic excursion by overdistention of the abdomen, which can compromise respiratory efforts. Early decompression via nasogastric or orogastric tube insertion should therefore be considered. Children in whom a stable pelvis has been established and who are not at risk for urethral trauma should have a Foley catheter inserted to decompress the bladder. The clinician should then evaluate for the presence of urinary retention and check for the presence of blood in the urine.
ED evaluation and management of blunt trauma is guided primarily by the stability of the patient and the presence of associated injuries. The blood volume of a child is approximately 80 mL/kg. The American College of Surgeons fluid resuscitation guidelines recommend an initial bolus of 20 mL/kg of warm isotonic fluids (0.9% normal saline or lactated Ringer’s) for the thermodynamically unstable child. In addition, other life-threatening injuries should be excluded. If the child remains hemodynamically unstable after 40 mL/kg of isotonic solution, administration of blood at 10-20 mL/kg should be strongly considered, and a thorough evaluation for the source of bleeding should be undertaken. It is imperative that a pediatric surgeon or trauma surgeon be consulted at this point. If hypotension persists and intra abdominal injury is suspected, additional blood and a laparotomy should be strongly considered.
After completion of the primary survey, perform a thorough secondary survey that consists of a head-to-toe physical examination to identify all traumatic injuries. Physical findings suggestive of intra abdominal injury include abrasions and contusions on the abdominal wall (seat belt sign), abdominal distention, and tenderness. Abdominal distention may be a sign of hemoperitoneum, but it can also be the result of significant aerophagia leading to massive gastric distention. Placement of a nasogastric or orogastric tube will decompress the stomach and reduce the risk of aspiration. Rectal examination is an important adjunct to the abdominal examination, as is evaluation of the pelvis.
Physical Examination
Prompt and accurate assessment of injuries is necessary to optimize the outcome. However, children sustaining blunt abdominal trauma pose a challenging dilemma because the initial abdominal examination is often unreliable and inaccurate, with a high rate of missed abdominal injuries. The initial abdominal examination may fail to show significant abdominal pathology (up to 45%), and sequential examinations are essential to exclude an evolving abdominal problem.81 Studies have demonstrated the difficulty in assessing abdominal tenderness on physical examination of pediatric traum patients.8,9,81-84 In children with significant hemoperitoneum, 40% had no clinical abdominal signs.85 Delays in diagnosis can be fatal in some patients. In addition, there are injuries that may develop symptoms very slowly, such as small gastrointestinal perforations, pancreatic contusions, pseudocyst or ductal injury, urinoma, obstructing duodenal hematoma, or hematobilia.
Bruising of the abdominal wall has been reported previously as an indicator of intra-abdominal injury.86-90 Abdominal wall bruising has been associated with the use of suboptimal restraint, such as the lap belt only restraint.91 Significant intraabdominal injury occurs in 6-16% of patients.86-90 Children with physical signs such as abrasions, contusions, pain and tenderness are more likely to have abdominal injury.81,84,92
Laboratory Evaluation
Difficulties in the evaluation of the injured child and the inherent risk for missed injuries and subsequent morbidity have led to standardized management protocols, including screening tests obtained during resuscitation. Before CT was readily obtained, “trauma panels” were performed as a means of predicting serious intra-abdominal pathology.82,93 Despite prior studies showing a limited use for trauma panel, their use is still recommended but controversial.82,83,94-97 The utility of the trauma panels, however, may be increased through use on select subsets of injured patients. These panels may include some or all of the following laboratory tests: a complete blood cell count, serum chemistries, and coagulation profiles along with organ-specific markers of injury such as liver function tests, amylase, lipase, and urinalysis.
A retrospective review of the utility of a trauma panel in children showed that no laboratory screen was clinically significant for abdominal pathology.98 Elevated AST and ALT levels, in addition to microscopic hematuria and an abnormal physical examination, are associated with an intra-abdominal injury.99 Elevation of glucose and white blood cell (WBC) count may occur as a stress response to the trauma and has no correlation with injury severity or impact on patient management.100-102
Initial hemoglobin and hematocrit levels might be normal in children with significant bleeding, as it may take hours for body fluid spaces to equilibrate and reflect the degree of hemorrhage. Serial hemoglobin and hematocrit levels are more useful tools that reflect the presence of ongoing blood loss.
Coagulation studies, including platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) are seldom useful acutely in previously healthy children. A review of 830 pediatric blunt trauma victims found that during hospitalization, an elevated PT or aPTT developed in 37% who were hypotensive, 18% with a PTS less than or equal to 8, 17% with open or multiple fractures, 16% with major open wounds, and 19% with a pediatric Glasgow Coma Scale (GCS) score of less than or equal to 13.103 Children who receive multiple units of blood are also at risk for developing transfusionrelated coagulopathies. Patients with an isolated intra-abdominal injury generally do not require coagulation studies if one of the above factors does not exist.
Electrolyte abnormalities are uncommon in acute trauma. A multicenter prospective study of 715 children with electrolyte panels obtained in the ED found that 1 of 42 children with trauma requiring blood or fluid resuscitation in the ED had an electrolyte abnormality.104 However, in children with shock caused by acute blood loss, metabolic acidosis and an elevated serum lactate level are expected.105 Base deficit is a useful marker for the presence of abdominal injury requiring surgery. A study of 3223 patients, mainly adults, with blunt abdominal trauma found that patients with a normal base deficit (-2 to 2) had a 4% probability of abdominal injury requiring surgery.106 The probability of abdominal trauma requiring surgery rose to 9% for a mild base deficit (-3 to -5), to 28% for a moderate base deficit (-6 to -14), and to 31% for a severe base deficit (less than -15). Other electrolyte abnormalities that occur primarily following massive transfusions include hyperkalemia, metabolic alkalosis, hyperphosphatemia, and hypocalcemia.
Hematuria is an important marker of serious renal and non-renal trauma in children.107 In one study, the most commonly injured organ in children with hematuria was not the kidney (26%), but the spleen (37%) and liver (33%).107 A study of 378 children evaluated after blunt abdominal trauma found that splenic injury was present in 11% and liver injury in 10% of patients with hematuria, while renal injury occurred in only 8% of children with hematuria.107 Renal trauma was found in 22% of those with gross hematuria, splenic injury in 17%, and liver injury in 8%. While the degree of hematuria correlated with a higher risk of abdominal injury, all children with hematuria and organ injury had other indications for CT, such as abdominal pain or abnormal abdominal examination. Hematuria can indicate trauma at any location within the genitourinary system. Conversely, hematuria might be absent in up to 50% patients with renal pedicle injuries.108 Blood in the urine may also come from the placement of a Foley catheter. A study of 285 consecutive children with minimal to moderate injury found that the abdominal examination combined with urinalysis detected 98% of all intraabdominal injuries.82
Children with hepatic transaminase abnormalities were more likely to have liver injury than children presenting with normal levels.102,109 Only transaminases in excess of 400 IU/L, however, were predictive of liver injury identifiable with abdominal imaging. Of note, in each child presenting with a transaminase level in excess of 400 IU/L, abdominal imaging was deemed necessary because of either injury mechanism or physical examination findings, such as decreased level of consciousness, abdominal tenderness, or shock, and was not influenced by these laboratory results. Another study showed that a serum AST greater than 400 IU/L and/or ALT greater than 250 IU/L predicted hepatic injuries.109,110 In addition, the degree of elevation of hepatic transaminases does not correlate with the degree of injury or outcome.110 Since CT is recommended to identify and grade suspected liver injuries, liver function tests are generally not required in managing liver injuries. Their main use might be to identify unsuspected injuries in children who do not undergo CT.
Elevated serum amylase and lipase may suggest pancreatic injury. However, serum values alone are not reliable as screening studies for pancreatic injury in the pediatric trauma population. Elevation of serum amylase has some correlation with injury to the pancreas in children. Some studies have noted elevated serum amylase levels in children with pancreatic injury, yet others do not.111-115 These tests have poor sensitivity in detecting pancreatic injury, with elevations reported in only 25-77% of CT or laparoscopic proven cases.113,116,117 Sensitivity might be increased if repeated values are obtained, especially in those with increasing abdominal pain.111,113 The magnitude of serum amylase elevation, however, does not predict the severity of injury to the pancreas.113 Serum amylase levels may be normal even in cases of major injury to the pancreatic duct.118 Serum amylase levels do not alter the management of patients with abdominal trauma in several large series and were felt to be of limited value in predicting pancreatic trauma.81,119 Amylase and lipase also are poor at discriminating between pancreatic and non-pancreatic trauma. In one study, 45 patients (53%) had an elevation of one of these tests and only one (1%) had a pancreatic injury. Furthermore, several studies have shown that severe head injury in the absence of pancreatic injury may result in hyperamylasemia in the early post-injury period.120 Therefore, inclusion of amylase and lipase values as a part of a trauma screening panel results in a significant number of elevated values that do not correlate with abdominal injury.12
In addition to the laboratory evaluation early in the resuscitation process, any multiply injured child should have blood drawn and sent for cross-match.
A favorable outcome for any pediatric trauma depends upon rapid and accurate diagnosis with prompt treatment of potential life-threatening injuries. Evaluation and management of the injured child should follow the paradigm of the Advanced Trauma Life Support protocols with assessment of airway, breathing, circulation, neurological status, and complete exposure during the primary survey with management of immediate life threats as soon as they are identified. The first step consists of assessment of airway patency and quality of breathing. Once the airway has been secured, evaluate the quality of the circulation. The heart rate is the most sensitive indicator of intravascular volume status in infants and young children. It should be emphasized that hypovolemic shock is heralded by tachycardia long before hypotension is apparent. A child with multiple injuries should undergo placement of two large-bore intravenous catheters. If intravenous access proves to be difficult, insertion of an intraosseous catheter can be life saving in any age group. An intraosseous catheter can be used for fluid resuscitation and administration of medications.79 The most common location is at least one finger breadth below the tibial tuberosity to make certain the physis is avoided. After the initial resuscitation has been performed using an intraosseous catheter, intravenous attempts are often successful.
Obtaining as much information as possible about a child’s past medical history is always worthwhile even in the abbreviated trauma history and examination. Medical conditions that affect a child’s neurological or developmental baseline are important to obtain. A few examples that may make evaluation more difficult include autism, cerebral palsy, or other medical conditions that result in mental or physical handicaps. Hemophilia patients or patients with recent or concurrent Epstein-Barr virus infection may have delayed splenic rupture and massive bleeding from minor abdominal trauma.80
Fear and pain can complicate the management of serious abdominal trauma in children. Children tend to distend the stomach greatly with ingested air and this can significantly decrease the diaphragmatic excursion by overdistention of the abdomen, which can compromise respiratory efforts. Early decompression via nasogastric or orogastric tube insertion should therefore be considered. Children in whom a stable pelvis has been established and who are not at risk for urethral trauma should have a Foley catheter inserted to decompress the bladder. The clinician should then evaluate for the presence of urinary retention and check for the presence of blood in the urine.
ED evaluation and management of blunt trauma is guided primarily by the stability of the patient and the presence of associated injuries. The blood volume of a child is approximately 80 mL/kg. The American College of Surgeons fluid resuscitation guidelines recommend an initial bolus of 20 mL/kg of warm isotonic fluids (0.9% normal saline or lactated Ringer’s) for the thermodynamically unstable child. In addition, other life-threatening injuries should be excluded. If the child remains hemodynamically unstable after 40 mL/kg of isotonic solution, administration of blood at 10-20 mL/kg should be strongly considered, and a thorough evaluation for the source of bleeding should be undertaken. It is imperative that a pediatric surgeon or trauma surgeon be consulted at this point. If hypotension persists and intra abdominal injury is suspected, additional blood and a laparotomy should be strongly considered.
After completion of the primary survey, perform a thorough secondary survey that consists of a head-to-toe physical examination to identify all traumatic injuries. Physical findings suggestive of intra abdominal injury include abrasions and contusions on the abdominal wall (seat belt sign), abdominal distention, and tenderness. Abdominal distention may be a sign of hemoperitoneum, but it can also be the result of significant aerophagia leading to massive gastric distention. Placement of a nasogastric or orogastric tube will decompress the stomach and reduce the risk of aspiration. Rectal examination is an important adjunct to the abdominal examination, as is evaluation of the pelvis.
Physical Examination
Prompt and accurate assessment of injuries is necessary to optimize the outcome. However, children sustaining blunt abdominal trauma pose a challenging dilemma because the initial abdominal examination is often unreliable and inaccurate, with a high rate of missed abdominal injuries. The initial abdominal examination may fail to show significant abdominal pathology (up to 45%), and sequential examinations are essential to exclude an evolving abdominal problem.81 Studies have demonstrated the difficulty in assessing abdominal tenderness on physical examination of pediatric traum patients.8,9,81-84 In children with significant hemoperitoneum, 40% had no clinical abdominal signs.85 Delays in diagnosis can be fatal in some patients. In addition, there are injuries that may develop symptoms very slowly, such as small gastrointestinal perforations, pancreatic contusions, pseudocyst or ductal injury, urinoma, obstructing duodenal hematoma, or hematobilia.
Bruising of the abdominal wall has been reported previously as an indicator of intra-abdominal injury.86-90 Abdominal wall bruising has been associated with the use of suboptimal restraint, such as the lap belt only restraint.91 Significant intraabdominal injury occurs in 6-16% of patients.86-90 Children with physical signs such as abrasions, contusions, pain and tenderness are more likely to have abdominal injury.81,84,92
Laboratory Evaluation
Difficulties in the evaluation of the injured child and the inherent risk for missed injuries and subsequent morbidity have led to standardized management protocols, including screening tests obtained during resuscitation. Before CT was readily obtained, “trauma panels” were performed as a means of predicting serious intra-abdominal pathology.82,93 Despite prior studies showing a limited use for trauma panel, their use is still recommended but controversial.82,83,94-97 The utility of the trauma panels, however, may be increased through use on select subsets of injured patients. These panels may include some or all of the following laboratory tests: a complete blood cell count, serum chemistries, and coagulation profiles along with organ-specific markers of injury such as liver function tests, amylase, lipase, and urinalysis.
A retrospective review of the utility of a trauma panel in children showed that no laboratory screen was clinically significant for abdominal pathology.98 Elevated AST and ALT levels, in addition to microscopic hematuria and an abnormal physical examination, are associated with an intra-abdominal injury.99 Elevation of glucose and white blood cell (WBC) count may occur as a stress response to the trauma and has no correlation with injury severity or impact on patient management.100-102
Initial hemoglobin and hematocrit levels might be normal in children with significant bleeding, as it may take hours for body fluid spaces to equilibrate and reflect the degree of hemorrhage. Serial hemoglobin and hematocrit levels are more useful tools that reflect the presence of ongoing blood loss.
Coagulation studies, including platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) are seldom useful acutely in previously healthy children. A review of 830 pediatric blunt trauma victims found that during hospitalization, an elevated PT or aPTT developed in 37% who were hypotensive, 18% with a PTS less than or equal to 8, 17% with open or multiple fractures, 16% with major open wounds, and 19% with a pediatric Glasgow Coma Scale (GCS) score of less than or equal to 13.103 Children who receive multiple units of blood are also at risk for developing transfusionrelated coagulopathies. Patients with an isolated intra-abdominal injury generally do not require coagulation studies if one of the above factors does not exist.
Electrolyte abnormalities are uncommon in acute trauma. A multicenter prospective study of 715 children with electrolyte panels obtained in the ED found that 1 of 42 children with trauma requiring blood or fluid resuscitation in the ED had an electrolyte abnormality.104 However, in children with shock caused by acute blood loss, metabolic acidosis and an elevated serum lactate level are expected.105 Base deficit is a useful marker for the presence of abdominal injury requiring surgery. A study of 3223 patients, mainly adults, with blunt abdominal trauma found that patients with a normal base deficit (-2 to 2) had a 4% probability of abdominal injury requiring surgery.106 The probability of abdominal trauma requiring surgery rose to 9% for a mild base deficit (-3 to -5), to 28% for a moderate base deficit (-6 to -14), and to 31% for a severe base deficit (less than -15). Other electrolyte abnormalities that occur primarily following massive transfusions include hyperkalemia, metabolic alkalosis, hyperphosphatemia, and hypocalcemia.
Hematuria is an important marker of serious renal and non-renal trauma in children.107 In one study, the most commonly injured organ in children with hematuria was not the kidney (26%), but the spleen (37%) and liver (33%).107 A study of 378 children evaluated after blunt abdominal trauma found that splenic injury was present in 11% and liver injury in 10% of patients with hematuria, while renal injury occurred in only 8% of children with hematuria.107 Renal trauma was found in 22% of those with gross hematuria, splenic injury in 17%, and liver injury in 8%. While the degree of hematuria correlated with a higher risk of abdominal injury, all children with hematuria and organ injury had other indications for CT, such as abdominal pain or abnormal abdominal examination. Hematuria can indicate trauma at any location within the genitourinary system. Conversely, hematuria might be absent in up to 50% patients with renal pedicle injuries.108 Blood in the urine may also come from the placement of a Foley catheter. A study of 285 consecutive children with minimal to moderate injury found that the abdominal examination combined with urinalysis detected 98% of all intraabdominal injuries.82
Children with hepatic transaminase abnormalities were more likely to have liver injury than children presenting with normal levels.102,109 Only transaminases in excess of 400 IU/L, however, were predictive of liver injury identifiable with abdominal imaging. Of note, in each child presenting with a transaminase level in excess of 400 IU/L, abdominal imaging was deemed necessary because of either injury mechanism or physical examination findings, such as decreased level of consciousness, abdominal tenderness, or shock, and was not influenced by these laboratory results. Another study showed that a serum AST greater than 400 IU/L and/or ALT greater than 250 IU/L predicted hepatic injuries.109,110 In addition, the degree of elevation of hepatic transaminases does not correlate with the degree of injury or outcome.110 Since CT is recommended to identify and grade suspected liver injuries, liver function tests are generally not required in managing liver injuries. Their main use might be to identify unsuspected injuries in children who do not undergo CT.
Elevated serum amylase and lipase may suggest pancreatic injury. However, serum values alone are not reliable as screening studies for pancreatic injury in the pediatric trauma population. Elevation of serum amylase has some correlation with injury to the pancreas in children. Some studies have noted elevated serum amylase levels in children with pancreatic injury, yet others do not.111-115 These tests have poor sensitivity in detecting pancreatic injury, with elevations reported in only 25-77% of CT or laparoscopic proven cases.113,116,117 Sensitivity might be increased if repeated values are obtained, especially in those with increasing abdominal pain.111,113 The magnitude of serum amylase elevation, however, does not predict the severity of injury to the pancreas.113 Serum amylase levels may be normal even in cases of major injury to the pancreatic duct.118 Serum amylase levels do not alter the management of patients with abdominal trauma in several large series and were felt to be of limited value in predicting pancreatic trauma.81,119 Amylase and lipase also are poor at discriminating between pancreatic and non-pancreatic trauma. In one study, 45 patients (53%) had an elevation of one of these tests and only one (1%) had a pancreatic injury. Furthermore, several studies have shown that severe head injury in the absence of pancreatic injury may result in hyperamylasemia in the early post-injury period.120 Therefore, inclusion of amylase and lipase values as a part of a trauma screening panel results in a significant number of elevated values that do not correlate with abdominal injury.12
In addition to the laboratory evaluation early in the resuscitation process, any multiply injured child should have blood drawn and sent for cross-match.
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