Blunt abdominal trauma is the third most common cause of pediatric deaths from trauma, but it is the most common unrecognized fatal injury. The history and physical examination, combined with the mechanism of injury, should be used to develop a thoughtful and directed diagnostic workup. The mainstays of diagnostic evaluation include laboratory testing, sonography, and computed tomography. However, due to the concern for radiation exposure and other risks, the routine use of these studies may not be necessary, and controversy exists as to which studies are beneficial and which are less valuable. This supplement discusses common mechanisms and injuries seen in children with blunt abdominal trauma and takes a closer look at evaluation and management techniques.
A 10-year-old girl involved in a motor vehicle crash is brought to your ED. She was restrained in the rear driver’s-side seat of the vehicle with a lap and shoulder belt when the vehicle was struck at high speed on the driver’s side. On arrival to the ED, she is awake and alert, and immobilized with a cervical collar and back board. Her vital signs are as follows: temperature, 37.5°C (99.5°F); heart rate, 130 beats/min; blood pressure, 105/70 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 98% on room air. On examination, she is able to maintain her airway and has clear and equal breath sounds without increased work of breathing, and she has strong distal pulses. She complains of abdominal pain. Her abdomen is soft and nondistended, but she has localized tenderness in the left upper quadrant. There are no bruises or abrasions noted on the abdomen. Several questions are running through your mind: What fluids should I give her, how much, and how fast? What labs should I order? Should I perform a FAST exam, or should I order a CT of the abdomen/pelvis? Do I need contrast for the CT? Or does she need to go emergently to the operating room?
In the next room, a 9-year-old boy has been brought to the ED for epigastric pain and 1 episode of nonbloody, nonbilious vomiting. He is awake and alert, and his vital signs are as follows: temperature, 37°C (98.6°F); heart rate, 110 beats/min; respiratory rate, 24 breaths/min; blood pressure, 95/55 mm Hg; and oxygen saturation, 98% on room air. He has no diarrhea, and there are no known sick contacts. While you are examining him, you note moderate tenderness with voluntary guarding of the epigastric area. On further examination, you notice a faint bruise to the epigastric area and ask the patient how it occurred. He states that he was riding his bicycle the day before, and fell onto the handlebars. You wonder if this could be the cause of his pain and vomiting. For what injuries is he at risk? What tests should you order? Do you need to obtain a surgery consultation? Should he be admitted to the hospital?
Trauma remains the leading cause of childhood death and disability in children aged > 1 year.1 While head and thoracic trauma account for most death and disability in children, abdominal injuries constitute the most commonly unrecognized cause of death.2 Blunt injury accounts for 90% of abdominal trauma in children.2 Common mechanisms include motor vehicle crashes (MVCs), falls, pedestrian injuries, bicycle and sports-related injuries, and nonaccidental trauma (NAT). Penetrating injuries are much less common in children than in adults.2
Management of pediatric trauma has unique challenges. The developmental stage of the patient, a lack of verbal skills in younger patients, and a lack of prehospital information create limitations in managing the injured child.3 Similar to their adult counterparts, children can have an unreliable abdominal examination from an associated head injury and a decreased Glasgow Coma Scale (GCS) score. Additionally, children are more likely to have an unreliable abdominal examination secondary to crying and abdominal distension.2
The routine use of trauma panels and computed tomography (CT) scans of the head, neck, chest, abdomen, and pelvis should not be employed in the pediatric patient. Unnecessary radiation exposure in the pediatric patient carries an increased lifetime risk of fatal malignancy, in addition to an increased cost burden.4,5 Instead, a more thoughtful and focused approach to assessing and managing the child with blunt abdominal trauma should be undertaken.
A literature search of Ovid, Clinical Key, and PubMed was completed using the terms pediatric blunt abdominal trauma, blunt abdominal trauma, pediatric trauma, and abdominal trauma and specific organs injured. The Cochrane Database of Systematic Reviews and the National Guidelines Clearinghouse were reviewed, but limited information on pediatric abdominal trauma was found. Additionally, ClinicalTrials.gov was reviewed for ongoing studies. The search was limited mostly to the last 20 years. Much research has been completed on trauma and on pediatric trauma, but the literature lacks strong randomized controlled trial data and prospective studies. Many of the studies on which our current evaluation and management strategies are based are retrospective reviews. There are a few prospective observational studies that validate the retrospective studies and an even smaller number of meta-analyses. For injuries with a low incidence of occurrence (such as adrenal injuries), case studies dominate the literature.
1. “The patient’s blood pressure was fine, and I thought his elevated heart rate was because he was crying, so I didn’t start fluids.”
Hypotension is a late indicator of hemodynamic instability in children. Although tachycardia may be secondary to pain or fear, it is also the first indicator of blood loss in injured children. Fluids should be initiated in any child who has suffered blunt abdominal trauma and has an elevated heart rate. If pain or fear is thought to be the cause, comforting measures should be implemented. If tachycardia continues, an additional fluid bolus and/or blood products should be given. If the heart rate remains elevated despite these measures, the patient should be considered hemodynamically unstable and undergo immediate surgery consultation.
3. “The FAST was negative, so I didn’t think there was an intra-abdominal injury.”
Several studies in children have shown that the sensitivity of FAST alone is only approximately 50% in detecting intra-abdominal injury. FAST can adequately detect hemoperitoneum; however, up to one-third of intra-abdominal injuries in children do not cause hemoperitoneum and are undetectable by ultrasound. A negative FAST in children is not sufficient to rule out intra-abdominal injury. In any child with a concerning mechanism of injury or examination findings, other diagnostic tests and serial examinations should be obtained to evaluate for intra-abdominal injury further.
8. “I knew the little girl wasn’t properly restrained at the time of the motor vehicle crash, and I saw the lap-belt marks on her abdomen, but her CT scan was normal, so I discharged her home.”
Injuries to the pancreas and gastrointestinal tract require a high index of suspicion, as they may have delayed presentation, and laboratory tests and CT scans may be normal. Therefore, the emergency clinician should be aware of mechanisms that have a higher risk of injury to these organs, including inappropriate restraint with a lap belt only, direct blow to the abdominal wall (such as in handlebar injuries or in some sports injuries), and NAT. If injury to the pancreas or hollow viscus is suspected, surgical consultation should be obtained, and the child should be hospitalized for serial examinations and observation.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Points to keep in mind:
Why to Use
The GCS score is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
Daniel Runde, MD
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
The evidence presented in 53 published reports on the reproducibility of the GCS was synthesized in a systematic review by Reith et al in 2016. Eighty-five percent of the findings in the studies identified as high quality showed substantial reliability of the GCS as judged by the standard criterion of a kappa statistic > 0.6. Reproducibility of the total GCS score was also high, with kappa > 0.6 in 77% of the observations. Education and training on usage of the GCS resulted in a clear beneficial effect on reliability (Reith 2016).
In its most common usage, the 3 sections of the scale are often combined to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1 + 1 + 2 for eye, verbal, and motor components, respectively, and a mortality rate of 27% if calculated 1 + 2 + 1, but a mortality rate of only 19% if calculated 2 + 1 + 1 (Healey 2014).
The modified GCS provides a nearly universally-accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale (as in the SMS) can perform as well as the GCS and is less complicated. However, the scores like the SMS may be less informative in patients with lesser injuries.
Sir Graham Teasdale, MBBS, FRCP
Why to Use
Due to the heterogeneous nature of trauma patients, standardizing the severity of traumatic injuries allows for comparison of much larger sample populations in trauma research studies.
When to Use
The ISS attempts to standardize the severity of injuries sustained during trauma. This standardization allows for more accurate study and prediction of morbidity and mortality outcomes after traumatic injuries.
As the ISS is intended primarily as a research tool, the score should not affect the initial management of a patient with traumatic injuries.
Max Berger, MD
Alexandra Ortego, MD
First, the most severe injury from each of 6 body systems is assigned an AIS score on a scale of 0 (no injury) to 6 (unsurvivable injury). Next, those scores are used to determine the 3 most injured body systems. Finally, the ISS is calculated by squaring the AIS score for each of the 3 most injured body systems, then adding up the 3 squared numbers (A2 + B2 + C2 = ISS, where A, B, and C are the AIS scores of the most severe injury in each of the 3 most severely injured body systems). Patients with an AIS of 6 in any body system are automatically assigned an ISS of 75, the maximum possible score.
The ISS is used primarily in research settings, so calculation of the score should not delay initial management of patients with traumatic injuries.
The ISS was derived by Baker et al (1974) by taking the previously used AIS (American Medical Association Committee on Medical Aspects of Automotive Safety 1971) and adding the squared value of each of the 3 most severely injured body systems, in an effort to add increasing importance to the most severe injuries. The top 3 most severe injuries were used to calculate the final score because it had been shown that injuries that would not necessarily be life-threatening in isolation could have a significant effect on mortality when they occurred in combination with other severe injuries. The derivation study included only injuries sustained from motor vehicle collisions, including the occupants of the vehicles and any pedestrians involved.
Further studies have validated the ISS to include other mechanisms of injury. A study by Beverland et al (1983) of 875 patients with gunshot wounds showed that an increasing ISS was associated with increasing mortality (chi-squared = 83.31, P < .001). A study by Bull (1978) confirmed the correlation between increasing ISS and increasing mortality in road traffic accidents, and showed correlation between increasing ISS and increasing mean hospital length of stay.
In a study of 8852 trauma patients from the Illinois Trauma Program (including both vehicular and nonvehicular trauma), Semmlow et al (1976) had similar findings to Baker et al regarding the relationship between ISS and mortality. They also found that the ISS correlated with hospital length of stay.
Susan P. Baker, MPH
Why to Use
The SIPA is more accurate than the SI at differentiating severely injured children from children with mild injury. In the original study (Acker 2015), an elevated SIPA was shown to identify approximately 25% of the most severely injured children, regardless of age, while an SI > 0.9 has been shown to identify anywhere from 32% to 71% of injured children, depending on age. Being able to accurately identify severely injured children is critical in reducing the overtriage of children who have sustained injuries. An elevated SIPA is associated with the following outcomes (Acker 2015; Nordin, Coleman, Shi, et al 2017):
When to Use
The SIPA can be used for patients aged 4 to 16 years who have sustained blunt trauma. The SIPA should not be used for young infants, toddlers, or patients with penetrating trauma.
The general management of pediatric blunt abdominal trauma includes performing the primary and secondary surveys and determining the extent, type, and severity of injury.
A thorough abdominal examination is ex-tremely important because abdominal injuries are often not apparent on physical examination. Depending on the examination findings, the use of imaging may be warranted.
Christian Hietanen, DO
Patients who present with an elevated SIPA for age have a higher risk of morbidity and mortality following blunt trauma. Early recognition and treatment of these patients, including a possible decision to transfer to a higher level of care, will improve outcomes.
There is no value or finding that necessarily defines shock, and children can compensate more readily than adults. Hypotension is often a late finding in children with hypovolemic shock.
The SIPA was originally developed by researchers at the Children’s Hospital of Colorado to help identify severely injured children following blunt trauma (Acker 2015). Mechanism alone has been found to be a poor predictor of injury severity in children (Qazi 1998). Clinical and physiologic parameters are better indicators (Wang 2001) and previous studies (Rousseaux 2013; Yasaka 2013) have shown that the shock index (SI) helps identify a higher risk of mortality versus using heart rate and blood pressure alone. The SIPA furthers builds on those findings by using specific vital sign cutoffs by age group.
Realizing that pediatric vital signs vary with age and that the SI might not be as useful in children, Acker et al (2015) sought and defined maximum normal heart rate and minimum normal systolic blood pressure using reference ranges from 2 pediatric textbooks and the United States Department of Health and Human Services’ Pediatric Basic and Advanced Life Support guidelines. The authors used these numbers to determine the maximum normal SI for 3 age groups, and then conducted a retrospective review of 543 children aged 4 to 16 years who had been admitted between January 2007 and June 2013 to 2 Colorado trauma centers following blunt trauma and with injury severity scores > 15.
An elevated SI was present in 49% of the children, while an elevated SIPA was present in only An elevated SI was present in 49% of the children, while an elevated SIPA was present in only 27.6% of the children, all of whom had the same adverse outcomes that were identified by using the SI. The SIPA demonstrated improved discrimination of severe injury compared to the SI in the following categories:
The authors concluded that the SIPA misses fewer children with severe injury while also minimizing overtriage.
A multicenter prospective observational study of 386 patients aged 4 to 16 years (Linnaus 2017) validated the original study with level II-quality evidence.
In 2017, Nordin, Coleman, and Shi, et al, developed SIPA cutoff values for patients aged 1 to 3 years and found the SIPA to be a significantly better predictor than the SI of transfusion needs, injury severity, intensive care unit admission, ventilator use, and mortality following blunt and penetrating trauma.
The authors of the original SIPA study conducted a follow-up study (Acker 2017) and found the SIPA to be superior to age-adjusted hypotension in identifying injured children who required trauma team activation. The criteria used as indicators included early blood transfusion, endotracheal intubation, and emergency operation.
A comparison of the accuracy of the SIPA, SI, and the revised trauma score for predicting outcomes in pediatric trauma patients was presented at the 2017 annual meeting of the Pediatric Trauma Society; the presenters found that the SIPA outperformed the SI and compared favorably to the revised trauma score (Nordin, Shi, Wheeler 2017).
Manuel Mutschler, MD
Nicole Schacherer, MD;Jill Miller, MD; Kelli Petronis, MD
Lara Zibners, MD, MMed, FAAP, FACEP
January 15, 2020
February 14, 2023
4 AMA PRA Category 1 Credits.™ Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Date of Original Release: January 15, 2020. Date of most recent review: December 31, 2019. Termination date: January 15, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; thorough review of current literature on the topic and practice gap assessment; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
CME Objectives: Upon completion of this activity, you should be able to: (1) identify the common patterns of injury that can occur in children with blunt abdominal trauma; (2) perform an evidence-based diagnostic workup in children with blunt abdominal trauma; (3) distinguish the management of specific abdominal organ injuries; and (4) discuss the indications for surgical consultation, admission, and discharge in children with blunt abdominal trauma.
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