Pediatric Blunt Abdominal Trauma: Recognition and Management in the Emergency Department - Trauma EXTRA Supplement

Table of Contents

 

Children are more susceptible than adults to serious injury secondary to blunt abdominal trauma. When a pediatric patient presents to the ED following blunt abdominal trauma, the abdominal examination may be unreliable due to the child’s age or developmental level, or due to an associated head injury; a negative abdominal examination and the absence of comorbid injuries do not completely rule out an intra-abdominal injury in these patients. However, the use of diagnostic CT scanning must be weighed against the risks associated with exposure to ionizing radiation in pediatric patients. This supplement provides evidence-based recommendations for the evaluation and management of blunt abdominal injuries in children, including injuries to specific organs. You will learn:

The most common mechanisms of traumatic intra-abdominal injury in children, including motor vehicle crashes, bicycle injuries, sports injuries, and nonaccidental trauma

Why seat-belt sign is an important clinical finding in a child who was involved in a motor vehicle crash

The role of diagnostic laboratory testing in assessing children with intra-abdominal injuries

The applications and limitations of FAST in the evaluation of pediatric patients

How clinical prediction rules can be used to help determine which patients do not need to undergo CT scanning

The appropriate initial management of pediatric blunt trauma patients, including fluid resuscitation for hemodynamically unstable patients

Diagnostic considerations and indications for operative versus nonoperative management of injuries to specific intra-abdominal organs, including splenic, liver, renal, pancreatic, gastrointestinal, and adrenal trauma

1. Key Points
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Epidemiology and Pathophysiology
   1. Epidemiology
   2. Etiology and Pathophysiology
7. Common Mechanisms of Injury in Blunt Abdominal Trauma
   1. Motor Vehicle Crashes
      1. Seat-Belt Syndrome
   2. Pedestrian Struck By Motor Vehicle
   3. Falls
   4. Bicycle Injuries
   5. Sports Injuries
   6. Nonaccidental Trauma
8. Prehospital Care
9. Emergency Department Evaluation
   1. Primary Survey
   2. Focused History
   3. Secondary Survey
      1. Physical Examination Findings Suggestive of Abdominal Injury
10. Diagnostic Studies
    1. Laboratory Tests
    2. Focused Assessment With Sonography in Trauma
    3. Computed Tomography
       1. Risks of Computed Tomography in Pediatric Patients
       2. Determining Which Patients Do Not Need Computed Tomography
11. Treatment
    1. Initial Management
    2. Management of Specific Organ Injuries
       1. Splenic Trauma
          • Diagnosis
          • Management
       2. Liver Trauma
          • Diagnosis
          • Management
       3. Renal Trauma
          • Diagnosis
          • Management
       4. Pancreatic Trauma
          • Diagnosis
          • Management
       5. Gastrointestinal Trauma
          • Diagnosis
          • Management
       6. Adrenal Trauma
12. Special Populations/Circumstances
    1. Nonaccidental Trauma
    2. Obesity
    3. Postmenarchal Females/Pregnancy
13. Controversies and Cutting Edge
    1. Massive Transfusion Protocols
    2. Thromboembolization
    3. Contrast-Enhanced Ultrasound
    4. Decreased Time on Bed Rest
    5. Pediatric Shock Index
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls in Blunt Abdominal Trauma in Pediatric Patients
18. Case Conclusions
19. Clinical Pathway for Management of the Pediatric Patient With Blunt Abdominal Trauma
20. Figure
    1. Figure 1. Seat-Belt Sign
21. References

Key Points

• A negative abdominal examination and the absence of comorbid injuries do not completely rule out an intra-abdominal injury.
• A negative FAST examination is not sufficient to rule out the presence of an intra-abdominal injury, but a positive FAST examination should prompt an immediate abdominal CT scan in a hemodynamically stable patient.
• The most useful tests are the complete blood cell count, liver function tests, and urinalysis. However, the physical examination and mechanism of injury should be used to guide the evaluation and choice of diagnostic testing.
• Many pediatric patients with solid-organ injury can be managed nonoperatively.

Abstract

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.

Case Presentations

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?

Introduction

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.

Critical Appraisal of the Literature

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.

Risk Management Pitfalls in Blunt Abdominal Trauma in Pediatric Patients

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.

References

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.

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96. Sheth S, Casalino D, Expert Panel on Urologic Imaging, et al. ACR Appropriateness Criteria^® renal trauma. 2012. Accessed January 15, 2020. (Guideline)
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112. Clendenon JN, Meyers RL, Nance ML, et al. Management of duodenal injuries in children. J Pediatr Surg. 2004;39(6):964-968. (Retrospective chart review; 42 patients)
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115. Lee YS, Jeong JJ, Nam KH, et al. Adrenal injury following blunt abdominal trauma. World J Surg. 2010;34(8):1971-1974. (Retrospective review; 11 patients)
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121. Uppot RN, Sahani DV, Hahn PF, et al. Effect of obesity on image quality: fifteen-year longitudinal study for evaluation of dictated radiology reports. Radiology. 2006;240(2):435-439. (Retrospective study; > 5 million reports reviewed)
122. Navarro-Jarabo JM, Ubina-Aznar E, Tapia-Ceballos L, et al. Hepatic steatosis and severity-related factors in obese children. J Gastroenterol Hepatol. 2013;28(9):1532-1538. (Cross-sectional study; 144 children)
123. Trifiletti LB, Shields W, Bishai D, et al. Tipping the scales: obese children and child safety seats. Pediatrics. 2006;117(4):1197-1202. (Database review and assessment)
124. Fitzharris MP, Bowman DM. Booster seat use by children aged 4-11 years: evidence of the need to revise current Australasian standards to accommodate overweight children. Med J Aust. 2008;189(10):597-598. (Questionnaire survey, convenience sample; 692 respon ses of 3959 questionnaires, total 1500 children)
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126. Oxford CM, Ludmir J. Trauma in pregnancy. Clin Obstet Gynecol. 2009;52(4):611-629. (Review)
127. Petrone P, Talving P, Browder T, et al. Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers. Injury. 2011;42(1):47-49. (Retrospective review; 321 patients)
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129. Wallace GW, Davis MA, Semelka RC, et al. Imaging the pregnant patient with abdominal pain. Abdom Imaging. 2012;37(5):849-860. (Review)
130. Hussain ZJ, Figueroa R, Budorick NE. How much free fluid can a pregnant patient have? Assessment of pelvic free fluid in pregnant patients without antecedent trauma. J Trauma. 2011;70(6):1420-1423. (Prospective study; 89 patients)
131. Goodwin H, Holmes JF, Wisner DH. Abdominal ultrasound examination in pregnant blunt trauma patients. J Trauma. 2001;50(4):689-693. (Retrospective study; 208 patients)
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133. Nosanov L, Inaba K, Okoye O, et al. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013;206(5):655-660. (Retrospective study; 105 patients)
134. Cannon JW, Johnson MA, Caskey RC, et al. High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017;83(2):211-217. (Retrospective review; 364 patients)
135. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. (Randomized controlled trial; 680 patients)
136. Kiankhooy A, Sartorelli KH, Vane DW, et al. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma. 2010;68(3):526-531. (Retrospective study; 127 patients with 149 injuries, 7 patients underwent angiographic embolization)
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140. McCarville MB. Contrast-enhanced sonography in pediatrics. Pediatr Radiol. 2011;41 Suppl 1:S238-S242. (Review)
141. Cagini L, Gravante S, Malaspina CM, et al. Contrast enhanced ultrasound (CEUS) in blunt abdominal trauma. Crit Ultrasound J. 2013;5 Suppl 1:S9. (Review)
142. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000;35(2):164-167. (Multi-institutional retrospective chart review; 832 patients)
143. St Peter SD, Sharp SW, Snyder CL, et al. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2011;46(1):173-177. (Prospective observational study; 131 patients)
144. St Peter SD, Aguayo P, Juang D, et al. 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(12):2437-2441. (Prospective observational study; 249 patien ts)
145. Notrica DM, Eubanks JW 3rd, Tuggle DW, et al. Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015;79(4):683-693. (Literature review and guideline dev elopment)
146. Acker SN, Ross JT, Partrick DA, et al. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015;50(2):331-334. (Retrospective study; 543 patients)