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.

1. Wegner S, Colletti JE, Van Wie D. Pediatric blunt abdominal trauma. Pediatr Clin North Am. 2006;53(2):243-256. (Review)
2. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part I: injury patterns and initial assessment. Pediatr Emerg Care. 2000;16(2):106-115. (Review)
3. Mannenbach M, Spahr C. Pediatric trauma evaluations: current challenges and controversies. Pediatric Emergency Medicine Reports. 2010;15(6):61-75. (Review)
4. Sola JE, Cheung MC, Yang R, et al. Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma. J Surg Res. 2009;157(1):103-107. (Retrospective review; 400 patients)
5. Sivit CJ. Contemporary imaging in abdominal emergencies. Pediatr Radiol. 2008;38 Suppl 4:S675-S678. (Review)
6. United States Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System. Leading causes of death reports, national and regional, 1999-2017. 2019. Accessed January 15, 2020. (Government statistical report)
7. United States Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System. Nonfatal injury reports, 2001-2012. 2019. Accessed January 15, 2020. (Government statistical report)
8. Baren J. Abdominal Trauma. In: Baren J, Rothrock S, Brennan J, et al, eds. Pediatric Emergency Medicine. Philadelphia, PA: Saunders; 2007:225. (Textbook chapter)
9. Overly FL, Wills H, Valente JH. ‘Not just little adults’ - a pediatric trauma primer. R I Med J (2013). 2014;971):27-30. (Review)
10. Eradi B, Fisher RM. Abdominal and thoracic trauma in children. Surgery. 2010;28(1):22-26. (Review)
11. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management. Pediatr Emerg Care. 2000;16(3):189-195. (Review)
12. Wood J, Rubin DM, Nance ML, et al. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma. 2005;59(5):1203-1208. (Retrospective chart review; 121 patients)
13. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support: Student Course Manual (ATLS). 10th ed. Chicago, IL: American College of Surgeons Committee on Trauma; 2018. (Textbook)
14. Potoka D, Saladino R. Blunt abdominal trauma in the pediatric patient. Clin Ped Emerg Med. 2005;6(1):23-31. (Review)
15. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Policy statement—child passenger safety. Pediatrics. 2011;127(4):788-793. (Policy statement)
16. United States Department of Transportation. Lives saved in 2015 by restraint use and minimum-drinking-age laws. Washington, DC: National Highway Traffic Safety Administration; 2016. (Government statistical report)
17. American College of Surgeons. National Trauma Data Bank: Pediatric Report, 2016. 2016. (Statistical report)
18. Nance ML, Lutz N, Arbogast KB, et al. Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes. Ann Surg. 2004;239(1):127-131. (Cross-sectional study of a probability sample; 10,927 crashes involving 17,132 restrained children aged < 16 years)
19. Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA. 2003;289(21):2835-2840. (Cross-sectional study of a probability sample; 3616 crashes involving 4243 children aged 4-7 years)
20. Lutz N, Arbogast KB, Cornejo RA, et al. Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes. J Pediatr Surg. 2003;38(6):919-923. (Probability sample; 13,558 restrained children aged 0-15 years)
21. Arbogast KB, Jermakian JS, Kallan MJ, et al. Effectiveness of belt positioning booster seats: an updated assessment. Pediatrics. 2009;124(5):1281-1286. (Longitudinal study; 7151 children aged 4-8 years involved in 6591 crashes, seated in rear rows, and restrained by seat belt or belt-positioning seat)
22. Yoganandan N, Pintar FA, Gennarelli TA, et al. Patterns of abdominal injuries in frontal and side impacts. Annu Proc Assoc Adv Automot Med. 2000;44:17-36. (Review of National Automotive Sampling System database)
23. Durbin DR, Arbogast KB, Moll EK. Seat belt syndrome in children: a case report and review of the literature. Pediatr Emerg Care. 2001;17(6):474-477. (Review)
24. Sokolove PE, Kuppermann N, Holmes JF. Association between the “seat belt sign” and intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med. 2005;12(9):808-813. (Prospective observational study; 399 children)
25. Paris C, Brindamour M, Ouimet A, et al. Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision. J Pediatr Surg. 2010;45(5):921-924. (Retrospective chart review; 53 children)
26. Chakravarthy B, Vaca FE, Lotfipour S, et al. Pediatric pedestrian injuries: emergency care considerations. Pediatr Emerg Care. 2007;23(10):738-744. (Review)
27. Peng RY, Bongard FS. Pedestrian versus motor vehicle accidents: an analysis of 5,000 patients. J Am Coll Surg. 1999;189(4):343-348. (Retrospective review of centralized county trauma database; 5000 patients, 38.1% children aged < 15 years)
28. Orsborn R, Haley K, Hammond S, et al. Pediatric pedestrian versus motor vehicle patterns of injury: debunking the myth. Air Med J. 1999;18(3):107-110. (Retrospective chart review; 4444 pediatric trauma patients, 465 with pedestrian vs motor vehicle crash)
29. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528-1534. (Retrospective review; 729 children)
30. Lallier M, Bouchard S, St-Vil D, et al. Falls from heights among children: a retrospective review. J Pediatr Surg. 1999;34(7):1060-1063. (Retrospective review; 1410 children)
31. Bulut M, Koksal O, Korkmaz A, et al. Childhood falls: characteristics, outcome, and comparison of the Injury Severity Score and New Injury Severity Score. Emerg Med J. 2006;23(7):540-545. (Retrospective review; 749 children aged < 14 years)
32. Huntimer CM, Muret-Wagstaff S, Leland NL. Can falls on stairs result in small intestine perforations? Pediatrics. 2000;106(2 Pt 1):301-305. (Meta-analysis and literature review; 989 patients)
33. Klin B, Rosenfeld-Yehoshua N, Abu-Kishk I, et al. Bicycle-related injuries in children: disturbing profile of a growing problem. Injury. 2009;40(9):1011-1013. (Retrospective review; 142 patients)
34. Abu-Kishk I, Vaiman M, Rosenfeld-Yehoshua N, et al. Riding a bicycle: do we need more than a helmet? Pediatr Int. 2010;52(4):644-647. (Retrospective review; 46 patients)
35. Alkan M, Iskit SH, Soyupak S, et al. Severe abdominal trauma involving bicycle handlebars in children. Pediatr Emerg Care. 2012;28(4):357-360. (Retrospective review; 8 children)
36. Klimek PM, Lutz T, Stranzinger E, et al. Handlebar injuries in children. Pediatr Surg Int. 2013;29(3):269-273. (Retrospective review; 40 patients aged < 16 years)
37. Cherniawsky H, Bratu I, Rankin T, et al. Serious impact of handlebar injuries. Clin Pediatr (Phila). 2014;537):672-676. (Retrospective review; 462 children aged < 17 years)
38. Noaman F, Lam LT, Soundappan SV, et al. The nature and characteristics of abdominal injuries sustained during children’s sports. Pediatr Emerg Care. 2010;26(1):30-35. (Retrospective review of prospective database; 513 children)
39. Wan J, Corvino TF, Greenfield SP, et al. Kidney and testicle injuries in team and individual sports: data from the national pediatric trauma registry. J Urol. 2003;170(4 Pt 2):1528-1523. (Review of National Pediatric Trauma Registry data from 50 United States pediatric trauma centers between 1990 and 1999; 81,923 patients aged 5-18 years, with 5439 sports-related injuries)
40. Walters BS, Wolf M, Hanson C, et al. Soccer injuries in children requiring trauma center admission. J Emerg Med. 2014;46(5):650-654. (Retrospective review; 20 patients aged < 18 years)
41. McCrone AB, Lillis K, Shaha SH. Snowboarding-related abdominal trauma in children. Pediatr Emerg Care. 2012;28(3):251-253. (Retrospective chart review; 213 patients aged 6-21 years)
42. Roaten JB, Partrick DA, Nydam TL, et al. Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center. J Pediatr Surg. 2006;41(12):2013-2015. (Retrospective review; 6186 patients aged < 18 years)
43. Saltzman D, Bulander R. Diagnosing occult internal injury in children after motor vehicle trauma: managing the golden hour. Pediatr Emerg Med Pract. 2007;4(9):1-24. (Review)
44. Shlamovitz GZ, Mower WR, Bergman J, et al. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care. 2007;23(8):537-543. (Observational chart review of consecutive series of pediatric trauma patients; 213 patients)
45. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59(6):1314-1319. (Prospective study; 512 patients)
46. Cotton BA, Beckert BW, Smith MK, et al. The utility of clinical and laboratory data for predicting intraabdominal injury among children. J Trauma. 2004;56(5):1068-1074. (Retrospective review; 351 patients)
47. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002;395):500-509. (Prospective observational study; 1095 patients)
48. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. 2009;544):528-533. (Prospective observational study; 1119 patients)
49. Karam O, Sanchez O, Chardot C, et al. Blunt abdominal trauma in children: a score to predict the absence of organ injury. J Pediatr. 2009;154(6):912-917. (Prospective study; 147 patients)
50. de Jong WJ, Stoepker L, Nellensteijn DR, et al. External validation of the Blunt Abdominal Trauma in Children (BATiC) score: ruling out significant abdominal injury in children. J Trauma Acute Care Surg. 2014;765):1282-1287. (Retrospective review; 216 patients)
51. Hynick NH, Brennan M, Schmit P, et al. Identification of blunt abdominal injuries in children. J Trauma Acute Care Surg. 2014;761):95-100. (Retrospective review; 571 patients)
52. Lutz N, Nance ML, Kallan MJ, et al. Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg. 2004;39(6):972-975. (Retrospective database review; 147,985 children, 1967 with abdominal bruising)
53. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22(7):480-484. (Retrospective review; 382 patients)
54. Herman R, Guire KE, Burd RS, et al. Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma. J Pediatr Surg. 2011;46(5):923-926. (Multicenter review; 131 patients)
55. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg. 2003;38(3):354-357. (Retrospective review; 1821 patients)
56. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. (Meta-analysis; 3838 patients)
57. Scaife ER, Rollins MD, Barnhart DC, et al. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013;486):1377-1383. (Prospective observational study; 536 patients)
58. Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011;18(5):477-482. (Prospective observational study; 357 patients)
59. Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr Opin Pediatr. 2012;24(3):314-318. (Review)
60. Retzlaff T, Hirsch W, Till H, et al. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatr Surg. 2010;45(5):912-915. (Retrospective analysis; 35 patients)
61. Emery KH, McAneney CM, Racadio JM, et al. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. J Pediatr Surg. 2001;36(4):565-569. (Prospective observational study; 160 patients)
62. Stassen NA, Lukan JK, Carrillo EH, et al. Abdominal seat belt marks in the era of focused abdominal sonography for trauma. Arch Surg. 2002;137(6):718-722. (Retrospective review; 23 patients)
63. Suthers SE, Albrecht R, Foley D, et al. Surgeon-directed ultrasound for trauma is a predictor of intra-abdominal injury in children. Am Surg. 2004;70(2):164-167. (Prospective observational study; 120 patients)
64. Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics. 2008;121(5):e1404-e1412. (Review)
65. Holmes JF, Brant WE, Bond WF, et al. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg. 2001;36(7):968-973. (Prospective observational study; 224 patients)
66. Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol. 2008;43(1):72-82. (Review)
67. Chatoorgoon K, Brown RL, Garcia VF, et al. Role of computed tomography and clinical findings in pediatric blunt intestinal injury: a multicenter study. Pediatr Emerg Care. 2012;2812):1338-1342. (Multi-institutional retrospective record review; 331 patients)
68. Hom J. The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography. Acad Emerg Med. 2010;175):469-475. (Meta-analysis; 3 studies, 2596 total patients)
69. Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289-296. (Estimated risk calculation)
70. Rice HE, Frush DP, Farmer D, et al. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg. 2007;42(4):603-607. (Review)
71. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;622):107-116. (Prospective observational cohort study from the Pediatric Emergency Care Applied Research Network [PECARN]; 12,044 patients)
72. Streck CJ, Vogel AM, Zhang J, et al. Identifying children at very low risk for blunt intra-abdominal injury in whom CT of the abdomen can be avoided safely. J Am Coll Surg. 2017;224(4):449-458. (Prospective observational study; 2188 patients)
73. Arbra CA, Vogel AM, Plumblee L, et al. External validation of a five-variable clinical prediction rule for identifying children at very low risk for intra-abdominal injury after blunt abdominal trauma. J Trauma Acute Care Surg. 2018;85(1):71-77. (Retrospective review; 2435 patients)
74. Cook SH, Fielding JR, Phillips JD. Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure. J Pediatr Surg. 2010;45(10):2019-2024. (Retrospective review; 388 patients)
75. Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002;37(3):453-456. (Multicenter prospective study; 312 patients, 16 centers)
76. Holmes JH 4th, Wiebe DJ, Tataria M, et al. The failure of nonoperative management in pediatric solid organ injury: a multi-institutional experience. J Trauma. 2005;59(6):1309-1313. (Retrospective study; 1880 patients)
77. Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med. 2002;30(11 Suppl):S416-S423. (Review)
78. Lynn KN, Werder GM, Callaghan RM, et al. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol. 2009;39(9):904-916. (Review)
79. Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J Trauma. 2009;67(2 Suppl):S135-S139. (Review)
80. Hsiao M, Sathya C, de Mestral C, et al. Population-based analysis of blunt splenic injury management in children: operative rate is an informative quality of care indicator. Injury. 2014;45(5):859-863. (Population-based retrospective cohort study; 3122 patients)
81. Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg. 2009;44(5):1005-1008. (Retrospective review; 486 patients)
82. Feigin E, Aharonson-Daniel L, Savitsky B, et al. Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality. Pediatr Surg Int. 2009;25(7):583-586. (Retrospective trauma registry review; 598 patients)
83. Bond SJ, Eichelberger MR, Gotschall CS, et al. Nonoperative management of blunt hepatic and splenic injury in children. Ann Surg. 1996;223(3):286-289. (Retrospective chart review; 179 patients, 156 of whom did not undergo immediate surgery)
84. Lindberg DM, Shapiro RA, Blood EA, et al. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013;1312):268-275. (Retrospective secondary analysis; 2890 patients)
85. Landau A, van As AB, Numanoglu A, et al. Liver injuries in children: the role of selective non-operative management. Injury. 2006;37(1):66-71. (Retrospective chart review; 311 patients)
86. Inchingolo R, Ljutikov A, Deganello A, et al. Outcomes and indications for intervention in non-operative management of paediatric liver trauma: a 5 year retrospective study. Clin Radiol. 2014;69(2):157-162. (Retrospective observational study; 37 patients)
87. Giss SR, Dobrilovic N, Brown RL, et al. Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes. J Trauma. 2006;61(2):334-339. (Retrospective study; 185 patients)
88. Eubanks JW 3rd, Meier DE, Hicks BA, et al. Significance of ‘blush’ on computed tomography scan in children with liver injury. J Pediatr Surg. 2003;38(3):363-366. (Retrospective review; 77 patients)
89. van der Vlies CH, Saltzherr TP, Wilde JC, et al. The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review. J Pediatr Surg. 2010;45(5):1044-1049. (Meta-analysis and review; 117 patients)
90. Graziano KD, Juang D, Notrica D, et al. Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg. 2014;49(1):198-200. (Prospective observational study; 70 patients)
91. Umbreit EC, Routh JC, Husmann DA. Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology. 2009;74(3):579-582. (Review and meta-analysis; 95 patients)
92. Fitzgerald CL, Tran P, Burnell J, et al. Instituting a conservative management protocol for pediatric blunt renal trauma: evaluation of a prospectively maintained patient registry. J Urol. 2011;185(3):1058-1064. (Prospective observational study; 39 patients)
93. Fraser JD, Aguayo P, Ostlie DJ, et al. Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int. 2009;25(2):125-132. (Review)
94. Jacobs MA, Hotaling JM, Mueller BA, et al. Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ? J Urol. 2012;187(5):1817-1822. (Retrospective review; 419 patients)
95. Henderson CG, Sedberry-Ross S, Pickard R, et al. Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center. J Urol. 2007;178(1):246-250. (Retrospective review; 126 patients)
96. Sheth S, Casalino D, Expert Panel on Urologic Imaging, et al. ACR Appropriateness Criteria^® renal trauma. 2012. Accessed January 15, 2020. (Guideline)
97. Abou-Jaoude WA, Sugarman JM, Fallat ME, et al. Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg. 1996;31(1):86-89. (Retrospective review; 100 patients)
98. Buckley JC, McAninch JW. Pediatric renal injuries: management guidelines from a 25-year experience. J Urol. 2004;172(2):687-690. (Retrospective review; 374 patients)
99. He B, Lin T, Wei G, et al. Management of blunt renal trauma: an experience in 84 children. Int Urol Nephrol. 2011;43(4):937-942. (Retrospective review; 84 patients)
100. Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children: mechanisms of injury. J Trauma. 1997;42(1):49-53. (Retrospective chart review; 26 patients)
101. Sutherland I, Ledder O, Crameri J, et al. Pancreatic trauma in children. Pediatr Surg Int. 2010;26(12):1201-1206. (Retrospective chart review; 91 patients)
102. Cuenca AG, Islam S. Pediatric pancreatic trauma: trending toward nonoperative management? Am Surg. 2012;78(11):1204-1210. (Retrospective review; 79 patients)
103. Abbo O, Lemandat A, Reina N, et al. Conservative management of blunt pancreatic trauma in children: a single center experience. Eur J Pediatr Surg. 2013;23(6):470-473. (Retrospective review; 36 patients)
104. Maeda K, Ono S, Baba K, et al. Management of blunt pancreatic trauma in children. Pediatr Surg Int. 2013;29(10):1019-1022. (Review)
105. Beres AL, Wales PW, Christison-Lagay ER, et al. Non-operative management of high-grade pancreatic trauma: is it worth the wait? J Pediatr Surg. 2013;48(5):1060-1064. (Retrospective review; 77 patients)
106. Bradley EL 3rd, Young PR Jr, Chang MC, et al. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg. 1998;227(6):861-869. (Retrospective chart review; 101 patients)
107. Klin B, Abu-Kishk I, Jeroukhimov I, et al. Blunt pancreatic trauma in children. Surg Today. 2011;41(7):946-954. (Retrospective chart review; 10 patients)
108. Wood JH, Partrick DA, Bruny JL, et al. Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg. 2010;45(2):401-406. (Retrospective review; 43 patients)
109. Mattix KD, Tataria M, Holmes J, et al. Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. J Pediatr Surg. 2007;42(2):340-344. (Multi-institutional chart review; 173 patients)
110. Khasawneh R, Ramakrishnaiah RH, Singh S, et al. CT findings in pediatric blunt intestinal injury. Emerg Radiol. 2013;20(6):545-552. (Review)
111. Gutierrez IM, Mooney DP. Operative blunt duodenal injury in children: a multi-institutional review. J Pediatr Surg. 2012;47(10):1833-1836. (Retrospective multi-institutional review; 54 patients)
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)
113. Jerby BL, Attorri RJ, Morton D, Jr. Blunt intestinal injury in children: the role of the physical examination. J Pediatr Surg. 1997;32(4):580-584. (Retrospective chart review; 32 patients)
114. Figler BD, Webman R, Ramey C, et al. Pediatric adrenal trauma in the 21st century: Children’s Hospital of Atlanta experience. J Urol. 2011;186(1):248-251. (Retrospective review; 42 patients)
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)
116. Roupakias S, Papoutsakis M, Tsikopoulos G. Adrenal injuries following blunt abdominal trauma in children: report of two cases. Ulus Travma Acil Cerrahi Derg. 2012;18(2):171-174. (Case report; 2 patients)
117. Maguire SA, Upadhyaya M, Evans A, et al. A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse Negl. 2013;37(7):430-445. (Review; 88 studies)
118. Backstrom IC, MacLennan PA, Sawyer JR, et al. Pediatric obesity and traumatic lower-extremity long-bone fracture outcomes. J Trauma Acute Care Surg. 2012;73(4):966-971. (Retrospective cohort study; 356 patients)
119. Haricharan RN, Griffin RL, Barnhart DC, et al. Injury patterns among obese children involved in motor vehicle collisions. J Pediatr Surg. 2009;44(6):1218-1222. (Database review, 1997 to 2006 National Automotive Sampling System Crashworthiness Dat a System fo r occupants aged 2 to 17 years involved in an MVC; 3902 obese and 13,517 nonobese children, representing an estimated 1.8 million obese and 7.2 million nonobese children)
120. Rana AR, Michalsky MP, Teich S, et al. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg. 2009;44(8):1601-1605. (Retrospective study; 1314 patients)
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)
125. Brown HL. Trauma in pregnancy. Obstet Gynecol. 2009;114(1):147-160. (Review)
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)
128. Mirza FG, Devine PC, Gaddipati S. Trauma in pregnancy: a systematic approach. Am J Perinatol. 2010;27(7):579-586. (Review)
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)
132. Johansson PI, Oliveri RS, Ostrowski SR. Hemostatic resuscitation with plasma and platelets in trauma. J Emerg Trauma Shock. 2012;5(2):120-125. (Meta-analysis; 16 retrospective studies, 3663 patients)
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)
137. Vo NJ, Althoen M, Hippe DS, et al. Pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization. J Vasc Interv Radiol. 2014;25(2):215-220. (Retrospective study; 97 patients undergoing angiography, including 54 requiring emb olization)
138. Menichini G, Sessa B, Trinci M, et al. Accuracy of contrast-enhanced ultrasound CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT. Radiol Med. 2 015;12011) :989-1001. (Retrospective review; 73 patients)
139. Ntoulia A, Anupindi SA, Darge K, et al. Applications of contrast-enhanced ultrasound in the pediatric abdomen. Abdom Radiol NY). 2018;434):948-959. (Review)
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)