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Pediatric Abdominal Trauma Clinical Presentation

  • Author: Amulya K Saxena, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
 
Updated: Aug 14, 2015
 

History

A pertinent history should be obtained as for abdominal trauma in adults. However, obtaining the history is frequently difficult in young children, who may be stressed from the pain and the unfamiliar hospital environment and staff. The possibility of inflicted abdominal injury should be considered in a child with unexplained or unusual clinical history or physical findings.

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Physical Examination

Any child with suspected abdominal trauma should be initially evaluated according to Advanced Trauma Life Support (ATLS) guidelines.[8, 9, 10] A focused primary survey aimed at rapidly assessing the ABCs (Airway, Breathing, Circulation) remains the initial priority.[11, 12, 13, 14] In addition, at the time of the primary survey, performing an abbreviated neurologic assessment (D) and completely exposing (E) the child to thoroughly search for injuries is appropriate.

This primary survey is followed by a secondary survey, which consists of a head-to-toe physical examination to identify all traumatic injuries. The abdomen is typically evaluated during the secondary survey. A tertiary survey, usually performed 24 hours after admission, is also recommended and includes a follow-up head-to-toe examination to minimize the risk of missed injuries.

The physical examination should include inspection, auscultation, and palpation. Inspection of the abdomen may reveal distention associated with bleeding or intraperitoneal air.[15] When a traumatic diaphragmatic hernia is present, a scaphoid abdomen might be observed. All abrasions and contusions should be documented because they may indicate associated intra-abdominal injury. For example, skin ecchymosis from a lap belt injury (see the image below) may indicate a hollow organ injury and spinal fracture.

Abdominal wall findings in passenger who was restr Abdominal wall findings in passenger who was restrained with only lap belt during motor vehicle accident.

Auscultation is helpful in determining the presence of intra-peritoneal fluid (dull to percussion) or free air (tympani); however, performing it reliably in the trauma bay may be difficult because of ambient noise.

Abdominal palpation reveals tenderness associated with injury in children who are neurologically healthy. Findings may include focal tenderness, which is often a result of abdominal wall contusion, or rebound tenderness, which suggests an intraperitoneal process, such as hemorrhage or perforation.[16]

Patterns of abdominal organ injury vary according to mechanism of injury (see Table 1 below).

Table 1. Patterns of Abdominal Organ Injury by Mechanism of Injury (Open Table in a new window)

Frequency of Organ Injury Blunt Penetrating
Liver 15% 22%
Spleen 27% 9%
Pancreas 2% 6%
Kidney 27% 9%
Stomach 1% 10%
Duodenum 3% 4%
Small bowel 6% 18%
Colon 2% 16%
Other 17% 6%

In all children with suspected inflicted injury, the abdomen must be thoroughly evaluated (see Workup).

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Contributor Information and Disclosures
Author

Amulya K Saxena, MD, PhD Consultant Pediatric Surgeon, Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Healthcare NHS Fdn Trust, Imperial College London, UK

Amulya K Saxena, MD, PhD is a member of the following medical societies: International Pediatric Endosurgery Group, British Association of Paediatric Surgeons, European Paediatric Surgeons' Association, German Society of Surgery, German Association of Pediatric Surgeons, Tissue Engineering and Regenerative Medicine International Society, Austrian Society for Pediatric and Adolescent Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Deborah F Billmire, MD Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP Professor of Surgery, Cooper Medical School of Rowan University; Chief, Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Southwestern Surgical Congress, Eastern Association for the Surgery of Trauma, Children's Oncology Group, International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Additional Contributors

Denis D Bensard, MD, FACS, FAAP Director of Pediatric Surgery and Trauma, Attending Surgeon in Adult and Pediatric Acute Care Surgery, Attending Surgeon in Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University of Colorado School of Medicine; Associate Program Director, General Surgery Residency, Attending Surgeon, Children's Hospital Colorado

Denis D Bensard, MD, FACS, FAAP is a member of the following medical societies: American Association for the Surgery of Trauma, Alpha Omega Alpha, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of University Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Michael L Nance, MD, Nicolas Lutz, MD, and Perry W Stafford, MD, FACS, FCCM, FAAP, to the development and writing of the source article.

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Computed tomography (CT) image of grade IV splenic laceration from auto-pedestrian accident.
Computed tomography (CT) image of grade IV renal laceration from handlebar injury. Reprinted with permission from Pryor JP, Stafford PW, Nance ML. Severe blunt hepatic trauma in children. J Pediatr Surg, 36:7, 2001, Elsevier Science.
Computed tomography (CT) image of grade V liver laceration in unrestrained passenger in motor vehicle accident.
Computed tomography (CT) image of duodenal hematoma from blow to abdomen. (Large arrow, hematoma; small arrow, lumen of duodenum.)
Abdominal wall findings from handlebar injury.
Abdominal wall findings in passenger who was restrained with only lap belt during motor vehicle accident.
Penetrating injury to abdomen from shotgun wound.
Volume management algorithm for pediatric trauma patient.
Table 1. Patterns of Abdominal Organ Injury by Mechanism of Injury
Frequency of Organ Injury Blunt Penetrating
Liver 15% 22%
Spleen 27% 9%
Pancreas 2% 6%
Kidney 27% 9%
Stomach 1% 10%
Duodenum 3% 4%
Small bowel 6% 18%
Colon 2% 16%
Other 17% 6%
Table 2. Clinical Pathway for Solid Organ Injury
Grade of Injury ICU Stay Ward Stay House Arrest Contact Activity Restriction
Grade I None 1 d 1 wk 1 mo
Grade II None 2 d 2 wk 2 mo
Grade III and above 1 d 3 d 3 wk 3 mo
ICU – Intensive care unit.
Table 3. APSA Guidelines for Management of Isolated Liver or Spleen Injuries in Children
Treatment CT Grade
I II III IV
ICU stay (d) None None None 1
Hospital stay (d) 2 3 4 5
Predischarge imaging None None None None
Postdischarge imaging None None None None
Activity restriction (wk)* 3 4 5 6
*Return to full-contact competitive sports (eg, football, wrestling, hockey, lacrosse, mountain climbing) should be at the discretion of the individual pediatric trauma surgeon. The proposed guidelines for return to unrestricted activity include typical age-appropriate activities.



APSA—American Pediatric Surgical Association; CT—computed tomography; ICU—intensive care unit.



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