Pediatric Abdominal Trauma

Unique pediatric aspects of the anatomy and physiology of the abdomen contribute to the abdomen’s biomechanical response to traumatic loads.

A young child’s abdomen is square and becomes more rectangular as the child matures. The abdominal wall of a child has thinner musculature than that of an adult, particularly during the first 2 years of life, providing less protection to underlying structures. The ribs are more flexible in the child and thus less likely to fracture; however, this increase in compliance makes the ribs less effective at energy dissipation and consequently less effective at protecting the upper abdominal structures (eg, the spleen and the liver).[2, 3, 4]

The solid organs are comparatively larger in the child than in the adult; therefore, more surface area is exposed, making the organ more at risk for injury. A lower fat content and more elastic attachments are typical of the intra-abdominal organs in children. These characteristics reduce the amount of energy absorption and may result in increased motility and vulnerability (eg, kidneys). The child’s spleen has a thicker capsule than that of the adult, yet the spleen is among the most commonly injured solid organs in blunt abdominal trauma.

In the young child, the intestine is not fully attached within the peritoneal cavity (especially the sigmoid and right colon), and this incomplete attachment potentially makes it more vulnerable to injury from sudden deceleration or abdominal compression. The bladder extends to the level of the umbilicus at birth and therefore is more exposed to a direct impact to the lower abdomen. With age, the bladder descends to its retropubic position.

The rapid growth of the spine during adolescence influences its anatomy and biomechanical properties, particularly in the lumbar area.[5] In a child with a thin abdominal wall who is poorly restrained (lap belt only), the fulcrum of a flexion injury would be at the body of the spine, which exposes it to a flexion-distraction injury (Chance fracture). A child with a Chance fracture is more likely to have a concomitant intra-abdominal organ injury than is an adult with such a fracture.[6]

More than 80% of traumatic abdominal injuries in children result from blunt mechanisms; most commonly, they are related to motor vehicle accidents. Abdominal injuries may also result from falls or direct blows to the abdominal wall (eg, handlebar injury; see the image below).

In the United States, firearm injuries are by far the most common cause of penetrating wounds. Other causes of penetrating injuries include stab wounds, impalements, dog bites, and machinery-related accidents.

Traumatic injuries continue to be the leading cause of death in children, far surpassing other causes in frequency.[7] Abdominal trauma accounts for 8-10% of all trauma admissions to pediatric hospitals. Penetrating injuries are less common in children and account for 8-12% of pediatric abdominal trauma admissions in most trauma centers.

Despite declining national trends in firearm-related injury, gunshot wounds (GSWs) are the most common cause of penetrating injuries in the pediatric age group and represent the leading cause of death in Black males aged 15-24 years.[8]

Nonoperative treatment of children with blunt abdominal trauma is successful in more than 95% of appropriately selected cases if trauma care providers have a thorough knowledge of the anatomy and physiology of the growing child.

The abdomen is injured in 25% of children with GSWs; of these wounds, 14% are fatal.

Out of all forms of pediatric abdominal trauma, abdominal trauma secondary to assault or abuse is associated with the highest mortality.[9] Abdominal trauma related to child abuse also carries a particularly high risk of hollow-viscus injury.

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.

Any child with suspected abdominal trauma should be initially evaluated according to Advanced Trauma Life Support (ATLS) guidelines.[10, 11, 12] A focused primary survey aimed at rapidly assessing the ABCs (Airway, Breathing, Circulation) remains the initial priority.[13, 14, 15, 16] 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 are 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.[17] 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.

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.[18]

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)

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

Workup of the pediatric trauma patient includes selected laboratory tests and computed tomography (CT). Ultrasonography (US), in the form of focused assessment with sonography in trauma (FAST), may also be considered, though definition of the role of FAST in the pediatric population has lagged behind that in the adult population. Diagnostic peritoneal lavage (DPL) is not used as frequently as it once was.

In all children with suspected inflicted injury, the abdomen must be thoroughly evaluated. This investigation may include laboratory assessment (eg, liver function tests [LFTs], amylase level, lipase level, complete blood count [CBC], and urinalysis), diagnostic imaging (eg, CT), or both to help detect abdominal injury. In the obtunded patient with inflicted injury, CT should be performed to exclude concomitant abdominal injury.[19]

Laboratory testing is a routine component of the trauma evaluation. The baseline tests performed are typically determined according to the suspected severity of injury and individual institutional guidelines. CBC and urinalysis are the only initial tests routinely performed in most children with suspected intra-abdominal injuries.

The CBC provides a baseline blood count. Overall, CBCs should be performed only as often as is necessary for adequate assessment of the patient’s clinical condition; the usual frequency is every 12 hours for the first 36 hours and daily thereafter. Urinalysis has proven useful in screening for injury to the urinary tract. Detection of blood should prompt further evaluation because even microscopic hematuria can be associated with significant renal trauma.

LFTs and pancreatic enzyme tests have variable sensitivity and specificity for abdominal organ injuries and should not be relied on as screening tools. However, trends in findings from LFTs or pancreatic enzyme tests may be useful for monitoring the course of a liver or pancreatic injury. In all cases in which significant abdominal injury is suspected or present, a blood specimen for typing and cross-matching should be obtained.

A prospective observational study by Kuas et al (N = 323) assessed the diagnostic value of laboratory tests for detection of solid-viscus injuries after blunt abdominal trauma in pediatric patients.[20]  They found that abnormal values for alanine aminotransferase (ALT), aspartate aminotransferase (AST), amylase, and lipase were statistically significant predictors of injuries to solid organs but that none of these tests were sufficiently sensitive or specific. They did not find hemoglobin, hematocrit, lactate, and base excess values to be statistically significant predictors.

CT with double contrast (intravenous [IV] and oral) is the criterion standard for the assessment of the abdominal cavity in a hemodynamically stable child.[21] Increasingly rapid scan acquisition times and better quality images make this modality ideal for trauma evaluation.[22]

IV contrast is essential for the evaluation and accurate grading of solid-organ injuries; oral contrast should be given to increase the sensitivity of CT scans for the diagnosis of pancreatic, duodenal, and proximal bowel injuries (see the images below).[23]

The use of oral contrast in the immediate radiologic assessment of abdominal trauma has been questioned.[24, 25] Administration of oral contrast may delay the scheduling of the scan and, because it may induce vomiting, poses an aspiration risk. Thus, the use of oral contrast in the immediate assessment of abdominal trauma should be selective and based on institutional best practice guidelines.

Some reports have described the acute extravasation of contrast (blush) as a sign of acute hemorrhage.[26] Although such a sign has been associated with the need for surgical intervention in adults, its clinical significance is still under evaluation in children.

Some studies have suggested that in low-risk patients, it is safe to forgo CT and thereby avoid the attendant radiation exposure.[27, 28]  Streck et al described a prediction rule that used history and physical examination, chest radiography, and laboratory evaluation at the time of presentation after blunt abdominal trauma to identify children who are at very low risk for intra-abdominal injury and in whom CT can therefore be avoided.[29]

The FAST examination has become a standard part of the initial evaluation of bluntly injured abdomens in adult trauma centers.[30, 31, 32, 33, 34] It allows rapid assessment of the peritoneal cavity and can detect free fluid.

In the pediatric population, studies have been slower to define the role of FAST. Despite its high sensitivity for the detection of free intraperitoneal fluid, there have been concerns that FAST is operator-dependent, lacks specificity, and does not provide detailed information regarding the grade of organ injury.

Another concern is that FAST produces a significant number of false-negative results (eg, solid-organ injury without free intraperitoneal fluid), which may lead to inappropriate triage and management. It has been widely held that because management protocols for solid-organ injury in the pediatric population are highly dependent on accurate grading of the organ injury, FAST cannot yet replace CT. Accordingly, evaluation of FAST in pediatric trauma centers is ongoing with the aim of validating and specifying its utility.[35]

In a study of 543 injured children (mean age, 8.2 years) who underwent FAST examination, Ben-Ishay et al found that whereas a positive FAST result was not necessarily correlated with the presence of intra-abdominal injury, a negative result was strongly suggestive of the absence of such injury (high negative predictive value).[36]

Holmes et et al performed a randomized clinical trial that evaluated a standard trauma evaluation with FAST in the emergency department (ED) against a standard trauma evaluation alone in 925 hemodynamically stable children and adolescents (< 18 y) with blunt torso trauma; the aim was to determine whether FAST during initial evaluation improved clinical care.[37]  They concluded that the addition of FAST did not improve care as compared with standard evaluation alone and that their findings did not support routine use of FAST in this setting.

Calder et al, in a multi-institutional study that included 2188 children younger than 16 years who were treated for blunt abdominal trauma, found that FAST had a low sensitivity for intra-abdominal injury, often missed intra-abdominal injuries necessitating acute intervention, and rarely had a significant effect on management in this setting.[38]  They also found that FAST was not more accurate in centers that performed it more frequently.

In March 2022, an international group comprising 26 experts on pediatric emergency point-of-care US published consensus definitions of complete, high-quality, and accurate FAST and extended FAST (eFAST) studies in children after injury.[39]  The panelists rated five anatomic views as important and appropriate for a complete FAST: (1) right-upper-quadrant abdominal view, (2) left-upper-quadrant abdominal view, (3) transverse suprapubic view, (4) sagittal suprapubic view, and (5) subxiphoid cardiac view. For eFAST, the panelists considered the same five views to be appropriate and important, with the addition of the lung or pneumothorax view. 

Before the advent of CT and FAST, DPL was the modality of choice for the assessment of the injured abdomen.[40] In current management algorithms, its use is significantly diminished. DPL may still be indicated when CT is unavailable or when a hemodynamically unstable child has suspected bleeding from an intra-abdominal injury.[41] In the intensive care unit (ICU), DPL may also be useful in the assessment of the critically ill and traumatized child in whom an evolving intraperitoneal process is present.

Although DPL is very sensitive for the detection of intra-abdominal blood and hollow-viscus injuries, it is nonspecific and invasive and has associated morbidity.

Laparoscopy has been used for assessment of both blunt and penetrating abdominal injuries. It also has therapeutic applications. The introduction of laparoscopy in the diagnosis of abdominal injuries has reduced the incidence of exploratory laparotomies and the morbidity associated with them.[42] Laparoscopy is useful in the management of the hemodynamically stable pediatric patient[43] but may be of less value in cases with a delayed presentation.[44] The laparoscopic approach can be used to repair many types of intra-abdominal injuries. The use of laparoscopy avoided the need for laparotomy more often in patients with penetrating trauma than in those with blunt abdominal trauma.

Fluid resuscitation is an important component of the management of abdominal injuries in children. Specific management depends on whether trauma is penetrating or blunt and on whether solid or hollow organs are injured. Blunt mechanisms of abdominal trauma predominate in the pediatric population.[45, 46, 47, 48, 49]

For more information, see Abdominal Vascular Injuries, Penetrating Abdominal Trauma, and Blunt Abdominal Trauma.

An algorithm for volume replacement in the injured child (both hemodynamically stable and unstable) has been taught by the American College of Surgeons as part of the Advanced Trauma Life Support (ATLS) course and provides a good point of reference for the management of children with abdominal injuries (see the image below).[10]

Because of the unique compensatory mechanisms of the injured child, hypotension secondary to hypovolemic shock is a late and ominous event. Early aggressive fluid resuscitation is indicated in injured children. Because young children have a disproportionately larger body surface area and less thermoregulation, preserving core temperature during the care of an injured child is important.

Elevated values for the Shock Index, Pediatric Age-Adjusted (SIPA) in children have been found to be predictive of the need for blood transfusion and the likelihood that nonoperative management will fail.[50]

Damage-control resuscitation, an overall management strategy aimed at rapidly restoring physiologic stability while mitigating hypothermia, coagulopathy, and acidosis, has been studied in children and neonates.[51, 52]

Because the vast majority of penetrating injuries to the abdomen call for surgical intervention, preparation of the operating room (OR) should occur simultaneously with patient assessment. In the case of a gunshot wound (GSW), determination of the trajectory is imperative. All entrance and exit wounds should be marked with radiopaque indicators, and plain films should be obtained (see the image below). A thorough search for all missiles is important because many children with intra-abdominal injury from a GSW have remote entrance sites (eg, thigh, buttock, or chest).

It should be kept in mind that during exhalation, the diaphragm ascends to the level of the nipple; thus, injuries to the lower thorax may pose a risk to the intra-abdominal contents.[53] About 15% of children with an intra-abdominal injury also have injuries to other body regions; thus, a complete assessment is required for every child.[54]

In selected cases (eg, isolated right-upper-quadrant GSW), computed tomography (CT) is useful for evaluating the trajectory of a bullet and permits the evaluation of solid-organ injury. For penetrating rectal injuries, triple-contrast (intravenous [IV], oral, and rectal) CT may also be useful to help define the trajectory and extent of injury before intervention.

When indicated, laparotomy for penetrating injuries should be expeditious and goal-directed. A generous midline incision should be performed to allow evaluation of the entire abdomen. Once the abdomen has been opened, all four quadrants should be packed to control hemorrhage. The packing is then systematically removed, and each quadrant is inspected.

The bowel should be thoroughly evaluated from esophagus to rectum.[55] The surgeon should also be mindful of the potential injuries that may be present on the basis of trajectory. Management of specific injuries is similar to that in adults and is not covered in this article.

Damage-control laparotomy, though established in injured adults, requires further study in the setting of pediatric trauma.[56, 57]

As a tool for both assessment and treatment of penetrating injuries to the abdomen, laparoscopy has proved useful in several select clinical situations.[58, 59]  Subsequent study has also found it useful for blunt abdominal trauma.[43] In a hemodynamically stable child with a possible diaphragmatic injury, laparoscopy may help clarify the integrity of the diaphragm. In the setting of a tangential GSW when violation of the parietal peritoneum is unknown, laparoscopy allows excellent visualization of the entire peritoneal wall with minimal morbidity. (See Penetrating Abdominal Trauma.)

Solid-organ injury

The management approach to injuries of the abdominal solid organs (eg, liver, spleen, kidney, and pancreas) has evolved from routine operative exploration to cautious observation.[60, 61, 62, 63, 64, 65, 66] The American Association for the Surgery of Trauma (AAST) has established grading classifications for all solid organs based on anatomic descriptive criteria (see AAST Injury Scaling and Scoring System). These classifications should be used to describe all blunt solid-organ injuries. (See Blunt Abdominal Trauma.)

The decision to intervene operatively for a solid-organ injury should be based on the physiologic response to the identified injury rather than on the anatomic severity of the injury.[67, 68] However, management guidelines, including postdischarge activity limitations, are based on the anatomic grade of the injury.[69]

This management approach is one that accepts the risk of potential missed injury so as to gain the benefit of avoiding laparotomy and potential organ loss.[70] This strategy has been used successfully in children with multiple solid-organ injuries, as well as those with concomitant head injuries. The decision not to operate, like the decision to operate, should be made by the treating surgeon.

Clinical pathways are available to facilitate and optimize the management of solid-organ injuries and have resulted in successful outcomes in more than 90% of cases.[71] A pathway based on injury grade may be used to evaluate blunt trauma in children (see Table 2 below).

Table 2. Clinical Pathway for Solid Organ Injury (Open Table in a new window)

Each child should be carefully evaluated for suitability to undergo expectant management. Children with grade I or II injuries require no intensive care unit (ICU) stay and a hospitalization of 2 days. Children with a grade III injury or higher require a minimum of 24 hours in the ICU, followed by 3 days of observation in the hospital.[72] A deviation from the expected course (eg, hemoglobin drop or increased pain) may warrant follow-up imaging.

Transfusion is occasionally necessary and should be based on guidelines established by the trauma care providers. Transfusion volumes of up to 40 mL/kg may be necessary before a course of observation is considered a failure.

An alternative management pathway was proposed by the Trauma Committee of the American Pediatric Surgical Association (APSA) for isolated liver or spleen injuries (see Table 3 below).

Table 3. APSA Guidelines for Management of Isolated Liver or Spleen Injuries in Children (Open Table in a new window)

Updated guidelines were published by APSA in 2019.[73]  Guidelines for management of liver trauma in children and adults were published by the World Society of Emergency Surgery in 2020 (see Guidelines).[74]

Although the nonoperative approach has been successfully used for all solid organs, the pancreas and kidney have historically been more problematic.[75] As adjunctive measures have improved, even high-grade complicated injuries to the kidney or pancreas can be managed without laparotomy in the selected stable pediatric patient. A selective but seemingly increasing role for laparoscopy has been reported in the stable pediatric blunt trauma patient.[76, 77, 78]

These improved adjunctive measures include the following[79] :

• Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drainage for management of pseudocyst or duct disruption complicating pancreatic injuries
• Cystoscopy and stent placement or percutaneous nephrostomy for kidney injuries with urinoma

 Selective embolization and endovascular stent placement for renovascular injuries have been reported.

One of the original reasons for pursuing nonoperative management and avoidance of splenectomy in children with splenic injuries was to preclude the possibility of overwhelming postsplenectomy infection (OPSI; also referred to as overwhelming postsplenectomy sepsis [OPSS]).[80, 81, 82] This entity was recognized as a significant risk in those children who were functionally or anatomically asplenic. The true prevalence of OPSI remains unclear, but it has been estimated to have a lifetime risk of 5%.

Patients who have undergone a splenectomy should generally receive routine vaccination against those organisms responsible for OPSI (encapsulated bacteria), including Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis. The current practice is to recommend daily prophylaxis with oral penicillin until age 18 years; however, this should be guided by institutional best practice guidelines.

Hollow-viscus injury

Injuries to hollow organs (eg, stomach, intestine, and bladder) remain the nemesis of the trauma surgeon and are a risk of the nonoperative management strategies adopted for solid-organ injuries.[83, 84] Repeat clinic examinations, a high index of suspicion, and follow-up imaging help detect these injuries early so as to minimize associated morbidity.[85]

Increasing abdominal pain or distention may indicate a hollow-viscus injury. Free intraperitoneal fluid on CT without evidence of an associated solid-organ injury may be the result of a hollow-organ injury.[86] The presence of a handlebar mark or lower abdominal wall ecchymosis in a lap belt–restrained child (seatbelt sign) should raise concerns for hollow-viscus injury.[87, 88]

Overall, hollow-viscus injuries are present in 3% of abdominal injuries. The risk of such injuries increases significantly with pancreatic injury or with injury to multiple intra-abdominal organs (eg, liver and spleen). The vast majority of detected hollow-organ injuries necessitate operative intervention, with the exception of some intestinal-wall hematomas (ie, duodenal), which can be first treated nonoperatively.

In children, the management of duodenal hematoma is nonoperative and involves decompression of the stomach until normal passage through the duodenum can be observed.[89, 90, 91] Most intramural duodenal hematomas resolve over the course of 1-3 weeks with gastric decompression alone.[92] Serial imaging can be performed to monitor the resolution of the hematoma. Surgical evacuation for hematomas that fail to resolve is rarely necessary.

Concomitant pancreatic or biliary tract morbidity due to direct trauma to or obstruction of the ampulla must be considered. In many cases, a nasoenteric feeding tube can be advanced beyond the hematoma to provide nutritional support during the hospital course.

Traumatic abdominal-wall injury

Traumatic abdominal-wall hernia from high-velocity injuries is extremely rare in the pediatric population and is generally a result of bicycle handlebar injury; however, reports of this injury in children resulting from a lap belt after motor vehicle collisions have been published.[93] This type of injury causes disruptions of multiple organs and necessitates immediate operative intervention.

After discharge from the hospital, to avoid contact and reinjury, the patient should be on "house arrest," which is defined as limited, non-peer-related, housebound activity. The duration of house arrest is determined by the injury grade. Outpatient follow-up care is scheduled to coincide with the completion of the house arrest period. At that time, an assessment is made to determine suitability to return to school.

Children are reevaluated in the outpatient clinic upon completion of the period of restricted activity. A healthy child can typically return to all activities with no anticipated increase in risk for rebleeding. Follow-up imaging may be useful for renal or pancreatic injuries; however, it is not routinely obtained, because it has been proved not to be beneficial or to modify treatment in asymptomatic children with blunt splenic or liver injuries.

In March 2020, the World Society of Emergency Surgery (WSES) published guidelines on nonoperative and operative management of liver trauma in pediatric and adult patients.[74]

Nonoperative management

In the absence of other internal injuries requiring surgery, nonoperative management should be the treatment of choice for all hemodynamically stable minor (WSES I; American Association for the Study of Trauma [AAST] I-II), moderate (WSES II; AAST III), and severe (WSES III; AAST IV-V) injuries.

In transient responders with moderate and severe injuries, nonoperative management should be considered only in selected settings where there is immediate availability of trained surgeons, operating rooms (ORs), continuous monitoring (ideally in an intensive care unit [ICU] or emergency department [ED]), and access to angiography (AG), angioembolization (AE), blood and blood products; and in locations where a system exists to quickly transfer such patients to higher-level-of-care facilities.

Computed tomography (CT) with intravenous (IV) contrast should always be performed when nonoperative management is being considered.

AG/AE may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT. In hemodynamically stable children, the presence of contrast blush on CT is not an absolute indication for AG/AE.

Serial clinical evaluations (physical examinations and laboratory testing) must be performed to detect a change in clinical status during nonoperative management.

Nonoperative management should be attempted in the setting of concomitant head trauma and/or spinal cord injury with reliable clinical examination, unless the patient could not achieve specific hemodynamic goals for the neurotrauma and the instability might be due to intra-abdominal bleeding.

ICU admission in isolated liver injury may be required only for moderate and severe lesions.

In selected cases where an intra-abdominal injury is suspected in the days after the initial trauma, interval laparoscopic exploration may be considered as an extension of nonoperative management and a means to plan patient management in a step-up treatment strategy.

In low-resource settings, nonoperative management could be considered in hemodynamically stable patients who have no evidence of associated injuries and negative findings on serial physical examinations, imaging, and blood tests.

Operative management

Hemodynamically unstable and nonresponder patients (WSES IV) should undergo operative management.

The primary surgical intention should be to control hemorrhage and bile leakage and initiate damage-control resuscitation as soon as possible.

Major hepatic resections should be avoided at first and considered only in subsequent operations, in a resectional debridement fashion, in cases of large areas of devitalized liver tissue, done by experienced surgeons.

AE is a useful tool in case of persistent arterial bleeding after nonhemostatic or damage-control procedures.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in hemodynamically unstable patients as a bridge to another, more definitive procedures for hemorrhage control.

Short- and long-term follow-up

Intrahepatic abscesses may be successfully treated with percutaneous drainage.

Delayed hemorrhage without severe hemodynamic compromise may be managed at first with AG/AE.

Hepatic artery pseudoaneurysm should be managed with AG/AE to prevent rupture.

Symptomatic or infected bilomas should be managed with percutaneous drainage.

A combination of percutaneous drainage and endoscopic techniques may be considered in managing posttraumatic biliary complications not amenable to percutaneous management alone.

Lavage/drainage and endoscopic stenting may be considered as the first approach in delayed posttraumatic biliary fistula without any other indication for laparotomy.

Laparoscopy as the initial approach should be considered in cases of delayed surgery so as to minimize the invasiveness of surgical intervention and allow tailoring of the procedure to the lesion.

The most important aspects of medical therapy for patients with vascular injuries are adequate oxygen delivery and crystalloid fluid administration. Although colloid solution is mentioned, the mortality benefit of colloid over crystalloid has never been proven. Blood transfusion may also be beneficial for patients with low hemoglobin concentrations.

Class Summary

Isotonic sodium chloride (normal saline [NS]) and lactated Ringer (LR) are isotonic crystalloids, the standard intravenous (IV) fluids used for initial volume resuscitation. They expand the intravascular and interstitial fluid spaces. Typically, about 30% of administered isotonic fluid stays intravascular; therefore, large quantities may be required to maintain adequate circulating volume.

Both fluids are isotonic and have equivalent volume-restorative properties. While some differences exist between metabolic changes observed with the administration of large quantities of either fluid, for practical purposes and in most situations, the differences are clinically irrelevant. No demonstrable difference in hemodynamic effect, morbidity, or mortality exists between resuscitation with NS or LR.

Normal saline (NS, 0.9% NaCl)

NS restores interstitial and intravascular volume. It is used in initial volume resuscitation.

Lactated Ringer

LR restores interstitial and intravascular volume. It is used in initial volume resuscitation.

Class Summary

Colloids are used to provide oncotic expansion of plasma volume. They expand plasma volume to a greater degree than isotonic crystalloids and reduce the tendency of pulmonary and cerebral edema. About 50% of the administered colloid stays intravascular.

Albumin (Buminate, Albuminar)

Albumin is used for certain types of shock or impending shock. It is useful for plasma volume expansion and maintenance of cardiac output. A solution of NS and 5% albumin is available for volume resuscitation. Five percent solutions are indicated to expand plasma volume, whereas 25% solutions are indicated to raise oncotic pressure.