Approach Considerations
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.
Fluid Resuscitation
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]
Penetrating Trauma
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.)
Blunt 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)
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. |
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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)
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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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.
Activity
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.
Long-Term Monitoring
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.
-
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.
Tables
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% |
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. |
||||
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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