Grand rounds presentation on pediatric abdominal trauma with the latest recommendations in literature reviewed.

1. Pediatric Abdominal Trauma
Yana Puckett, MD

2. Topics to Discuss
• Labs
• Diagnostic Modalities –Ultrasound, CT, Laparoscopy
• Treatment Modalities –Angiography
• Liver and Spleen Management
• Pancreas Injury
• Renal Injury
• Duodenal Injury
• Hollow Viscus Injury
• Gallbladder Injury
• Urinary Bladder Injury

3. Abdominal Trauma
• Falls are the most frequent mechanism in
children.
• MVC abdominal trauma is most deadly.
• Anatomically smaller size of children & less
fatty tissue surrounding major organs results
in increased abdominal trauma with less
velocity than in adults.

4. Initial Evaluation and Diagnosis of
Abdominal Injuries
• Thorough History and Physical
• Seatbelt Sign, Handle Bar Mark suspicious for
abdominal injuries.
• Vital signs – can lose up to 45% of circulating
blood volume, and exhibit tachycardia as only
abnormal vital sign.

5. Laboratory Testing
• CBC, CMP, Amylase, Lipase, Coag Studies, Urinalysis.
• Elevated AST/ALT with positive physical exam highly
predictive for abdominal trauma in some studies - not
diagnostic for a particular injured organ *.
• Interestingly, routine amylase and lipase
determinations do not appear to be very reliable or
cost effective screening tools*.
*Capraro AJ, Mooney D, WaltzmanML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg
Care 2006;22:480–4.

6. Laboratory Testing
• Overall: laboratory panels in the evaluation of
children at risk for intra-abdominal injuries are
best utilized in conjunction with physical
examination findings and as a screen to
determine those children who might require
further diagnostic testing, particularly
imaging. *
*Capraro AJ, Mooney D, WaltzmanML. The use of routine laboratory studies as screening tools in pediatric abdominal
trauma. Pediatr Emerg Care 2006;22:480–4.

7. Computed Tomography
• CT Abdomen with IV contrast is preferred
modality for diagnosis of intra-abdominal injuries
in hemodynamically stable children (1).
• Intestine and Pancreas are more difficult to
definitvely diagnose by CT – request coronal
reconstructions.
• Addition of oral contrast to the standard IV
contrast may be helpful, especially in evaluating
the duodenum and pancreatic head(2).

8. Computed Tomography
• Radiation exposure during CT of major concern in children.
• Over 7 million scans performed in children over last
decade, mostly for trauma and appendicitis.
• Longitudinal, population-based study in Great Britain
demonstrated an increased incidence of leukemia and brain
cancer after repeated CT scans in children (3).
• Models extrapolated from radiation exposure from atomic
bomb explosions- one fatal cancer per 1000 CT scans
performed in young children estimated (3).

9. Computed Tomography
• Children have a longer life expectancy than
adults, resulting in a larger window of
opportunity for expressing radiation damage.
• Children may receive a higher radiation dose
than necessary if CT settings are not adjusted
for their smaller body size.

10. Ultrasound
• FAST examination developed to assess the
presence of intra-abdominal free fluid (with
examination of Morrison’s pouch, the pouch of
Douglas, and the left flank) or fluid within the
pericardial sac (subxiphoid view), thus indicate
the need for operative exploration.
• In multiple studies, traditional FAST examination
has been found to have a low sensitivity and
specificity for the diagnosis of injury in children
(4-5).

11. FAST

12. Laparoscopy
• Allows for direct visualization of bowel, mesentery, and
diaphragmatic surfaces - regions that CT has
traditionally not been as accurate.
• Child with free fluid without evidence of solid organ
injury, especially if physical exam finding of seatbelt or
handlebar mark is found.
• In two relatively large reviews, laparoscopy was found
to be safe and beneficial by avoiding laparotomy in a
significant number of patients (6,7).

13. Liver and Spleen Injury Management
• 90–95% injuries to liver and spleen in children
managed non-operatively.
• Child should have normal hemodynamics, be
monitored closely for signs of ongoing
hemorrhage.
• Most children who fail nonoperative
management do so within four hours of injury as
a result of shock, peritonitis, or persistent
bleeding (8).

14. Liver and Spleen Injury Management

15. Pancreatic Injuries

18. Liver and Spleen Management

19. Liver and Spleen Management
• Splenectomy easily controls bleeding in
hemodynamically unstable patient with active
exsanguination from a massively damaged
spleen, although at the theoretical cost of a
long-term risk of postsplenectomy sepsis.
• Partial splenectomy, spenorhaphy obtions if
not in shock.

20. Postsplenectomy Sepsis
• The reported incidence is around 0.23% a
year, with an increased incidence in children
less than 2 years of age, and those that
underwent splenectomy for hematologic
reasons (9).
• Vaccination with 23-valent pneumococcal
vaccine, meningococcus vaccine, and H.
Influenza B after splenectomy required.

21. Interventional Radiology in Abdominal
Trauma
• Angioembolization frequently used in adults with splenic or liver vascular injuries.
• Multiple studies in children, however, demonstrate that a contrast blush is
associated with the need for operative intervention in less than 20% of splenic
injuries .*
*Lutz N, Mahboubi S, Nance ML, et al. The significance of con- trast blush on computed tomography in children with splenic injuries. J Pediatr Surg
2004;39:491–4.
• On the other hand, small single-center studies and case reports demonstrate that
interventional radiological techniques are safe in children, and have been effective when
utilized.*
*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;68:526–31.
• The pediatric population that seems most amenable to this technique are children with
evidence of ongoing bleeding but are hemodynamically stable, or those that develop
bleeding later in their hospital course.

23. Pancreatic Injury Management
• Occur in fewer than 5% of pediatric abdominal injuries,
and can be difficult to diagnose.
• Blunt mechanism MCC: MVC, handlebar of bike.
• Epigastric pain and bilious emesis, particularly in the
case of injuries that have a delayed presentation .
• Contusions, without evidence of pancreatic ductal
injury, can be managed nonoperatively with nothing by
mouth.

24. Pancreatic Injury Management
• Trends in serum amylase and lipase may be
helpful, although the absolute value of these
tests does not correlate with outcome (10).
• Child should be followed clinically as an oral
diet is reintroduced.
• Management of ductal transection is currently
controversial.

28. Pancreatic Injury Management
• Distal pancreas duct injury – spleen preserving distal
pancreatectomy.
• High morbidity: endocrine insufficiency.
• Roux-en-Y distal pancreaticojejunostomy to drain distal
pancreas has been advocated.
• Nonoperative approach with percutaneous or
endoscopic drainage of subsequent pseudocysts has
been proposed by several studies.

29. Pancreatic Trauma Management
• APSA Trauma Committee retrospective review compared operative and
nonoperative management.
• Demonstrated similar length of hospitalization, but higher rate of
pseudocyst formation and days on TPN in nonoperative group (11).
• Grade I and II– conservative treatment.
• Grade II and III and even IV- drainage of pancreatic bed.
• Grade V- unclear, needs further research.
• Patients undergoing NOM often require ERCP to define the ductal
anatomy, perform sphincterotomy, and potentially stent the pancreatic
duct, as well as percutaneous or endoscopic drainage of pseudocysts.

30. Renal Trauma
• Most commonly injured GU organ.
• Blunt trauma accounts for 80-90% of renal injuries in children.
• In several series, the most severe grade of injury was related to dirt
bikes, ATV rollovers, and bicycles (14-15).
• Stable patients with high grade injury are typically placed at bed
rest with serial exams, blood counts, and close hemodynamic
monitoring until the gross hematuria resolves.
• However, there are no evidence-based guidelines regarding length
of activity restriction in these patients.

34. Renal Trauma
• Present with gross hematuria and flank pain.
• The diagnosis is confirmed by abdominal CT scan which is highly
sensitive.
• Expectant NOM is widely accepted for hemodynamically stable
grade I-III renal injuries which do not have urinary extravasation.
• The main indications for immediate explo- ration in a child with a
renal injury are hemodynamic instability.
• Selective angioembolization of renal artery branches has been
successful in nearly 80% of cases with delayed hemorrhage (16).

37. Renal Trauma
• Penetrating renal injury in children is rare, but typically
requires exploration for management. Selective
observation for penetrating renal trauma, however, is
also being investigated.
• Hemodynamically unstable patients with penetrating
injury or patients with an expanding retroperitoneal
hematoma require renal exploration.
• During exploration, a one-shot IVP may be helpful to
identify the injured area and confirm the pres- ence of
a functioning contralateral kidney.

38. Diaphragmatic Injury
• Rarely occurs in isolation.
• Emergent exploration in patients with diaphragm injury indicated in
hemodynamically unstable patient with multiple organ injury.
• Repair of diaphragmatic defect is typically possible after debridement of
any compromised tissue.
• If large defects are found, prosthetic patch may be needed to minimize
tension.
• Successful laparoscopic or thoracoscopic repair of diaphragmatic injuries
can be performed in hemodynamically stable children or delayed
diagnoses.

39. Hollow Viscus Injury
• Areas of mesenteric fixation - proximal jejunum near
ligament of Treitz, distal ileum near ileocecal valve,
rectosigmoid junction are particularly vulnerable to
injury via acceleration/deceleration shearing forces.
• Seat belt sign markers of severe deceleration injury to
the abdomen.
• CT findings suggestive of hollow viscus injury include
bowel wall thickening and enhancement, mesenteric
stranding, and free intraperitoneal fluid in the absence
of solid organ injury.

40. Hollow Viscus Injury
• Hemodynamically stable patients with evidence
of bowel injury or in equivocal cases with
concerning physical signs or symptoms -
diagnostic laparoscopy is a very reasonable
approach.
• In cases with penetrating trauma, local wound
exploration to identify penetration of the anterior
abdominal fascia is recommended as the initial
diagnostic maneuver – if unclear, diagnostic
laparoscopy.

41. Duodenal Injuries
• Majority of duodenal injuries in children result from blunt
mechanisms .
• Abdominal CT is the test of choice to evaluate for duodenal
injury.
• Duodenal hematomas may be found on CT or upper GI
studies revealing transmural thickening with lumenal
duodenal narrowing, or partial obstruction without evi-dence
of extravasation of air or contrast .
• Typically managed nonoperatively with nasogastric
decompression and TPN over one to three weeks.

42. Grades of Duodenal Injury

44. Duodenal Injury
• When high clinical suspicion for duodenal injury
exists and initial radiographs and abdominal CT
scans do not reveal significant injury, serial CT
scans may be indicated to look for the delayed
development of retroperitoneal air (12).
• Delay in diagnosis of greater than 24 hours is
associated with established peritoneal
inflammation, poor tissue integrity, and higher
leak rate following primary repair (12).

46. Duodenal Injury
• Operative intervention for duodenal injuries should be made based
on clinical judgment.
• Most full-thickness injuries with minimal tissue destruction repaired
primarily.
• In patients with a complex duodenal injury, diversion and drainage
may be needed.
• Earlier diagnosis of duodenal injuries may make the injury more
amenable to primary repair while a significant delay in diagnosis
(>24 hours), or those with a grade III or greater injury, may warrant
proximal drainage via a gastrojejunostomy and pyloric exclusion
(12).

47. Injury to Stomach
• Very rare, but blunt injury to the stomach can
occur and is typically seen in the patient who has
just eaten, as the full stomach is more vulnerable
to burst injury.
• When gastric rupture occurs, usually located
along the greater curvature with a blow-out or
stellate configuration.
• Debridement with repair of the injury is
sufficient.

48. Gallbladder Injury
• Gallbladder is rarely injured in children.
• Predisposing factors for gallbladder trauma are a
thin-walled normal gallbladder, a distended
gallbladder after a meal, and alcohol ingestion.
• If identified, a cholecystectomy is usually per-formed.
This may be performed via laparoscopy
or laparotomy.

49. Urinary Bladder Injury
• Second most common GU injury in children.
• CT Cystoscopy is used to evaluate a suspected bladder
injury.
• Prompt repair for intraperitoneal ruptures – two
layered closure with absorbable suture material and
either transurethral or suprapubic drains.
• Extraperitoneal ruptures- uretheral catheter drainage is
sufficient.

50. References
1. Trauma AcoSCo. Advanced Trauma Life Support for Doctors, Student Course Manual. In: American College of Surgeons Committee on
Trauma. Chicago; 2004. p. 251.
2. Nastanski F, Cohen A, Lush SP, et al. The role of oral contrast administration immediately prior to the computed tomographic evaluation
of the blunt trauma victim. Injury 2001;32:545–9.
3. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain
tumours: A retrospective cohort study. Lancet 2012;380: 499–505.
4. Benya EC, Lim-Dunham JE, Landrum O, et al. Abdominal sonography inexamination of children with blunt abdominal trauma. AJR Am J
Roentgenol 2000;174:613–1616.
5. Coley BD, Mutabagani KH, Martin LC, et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J
Trauma 2000;48:902–6.
6. Feliz A, Shultz B, McKenna C, et al. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006;41:72–7.
7. Marwan A, Harmon CM, Georgeson KE, et al. Use of laparos- copy in the management of pediatric abdominal trauma. J Trauma
2010;69:761–4.
8. Holmes JH 4th, Wiebe DJ, Tataria M, et al. The failure of non- operative management in pediatric solid organ injury: A multi-institutional
experience. J Trauma 2005;59:1309–13.
9. Morgan TL, Tomich EB. Overwhelming post-splenectomy infec- tion (OPSI): A case report and review of the literature. J Emerg Med
2012;43:758–63.
10. 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;46:923–6.
11. Paul MD,Mooney DP. The management of pancreatic injuries in children: Operate or observe. J Pediatr Surg 2011;46:1140–3.
12. Ladd AP, West KW, Rouse TM, et al. Surgical management of duodenal injuries in children. Surgery 2002;132:748–53.
13. Nelson R, Singer M. Primary repair for penetrating colon injuries. Cochrane Database Syst Rev 2003:CD002247.
14. Kluemper C, Rogers A, Fallat M, et al. Genitourinary injuries in pediatric all-terrain vehicle trauma–a mechanistic relationship? Urology
2010;75:1162–4.
15. Wu HY, Gaines BA. Dirt bikes and all-terrain vehicles: The real threat to pediatric kidneys. J Urol 2007;178:1672–4.
16. Goffette PP, Laterre PF. Traumatic injuries: Imaging and inter- vention in post-traumatic complications (delayed intervention). Eur
Radiol 2002;12:994–1021.