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Paediatric Abdominal Solid organ injury
1. Dr Arka Banerjee
M.Ch. Resident
Paediatric Surgery
MAMC & assoc.LNJP Hospital
Moderator: Dr C. K. Gupta
2. ▪ 8-12% of children with blunt trauma have an abdominal injury
▪ Much more common than thoracic injuries (but much less fatal)
▪ Even the most severe solid organ injuries can be treated without surgery, if there is
a prompt response to resuscitation
▪ Most common cause – Fall
▪ Most lethal cause – RTA
▪ Organs injured
▪ Spleen (25-40%)
▪ Liver (15-37%)
▪ Kidney (19-25%)
▪ Pancreas (~7%)
3. ▪ Children are more susceptible to internal injuries
▪ Smaller size closer proximity to organs
▪ Less protection from underdeveloped abdominal wall/rib cage/pelvic girdle
▪ Less body fat, and hence, less ‘padding’ to absorb and diffuse external force
▪ Injured pediatric patients are better able to effectively compensate for physiologic
insults such as acute blood loss
▪ Fewer underlying medical problems
▪ Generally not on any medications that affect hemostasis
▪ Tachycardia is the only abnormal sign till upto 45% of blood loss
▪ Hypotension is an ominous development – suggests failure of compensatory
mechanisms
A child is not a small adult
7. ▪ Head to toe evaluation
▪ Reassessment of ABCs
▪ Vitals
▪ Non-emergent procedures
▪ Foley’s catheter insertion
▪ Nasogastric tube placement
▪ Analgesics, antibiotics and tetanus administration
▪ Additional imaging not completed in the primary survey
▪ Extremity radiographs
▪ Cervical spine films
▪ CT scan
▪ Detailed AMPLE history
▪ A-Allergies
▪ M-Medications
▪ P-Past medical history
▪ L-Last oral intake
▪ E-Events surrounding injury
8. ▪ FAST [Focussed Abdominal Sonography for Trauma]
▪ Views
▪ Subxiphoid (Pericardium)
▪ RUQ, Morrison’s pouch
▪ Left paracolic region (including perisplenic)
▪ Pelvis and Pouch of Douglas
▪ Rapid screening
▪ Specificity 95% Sensitivity 33%
9. ▪ CT scan
▪ Imaging of choice
▪ Has reduced the incidence of non-therapeutic EL
▪ Use of IV contrast – essential
▪ Enteral contrast – controversial
▪ Useful for pancreatico-duodenal injuries
▪ Increases risk of aspiration
▪ Indications (hemodynamically stable)
▪ Penetrating injury
▪ FAST positive
▪ Limitation: Inability to reliably identify intestinal rupture
▪ Suggestive features
▪ Pneumoperitoneum
▪ Bowel wall thickening
▪ Free intraperitoneal fluid
▪ Bowel wall enhancement
▪ Dilated bowel
▪ High index of suspicion should exist for the presence of bowel injury in a child with
intraperitoneal fluid and no identifiable solid organ injury on CT
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13. ▪ Indication for surgery
▪ Hemodynamically unstable pt
▪ Low BP
▪ Tachycardia
▪ Decreased U/O
▪ Falling Hct unresponsive to crystalloid/blood transfusion
▪ Success rate of Non-Operative Management (NOM) – 90%
▪ Predictors of NOM failure
▪ Associated pancreatic injury
▪ High ISS
▪ Low GCS
▪ >1 Solid Organ Injury (SOI)
▪ Grade 5 SOI
▪ 3.2% have associated hollow visceral injury (more common in assault pts and pts with multiorgan
injury/pancreatic injury)
▪ No added morbidity form missed injuries/delayed surgery (Morse and Garcia)
▪ No justification for an exploration solely to avoid missing potential associated injuries in children
(NPTR review)
14. ▪ Indication
▪ Hemodynamically stable
▪ Can be monitored closely for signs of ongoing haemorrhage
▪ Initial resuscitation
▪ Absolute bed rest
▪ Enteral feeding
▪ Hospital stay = Grade + 1 day
▪ Post op bed rest = Grade + 2 wks
▪ Routine F/U imaging not advised
15. ▪ Failure
▪ Shock
▪ Peritonitis
▪ Persistent hemorrhage
▪ Delayed haemorrhage (0.33%)
▪ Splenic pseudocyst
▪ Pain
▪ GI disturbances
▪ Rx – Lap excision/marsupialization
▪ Pseudoaneurysm
▪ Asymptomatic
▪ Incidence not known (F/U imaging after NOM is not indicated)
▪ Risk of rupture unclear
▪ Rx – Angiographic embolization, if symptomatic
16. ▪ Methods of hemostasis
▪ Manual compression
▪ Direct suture
▪ Topical hemostatic agents
▪ Mesh wrapping
▪ Significant hepatic injuries – Total hepatic
vascular isolation (Tolerable time – 30 mins)
▪ Venovenous bypass
▪ Direct suture repair/ligation of offending vessel
▪ Endovascular balloon catheters for temporary
vascular occlusion to allow access to the
juxtahepatic IVC
18. ▪ Alternative strategy in
hemodynamically unstable pts
in whom further blood loss
would be unsustainable
▪ Resuscitative end points
▪ Vitals
▪ U/O
▪ Serum lactate
▪ Base deficit
▪ MvO2
▪ Gastric mucosal pH
▪ Survival 32-73%
▪ Hemostasis 80%
▪ Abdominal abscess rate 10-40%
19. ▪ Criteria for DCS
▪ pH - 7.2
▪ Core temperature <35C)
▪ Prothrombin time >16 s
▪ In a patient with profuse haemorrhage
▪ Requiring large volumes of blood product transfusion.
▪ Abbreviated laparotomy, perihepatic packing,
temporary abdominal closure, angiographic
embolization and endoscopic biliary stenting
▪ Patients who survived the initial operative control of
hemorrhage may go for postoperative angiographic
embolization
▪ Survival
▪ ~63% in grade IV patients
▪ ~24% in grade V patients
▪ Significant hepatic necrosis and biliary leaks – in 30%
to 40% of patients (needs cautious patient selection)
21. ▪ Adequate sedation and paralysis – Improves abdominal wall compliance
▪ Evacuation of intraluminal intestinal contents
▪ Evacuation of large abdominal fluid collections
▪ Optimization of fluid administration
▪ Positive fluid balance
▪ Optimization of abdominal perfusion pressure
▪ Surgery – Emergent decompressive laparotomy + temporary abdominal wall
closure, while awaiting resolution of IAH
22. ▪ Maintaining an open abdomen with
planned staged closure may prevent the
development of ACS in the unstable
trauma patient who requires an
emergent laparotomy and massive fluid
resuscitation, but often needs to be
performed prophylactically
▪ Goals of surgery
▪ Decrease the ed IAP to stop organ
dysfunction
▪ Allow room for continued expansion of the
viscera during ongoing resuscitation
▪ Provide temporary abdominal closure
▪ Prevent excessive fascial retraction
▪ Allow a means for continued evacuation of
fluid from the abdominal cavity
