1. Conservative management
of blunt abdominal trauma
in children at SKMC
By
Dr Omar El Shiwihy
MBBCH-M.Sc-FRCS
Pediatric surgical division-SKMC

2. Introduction

3.  Evoluted due to:
1- The remarkable report from
hospital for sick children in Toronto
1978.
2-Our awareness about the well
documented danger of OPSI with the
development of “Save our spleen”
concept which later on was extended
to include other solid organs.

4.  Criteria for conservative T/t of blunt
abdominal trauma:
1- hemodynamic stability
2- documentation of the extent of solid
organ injury by CT scan.
3- admission and observation in a PICU.
 Urgent laparotomy is done if the child
becomes hemodynamically unstable or
requires repeated blood transfusion .

6. Aim of the work

7.  To determine the results and
outcome of the conservative
approach in the treatment of
pediatric blunt abdominal trauma at
SKMC over a period of 8 year.

8. Material and methods

9.  Charts of all pediatric patients with
blunt abdominal trauma admitted to
SKMC under care of ped sur. during
the period from Feb 2000 to April
2008 were reviewed and analysed.
 31 charts were available for the
review.

10. Results

11.  Age : 1-12y
 Sex: 23 boys, 8 girls
 Mechanism of injury:
- 13 cases MVA
- 8 cases fall from height
- 3 cases Bike accident.
- 1 case MCA
- 2 case pedestrian hit by bus
- 2 case playground
- 1 case fall of heavy object on
the abd.
- 1 case hit by a wooden bar

12.  Solid organs involved:
- 13 ……….. Liver
- 9 ……….. Spleen
- 2 ……….. pancreas
- 1 ……….. Kidney
 Associated injuries in 17 cases
- thoracic …………… 12 cases
- musculo-skeletal …. 7 cases
- head injuries ………. 6 cases

13.  Investigations:
CT …… 27
US ……. 15
ERCP….. 2
IVP ……. 1
MRCP…. 1
CXR, Abdominal , extremities X-rays
 Hospital stay: 1-53 days ( 30 days for
renal injury & 53 days for severe brain
injury , liver injury , # rib & femur ).
with most of the patients spent the 1st
day(s) in the PICU.

14.  Primary management:
- close monitoring and observation.
- fluid resuscitation with crystalloid +/- blood
transfusion ( 8 patients ).
- ICD …………………. 8 patients.
- craniotomy …….. 2 patients.
- Splenectomy …. 1 patient
- perc. insertion of drain for perinephric collection
+ insertion of double J stent.
- Closed reduction & IM nailing for # femur in 1
pt.
- Bilateral decompression frontal craniotomy in 1
pt.
- Second look laparotomy for removal of liver
pack in 1 pt.

15.  Outcome & mortality:
2 patients required laparotomy : 1 for
splenectomy & 1 second look
laparotomy for removal of pack
2 patient died from severe head injury.
1 patient required delayed repair of
traumatic abdominal wall hernia.
1 patient required delayed SSG.

16. Selected cases

17. Case 1
 KM # 037661. 27th -12-2002
 8 y, boy .
 Involved in Motor cycle accident.
 ER: hemodynamicallly stable .
 CT: - Rt lung contusion and
hemopneumothorax.
- transverse disruption of the Rt
kidney extending into the pelvis
with large perinephric collection.
- # Rt clavicle and Rt 2nd rib.
- no intra peritoneal fluid

20.  Chest tube inserted and CV Line.
 Admitted to ICU and ventilated.
 Remained stable.
 on Day 7 FU with IVP; complete disruption of the
pelvicalyceal system …………percutaneous
insertion of a drain( 3 wks).
 2nd week retrograde pyelography ;complete
rupture of the renal collecting system
…………….double J stent inserted.
 On 3rd week , developed septic episode (Staph
aureous) ……..treated with antibiotic .
 Perinephric collection completely disappeared
,The pt. recovered well and D/c home after 1
month on antibiotic for another 2 wks.
 FU after 2 wks with US …….no collection ,stent
was removed.
 DMSA scan 2 yrs post injury.

29. Case 2
 KM # 165845. 6th-5-05
 11 y boy.
 Fell on his abdomen.
 ER: hemodynamically stable , abd pain
and vomiting, tender upper abd.
with Raised amylase 1st = 350.
 CT : laceration in the pancreas with
possible involvement of the main
pancreatic duct
retroperitoneal fluid collection.

30.  ERCP ….. Partial laceration of the proximal
part of the main pancreatic duct .
 Admission to ICU 1 day.
 NPO for 3 wks.
 CV Line inserted, TPN started.
 FU with CT, US to R/o cyst formation and
Serial amylase level.
 Pt. recovered well with no complication
and sent home 26 days later.
 FU with US…….free.

34. Case 3
 KM # 050430
 8 yrs boy
 Kick in the abdomen
 Admitted on 2nd June 2007 with abd. pain and vomitting & high
pancreatic enzymes.
 CT : Laceration of head & uncinate process , large peripancreatic
fluid collection.
 CVL inserted , TPN , NPO , Antibiotics , octreotide --- 3 weeks.
 CT (14TH June ) : Normal study
 Discharged on 19th June
 Readmitted on 17th July with picture of pancreatitis
 Kept NPO , peripheral nutrition.
 MRCP done to exclude congenital anomalies.
 Discharged 7 days later and on followup he was free with no
complication

37. Case 4
 KM # 043626, 28-12-00.
 4 y boy.
 Involved in MVA. referred from Mafraq
Hospital.
 ER: hemodynamically stable.
 Ct : - splenic injury.
- Rt lung contusion.
- partial dehiscence of the abdominal
wall with herniation of the colon.

40.  Admitted to ICU for observation …1
day.
 Recovered well , DC home 9 days
later,
Came for hernial repair after 2
months.
 FU with abd US…..free.

42. Case 5
 KM # 188789, 8-3-06.
 8 y boy.
 Received a kick to his abdomen while
playing referred from ZMH as a liver
haematoma with his CT scan.
 ER: hemodynamically stable.
 Admitted to ICU……..1 day.
 Review of CT revealed???????

44. Case 6
 KM : 199680

47. Hollow visceral injury
 None in our pts.
 A concern with nonoperative management
 CT findings suggestive of perforation
 Pneumoperitoneum
 Bowel wall thickening or enhancement
 Dilated bowel loops
 Streaking of mesenteric fat
 Peritoneal fluid in absence of SVI
 ? Free peritoneal fluid
 In a study of over 10 yrs. period : 2971 cases , sustained
SVI. The incidence was 3.2% (Childrens hospital of
Philadelphia).
 More with assault cases & pts. with multiple SVI &
pancreatic injury

48. Conclusion

49.  Conservative management of blunt
abdominal trauma with solid organ injury
is safe and appropriate if carried out under
continuous surgical observation in a PICU.
 CT scan is our method of choice to
investigate patients with abdominal
trauma.
 GIT perforations are uncommon in blunt
abdominal trauma