This is a lucid presentation on the management of abdominal trauma/injury in children of paediatric age. Even though it focused on paediatric trauma, the information is also relevant to adult trauma. It went ahead to discuss the definition, causes, and initial management of abdominal trauma. It further went to highlight the management algorithms and outcomes of management. Finally, the presentation ended with management of abdominal compartment syndrome

1. Abdominal Trauma in
Children
Dr Adewunmi Olayinka Lukman
Paediatric Surgery unit
UMTH

2. Outline
• Introduction
• Epidemiology
• Relevant anatomy
• Aetiology
• Clinical presentation
• Investigation
• Treatment
• Damage control
• Abdominal compartment syndrome
• Conclusion

3. Introduction
• Traumatic disruption of normal anatomical and physiological
configuration of abdominal wall with or without its content
• Trauma is the leading cause of morbidity and mortality in the
pediatric population
• The abdomen is the third most commonly injured anatomic region in
children, after the head and the extremities

4. Epidemiology
• Traumatic injuries continue to be the leading cause of death in
children, far surpassing other causes in frequency
• 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.

5. Relevant Anatomy
• 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, which makes them less likely to
fracture. However, this increase in compliance makes them less
effective at energy dissipation and, therefore, less effective at
protecting the upper abdominal structures (eg, the spleen and the
liver)

6. Relevant Anatomy
• 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.
• the intestine is not fully attached within the peritoneal cavity
(especially the sigmoid and right colon), and this incomplete
attachment potentially making 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

7. Aetiology
• VMA
• Fall from height
• Blow to the abdomen
• Assaults with knife, etc
• Child abuse
• Gunshot
• etc

8. Types of Abdominal Trauma in children
• Blunt
• VMA, fall, child abuse, assault
• Penetrating
• Broken bottles, knife, impaled stick
• Perforating
• Involvement of bowel lumen
• Fall on sharp object,

9. Patterns of abdominal organ injury vary according
to mechanism of injury
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%

10. Clinical presentation
• Symptoms
Abdominal pain
Vomiting
Haematemesis
lower GI bleeding
Anterior abdominal wall bleeding

11. Clinical presentation
• Signs
Conscious, drowsy, coma- GCS or Blantyre score
Pallor, dehydration, tachypnea, tachycardia, hypotension
Chest
Abdomen- distended or normal/full
Abrasion, ecchymosis, Grey Tunner, Cullen signs
Tenderness, rebound, guarding, peritonism, rigidity
Percussion-Tympanic, dull
Genitals- Blood in the meatus, perineal hematoma/urinoma

12. Investigations
• Laboratory
PCV/full blood count
Urinalysis
GXM
Others- LFT, Serum amylase,

13. Investigations
• Abdominal Paracentensis
• Diagnostic peritoneal lavage
• Focus Abdominal Sonar for Trauma (FAST)
• Abdominal CT
• Diagnostic Laparoscopy

14. Determination of injury severity
(The scoring systems)
• Physiologic
• Glasgow coma scale
• Champion score
• Revised trauma score
• Pediatric trauma score
• Anatomic
• Abbreviated injury score
• Injury severity score
• Penetrating abdominal trauma index
• Anatomic profile
• Combined

15. Treatment
• Advanced Trauma life support (ATLS principle)
• Primary survey
• Resuscitation
• Secondary survey
• Tertiary survey
• Definitive treatment

16. Primary survey/Resuscitation
Immediate life threatening injuries
• Airway obstruction
• Tension pneumothorax
• Pericardial tamponade
• Open pneumothorax
• Massive haemothorax
• Flail chest
Potential life threatening injuries
• Aortic injuries
• Tracheobronchial injuries
• Myocardial contusion
• Rupture of diaphragm
• Oesophageal injuries
• Pulmonary contusion

17. Primary survey/Resuscitation
• Airway and C-spine control
• Breathing
• Circulation and Haemorrhage control
• Disability
• Exposure

18. Secondary Survey
• Frequent serial examinations with appropriate diagnostic
measures improves accuracy
• Aim at rapid identification of patients who need immediate
or expedited laparotomy and those for observation
• Most reliable features in alert patients are pain, tenderness,
evidence of GI hemorrhage, hypovolaemia, peritonism
• Abrasions, ecchymoses, (esp seat belt and steering), Grey-
Tunner, Cullen indicate retro peritoneal injury)

19. Secondary Survey
• Abdominal distension, guarding, rigidity, tenderness, doughy
consistency indicate intraperitoneal injury
• Examination of genitals for urethral bleeding and perineum
for hematoma
• Passage of NG tube and inspection of contents for bleeding

20. Tertiary Survey
• New concept by Enderson et al
• It is usually done after 24 hours of traumatic injury
• Assist diagnosis of injuries that may have been missed
• Involves repetition of Primary and Secondary surveys and
revision of all radiologic and laboratory data
• Janjua et al found tertiary survey detected 56% of injuries
missed at initial assessment

21. Treatment
• IV access
• NPO
• Pass NG tube
• Urethral catheter
• Antibiotics
• Analgesics
• Proton pump inhibitors- Omeprazole

22. Treatment
• Fluid resuscitation
Normal Saline/Ringers Lactate- 20ml/kg
10ml/kg of packed RBCs

23. Treatment
• Blunt abdominal Injury
Admit for observation
Persistent/resolving symptoms- bleeding, pain, etc
Close vital sign monitoring
PR, BP, RR, Temp
Serial abdominal exam
Tenderness,
abdominal girth

24. Treatment
• Penetrating/perforating Injury
Book Theatre
Anaesthetic consideration- full stomach
Laparotomy
Definitive repair or colostomy
post op vital sign
Antibiotics
Analgesics

25. Damage control
• Coordinated medical and surgical primary resuscitative measures in
achieving a steady state in acutely injured patient before the
definitive treatment
• Indications
• Major abdominal vascular injuries with multiple visceral injury
• Multiregional exsanquinating injuries with concomitant visceral injury
• Multiregional injuries with competing priority
• Severe metabolic acidosis pH >7.2
• Hypothermia T < 34o C
• Coagulopathy

26. Phases of damage control
• Phase I
• Control of hemorrhage
• Hemostasis
• Avoid complex repair
• Control of contamination
• Ligation
• Drainage
• Packing
• Abdominal closure

27. Damage control
• Phase II
• maximization of hemodynamics
• Core warming
• Lavage
• Increase ambient temprature
• Infusion of warm fluid
• External warming
• Coagulopathy correction
• Ventilatory support
• Continuous monitoring for missed injury
• Monitor for abdominal compartment syndrome
• Phase III
• Definitive treatment

28. Abdominal compartment syndrome
• Definition
• A clinical condition characterized by intraabdominal hypertension that leads to
cardiorespiratory compromise and end organ hypoperfusion with resultant MODS and
possible death.
• Types
• Primary –commonly follows laparotomy for trauma
• Secondary- follows massive resuscitation in patients with burns or extremities injury
• Presentation
• Abdominal distension (stony hard) with oliguria

29. Abdominal compartment syndrome
• Classification
• Class I – pressure <15mmHg
• Class II – pressure 16 – 25mmHg
• Class III – pressure 26 – 35mmHg
• Class IV – pressure > 36mmHg
• Diagnosis
• Urinary bladder pressure measurement
• Water column manometer
• Intraarterial pressure transduser

30. Conclusion
• Traumatic abdominal injury is a common problem in paediatric age
group and management should be channeled towards restoring
normal anatomy and physiology of the body

31. •THANK YOU