Blunt Abdominal Trauma

I think I heard the BAT phone

Objectives
Describe the 3 most common visceral injuries after blunt abdominal trauma Compare and contrast the use of ultrasound vs. CT scan for evaluation of blunt abdominal trauma Predict the resuscitation needs of children with blunt abdominal trauma

Background
Most pediatric abdominal injuries are from blunt, not penetrating trauma Notify surgery immediately if high index of suspicion of visceral injury

Background
Most common causes of BAT in children
Falls Motor Vehicle Accidents

Anatomy
Compared to adults, children have:
Weaker abdominal muscles Relatively larger abdominal viscera Less overlying fat Smaller AP diameter of torso Less area to distribute force from BAT

Anatomy - common injuries

Anatomy
Spleen
Most common injured organ in BAT MVA and auto vs. pedestrian most common cause

Anatomy
Spleen
Kids run out into oncoming traffic often hit on left side Can present with hemorrhagic shock, abdominal tenderness, LUQ pain, left shoulder pain

Anatomy
Spleen
Delayed presentation can occur more than 48 hours after injury Complain of left subcostal or shoulder pain Abdominal distension or rigidity Fullness in LUQ CT if stable Non-operative management for lower grade injury

Anatomy
Liver
Most common fatal abdominal injury
Mortality 10-20%

Anatomy
Liver
2nd most common injured organ in BAT Present with hemorrhagic shock May have RUQ pain CT if stable, surgery if unstable

Anatomy
Pancreas
Less than 3% of kids with BAT More common after handlebar injury, MVA and direct blow to abdomen Present with vomiting and abdominal pain radiating to back, persistent epigastric pain CT and US may miss pancreatic injury

Anatomy
GI tract
Children have more bowel injuries than adults Still uncommon - between 1 and 15% Most GI injuries caused by discrete point of energy transfer
Handle bar Seatbelt Direct blow

Anatomy
Other intraabdominal or retroperitoneal structures to consider
Kidneys Vasculature Ureters Bladder Female reproductive tract

Approach to the injured child

How do we start?

Approach to the injured child

Primary survey
ABCDE
Airway Breathing Circulation Disability Environment

Rapid assessment Begin management

Airway, IV, labs

Maintain in-line spinal immobilization throughout

Approach to the injured child

Secondary survey
Detailed neurologic exam
Sesory and motor

Rectal exam
Tone and occult blood

Initiate imaging OG/NG tube and Foley to decompress abdomen

History
Mechanism Location of pain Previous abdominal surgeries Possibility of pregnancy

Physical exam
Abdominal distention
reduce by placing NG/OG and foley

Localized pain Vomiting or ileus

Physical exam
Abdominal bruising
74% of children with significant abdominal injury had abdominal wall bruising 99% of children without abdominal injury had no bruising

Laboratory testing
Complete blood count, type and screen Liver function tests
can be elevated with injury

Pancreatic enzymes
less predictive of clinically significant injury

Urinalysis to evaluate for blood Urine pregnancy test for all adolescent girls

Diagnostic Imaging
Ultrasound Pros
Fast, can be bedside No radiation No contrast Specificity high (97%)

CT Scan
Sensitive 98% Specific 92% Defines injury extent

Cons

Operator dependent Sensitivity low (68%) Availability Can miss bowel, diaphragm and pancreas injuries

Only for stable patients Cost and time Can miss bowel, diaphragm and pancreas injuries

Diagnostic Imaging
If patient is unstable
Focused Assessment with Sonography for Trauma (FAST) Presence of free fluid in abdomen mandates early surgical exploration Volume resuscitate aggressively No role for CT scan

Case 1
12 year old boy riding bike ran into a parked car Sustained blunt trauma to abdomen when he hit handlebar Primary and secondary survey completed and normal except abdomen Mild pain in right upper quadrant on exam Emesis after PO challenge

Case 1
What injury should we suspect by mechanism? Duodenal hematoma When will this injury most likely be recognized? Several hours to days after injury

Case 1
What is the best imaging for this injury?
What is the treatment for this injury?

Case 1
US or CT can be used Nasogastric suction and TPN until obstructive symptoms resolve

Case 2
8 year old girl, restrained backseat passenger wearing only lap belt After primary and secondary survey, midline back tenderness is noted at L2-L3 and XRAY demonstrates a L3 fracture (Chance fracture)

Case 2
Abdominal exam is unremarkable except for mild bruising OR is calling for patient to stabilize spine

Can she go to OR?

Case 2
What abdominal injury should we suspect by mechanism? Bowel perforation or rupture When will this injury most likely be recognized? Immediate to several hours later, could be missed if taken directly to OR

Case 2
What is the best imaging for this injury?
Both US and CT can miss this; need high index of suspicion and exploratory laparotomy at time of spinal fixation

What is the treatment for this injury?

Surgical repair

Case 2

Bowel rupture secondary to blunt abdominal injury

Case 3
10 year old boy belly flops 10 feet from roof onto a mattress During primary survey, shows signs of shock with no obvious hemorrhage Shock improves with 20 ml/kg bolus of LR Secondary survey shows abdominal tenderness in both upper quadrants.

Case 3
What injury should we suspect by mechanism?
Solid organ injury to liver, spleen

When will this injury most likely be recognized?

Immediate pain, hemodynamic instability may be delayed

Case 3
What is the best imaging for this injury?
If patient is stable, CT with IV contrast gives more detail

What is the treatment for this injury?

Prefer serial hematocrit and observation, may need surgery if conservative management fails

Case 3
Solid organ injury
Liver Spleen Kidney

Summary
Always start with primary survey
ABCDE

Volume resuscitate aggressively

IV Crystalloid, blood if needed

Unstable patients dont go to CT

Summary
Recognize common injury patterns
Solid organ injuries high risk blood loss Seatbelt injuries Chance Fracture and bowel perforation Bowel and pancreas injuries