Pediatric blunt abdominal trauma: Initial evaluation and stabilization

Authors:
Richard A Saladino, MD
Kavitha Conti, MD
Section Editors:
Richard G Bachur, MD
George A Woodward, MD
Deputy Editor:
James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: May 2018. | This topic last updated: Apr 24,
2018.

INTRODUCTION — The evaluation of children with blunt abdominal trauma will

be reviewed here. The assessment and treatment of children with specific
injuries to the spleen, liver, pancreas, gastrointestinal tract or genitourinary tract
are discussed separately. (See "Hollow viscus blunt abdominal trauma in
children" and "Liver, spleen, and pancreas injury in children with blunt
abdominal trauma" and "Blunt genitourinary trauma: Initial evaluation and
management", section on 'Pediatric considerations'.)

EPIDEMIOLOGY — Children are more vulnerable to blunt abdominal injury

than adults because they have (see "Trauma management: Unique pediatric
considerations", section on 'Abdomen'):

●Relatively compact torsos with smaller anterior-posterior diameters, which

provide a smaller area over which the force of injury can be dissipated

●Larger viscera, especially liver and spleen, which extend below the costal
margin

●Less overlying fat, and weaker abdominal musculature to cushion

intraabdominal structures

Among all children with blunt torso trauma, intraabdominal injury (IAI) occurs in
approximately 5 to 10 percent of patients [1]. Up to 25 percent of prepubertal
children with multisystem injury who undergo additional testing have significant
abdominal injury [2,3]. Motor vehicle crashes, auto-pedestrian injury, and falls
are the major causes of blunt abdominal injury in children; bicycle injuries, all-
terrain vehicle injuries, and child abuse also contribute [4-6]. (See "Physical
child abuse: Recognition", section on 'Visceral injuries'.)

The most common structures injured in pediatric blunt abdominal trauma are
solid organs, with liver and spleen being the most commonly injured, followed
by kidneys. Hollow viscus injuries are the next most common form of injury,
followed by injuries to the abdominal vasculature [7].

Mortality after blunt abdominal trauma is rare, occurring in <1 percent of

patients with blunt torso trauma [8]. The mortality due to blunt abdominal trauma
in children is directly related to the number and type of structures injured: it is
less than 20 percent in isolated liver, spleen, kidney, or pancreatic trauma;
increases to 20 percent if the gastrointestinal tract is involved; and increases to
50 percent if major vessels are injured [5].

STABILIZATION AND INITIAL ASSESSMENT — The initial management of

children with suspected intraabdominal injury (IAI) should proceed in a
systematic fashion and adhere to the Advanced Trauma Life Support guidelines
for diagnosis and treatment of immediately life-threatening injuries (table 1).
(See "Trauma management: Approach to the unstable child", section on 'Initial
approach'.)

During stabilization, children with signs of IAI and hemodynamic instability that
do not respond to fluid resuscitation and blood transfusion warrant emergency
laparotomy. (See'Laparotomy' below.)

After the patient has been assessed, resuscitated, and stabilized, the patient
should receive ongoing care directed by a pediatric surgeon with trauma
expertise, whenever possible. Because optimal care and outcomes occur when
the critically injured child is initially resuscitated and subsequently managed in a
pediatric trauma center (PTC), it is preferable to provide initial care in such
facilities from the outset, whenever possible, or to arrange transfer to a PTC for
ongoing management. (See "Trauma management: Approach to the unstable
child", section on 'Definitive care'.)

EVALUATION IN THE STABLE PATIENT — In hemodynamically stable

children, evaluation for blunt intraabdominal injury (IAI) should take place as
part of the secondary survey. This evaluation may disclose other indications for
observation, laboratory evaluation, imaging, or laparotomy.
(See 'Approach' below and 'Radiologic evaluation' below
and 'Laparotomy'below.)

History — Unlike penetrating trauma, which is usually apparent upon inspection,

blunt abdominal trauma must be suspected from historical information,
particularly the mechanism of injury, and careful physical examination [1,9-11].

Mechanisms of blunt injury that are associated with IAI include isolated, high-
energy blows to the abdomen (eg, fall from a bicycle on to the handlebar
(picture 1)) and high-risk trauma mechanisms including motor vehicle collisions,
seat belt usage (picture 2), and falls from a height greater than 10 feet or two to
three times the patient’s height (table 2) [1,12-14]. (See "Prevention of falls in
children", section on 'Falls from height'.)
Patients who report abdominal pain after blunt torso trauma are also at
significant risk of intraabdominal injury. As an example, in a large, prospective
multicenter trial of 10,176 children two years of age or older with blunt torso
trauma, any reported abdominal pain was associated with a 13 percent risk of
IAI compared to a 2 percent risk of IAI in patients with a Glasgow coma scale of
15 and no pain or tenderness on physical examination [15].

Physical examination — Children with blunt abdominal trauma warrant a

complete physical examination as part of the secondary survey and consistent
with the principles of Advanced Trauma Life Support. (See "Trauma
management: Approach to the unstable child", section on 'Physical examination
and management'.)

During the secondary survey, the clinician should pay close attention to signs of
hemorrhagic shock such as tachycardia, narrowed pulse pressure, prolonged
capillary refill time, pallor, or altered mental status. Although not definitive, these
findings may indicate ongoing intraabdominal hemorrhage. Significant
intraabdominal hemorrhage in children can be masked by their ability to
maintain normal systolic blood pressure despite large volume blood loss.
(See "Hypovolemic shock in children: Initial evaluation and management",
section on 'Pathophysiology and classification'.)

Abdomen — In patients with vomiting, abdominal distension, or suspicion for

significant abdominal injury, a nasogastric or, in patients with maxillofacial
trauma, an orogastric tube should be placed before abdominal examination.
Gastric decompression may facilitate accurate examination in these selected
patients and minimize risk of aspiration of gastric contents if vomiting occurs [9].

Physical signs that indicate an increased risk of IAI include each of the following
[9,15,16]:

●Ecchymoses (particularly of the umbilical or flank regions), such as in

handlebar injuries (image 1)

●Abrasions

●Tire-track marks

●Seat belt sign in restrained passengers from motor vehicle collisions

(see 'Seat belt sign' below)

●Abdominal tenderness

●Abdominal distension

●Peritoneal irritation (eg, abdominal wall rigidity, rebound, guarding, or pain

in the left shoulder induced by palpation of the left upper quadrant [Kehr's
sign])
 ●Absent bowel sounds indicating a prolonged ileus (greater than four
hours)

In a prospective, multicenter observational study of 12,044 children, including

1868 children younger than two years of age, undergoing evaluation for blunt
torso trauma the percent risk for IAI in patients with selected findings was
significantly increased compared to the baseline risk of 5 percent for the 2217
patients without abdominal pain or tenderness as follows [15]:

●Peritoneal irritation present: 44 percent

●Abdominal distension present: 31 percent

●Any abdominal tenderness present: 13 percent

●Bowel sounds absent: 8 percent

Repeated, serial examinations are necessary in children with abdominal trauma

because serious IAI may not be apparent upon the initial examination [8,17].
Abdominal tenderness may be especially difficult to determine in young children
who are frightened and cannot clearly communicate and in older children who
are uncooperative or neurologically impaired [18,19].

Abdominal injury can also be difficult to identify in children with concurrent

extraabdominal injury (eg, head trauma, thoracic trauma, or extremity fracture)
or impaired neurologic status (eg, traumatic brain injury or substance use)
[15,20]. Clinicians should have a lower threshold for additional studies and
observation in these patients.

Seat belt sign — The seat belt sign was first described as part of a trio of
findings consistent with "seat belt syndrome," which included vertebral chance
fracture (image 2), abdominal wall ecchymosis (picture 2), and IAI (image
3 and image 1). Abdominal wall ecchymosis in a linear pattern across the
abdomen in restrained children who are injured in a motor vehicle collision (seat
belt sign) is strongly and independently associated with significant IAI,
especially hollow viscus injuries [8,14]. Thus, most patients with a seat belt sign
warrant definitive determination of IAI (computed tomography [CT] of the
abdomen and pelvis in stable patients or laparotomy in unstable patients who
do not respond to fluid resuscitation and blood transfusion). Alert patients
without abdominal tenderness who have the seat belt sign still have a significant
risk of IAI and, at a minimum, warrant continued observation and laboratory
evaluation [8]. Abdominal and pelvic CT is often still necessary in these patients
to identify or exclude IAI.

The following observational studies support the association between the seat
belt sign and IAI in restrained children who are injured in motor vehicle
collisions:
 ●In a retrospective study of a large database of almost 150,000 children,
aged 4 to 15 years, who were restrained passengers, children with
abdominal bruises were 232 times more likely to have IAI than those
without bruising (95% CI, 76-710) [14]. Abdominal bruises had a sensitivity
and specificity for IAI of 74 and 99 percent, respectively. Among patients
without abdominal wall bruising, the negative predictive value for IAI was
99.9 percent. Among all patients, significant IAI was present in 0.2 percent
(309 children) and abdominal bruising in 1.3 percent (1967 patients).

●In a multicenter, prospective, observational study of 1864 children injured

in a motor vehicle collision who underwent definitive determination of the
presence of an IAI by CT, laparotomy, or autopsy, IAIs occurred more
frequently in children demonstrating a seat belt sign than those who did not
(19 versus 12 percent, respectively) [8]. A greater number of hollow viscus
or mesenteric injuries in children with a seat belt sign accounted for the
difference in rates of IAI between the groups. The seat belt sign was
independently associated with IAI after adjustment for vomiting,
hypotension, altered mental status, evidence of thoracic trauma, and
abdominal or costal margin pain (risk ratio [RR] 1.8, 95% CI 1.3-2.4).
Among patients with normal or near-normal mental status
and no abdominal tenderness, IAI occurred in 6 percent of the 194 patients
with a seat belt sign and 2 percent of the 1714 patients without.

Associated injuries — Tenderness during palpation of the lower ribs may

indicate rib fracture. Among 476 hospitalized children and adults with solid
abdominal organ injury, lower rib fractures were associated with splenic or
hepatic injury in 31 and 15 percent of cases respectively [21].

Children with abdominal trauma should have their genitalia and perineum
evaluated during the secondary survey. The index of suspicion for pelvic, rectal,
urethral, and vaginal injuries should be heightened in patients with lacerations,
bruising, urethral bleeding, or straddle injuries. (See "Trauma management:
Approach to the unstable child", section on 'Perineum'and "Straddle injuries in
children: Evaluation and management", section on 'Girls'.)

While digital rectal exams are not routinely helpful in the evaluation of pediatric
trauma patients, they should be performed if the mechanism of injury or
examination indicate possible spinal cord injury. Decreased rectal sphincter
tone may indicate spinal cord injury. Additional signs of spinal cord injury
include priapism, hypotension with relative bradycardia, and decreased strength
and sensation [22].

Laboratory evaluation

Approach — While there is no standardized "trauma panel," the following

laboratory studies are warranted in children with blunt abdominal trauma and
suspected intraabdominal injury:
●Complete blood count (CBC)

●Blood type and crossmatch

●Arterial or venous blood gas

●Serum transaminases (alanine aminotransferase [ALT] and aspartate

aminotransferase [AST])

●Serum electrolytes, creatinine, blood urea nitrogen

●Blood glucose

●Amylase, and lipase

●Prothrombin time (PT), partial thromboplastin time (PTT)

●Urinalysis

●Hemodynamically unstable patients – Children with hemodynamic

instability due to intraabdominal bleeding that is unresponsive to crystalloid
infusion (40 to 60 mL/kg,maximum volume: 3 L) and blood transfusion (no
response after 20 mL/kg [relative indication]; no response after transfusion
of approximately half of their estimated blood volume [strong indication])
require emergent laparotomy; laboratory tests, especially a CBC and blood
type crossmatch, should be obtained in a manner that does not delay
operative care. (See 'Laparotomy' below.)

●Hemodynamically stable patients with signs of IAI – Hemodynamically

stable children in whom IAI is strongly suspected on the basis of clinical
findings should undergo emergency CT of the abdomen and pelvis without
waiting for laboratory results [19]. Although laboratory studies should be
obtained, the CT should be obtained without waiting on the results of the
laboratory tests. (See 'Physical examination' above and 'Abdominal and
pelvic CT' below.)

●Hemodynamically stable patients without signs of IAI – Hemodynamically

stable children who are alert, cooperative, and have a normal physical
examination but a concerning mechanism of injury may occasionally have
IAI that can be identified by serial abdominal examination and laboratory
testing. We recommend that these patients undergo the above laboratory
testing. The presence of unexplained anemia, gross or microscopic
hematuria (≥50 red blood cells [RBCs] per high-powered field) or elevation
of serum transaminases (AST >200
international unit/L [3.33 microkatal/L] or ALT >125
international unit/L [2.08 microkatal/L]) indicates the need for abdominal
and pelvic CT [18,19]. (See 'Specific tests' below and 'Abdominal and
pelvic CT' below.)
Specific tests

Hemoglobin and hematocrit — In hemodynamically unstable patients,

hemoglobin and hematocrit should be measured frequently. A decline in these
values over time indicates profuse hemorrhage. In hemodynamically stable
patients with abdominal pain or tenderness after significant blunt trauma,
hemoglobin and hematocrit should be followed serially (every four to six hours
until measurement is unchanged) because the initial hemoglobin and hematocrit
in a patient with acute blood loss can be normal if equilibration of intravascular
volume has not yet occurred. An initial hematocrit of less than 30 percent
suggests severe blood loss. (See "Trauma management: Approach to the
unstable child", section on 'Laboratory studies'.)

Blood type and crossmatch — Type and cross for packed RBCs permits
efficient transition to type specific blood product transfusion if crystalloid fluid
resuscitation does not reverse shock. The emergency clinician should order a
blood type and crossmatch for any victim of significant blunt abdominal trauma
in anticipation of the need for transfusion. For the patient with evidence of a
potentially life-threatening intraabdominal hemorrhage, O negative
uncrossmatched packed RBCs should be given emergently. Consideration
should also be given to transfusing with whole blood, if available [23]. The blood
bank should be rapidly notified by phone or in person so that type-specific blood
and, when necessary, other blood products (eg, FFP, platelets, rVIIa) can be
made available as soon as possible. (See "Trauma management: Approach to
the unstable child", section on 'Laboratory studies'.)

Urinalysis — Urinalysis is usually performed as a screening test for

genitourinary and renal trauma and to assess the need for imaging.
Observational studies suggest that CT of the abdomen and pelvis with
intravenous (IV) contrast is only indicated in children with gross hematuria,
microscopic hematuria ≥50 RBCs per high-powered field, vertical deceleration
injuries (eg, falls >20 feet), and/or physical signs of renal injury (eg, flank pain or
ecchymosis) [24,25]. Asymptomatic patients with microscopic hematuria and
otherwise normal physical findings have major renal injuries less than 2 percent
of the time and may not require imaging. These patients may be followed as an
outpatient to ensure that the hematuria clears.

Hematuria is variably present in patients with serious renal injury and may be
transient. Thus, the first urine sample obtained from the patient should be tested
for blood.

Liver transaminases — We recommend that clinicians obtain transaminases in

patients who have sustained potentially significant blunt abdominal trauma and
are hemodynamically stable. We recommend that patients with elevated liver
enzyme studies (AST >200 international unit/L [3.33 microkatal/L] or ALT >125
international unit/L [2.08microkatal/L]) undergo CT of the abdomen and pelvis.
Elevation of transaminases in hemodynamically stable children with blunt
abdominal trauma appears to be a sensitive and specific indicator of IAI [19,26].

●In one prospective observational study of 107 IAI in 1095 children

younger than 16 years who presented to an urban Level I trauma center for
management of blunt abdominal trauma, elevation of aminotransferases
(AST >200 U/L [3.33 microkatal/L] or ALT
>125 unit/L [2.08 microkatal/L]) was independently associated with IAI
identified by radiologic imaging, laparotomy, or autopsy (odds ratio [OR]
17.4, 95% CI 9.4-32.1) [19].

●In another retrospective study of 43 hemodynamically stable children who

underwent abdominal CT for blunt abdominal trauma, AST >450
international unit/L (7.50 microkatal/L)and ALT >250
international unit/L (4.17 microkatal/L) were present in 19; 17 of these had
hepatic injury identified on abdominal CT scan [26]. By contrast, none of
the patients with AST <450 international unit/L (7.50 microkatal/L) and ALT
<250 international unit/L (4.17 microkatal/L) had evidence of hepatic injury
on CT scan. Beyond these threshold levels, no correlation was found
between the serum enzyme level and extent of hepatic injury visible on CT
scan [26].

Pancreatic enzymes — Elevated serum amylase (>125

international unit/L [2.08 nkat/L]) may indicate IAI but is not specific for
pancreatic injury [27,28]; nor is elevated amylase a sensitive indicator of CT- or
laparoscopically-proven pancreatic injury [6,27-33]. Similarly, lipase is not a
sensitive indicator for IAI. In one prospective study of 85 consecutive blunt
abdominal trauma victims, amylase and lipase were measured serially [27].
Although one-half of the patients had elevation of one of these enzymes, only
one patient had pancreatic injury documented by clinical course, operation, or
autopsy. In another observational study of 83 children with blunt abdominal
trauma and evidence of IAI on CT, lipase had a positive predictive value of 75
percent.

Thus, some authors conclude that amylase is of no value in the clinical

management of patients with blunt abdominal injury [34], whereas others
continue to recommend its measurement [6]. We usually measure serum
amylase and lipase in children with significant blunt abdominal trauma to serve
as a baseline measure for comparison if symptoms of abdominal pain persist
after initial evaluation.

Other testing — Postmenarcheal females should undergo urine or serum

pregnancy testing. A blood ethanol level and urine drug screen is warranted in
adolescent patients and in children with signs of intoxication. (See "Trauma
management: Approach to the unstable child", section on 'Laboratory studies'.)
Radiologic evaluation — The primary imaging modalities for the evaluation of
IAI are ultrasound, specifically the focused assessment with sonography for
trauma (FAST), and CT of the abdomen and pelvis.

Ultrasonography — FAST is a rapid ultrasound examination of four abdominal

locations (right upper quadrant, left upper quadrant, subxiphoid region, and
pelvis) performed at the bedside of the injured patient. The primary utility of this
examination for the unstable trauma patient is the detection of
hemopericardium and/or intraperitoneal fluid secondary to IAI. Unstable children
with blunt abdominal trauma and intraperitoneal fluid on FAST may warrant
operative intervention in lieu of CT of the abdomen and pelvis.

In the stable patient, the presence of intraperitoneal fluid on FAST indicates the
need for abdominal CT. However, a negative FAST does not have adequate
sensitivity or specificity to exclude IAI, especially solid organ or hollow viscus
injury. In a 2007 meta-analysis, the FAST had a sensitivity of 66 to 80 percent in
detecting IAI [35]. A 2011 prospective, observational study found the FAST to
have a sensitivity of 52 percent and specificity of 96 percent in identifying IAI
[36]. Due to its poor sensitivity, the FAST should be interpreted in the setting of
the patient's overall clinical status. (See "Trauma management: Approach to the
unstable child", section on 'FAST (Focused Assessment with Sonography for
Trauma)'.)

Abdominal and pelvic CT — Hemodynamically unstable patients who remain

unstable after receiving fluid resuscitation and blood transfusion warrant
emergent laparotomy and should not have this procedure delayed by abdominal
and pelvic CT.

Abdominal and pelvic CT with IV contrast is the preferred diagnostic imaging

modality to detect IAI in hemodynamically stable children who have sustained
significant blunt abdominal trauma. CT is both sensitive and specific in
diagnosing liver, spleen, and retroperitoneal injuries. It is, however, less
sensitive in identifying hollow viscus injuries. (See "Liver, spleen, and pancreas
injury in children with blunt abdominal trauma", section on 'Imaging'.)

Our approach is to perform the initial abdominal CT using IV contrast only when
evaluating hemodynamically stable children with signs of IAI.

Indications — Indications for abdominal CT scan (only for use in the

hemodynamically stable patient) include the following [6,9,10,19,37]:

●Abdominal tenderness not caused by minor, superficial injury (eg, bruise,

abrasion)

●Seat belt sign or syndrome (see 'Seat belt sign' above and "Hollow viscus

blunt abdominal trauma in children", section on 'Seat belt syndrome')
 ●Findings that suggest a significant risk for IAI in a patient with distracting
injuries

●Initial serum AST >200 international unit/L or ALT >125

international unit/L

●Gross hematuria or microscopic hematuria with ≥50 RBCs per high-

powered field in otherwise asymptomatic patients

●Declining or unexplained hematocrit or hematocrit <30 percent

●Unclear etiology for fluid or blood requirements

●Inability to perform adequate abdominal examination or serial abdominal

examinations (eg, uncooperative children younger than two to three years
or those with impaired mental status, or planned operative management
under general anesthesia) in a patient with findings indicating IAI

●Positive FAST exam in a hemodynamically stable patient when there is

concern for IAI

Use of contrast — We suggest that hemodynamically stable children

undergoing CT of the abdomen and pelvis after blunt trauma receive only IV
contrast, rather than both IV and oral contrast. In a preplanned subanalysis of a
multicenter, prospective observational study of 5276 children undergoing CT
with IV contrast of whom 1010 also received oral contrast, the sensitivity for
identifying intraabdominal injury was not significantly different with or without
oral contrast (99 versus 98 percent, respectively) [38]. The specificity for IAI
was 4 percent greater among those patients who received oral contrast (85
versus 81 percent). Trauma centers that only use IV contrast report similar
detection of abdominal injuries during the initial evaluation of children with blunt
abdominal trauma when compared to centers that continue to use oral and IV
contrast.

In addition, oral contrast has the following practical limitations:

●Delayed time to CT [38]

●Vomiting [39] although low rates of aspiration have been documented in

retrospective studies [40,41]

●Inadequate penetration and visualization of the small or large bowel

which, based upon one small observational study, may occur in up to 60
percent of children [42]

In the above subanalysis, patients who received oral contrast had a significantly
longer delay (median 12 minutes) in undergoing CT compared with children
who received IV contrast alone. This delay in determination of intraabdominal
injury in the stable pediatric trauma patient is of great concern, especially in
patients with time sensitive injuries to other parts of the body such as the head,
chest, or extremities.

Initial CT alone is less sensitive in detecting injuries of the pancreas, intestinal

tract, and bladder. In particular, the presence of blunt hollow viscus injury is
often subtle and may not be identified on the first abdominal and pelvic CT, and
recognition may require a high index of suspicion and hospital observation over
time to make the diagnosis. (See "Liver, spleen, and pancreas injury in children
with blunt abdominal trauma", section on 'Imaging' and "Hollow viscus blunt
abdominal trauma in children", section on 'Imaging' and "Blunt genitourinary
trauma: Initial evaluation and management", section on 'CT scanning'.)

Low-risk rule for intraabdominal injury — Abdominal CT is associated with

significant radiation exposure, and this imaging risk must be balanced with the
likelihood of finding a clinically important IAI. A multicenter, prospective
observational study of 12,044 children with blunt torso trauma has derived
clinical features that predict a very low risk of IAI requiring intervention (eg,
laparotomy, angiographic embolization, blood transfusion, or hospitalization for
two nights or longer) as follows [1]:

●Glasgow coma scale ≥14

●No evidence of abdominal wall trauma or seat belt sign

●No abdominal tenderness

●No complaints of abdominal pain

●No vomiting

●No thoracic wall trauma

●No decreased breath sounds

The absolute risk of IAI for the 5034 children who met all seven of these criteria
was 0.1 percent. However, 23 percent of these patients underwent abdominal
and pelvic CT. The six very low-risk patients who did have IAI had other
features commonly associated with IAI (eg, hematuria, elevated liver enzymes,
a distracting injury, or ethanol intoxication). Thus, implementation of this rule, if
validated, has significant potential to reduce the number of abdominal and
pelvic CTs in children. The authors note that failure to meet the very low-risk
criteria derived in this study is not necessarily an indication for abdominal and
pelvic CT and that further validation of these criteria are needed before
widespread use can be recommended.

In a planned analysis of 3819 children from the low-risk IAI rule derivation study
in whom abdominal CT was normal, the sensitivity and specificity for any IAI
were 98 and 82 percent, respectively [43]. Only six patients (0.2 percent)
subsequently received an acute intervention after CT. This evidence suggests
that children who have negative findings of IAI on abdominal CT after blunt
trauma are at low risk for IAI and may be candidates for discharge home rather
than admission for observation if they meet the following criteria [43]:

●No abdominal pain

●No seat belt sign

●No concern for physical abuse

●No serious associated injuries

Plain radiographs — Plain abdominal radiographs are not routinely employed

for the diagnosis of IAI because they lack sensitivity and specificity relative to
abdominal CT [9]. Pelvic radiographs are indicated in hemodynamically
unstable patients or those with clinical findings suggestive of pelvic fracture.
(See "Pelvic trauma: Initial evaluation and management", section on 'Plain
radiograph'.)

Peritoneal lavage — Diagnostic peritoneal lavage (DPL) has largely been

supplanted by FAST, CT, or laparoscopy. DPL may rarely be useful in the
evaluation of a hemodynamically unstable child, particularly if he or she requires
emergent surgery (eg, craniotomy), and time does not permit an abdominal CT
scan and a FAST scan is indeterminant [9]. Some surgeons prefer performance
of emergent laparotomy to DPL.

DPL is considered positive if [9,44]:

●More than 5 mL of gross blood are obtained

●Obvious enteric contents (eg, bile, stool) are obtained

●Extravasation of peritoneal lavage fluid from a chest tube or urinary

bladder catheter occurs

●Lavage fluid contains >100,000 RBCs or >500 white blood cells (WBCs)
per mm3

●The amylase concentration of peritoneal lavage effluent is elevated (>175

international unit/L [2.92 nkat/L])

Abdominal CT is performed instead of DPL in the hemodynamically stable child

because DPL is less injury- and organ-specific, cannot detect retroperitoneal
injury, and has potential risks, including the introduction of air or fluid into the
abdomen, peritoneal irritation, and false positive results that may lead to
exploratory surgery when clinical observation would be the more appropriate
treatment [44].

Relative contraindications to DPL include pregnancy or previous abdominal

surgery.
DEFINITIVE MANAGEMENT — Definitive management of children with
intraabdominal injury (IAI) after blunt trauma should be determined by a
pediatric surgeon with trauma expertise, whenever possible. In regions in which
such expertise is not available, a trauma surgeon with pediatric expertise is also
acceptable. Most hemodynamically stable children with IAI can be managed
nonoperatively.

Laparotomy — Indications for immediate laparotomy include supporting

evidence of significant intraabdominal injury (based upon history, physical
examination, computed tomography [CT], diagnostic peritoneal lavage [DPL], or
ultrasound) and [9]:

●Perforation from a hollow viscus injury demonstrated as

pneumoperitoneum.

●Intraabdominal bleeding of more than half the patient's blood volume

demonstrated as persistent or recurring hemodynamic instability, despite
crystalloid infusion and blood transfusion, especially when accompanied by
abdominal distension. Of note, hemodynamic instability caused by a pelvic
fracture frequently warrants treatment other than laparotomy. All
hemodynamically unstable children warrant initiation of a predetermined
massive transfusion protocol. (See "Trauma management: Approach to the
unstable child", section on 'Massive transfusion protocol'.)

Relative indications for laparotomy include [4,45]:

●Increasing abdominal tenderness or peritoneal irritation

●Transfusion requirement of packed red blood cells (RBCs) or whole blood

for intraabdominal bleeding

Other indications for laparotomy vary according to the specific injury:

●Diagnosis of hollow visceral injury (see "Hollow viscus blunt abdominal

trauma in children", section on 'Operative management')

●Solid organ injury with evidence of continued bleeding (see "Liver, spleen,

and pancreas injury in children with blunt abdominal trauma", section on
'Damage control surgery' and"Liver, spleen, and pancreas injury in children
with blunt abdominal trauma", section on 'Spleen' and "Blunt genitourinary
trauma: Initial evaluation and management", section on 'Definitive
management')

●Pancreatic injury with major parenchymal or ductal disruption (see "Liver,

spleen, and pancreas injury in children with blunt abdominal trauma",
section on 'Pancreas')

Nonoperative management — Careful observation without operative

intervention for hemodynamically stable children with solid organ injuries from
blunt abdominal trauma, in a facility with operative capability and surgical
expertise, is a standard practice that is safe and improves patient outcome and
resource utilization. In addition, preservation of the spleen in children with
splenic injuries avoids the infectious risks associated with splenectomy.
(See "Liver, spleen, and pancreas injury in children with blunt abdominal
trauma", section on 'Nonoperative management'.)

In addition, whenever possible, initial care for children with blunt abdominal
trauma should occur in pediatric trauma centers (PTC). When this option is not
available, consultation with and transfer to a PTC for ongoing management is
strongly encouraged. (See "Trauma management: Approach to the unstable
child", section on 'Definitive care'.)

Characteristics of injuries that ultimately required surgery were reported in a

retrospective series from seven level I pediatric trauma centers describing 1818
children with solid organ injury initially managed nonoperatively [46]. The
following findings were noted:

●Surgery was subsequently required for 89 (5 percent) patients with the

following injuries: kidney (3 percent), liver (3 percent), spleen (4 percent),
and pancreas (18 percent).

●The reasons for failure of nonoperative management included the

following: shock (33 percent), peritonitis (27 percent), persistent
hemorrhage (16 percent), hollow viscus injury-related (15 percent), isolated
pancreatic injury (8 percent), and ruptured diaphragm (1 percent).

●Failure of nonoperative management was significantly associated with

injury severity, pancreatic injury, and multiple organ system involvement.

●Need for operative intervention was determined within 12 hours of the

injury for 76 percent of patients.

Despite the proven advantages of nonoperative management for solid organ

injuries from blunt abdominal trauma, observational studies document that
children cared for in general hospitals are significantly more likely to undergo
splenectomy than those cared for in children's hospitals [47-50]. Thus,
strategies need to be created to increase compliance with guidelines for the
nonoperative management of solid organ injury in children that target clinicians
and other clinicians in general hospitals, where the majority of injured children
receive care.

Discharge after initial evaluation — Children who have negative findings of IAI

on abdominal CT after blunt trauma are at low risk for IAI and may be
candidates for discharge home rather than admission for observation if they
meet the following criteria [43]:

●No abdominal pain

 ●No seat belt sign

●No concern for physical abuse

●No serious associated injuries

SPECIFIC INJURIES

Liver, spleen, or pancreas injury — The evaluation and management of children

with liver, spleen, or pancreas injury after blunt trauma is discussed in detail
separately. (See"Liver, spleen, and pancreas injury in children with blunt
abdominal trauma".)

Gastrointestinal tract — The evaluation and management of hollow viscus

injuries in children who sustain blunt trauma is discussed in detail separately.
(See "Hollow viscus blunt abdominal trauma in children".)

SUMMARY AND RECOMMENDATIONS

●The general approach to the child with blunt abdominal trauma is the
same as for any seriously injured child. Initial evaluation of pediatric trauma
patients should first address life-threatening injuries that compromise
airway, breathing, and circulation (table 1). Hemodynamically unstable
children with suspected intraabdominal injury (IAI) who are not responsive
to intravenous crystalloid and blood transfusions during stabilization
warrant emergent laparotomy. (See 'Stabilization and initial
assessment' above and 'Laparotomy'above.)

●In hemodynamically stable patients, assessment for blunt IAI should take
place as part of the secondary survey. (See 'Stabilization and initial
assessment' above and 'Evaluation in the stable patient' above.)

●Mechanisms of blunt injury that are associated with IAI include isolated,
high-energy blows to the abdomen (eg, fall from a bicycle on to the
handlebar) and high-risk trauma mechanisms including motor vehicle
collisions, seat belt usage, and falls from a height greater than 10 feet or
two to three times the patient’s height (table 2). (See 'History'above.)

●Signs of IAI include ecchymoses (particularly of the umbilical or flank

regions); abrasions; tire-track marks; seat belt marks; abdominal
distension, tenderness, rigidity, or masses; signs of peritonitis, such as pain
in the left shoulder induced by palpation of the left upper quadrant (Kehr's
sign); or prolonged ileus (greater than four hours). Signs of abdominal
injury are variable and may evolve over time necessitating serial
examinations. (See 'Abdomen' above and 'Associated injuries' above.)

●IAI can be obscured by concurrent extraabdominal injury (eg, head

trauma, thoracic trauma, extremity fracture). In addition, the examination
may be unreliable if the patient's neurologic status is impaired due to brain
or spinal cord injury or substance use, and in younger children who may be
uncooperative. Such patients should be assumed to be at significant risk of
IAI. (See 'Abdomen' above.)

●The following laboratory studies are warranted in children with blunt

abdominal trauma and suspected intraabdominal injury
(see 'Approach' above):

•Complete blood count (CBC)

•Blood type and crossmatch

•Arterial or venous blood gas

•Serum transaminases (alanine aminotransferase [ALT] and aspartate

aminotransferase [AST])

•Serum electrolytes, creatinine, blood urea nitrogen

•Blood glucose

•Amylase, and lipase

•Prothrombin time (PT), partial thromboplastin time (PTT)

•Urinalysis

●Children with hemodynamic instability due to suspected IAI that is

unresponsive to fluid resuscitation and blood transfusion require
emergency laparotomy; preoperative laboratories, should be obtained in a
manner that does not delay operative care. Hemoglobin and hematocrit
should be followed serially in these patients because the initial hemoglobin
and hematocrit in a patient with acute blood loss can be normal if
equilibration of intravascular volume has not yet occurred. Operative care
should occur without waiting for these laboratory results.
(See 'Laparotomy' above and 'Hemoglobin and hematocrit' above.)

●Hemodynamically stable children with clinical signs of IAI should undergo

emergency computed tomography (CT) scanning of the abdomen and
pelvis without waiting for laboratory results. Although laboratory studies as
described should be obtained, the results should not be used to decide the
need for CT. (See 'Liver transaminases' above and'Urinalysis' above
and 'Abdominal and pelvic CT' above.)

●Hemodynamically stable children who are alert, cooperative, and have a

normal physical examination but a concerning mechanism of injury may
occasionally have IAI that can be identified by serial abdominal
examination and laboratory testing as previously described.
(See 'Hemoglobin and hematocrit' above and 'Urinalysis' above and 'Liver
transaminases' above.)
●Ultrasonography (focused assessment with sonography for trauma
[FAST]) is useful, when available, for the rapid, early evaluation of
hemodynamically unstable children with potential blunt abdominal trauma.
Because ultrasonography lacks adequate sensitivity, abdominal and pelvic
CT with intravenous (IV) contrast is usually performed in all
hemodynamically stable patients with clinical findings suggestive of IAI
regardless of ultrasound results. (See 'Ultrasonography' above
and 'Abdominal and pelvic CT' above.)

●Abdominal and pelvic CT with IV contrast is the preferred diagnostic

imaging modality to detect IAI in hemodynamically stable children with
clinical findings suggesting IAI. Our approach is to perform the initial
abdominal and pelvic CT using IV contrast only. Indications for abdominal
and pelvic CT in children with serious blunt abdominal trauma are provided.
(See 'Abdominal and pelvic CT' above.)

●Definitive management of children with IAI after blunt trauma should be

determined by a pediatric surgeon with trauma expertise, whenever
possible. Most hemodynamically stable children with IAI can be managed
nonoperatively. (See 'Definitive management' above and 'Specific
injuries' above.)