Pediatric Blunt Abdominal Trauma Sabrina Sanchez, MD, MPH December 20th, 2012

Epidemiology Trauma is the leading cause of childhood death Boys are injured twice as often as girls Blunt abdominal trauma occurs in 10-15% of injured children Vyrostek, MMWR Surveill Summ 2004 Gaines, J Trauma 2009 Wilson, Injury 1992

Blunt Trauma and Pediatric Anatomy Children are smaller More concentrated impact Children have less calcified bones and more elastic tissues Fewer broken bones Occult organ damage Children have increased surface area to volume ratio Rapid dehydration and hypothermia Abdominal wall is thin and less muscular Liver and spleen are located lower in the abdomen and are relatively large Compact torsos and smaller AP diameter No external signs of injury

Pediatric Trauma Biomechanics Most pediatric injuries result from blunt force Liver and spleen injuries are the most common intrabdominal injuries in children who sustain blunt trauma

How do we evaluate children with blunt abdominal trauma accurately and safely? Minimizing radiation Not missing any injuries

Published in 2002. Children <16 at a major level 1 trauma center sustaining blunt trauma. Intrabdominal injury= spleen, liver, pancreas, kidney, adrenal glands or GI tract. Enrolled 1095 patients and 107 (10%) had intrabdominal injuries

Clinical Variables Age Systolic blood pressure Abdominal tenderness Thoracic examination Pelvic examination Femur fracture GCS score Urinalysis Initial hematocrit Serum hepatic transaminase concentrations

365 CT scans would have been avoided!

Know Your Vital Signs AGE GROUP WEIGHT RANGE (kg) HR (beats/min) SBP (mm Hg) RR (breaths/min) Infant 0–1 0–10 <160 >60 <60 Toddler 1–3 10–14 <150 >70 <40 Preschool 3–5 14–18 <140 >75 <35 School age 6–12 18–36 <120 >80 <30 Adolescent >12 36–70 <100 >90 ATLS, 8th edition

High Risk Mechanism MVC with ejection or death of occupant in vehicle MVC with intrusion >12 inches into patient compartment or >18 inches into any compartment Auto vs. pedestrian Auto vs. bike with significant impact MCC >20mph or with separation of rider from motorcycle Fall >10 ft or 2-3x the patient’s height

High Risk for Blunt Abdominal Trauma Direct blow to the abdomen Complaint of abdominal or flank pain Tenderness on abdominal exam Seat belt sign or handle bar mark Suspected pelvic fracture Lower rib fractures Unknown mechanism with altered level of consciousness

Injury Management Non-operative management of blunt spleen and liver injury is successful in 90% of children Treatment modality in hemodynamically stable patients irrespective of the grade of injury Indications for operative management include ongoing blood loss and hemodynamic instability Trend towards transfusing hemodynamically stable patients with ongoing bleeding Alonso, East 2003 McVay, J Pediatr Surg 2008

Stylianos and the APSA Liver/Spleen Study Group, J Pediatr Surg 2002