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Paediatric Abdominal Trauma LA Hodsdon Oct 09 UPDATE ON BURNS MANAGEMENT IN CHILDREN
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Considerations Incidence Type Anatomical Considerations History & Examination Diagnostic Modalities Suggested Investigative Approaches
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Incidence: Abdominal Trauma: – 8-10% admissions to Paediatric Trauma Centres – 3 rd most frequent cause of death ( ) – MOST COMMON UNRECOGNIZED FATAL INJURY – NAI – 5% admitted with Abdominal Trauma
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Type of Injury: Blunt Abdominal Trauma: – 85% of paeds abdo trauma (US/UK) – > 50 due to MVA’s – Other common causes bicycles, sports, falls, NAI RSA ?% Penetrating Trauma – Likely to be >15%
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Anatomical Considerations: Solid Organs: proportionally larger & more anterior Kidneys: larger, more mobile +/- foetal lobulations Subcutaneous Fat: ↓ Abdominal Musculature: ↓ AP Diameter: ↓ Flexible Cartilaginous Ribcage
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Increased Solid Organ Injury – Both Blunt & Penetrating Injury GIT Trauma not uncommon – Duodenal & Small Bowel haematomas & perforation – Pancreatic injuries – Mesenteric lacerations
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History & Examination: Age dependant Often difficult for kids to localise / verbalise FEAR – Often hard to reassure – Fear of unknown / vague concepts – Separation – Fear of Medical Personnel
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Haemodynamically stable child - who is alert and co-operative - able to communicate effectively history and examination approach reliability rates of adults
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2004 Poletti et al: Awake, haemodynamically stable (adults): abdo pain, tenderness & peritoneal signs more reliable physical signs & can be found in 90% BUT significant injuries can be missed No physical signs ≠ exclude intra-abdominal injury 7.1% pts with normal physical examination = intra-abdominal injuries on CT Multiple small studies suggest normal examination excludes the need for therapeutic surgery
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Plain X-Rays Free Air – Gastric, duodenal bulb & colonic perforation – Only 25-33% of jejunal & ileal perforations have FA – Better viewed on CT Foreign Bodies Projectory Paths
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FAST Advantages: – Rapid ID of Intraperitoneal Haemorrhage – Non Invasive – Portable – Rapid (5min FAST) – Widespread (US) therefore not rely on Radiologists – Serial examinations possible – No side effects
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FAST Disadvantages: – Not able to image extent of organ damage – Not able to visualise retroperitoneum – Operator dependant – Patient dependent – Can’t differentiate blood from ascites – Can’t pick up contained bleeding
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FAST in ABDO Trauma Most studies: – sensitivity for haemoperitonium 86-89% – Depends on required end point (Intra-abdominal Injury / Intra-abdominal Injury requiring ø / Potentially Fatal intra-abdominal Injury) Ollerton et al: U/S & Trauma Management – Changed Mx decisions 32.8% of time – ↓ CT (47 34%) & ↓ DPL (9 1%) Branay et al: U/S key pathway – ↓CT (56 26%) & ↓DPL (17-4%)
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FAST: Reliability in Kids: Holmes: 224 kids (mean age 9 yrs) – Prospective – Hypotension (13): 100% sens, 100% spec – All Patients (244): 82% sens, 95% spec Soudack: 313 kids (2months – 17yrs) – Retrospective – 275 Negative FASTs – 73 of Negative FASTs had abdominal signs & CTs: 3 Positive – Parenchymal Injuries, none requiring ø – 92.5% sens, 97.% spec
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CT Scan Advantages – Define extent of injury & organ involvement – Non Invasive – Most Accurate S/I for Solid Organ injury – Evaluates retroperitoneum 3 Contrast Studies have 97% sens, 98% spec Velmahos et al achieved similar rates with IVI contrast alone.
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CT Scan Disadvantages – Time consuming & unable to monitor patients – Requires IVI Contrast – Requires Sedation in most kids – Can’t visualise pancreas, diaphragm, small bowel or mesentery – Radiation Dose – Brenner et al 1 yr old child: lethal malignancy risk of 1 abdominal CT was ± 1 in 550
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CT Scan in Kids High Sensitivity & Specificity for the solid organ pattern common in kids Radiation dose and need for sedation major drawback in kids, so CT scans should be considered not just ordered as ‘routine’
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DPL Rapidly reveals/excludes the abdomen as the source of hypotension Advantages May detect Bowel Injury (GIT matter) Disadvantages Invasive with complication rate of 0.3% Operator dependant Comparatively time consuming (vs. FAST) Widespread replacement by FAST
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Other Diagnostic Modalities Local Wound Exploration: – Bedside surgical exploration of tract – Determine whether Peritoneal Violation has taken place – Patient Factors Contrast Studies Angiography ERCP Laparoscopy
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Management Questions: Blunt Abdominal Trauma – Trauma vs. Medical component – Single vs. Multisystem trauma – Emergency Laparotomy vs. Dx workup – Single vs. Multiple Intraperitoneal Injury – Expectant vs. Necessary Laparotomy Paediatric patients tolerate expectant management better than adults. If paediatric patient is stable and adequate monitoring is available: normally follow expectant management.
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Management Questions: Penetrating Trauma Trauma vs. Medical component Single vs. Multisystem trauma Emergency Laparotomy required? Peritoneal Violation? Intraperitoneal Injury? Stab Wounds – 70% have peritoneal violation but only 25-33% of those require surgery. Expectant: Shaftan 1960’s
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Operative vs. Non-operative Management. Successful: mod – high grade liver / spleen trauma Failures considerable morbidity / mortality Balance between avoiding unnecessary laparotomy & preventing significant morbidity or mortality by waiting too long. Requirements: Patient – alert & co-operative, mild-mod MOA Institution - experienced nursing staff, trauma surgeons, radiologists & facilities for urgent laparotomy
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Pitfalls: 1) Hollow Viscera Injuries: missed 2) Increased use of blood products 3) Approach will fail if haemorrhage ≠ respond to Rx angiography + embolization or not abate from solid organs. Time from injury operation: increase morbidity and mortality.
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Resources: Advances in Abdominal Trauma; J.L. Isenhour, MD, J Marx, MD; Emerg Med Clin N Am 25 (2007) 713–733 Pediatric Major Trauma: An Approach to Evaluation and Management; J.T. Avarello, MD, FAAP, R.M. Cantor, MD, FAAP, FACEP; Emerg Med Clin N Am 25 (2007) 803–836 Rosen’s Emergency Medicine Emergency Medicine Manual, 6 th Ed; O.John Ma & Davis M Kline Oxford Handbook of Trauma for Southern Africa; A Nicol & E Steyn
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