1. Abdominal Trauma

2. Etiology: – Blunt injuries: 90% Automobile injuries - 60% ≥90% = survive 22% = death – Penetrating abdominal trauma: 10% Gunshot or stab wound Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON

3. Factors that make children vulnerable to abdominal injury: Abdominal wall and lower rib cage are thin in children Liver and kidneys lie relatively lower in the abdomen Kidneys and pancreas lie only a short distance away from the abdominal wall in thin children Liver occupies a large percentage of the abdominal cavity

4. Key Components of Abdominal Assessment I NSPECTION A USCULTATION P ALPATION P AIN ASSESSMENT R ESPIRATION

5. Diagnostic Procedures Laboratory Tests: – CBC Hemoglobin and hematocrit maintain Hct >30% – Serum Amylase – Urinalysis – Transaminase – Blood typing and crossmatching – Peritoneal Lavage

6. Radiological Studies Supine and Upright abdominal films (Upright CXR) – free air in the abdomen (pneumoperitoneum) – extent of injury in penetrating trauma CT Scan – diagnostic test of choice – solid organ injuries – grade of injury Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON

7. Conservative Approach Assessment should include determination: – level of consciousness (GCS) – Vital signs – palpation and auscultation of the abdomen – accurate intake and output measurement Patient Stabilization: aggressive volume expansion

8. Surgical Intervention Indications for surgery: – blood transfusions of 40 ml/kg or 50% of circulating blood volume is required – most penetrating injuries – inability to achieve hemodynamic stability even after aggressive fluid and blood replacement – severe abdominal distention accompanied by hypotension

9. Types of Abdominal Injuries 1.Solid Organ Injury Liver Spleen 2.Pancreatic Injury 3.Stomach and Intestinal Injury

10. LIVER INJURY Most fatal due to the potential for massive hemorrhage Signs and Symptoms: – Pain in right upper shoulder – Pain and tenderness in right upper quadrant of abdomen – Bruising, abrasions and seatbelt marks – Vital Signs: hypotension with major bleeding Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON

11. Conservative – Standard practice for stable pediatric patients – monitored for at least 48 hours – Strict bedrest for 7 days with serial H and H – Limit activity for 2-3 months after discharge Surgical – control of massive bleeding or liver resection – Indications: Child continues to deteriorate more than 50% of the circulating blood volume requires replacement within 24 hours Pediatric Trauma Pathophysiology, Diagnosis, and Treatment edited by DAVID E. WESSON Management

12. SPLENIC INJURY Blow to the LUQ/epigastric region of the abdomen Signs and Symptom: Abdominal tenderness and pain Kehr’s Sign (pain in the left shoulder) Pain in left part of chest with respirations Decreased breath sounds Turner sign (ecchymoses in the left flank) Cullen sign (ecchymoses around the umbilicus)

13. Management Preservation of the spleen to prevent the occurrence of postsplenectomy sepsis Conservative – Standard practice for stable pediatric patients – Receives ≤ 50% blood volume replacement – Monitored in the ICU for at least 48 hours Surgical ( splenorrhaphy or splenectomy) – Hemodynamic instability after aggressive fluid resuscitation – Continued blood loss – Separation of the spleen from its blood supply – Severe head injury that cannot tolerate volume resuscitation

14. The decision to operate for spleen or liver injury, which should always be made by a surgeon, is best based on clinical signs of continued blood loss such as: – low blood pressure, – elevated heart rate, – decreased urine output, and – falling hematocrit

17. PANCREATIC INJURY uncommon in children difficult to diagnose

18. Conservative – complete gastrointestinal rest Surgery – pancreatic duct is transected requiring a partial or total pancreatectomy Management

19. STOMACH AND INTESTINAL TRAUMA contusions, lacerations, hematomas or perforation Signs of hollow organ injury: – abdominal tenderness, ecchymosis of the upper and lower abdomen, bloody gastric drainage

20. Management Surgery