Blunt Abdominal Trauma

Jose David Gamez, MD.

Causes

• Motor vehicle crashes• Auto-pedestrian injury• Falls• Bicycle injuries• All-terrain vehicle

injuries• Child abuse

Mortality

• Less than 20% in isolated

• 20% in GI tract• 50% with major

vessels

Cantor RM, Leamin JM. Evaluation and management of pediatric major trauma. Emer Med Clin Noth Am 1998.

Anatomy

• Compact torsos• Smaller AP diameters• Large viscera• Less overlying fat• Weaker abdominal

musculature

Evaluation

• History information• Mechanism of injury• Physical examination

Moos RL, Musemeche CA. Clinical judgment is superior to diagnostic test in the management of pediatric small bowel injury. J pediatr Surg 1996.

Mechanism of injury

• Lateral motor vehicle collisions

• Seal belt usage• falls

Physical Exam

• Initial assessmento Airway compromiseo Respiratory mechanicso Hemorrhagic shocko Level of

consciousness• Secondary survey

o Head to toe examination

Abdomen

• NG tube: gastric decompression• Serial examinations• Signs

o Ecchymoseso Abrasionso Tire-trackso Seal-belt markso Abdominal distentiono Tendernesso Rigidityo Masseso Kehr’s signo Prolonged ileuso Blood on rectal examination

Associated injuries

• Rib fractureo 20 % splenic injuryo 10% hepatic injury

• Perineal laceration: pelvic fracture• Decreased rectal sphincter tone: spinal cord

injuryo Priapismo Hypotensiono Decreased strengtho Decreased sensation

Laboratory Evaluation

• CBC• Type and cross• UA• Transaminases• Amylase

Taylor GA et al. Hematuria. A marker of abdominal injury in children after blunt trauma. Ann Surg 1988

Laboratory Evaluation

• Prospective observational• Younger than 16 years• Level I trauma center in Sacramento, CA• 1095 patients• 107 intraabdominal injuries• Findings associated:

o Low systolic BPo Abdominal tendernesso Femur fractureo AST>200 or ALT>125o UA with >5 RBCo Initial hematocrit < 30%

Holmes et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002.

Radiologic Evaluation

• X Rayo Elevated hemi

diaphragmo Displaced gastric

bubbleo Free abdominal gas

Radiologic Evaluation: CT

• Sensitive and specifico Livero Spleeno Retroperitoneal injuries

• Less sensitiveo Pancreaso Intestinal tracto Bladdero Lumbar spine

Indications CT scan

• Injury suggestive of intraabdominal trauma

• AST>450 IU/L and ALT>250 IU/L• Hematuria• Declining hematocrit• Unaccountable fluid o blood requirements• Inability to perform adequate examination

Rothrock et al. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Pediatr Emerg Care 2000.

Radiologic Evaluation: US

• Detection of intraperitoneal fluid.o Bedsideo Rapido No adverse effectso Inaccurate to detect

hollow viscus injuryo Poor image quality in the

presence of bowel gas o fat

o Sonographer dependento Low sensitivity

Peritoneal lavage

• Less injury and organ-specific

• Cannot detect retroperitoneal injury

• Risks:o Introduction of air or

fluid into the abdomeno Peritoneal irritationo oversensitivity

Peritoneal lavage

• Positive:o More than 5 ml of gross bloodo Bile or stool obtainedo Extravasation of fluid from chest tube or

bladder cathetero Lavage fluid with >100,000 RBC or >500

WBC/mm3

Spleen

• Most common organ injured

• Hemorrhagic shock• Diffuse abdominal

tenderness• LUQ pain• Left shoulder pain

Spleen

• Delayed presentationo Left subcostal paino Left shoulder paino Jaundiceo Abdominal distentiono Rigidityo Reboundo Anemia

Splenic laceration classificationGRADE TYPE FINDINGS

I Hematoma Subcapsular, < 10% surface area

Laceration Capsular tear, < 1cm parenchymal depth

II Hematoma Subcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter

Laceration 1-3cm parenchymal depth; trabecular vessels not involved

III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm or expanding

Laceration >3cm parenchymal depth or involving trabecular vessels

IV Laceration Involves segmental or hilar vessels producing major devascularization (>25% of spleen)

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularizes spleen

Moore et al. Organ injury scaling: spleen and liver. J Trauma 1995

Grade I

HematomaSubcapsular,

< 10% surface area

LacerationCapsular tear,

< 1cm parenchymal depth

Grade II

HematomaSubcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter

Laceration1-3cm parenchymal depth;

trabecular vessels not involved

Grade III

HematomaSubcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm or expandingLaceration

>3cm parenchymal depth or involving trabecular vessels

Grade IVLacerationInvolves segmental or hilar vessels producing major devascularization

(>25% of spleen)

Grade V

LacerationCompletely shattered spleen

VascularHilar vascular injury that devascularizes spleen

Guidelines

• 856 children• 32 pediatric surgical centers• July 1995 to June 1997• Isolated grade IV: observation 1 day in

PICU and in hospital 5 days• Hospital stay for grade I-III: grade + 1

(day)• Activities restriction: grade + 2 (weeks)

Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Commite. J Pediatr Surg. 2000

Guidelines

• 312 children• 16 centers• 1998 to 2000• Reduction in ICU and hospital stay• Better patient management• Improved utilization of resources• Validation of guidelines

Evidence-based guidelines for children with isolated spleen or liver injury. Canadian AGS-EBRS. J Can Chir. December 2004

Liver

• Larger and less fibrous stroma, more susceptible to laceration and bleeding

• 2nd most common injured organ

• More severe than splenic injury

• Most common fatal abdominal injury

• Mortality 10-20%

Hemobilia

• Bleeding from hepatobiliary tract

• Classic triad:o Biliary colico Obstructive jaundiceo Occult or acute GI

bleeding• Diagnosis:

Cholangiography

Pancreas

• Less than 3%• Mechanism:

o Bicycle handlebarso Motor vehicle crasheso Child abuse

• Signs:o Vomitingo Abdominal pain radiated to

the backo Epigastric tendernesso Peritonitiso Hypovolemia

Pancreas

• Delayed presentation:o Pancreatic pseudocysto Epigastric paino Palpable abdominal

masso Hyperamylasemia

GI tract

• 1-15%• Mechanism:

o Motor vehicleo Bicycle relatedo Child abuse

Perforation

• Most common intestinal injury• Jejunum>ileum>duodenum• Bruising abdominal wall• Peritonitis• Abdominal X-Ray

o Free airo Scoliosis towards affected sideo ileus

• CTo Pneumoperitoneumo Free peritoneal fluid

Duodenal Hematoma

• 1-5 days after injury• Gastric distention• Abdominal pain• Anorexia• Bilious vomiting• Dehydration• Upper abdominal mass• X-Ray nonspecific• Abdominal US• CT

Seat belt syndrome

• Abdominal wall contusions

• GI tract perforation• Lumbar spine injuries• Abdominal aortic

injury• 5-9 years old• Serial exams

Management

• ABC• Vascular acces• Warm IV solutions• Bladder catheterization

o Gross hematuriao Blood in urethral meatuso Scrotal hematomao Perineal hematoma

Laparotomy

• Persistent o recurrent hemodynamic instability

• Penetrating abdominal wound• Pneumoperitoneum• Abdominal distention and hypotension