In this section
Significant abdominal injuries are relatively uncommon in childhood trauma. However, the signs can be difficult to interpret in a scared, traumatised child. A high index of suspicion is needed, based on the child's history, to identify these injuries.
Over the three-year period from July 1, 2000 to June 30, 2003, 271 abdominal injuries were recorded in 220 patients at the RCH. A breakdown of these admissions by injury cause is given in Fig 1, with a breakdown of type of injuries sustained presented in Table
Fig 1. RCH abdominal injury admissions by mechanism, 2000-2003 (n=220)
Table 1. Abdominal injuries by injury type
30% of patients with abdominal injuries had an injury to one or more other body regions.
Airway with c-spine stabilisation (see chapter 1.3) Breathing (see chapter 1.4) Circulation assessment and management (see chapter 1.5)
Perform a thorough back & front / head-to-toe examination for other injuries.
Patients at risk include those with:
The abdomen of the frightened child is very difficult to assess. The best clinical yield of information occurs in the presence of the child's carers, and when every effort is made to help calm and relax the child with adequate explanations, reassurance and
Lap belt bruising
PR or PV examination is rarely required, and simply
traumatises the child. Should only be considered if evidence of
trauma to the area.
Even where there is significant disruption of solid organs with haemodynamic insatiability conservative management is usually possible with adequate resuscitiation.
Conservative management implies close and continuous observation, and is not the easy option. It should only be undertaken only in an institution where rapid access to surgical intervention is available at all times.
The vast majority of solid organ injuries (i.e.
liver, spleen, pancreas & kidney) can be treated
Gastric dilation and NO gastric tube
Note the severe gastric dilation in this intubated patient, compromising the ventilation, who does not have an orogastric tube. Once the tube was passed the dilation resolved and the patient stabilized.
All patients undergoing CT scan should have an OG/NG tube
prior to the investigation
Acute gastric dilatation can occur with relatively minor
When in doubt, do not hesitate to place an orogastric/ nasogastric tube in cases of paediatric trauma. It should always be considered prior to transfer of the child with abdominal injury.
Acute gastric dilatation should also be considered in
the differential diagnosis
Where a child has abdominal pain and distension associated with signs of shock following abdominal or major trauma. Even when the abdominal trauma may not appear severe in nature.
Diagnostic peritoneal lavage (DPL) has no significant role in children
Late rupture. This is a risk, but there is no clear evidence of it being linked to insufficient bed rest, or to returning too early to unrestricted activity. The adult literature suggests that late rupture occurs in about 6% of patients.1 However, it is only
rarely reported in children.2,3,4 Healing of the spleen can be documented radiologically on ultrasound, and appears to correlate closely with the severity of rupture.3 Studies in Pittsburgh have shown that healing takes from 3 weeks in minor splenic injury,
to 20 weeks for a severely shattered spleen.3 However, it is not known whether this constitutes full physiological healing, or how it relates to late rupture.
Delayed rupture can still be treated conservatively, following the same protocol as the acute injury.
Loss of splenic function: Studies in adults demonstrate that approximately one-third of the spleen is needed for normal immunological function3 . Assess the percentage of spleen remaining on the initial CT scan, and repeat the splenic ultrasound. Look for Howell Jolly bodies on blood film. If
suspicious, immunise & start on oral Pen V.
At least 80% of blunt liver injuries can be treated conservatively
Liver injury treated conservatively
Investigations include a HIDA isotope scan, ERCP and repeat ultrasound scan. A continued bile leak may be treated conservatively with intraperitoneal drainage of the collection, and stenting of the common bile duct.3
With acute resuscitation and pain management.
Routine oral intake is withheld until resolution of symptoms and normalisation of amylase and lipase
Nasogastric drainage with possible NJ feeds or TPN may be required depending on severity.
Where there has been significant trauma a CT scan should be performed to assess the pancrease. Specifically transection of the pancreas should be looked for raising the possibility of duct transection.
If a duct injury is suspected a ERCP can be performed in an older child and possible stenting of the duct considered.
If distal duct has been transected and stenting is not possible then an early distal pancreatectomy should be considered. Conservative treatment can be undertaken but recovery from this injury is slow with associated morbidity.
Note: There is no indication for urgent
Symptoms include continued or worsening abdominal pain or increasing nausea and vomiting.
If there is concern then an amylase/lipase along with ultrasound scan should be performed.
Pseudocysts may be treated conservatively though some form of drainage procedure may be necessary if the cyst continues to enlarge.
Drainage usually involves a cystgastrostomy procedure which can be accomplished as an open, laproscopic or radiological procedure depending on expertise.
All these mechanisms of injury demand a high index of suspicion of intestinal injury.
Diagnosis is often delayed.
Plain X-ray or CT scan with presence of free air may suggest intestinal injury, but are not always reliable indicators. Regular clinical evaluation, including auscultation for
bowel sounds, associated with repeat x-rays, may be necessary to
make the diagnosis.
If there is injury to the mesentery and devascularisation of the associated bowel, associated perforation may appear only some days after the original injury.
Evidence of free intra-peritoneal gas is an indication
for urgent laparotomy.
Duodenal intramural haematoma can be seen on CT scan, and confirmed - if necessary - on upper GIT contrast study. It may also become apparent if there is ongoing obstruction post-trauma. This can be treated conservatively with nasogastric drainage, but may
take up to 3 weeks to resolve. TPN will be required over this time.
Retroperitoneal air seen as ground glass type appearance
All abdominal trauma patients should have urine analysis done.
Careful monitoring of urine output, with further investigation if microscopic haematuria is seen.
If the patient is relatively well, ultrasound is the simplest way to image the kidney.
However, CT scan with iv contrast is again the investigation of choice, and will give evidence of renal function.2 IVP is irrelevant if a CT scan has been done.
Right renal injury
Most sharp and blunt renal injuries can be treated conservatively.
Antibiotics should be given to patients with renal trauma, and then continued at a prophylactic dose until the injuries have healed.
On-going blood loss despite resuscitation.
The majority of explorations will lead to a nephrectomy.1
Continued haematuria secondary to an AV fistula.
Some of these injuries can be managed by selective radiological embolisation.
Patients with significant injury should be followed up with repeat ultrasound scan and DMSA scan, to assess renal function at 3 months.
Patients with persistent renal damage are at risk of hypertension, and should be followed up for at least 1 year.
Serious further injury can be caused by inappropriate
attempts at urethral catheterisation
9. External genitalia