The Child With Abdominal Injury

Question 1

What causes abdominal injuries in children?

Answer 1

ABDOMINAL INJURIES

CAUSES

• Blunt trauma - majority e.g.

1. Accidents on the road
2. Recreational activities
3. NAI - high index of suspicion

Question 2

Why are the abdominal contents in children susceptible to injury?

Answer 2

ABDOMINAL CONTENTS IN CHIDLREN ARE SUSCEPTIBLE TO INJURY

• Ribs elastic –> less protection
• Abdominal wall thin –> “
• Diaphragm more horizontal –> liver + spleen lower and more anterior
• Bladder intra-abdominal not pelvic –> more exposed when full

Question 3

What causes respiratory compromise and comlpicates the management of children with abdominal injury?

Answer 3

Diaphragmatic irritation

Splinting - reduced inspiratory effort as a result of pleuritic chest pain (on inspiration).

Question 4

Give examples of how the history of mechanism of abdominal injury can aid diagnosis.

Answer 4

MECHANISM OF ABDOMINAL INJURY

• Road Traffic Accident (RTA)
  
  • rapid deceleration
  • abdominal compression
  • sheering of fixed organs
  • solid organs and duodenum at risk
• Direct blows e.g. punching, NAI, bicycle handlebars
  
  • solid organs
• Handlebar injury
  
  • pancreas & duodenum
  • fixed position anterior to the spine
• Straddling injuries
  
  • Urethral injury
    
    • significant perineal haematoma
    • urethral bleeding

Question 5

Describe the assessment of the injured abdomen.

Answer 5

ABDOMINAL INJURY

<>ABCDEFG

• Examination
  
  • PRIMARY SURVEY
    
    • Consider intra-abdominal injury as the cause of blood loss when
      
      • shock not responding to fluid replacement
      • no obvious site of haemorrhage
    • Surgical or IR management
  • SECONDARY SURVEY
    
    • apart from haemorrhage - abdominal exam occurs in 2ndary survey
    • rectal/ vaginal examinations rarely required
    • LOOK - but remember that major injury can occur without obvious external signs
      
      • bruising - increases the likelihood of significant injury (have a high index of suspicion and repeat clinical exam frequently)
      • lacerations
      • penetrating wounds
      • external urethral meatus - blood
    • LISTEN
    • FEEL
      
      • tenderness
      • rigidity

Aids to assessment – by decompressing the abdomen:

• Gastric drainage
  
  • Gastric dilatation common in children
    
    • due to air swallowing during crying
    • If massive can
      
      • mimic intra-abdominal pathology
      • cause serious diaphragm splintage with resp compromise
  • NGT/ OGT - ASAP
    
    • OGT if base of skull # suspected
    • leave on free drainage
    • aspirate regularly
• Urinary catheterisation
  
  • ​ONLY if:
    
    • unable to pass spontaneously OR
    • accurate input/ output to achieve stabilisation after a serious physiological insult
  • Urethral or Suprapubic- depending on evidence of injury:
    
    • urethral e.g. blood at the external meatus
    • bladder
    • intra-abdominal
    • pelvic e.g. bruising in the scrotum/ perineum
    • Consider:
      
      • Exclude urethral damage before catheterising a boy
      • If there is doubt about catheterisation let the surgeon decide
      • Use the smallest silastic catheter possible to avoid stricture formation

Question 6

What blood tests should be done in abdominal injury?

Answer 6

BLOOD TESTS

ABDOMINAL INJURY

1. Baseline - FBC, U+E, LFTs
2. Amylase/ tryptase
3. Cross-match

Question 7

What is essential for children with abdominal injury who can be managed without surgical intervention?

Answer 7

• Monitoring - frequent
• Fluid management - precise
• Paediatric surgeon or IR immediately available

Question 8

What are the benefits of managing abdominal injury conservatively and avoiding laparotomy?

Answer 8

REDUCED

• Morbidity and mortality
• Risk of sepsis post splenectomy
• Use of blood products

Question 9

What are the indication for surgical intervention in abdominal injury?

Answer 9

INDICATIONS FOR SURGICAL INTERVENTION

ABDOMINAL INJURY

1. Haemorrhage
   
   • uncontrolled or significant despite resus
   • reduces the risk of death in trauma due to progression of
     
     • acidosis
     • hypothermia
     • coagulopathy
2. Penetrating injuries
3. Intestinal perforation

Question 10

What are the main causes of death in trauma?

Answer 10

1. Acidosis
2. Hypothermia
3. Coagulopathy

Question 11

What is the imaging modality of choice in abdominal injury?

Answer 11

IMAGING IN ABDOMINAL INJURY

• CT abdo + contrast
• Limited evidence for FAST