Paediatric Abdominal Trauma

1. Paediatric Abdominal Trauma LA Hodsdon Oct 09

2. Considerations Incidence Type Anatomical Considerations History & Examination Diagnostic Modalities Suggested Investigative Approaches

3. Incidence: Abdominal Trauma: 8-10% admissions to Paediatric Trauma Centres 3rd most frequent cause of death (?) MOST COMMON UNRECOGNIZED FATAL INJURY NAI – 5% admitted with Abdominal Trauma

4. 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%

5. Anatomical Considerations: Solid Organs: proportionally larger & more anterior Kidneys: larger, more mobile +/- foetal lobulations Subcutaneous Fat: ? Abdominal Musculature: ? AP Diameter: ? Flexible Cartilaginous Ribcage

6.  Increased Solid Organ Injury Both Blunt & Penetrating Injury GIT Trauma not uncommon Duodenal & Small Bowel haematomas & perforation Pancreatic injuries Mesenteric lacerations

7. 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

8.  Haemodynamically stable child - who is alert and co-operative - able to communicate effectively history and examination approach reliability rates of adults

9. 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

10. 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

11. 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

12. 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

13. 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%)

14. 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

15. 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.

16. 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

17. 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’

18. 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

19. 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

20. 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.

23. 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

27. 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

28.  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.

29. 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, 6th Ed; O.John Ma & Davis M Kline Oxford Handbook of Trauma for Southern Africa; A Nicol & E Steyn