Download Evaluation And Management Of Pediatric Abdominal Trauma

Evaluation And
Management Of Pediatric
Abdominal Trauma
March 2008
Volume 5, Number 3
Authors
Antonio Muñiz, MD, FACEP, FAAP, FAAEM
Associate Professor of Emergency Medicine and
Pediatrics, The University of Texas Medical School;
Medical Director of the Pediatric Emergency Medicine
Department, Children’s Memorial Hermann Hospital,
Houston, TX
A four-year-old female, who was a lap belt restrained, back-seat-passenger involved in a motor vehicle collision, presents with head pain and
right thigh pain. The car she was in hit the guardrail with a frontal
impact at 70 mph. The child lost consciousness momentarily. Initial
vital signs included a blood pressure of 100/62 mmHg, a heart rate of
136/minute, and a respiratory rate of 36/minute. The only abnormalities on examination included a left parietal contusion and deformity to
her right femur. A large-bore intravenous catheter was initiated and 20
mL/kg of 0.9% normal saline solution was administered as she was
transported to your emergency department. Your abdominal evaluation
revealed a seat-belt contusion with a soft and nontender abdomen.
What are the priorities in the initial evaluation and management of
this child? How do you evaluate the potential intra-abdominal
injuries?
Peer Reviewers
T
4. Recite the rationale for non-operative management
of children with blunt intra-abdominal injuries.
rauma is the leading cause of morbidity and mortality in children.1 Trauma stats include nearly 1.5 million injuries,
500,000 hospitalizations, 20,000 deaths, and over 120,000 permanently disabled victims annually.2 Blunt trauma accounts for
approximately 90% of all pediatric injuries, with falls and motor
vehicle collisions representing the most common mechanisms of
injury.3 Head and extremity injuries occur most frequently; however, injury to the abdomen can occur in up to 8% of children,
and abdominal injury is responsible for 9% of all trauma deaths.4
Significant abdominal trauma occurs in 25% of children
AAP Sponsor
Martin I. Herman, MD, FAAP,
FACEP
Professor of Pediatrics, UT
College of Medicine, Assistant
Director of Emergency
Services, Lebonheur Children’s
Medical Center, Memphis, TN
Editorial Board
Jeffrey R. Avner, MD, FAAP
Professor of Clinical Pediatrics,
Co-Director of Medical Student
Education in Pediatrics, Albert
Einstein College of Medicine;
Chief, Pediatric Emergency
Medicine, Children’s Hospital
at Montefiore, Bronx, NY
T. Kent Denmark, MD, FAAP,
FACEP
Residency Director, Pediatric
Emergency Medicine; Assistant
Professor of Emergency
Medicine and Pediatrics, Loma
Linda University Medical
Center and Children’s Hospital,
Loma Linda, CA
Michael J. Gerardi, MD, FAAP,
FACEP
Clinical Assistant Professor,
Medicine, University of
Medicine and Dentistry of New
Jersey; Director, Pediatric
Emergency Medicine,
Children’s Medical Center,
Atlantic Health System;
Department of Emergency
Medicine, Morristown Memorial
Hospital, Morristown, NJ
Ran D. Goldman, MD
Associate Professor,
Department of Pediatrics,
University of Toronto; Division
of Pediatric Emergency
Medicine and Clinical
Pharmacology and Toxicology,
The Hospital for Sick Children,
Toronto, ON
Mark A. Hostetler, MD, MPH
Associate Professor,
Department of Pediatrics;
Chief, Section of Emergency
Medicine; Medical Director,
Pediatric Emergency Department, The University of
Chicago, Pritzker School of
Medicine, Chicago, IL
Alson S. Inaba, MD, FAAP,
PALS-NF
Pediatric Emergency Medicine
Attending Physician, Kapiolani
Medical Center for Women &
Children; Associate Professor
of Pediatrics, University of
Hawaii John A. Burns School
of Medicine, Honolulu, HI;
Pediatric Advanced Life
Support National Faculty
Representative, American
Heart Association, Hawaii &
Pacific Island Region
Andy Jagoda, MD, FACEP
Vice-Chair of Academic Affairs,
Department of Emergency
Medicine; Residency Program
Director; Director, International
Studies Program, Mount Sinai
School of Medicine, New York,
NY
Tommy Y. Kim, MD, FAAP
Attending Physician, Pediatric
Emergency Department;
Assistant Professor of
Adam Vella, MD
Assistant Professor of Emergency Medicine, Pediatric
Emergency Medicine Fellowship Director, Mount Sinai
School of Medicine, New York, NY
Paula Whiteman MD, FACEP, FAAP
Medical Director, Pediatric Emergency Medicine,
Encino-Tarzana Regional Medical Center; Attending
Physician, Cedars-Sinai Medical Center, Los Angeles,
CA
CME Objectives
Upon completion of this article, you should be able to:
1. Cite the common mechanisms for blunt abdominal
trauma in children.
2. Interpret the laboratory evaluation of children
suspected of having intra-abdominal injuries.
3. Identify the different radiographic procedures utilized
in the diagnosis of intra-abdominal injuries in
children.
5. Identify specific solid organ and hollow viscus
injuries after blunt trauma in children.
Date of original release: March 1, 2008
Date of most recent review: February 10, 2008
Termination date: March 1, 2011
Time to complete activity: 4 hours
Medium: Print & online
Method of participation: Print or online answer form
and evaluation
Prior to beginning this activity, see “Physician CME
Information” on back page.
Emergency Medicine and
Pediatrics, Loma Linda Medical
Center and Children’s Hospital,
Loma Linda, CA
Brent R. King, MD, FACEP,
FAAP, FAAEM
Professor of Emergency
Medicine and Pediatrics;
Chairman, Department of
Emergency Medicine, The
University of Texas Houston
Medical School, Houston, TX
Robert Luten, MD
Professor, Pediatrics and
Emergency Medicine,
University of Florida,
Jacksonville, FL
Ghazala Q. Sharieff, MD, FAAP,
FACEP, FAAEM
Associate Clinical Professor,
Children’s Hospital and Health
Center/University of California,
San Diego; Director of
Pediatric Emergency Medicine,
California Emergency
Physicians, San Diego, CA
Gary R. Strange, MD, MA,
FACEP
Professor and Head,
Department of Emergency
Medicine, University of Illinois,
Chicago, IL
Adam Vella, MD, FAAP
Assistant Professor of
Emergency Medicine, Pediatric
EM Fellowship Director, Mount
Sinai School of Medicine, New
York
Michael Witt, MD, MPH, FACEP,
FAAP
Attending Physician, Division of
Emergency Medicine,
Children’s Hospital Boston;
Instructor of Pediatrics,
Harvard Medical School,
Boston, MA
Research Editor
Christopher Strother, MD
Fellow, Pediatric Emergency
Medicine, Mt. Sinai School of
Medicine; Chair, AAP Section
on Residents, New York, NY
Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education
(ACCME) through the joint sponsorship of Mount Sinai School of Medicine and Pediatric Emergency Medicine Practice. The Mount Sinai School of Medicine is accredited by the
ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Muñiz, Dr. Vella, and Dr. Whiteman report no significant financial interest or other
relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: Pediatric Emergency Medicine does not
accept any commercial support.
sustaining multisystem injuries. While head and
thoracic injuries are the most common cause of
trauma-related death, abdominal trauma is the leading cause of initially unrecognized fatal injury in
children.5 These injuries can be potentially lifethreatening; therefore, physicians who manage pediatric trauma must have a complete understanding
and systematic approach to the presentation, evaluation, and initial management of pediatric patients
with blunt abdominal trauma.
with some prospective evaluations, making inference from the literature difficult.
Anatomical Features
Unique anatomic features predispose children to a
variety of injuries, while particular mechanisms,
such as bicycle accidents, pedestrian trauma, nonaccidental trauma, and lap belt complex, lead to specific injuries that might be difficult to identify. Because of their body habitus and relatively immature
musculoskeletal system, children are at increased
risk of sustaining injuries to intra-abdominal organs
after blunt abdominal trauma. Compared with the
adult patient, the child’s intra-abdominal organs are
proportionally larger and are in relatively close
proximity to each other. The small size of a child
results in a greater degree of force per body surface
area, which can lead to significant injury to multiple
organs. Furthermore, there is little fat or connective
tissue to cushion organs and the abdominal wall is
less muscular, providing little protection to the
intra-abdominal contents. The pediatric kidney also
retains fetal lobulation, which might lead to easier
separation and fracture, while congenital anomalies
and tumors might predispose to renal injury.6 The
chest wall consists of an incompletely ossified rib
cage which is also higher and thus provides limited
protection to the liver, spleen, and kidneys. Abdominal distention following aerophagia from pain or
crying is common and is difficult to differentiate
from distention due to bleeding. The bladder is an
abdominal organ in young children making it easier
to be injured from blunt abdominal forces. Finally,
the increased ratio of body surface area to volume
results in an increased propensity toward
hypothermia.
Abbreviations Used In This Article
AAST: American Association Of Trauma
ALARA: As Low As Reasonably Achievable
ALT: Alanine Aminotransferase
APSA: American Pediatric Surgical Association
aPTT: Activated Partial Thromboplastin
AST: Aspartate Aminotransferase
CT: Computed Tomography
DL: Diagnostic Laparotomy
DPL: Diagnostic Peritoneal Lavage
ED: Emergency Department
EMS: Emergency Medical Service
ERCP: Endoscopic Retrograde
Cholangiopancreatography
FAST: Focused Abdominal Sonography For Trauma
GCS: Glasgow Coma Scale
GU: Genitourinary
HPF: High Power Field
ISS: Injury Severity Score
IV: Intravenous
IVP: Intravenous Pyelography
MRCP: Magnetic Resonance
Cholangiopancreatography
MRI: Magnetic Resonance Imaging
PT: Prothrombin Time
PTS: Pediatric Trauma Score
RBC: Red Blood Cells
RTS: Revised Trauma Score
WBC: White Blood Cell
Differential Diagnosis
Mechanisms
The mechanism of abdominal injuries in children is
most commonly caused by motor vehicle accidents
(32-66%), followed by pedestrians struck by a cars
(24-27%), falls (13-14%), and bicycle accidents
(12%).7,8 Other less common causes include sports
injuries or falls from animals. Intentional injuries,
including abuse and assaults, are less common but
important mechanisms of injury because of the
potential for severe trauma and high mortality.
A retrospective study using logistic regression in
793 children identified predictors of abdominal
injuries in children after blunt trauma.9 They found
that mechanism of injury, revised trauma score
(RTS) less than or equal to 12, abdominal tenderness, abdominal distention, absent bowel sounds,
fractured pelvis, gross hematuria, chest trauma, and
hematocrit less than 30% were all associated with
Critical Appraisal Of The Literature
During the last 40 years, interest and research in
nonoperative management of blunt abdominal
trauma in children with known solid-organ injuries
has evolved considerably. With the emergence of
the ultrasound for evaluation of suspected injuries,
different types of physicians, including surgeons,
radiologists, and emergency medicine physicians,
have been involved in studying the accuracy of this
instrument. Despite the data that has been
published, the computed tomography (CT) scan
remains the radiologic method-of-choice for most
physicians. Most of the literature regarding the
evaluation and management of pediatric blunt
trauma consists of retrospective reviews of patients
Pediatric Emergency Medicine Practice©
2
March 2008 • EBMedicine.net
abnormal CT scans. Another prospective study of
1095 children found that low blood pressure,
abdominal tenderness, femur fracture, hematocrit
less than 30%, alanine aminotransferase (ALT)
greater than 125 U/L and/or aspartate aminotransferase (AST) greater than 200 U/L, and urinalysis
with greater than 5 RBC/HPF (red blood cells per
high power field) were significantly associated with
abdominal injuries on CT scan.8
states, two-thirds of the children fatally injured in
motor vehicle accidents were reported to be unrestrained or improperly restrained.20
Lap Belt Injuries
Children with blunt abdominal trauma who also
have a “seat belt sign” (contusion to the torso
caused by the seat belt) have an increased incidence
of abdominal injury.21-23 The “seat belt syndrome”
was introduced in 1962 by Garrett and Braunstein24
to denote a distinctive pattern of injury resulting
from the use of lap belts in automobile collisions
(Figure 1). This syndrome describes injuries in the
plane of the lap belt and includes small and large
bowel and their mesentery, stomach, liver, spleen,
pancreas, kidneys, lumbar vertebrae (Chance fracture), spinal cord injuries, pelvic fractures, and rib
fractures.25,26 In one review, up to 78% of patients
with a seat belt contusion had intra-abdominal
injuries.27 Other studies have reported that 67-79%
had a hollow viscous injury, mostly in the jejunum
or ileum.25,28 Anatomic characteristics of children
further increase their risk for serious injury. The
small anteroposterior diameter of children’s abdominal cavity, the relative lack of protective abdominal
muscles, the underdeveloped pelvis and rib cage,
and the higher center of gravity make children
wearing lap belts especially vulnerable to injury in
the event of sudden deceleration. The lap belt type
of restraint is designed to be worn at or below the
level of the anterior superior iliac spines. The relatively underdeveloped pelvis in children allows the
lap belt to ride cephalad from the recommended
across-the-hips position to a higher location across
the abdominal cavity. When a rapid deceleration
force occurs, the lap belt rides above the iliac crests
and over the abdomen, which allows the child to
submarine forward under the lap belt concentrating
most of the force at the level of the upper lumbar
spine with intra-abdominal injuries involving a similar level. This results in hyperflexion of the upper
Motor Vehicle Accident
Blunt trauma from motor vehicle accidents is the
most common cause of abdominal trauma. The
majority of children with blunt abdominal trauma
caused by motor vehicle accidents have associated
nonabdominal injuries.
A detailed history of the motor vehicle accident
should be obtained after the initial resuscitation of
the patient is performed. Important questions
regarding any motor vehicle accident include: the
speed and direction of the vehicles, the location of
the occupants and whether ejection occurred,
whether other persons where injured, the location of
the impact in relation to the patient, and whether
the type and location of any restraint or deployment
of the air bag occurred.
Studies of adult occupants in motor vehicles
reveal that accidents involving lateral intrusion
more frequently cause trauma to the liver, kidney,
spleen, and lung, while head-on collisions more frequently injure the bowel, face, and extremities.10 It
is uncertain whether these injury patterns are applicable to children, as back-seat occupancy and the
presence of car seats are likely to substantially alter
injury patterns.
Restraint use by children involved in crashes has
proven effective in reducing both mortality rates
and the risk for significant injuries.11 Properly positioned lap belts, when worn with shoulder
harnesses, reduce craniofacial injuries, chest injuries,
solid organ injuries, and extremity fractures.12-15
Properly restrained children and infants also are less
frequently and less severely injured and have a
lower mortality rate than their unrestrained counterparts.16 Unrestrained children are more likely to
have head and neck injuries, as well as injuries to
the face, thorax, and extremities.17 However,
restrained children may be more predisposed to
abdominal injury. Children are especially vulnerable to blunt abdominal injury as incorrect belt positioning, increased head-to-body ratio, and a poorly
developed iliac crest all contribute to abdominal
injuries. A three-point restraint is more protective
than a two-point restraint but does not necessarily
preclude this injury.18 Child seats and booster
chairs have an even greater ability to reduce morbidity and mortality than the two-point lap belt.16,19
Despite public awareness and seat belt laws in all 50
EBMedicine.net • March 2008
Figure 1. Lap Belt Ecchymosis
Image courtesy of Dr. Antonio Muñiz.
3
Pediatric Emergency Medicine Practice©
lumbar spine and compression of abdominal
contents between seat belt and spine.29
begins to fall. Subsequently, the child strikes the
end of the handlebars, leading to injury. Direct
impact from the end of the handlebar is generally
underappreciated and typically results in isolated
but often severe injuries. The percentage of children
with abdominal or pelvic injury after bicycle-related
trauma, who sustained direct impact from a handlebar, may be as high as 78%.36 Injury occurs when
the handlebar acts like a spear and effects blunt
trauma to the abdomen. The severity of these
injuries may be quite significant. Direct-impact handlebar injuries to the liver, spleen, pancreas, duodenum, intestines, kidneys, urethra, and major vessels
have all been reported. Splenic injuries, soft-tissue
lacerations, pancreatic injuries, liver injuries, and
bowel perforation are the most common. Although
an abdominal wall contusion or abrasion may often
alert the clinician to the potential for significant
internal damage, the external signs of trauma to the
abdominal wall can be relatively unimpressive in
patients with direct handlebar injuries. Injuries to
the small bowel and pancreas may become clinically
manifest in a delayed manner and are thus associated with delayed hospital presentation and diagnosis. A series of 30 children with handlebar-related
injuries found that one-third were examined soon
after their accident and discharged before developing vomiting or peritonitis.37 The mean delay
before correct diagnosis of abdominal injury was 24
hours. The mean age of children with this mechanism is about 10 years of age, and males are generally more often affected. Children who sustained
direct-impact handlebar injuries are more likely to
require operative treatment when compared to children who flipped over the handlebars.37 The
reported incidence of operative intervention ranges
from 20-40%.38-40
Pedestrians Struck By Motor Vehicles
These injuries are the second most common cause of
abdominal trauma in children.4 Common injuries in
pedestrians struck by cars involve those to the
extremities and head, while 10% have abdominal
injuries.30 Mortality is generally related to the
degree of multisystem trauma, with 80% of deaths
resulting from head trauma.30 See the December
2007 Pediatric Emergency Medicine Practice issue, “An
Evidence-Based Approach To Severe Traumatic
Brain Injury In Children.”
Patient age is an important determinant of location and type of injury. Children less than five years
of age are more likely to be run over by a slow moving car in a driveway or parking lot, resulting in
crush injuries to the head and trunk.31 Children
older than five years are often injured crossing a
street, sustaining impact injuries. Waddel’s triad
describes these injuries; although the original
description was based on 10 adult patients—the
youngest being 21 years of age. The original
description was: “… three separate but related
injuries: injury about the knee produced by direct
impact and valgus strain, injuries to the hip or
pelvis, and craniocerebral injury.”32 This triad
occurs as children are hit from the left side by an
approaching car, causing left-sided abdominal
trauma injuring the spleen and left kidney, extremity trauma (such as a femur fracture), and closed
head injury as the child is thrown and the head
comes in contact with the pavement. Right-sided
abdominal injuries, such as liver injury, are more
common in countries where people drive on the left
side of the road. However, the predictive accuracy
of this injury pattern has come under suspicion.33
Two studies have shown that the Waddell triad only
occurred in less than 2.4% of children who
sustained injury after being struck by a car.33,34
All-Terrain Vehicle Injuries
All-terrain vehicles (ATVs) account for approximately 33,000 injuries annually and more than 200
deaths per year.41 Children account for up to 50% of
ATV-related injuries and 35% of ATV deaths. A
number of risk factors for injury include a younger
child age, male sex, rider inexperience, alcohol use,
excessive speed, and failure to wear a protective
helmet.42 These vehicles are large, heavy, and difficult for children to control. Rollover accidents, with
the vehicle often crushing the driver or passenger,
account for 40% of ATV injuries, followed by collisions and falls from the vehicle. Abdominal trauma
accounts for a quarter of all injuries and up to 19%
of deaths.43 The spectrum of injuries parallels that
of motor vehicle accidents with involvement of all
organs. Traumatic brain injuries, orthopedic
injuries, and facial fractures were the most common
injuries, while abdominal injuries occurred 4% of
the time.44,55
Bicycle Accidents
Accidents involving bicycles are responsible for a
significant proportion of trauma in children, resulting in an estimated 430,000 hospital visits and 275
deaths annually.35 Two types of mechanisms causing bicycle-related trauma may be seen. First are
high-speed mechanisms, in which the rider is
thrown from the bicycle or the bicycle collides with
a car or stationary object. These mechanisms are
often associated with severe multi-system trauma.
The second mechanism of injury occurs following a
relatively low speed crash, in which the bicycle handlebars strike the rider in the neck, abdomen, or
pelvic region. In the typical collision, the front
wheel rotates in a plane perpendicular to the child’s
body as the child loses control of the bicycle and
Pediatric Emergency Medicine Practice©
4
March 2008 • EBMedicine.net
maintained. In more recent reports, liver and spleen
injuries are the most common, followed by duodenojejunal rupture, duodenal rupture, and pancreatic,
vena cava, and renal trauma.50,52,59 These injuries
are thought to be due to compression of abdominal
viscera against the vertebral column following a
punch or kick.50 Associated non abdominal injuries
are common and include soft tissue injuries (95%),
head trauma (45%), extremity fractures (27%), and
skull fractures (18%).50
The most common presentation from abusive
abdominal injuries include shock, owing to massive
intra-abdominal hemorrhage, followed by peritonitis from hollow viscous rupture, and bilious vomiting, which is due to bowel wall hematomas and visceral trauma.50
Falls
Falls account for a small number of abdominal
injuries in children. Those who sustain injury from
falls are typically younger, usually less than two
years of age, and more frequently sustain head and
extremity injuries.31 Abdominal trauma is only
found in 3% of children admitted to the hospital for
falls, and the severity of trauma is generally less
than that caused by motor vehicle collisions.46,47 A
review of 45 children who fell 1-6 stories found that
only 2% sustained significant abdominal trauma.47
Sports-Related Injuries
The incidence of sports-related injuries is 0.73% of
sports participants.48 These injuries are most commonly associated with isolated organ injury, such as
a result of a blow to the abdomen. At particular risk
is the kidney, spleen, liver, and intestinal tract in
children involved in sports-related abdominal
injury.
Prehospital Care
It has been shown that the presence of prehospital
care providers with advanced life support training
lowers pediatric trauma deaths.60 In contrast, several studies have shown that paramedics often have
difficulty with procedural intervention in the field.
Successful pediatric intubation by paramedics varies
widely from 41% to 89%.61-63 In a prospective trial,
children less than 12 years of age requiring field airway management were randomized to endotracheal
versus bag-valve-mask ventilation.64 Survival and
neurological outcome were not affected by the type
of airway procedure used, although children undergoing endotracheal intubation had significantly
longer scene duration. Paramedics also have difficulty with venous access, with success rates less
than 50% in critically ill children who were less than
six years of age.65
Controversy has arisen regarding the administration of intravenous fluids to patients with uncontrolled hemorrhage.66 Several animal studies found
that administration of intravenous fluids prior to
controlling hemorrhage increased mortality.67,68
Postulated mechanisms include hydraulic acceleration of ongoing hemorrhage owing to elevated systemic blood pressure, disruption of thrombus at the
bleeding site, and dilution of clotting factors.66 Prehospital intravenous (IV) fluid administration in
hypotensive adults with penetrating torso trauma
injuries resulted in increased mortality despite
improved blood pressure, compared with victims
who did not receive prehospital IV fluids.69 Administration of fluids was only effective after bleeding
was controlled in the operating room. Despite these
findings, no studies have evaluated adults with
blunt trauma or children with any trauma to determine if prehospital fluid administration can be
detrimental. Until this is established, fluid administration remains an accepted standard component of
prehospital care.
Abusive Abdominal Injuries (Child Abuse)
Approximately 1 million children are victims of
abuse or neglect in the United States, with 1400
deaths annually.49 Only 1% of children hospitalized
because of child abuse sustain intra-abdominal
injury.50-52 Children with inflicted abdominal
injuries are younger than most trauma patients,
usually with a mean of 2-3 years of age, and have
more severe injuries.46 The mortality rate varies
from 45% to 50%, making abdominal trauma the
second most common form of fatal physical child
abuse.46,50,52,53 In abused children with abdominal
trauma, more than half of all involved families have
been reported to civil authorities for child abuse.50
A reason that inflicted abdominal trauma has
significant morbidity and mortality has to do with
the difficulty in achieving the diagnosis. Early diagnosis is problematic due to the inaccurate and misleading histories provided by the caregiver and the
frequent lack of external abdominal bruising, even
in cases of severe injuries.7,54,55 The young age of
the abused victim makes both the history and physical examination difficult. Another factor that may
contribute to increased mortality is the delay in
seeking medical care that occurs frequently after
inflicted abdominal trauma.50,55,56
Head injuries are the most common inflicted
injuries and most common cause of mortality.57 In
earlier studies, hollow viscous injury was the most
common intra-abdominal injury seen in abused children. In fact, when compared to accidental blunt
abdominal trauma patients, the rate of hollow organ
injuries was found to be almost three times higher
among abused children.58 Therefore, when a child
presents with a hollow viscous organ injury,
particularly when another solid organ injury is present, a high index of suspicion of abuse must be
EBMedicine.net • March 2008
5
Pediatric Emergency Medicine Practice©
The Pediatric Trauma Score (PTS) was developed
as a prehospital tool to rapidly determine the need
for children to be transported to a trauma center
(Table 1).67 Initial studies found that children with
a PTS less than 0 had 100% mortality, a PTS of 1-4
had 40% mortality, a PTS of 5-8 had 7% mortality,
and a PTS greater than 8 virtually no mortality following trauma.68,70 Based on these data, a PTS less
than or equal to 8 is the recommended threshold for
diverting children to a designated pediatric trauma
center. Another score, the Revised Trauma Score
(RTS) (Table 2) is as accurate as the PTS for determining injury severity, with improved ability to predict overall outcome, although the PTS is slightly
better at determining appropriate emergency
department (ED) and hospital disposition.71-73 Proponents of the RTS believe that this score is easier to
calculate and allows for a single score to be used at
all ages.71-73 An RTS less than 12 is the
recommended threshold for diverting a child to a
trauma center.71 While the RTS and the PTS can
stratify the risk of deterioration following trauma, it
is important to note that children with isolated
abdominal injuries may manifest initial vital sign
stability and relatively normal trauma scores. In
fact, 86% of children with isolated spleen or liver
injuries will have normal heart rates, 94% will have
normal systolic blood pressure, and most will have
a PTS above 10.74
Optimal care of pediatric trauma patients
requires that the responsible treating physician and
institution have specific expertise and resources.
Patient care is different among pediatric trauma centers and adult trauma centers.75 At pediatric trauma
centers it has been shown that treatment outcome
for children with blunt trauma is better and there is
a higher incidence of nonoperative management of
liver and spleen injuries.75-78 Therefore, children
with significant injuries should be transported to a
pediatric trauma center by the EMS system if one is
available.
Emergency Department Evaluation
Initial Evaluation And History
A favorable outcome for any pediatric trauma
depends upon rapid and accurate diagnosis with
prompt treatment of potential life-threatening
injuries. Evaluation and management of the injured
child should follow the paradigm of the Advanced
Trauma Life Support protocols with assessment of
airway, breathing, circulation, neurological status,
and complete exposure during the primary survey
with management of immediate life threats as soon
as they are identified. The first step consists of
assessment of airway patency and quality of breathing. Once the airway has been secured, evaluate the
quality of the circulation. The heart rate is the most
sensitive indicator of intravascular volume status in
infants and young children. It should be emphasized that hypovolemic shock is heralded by tachycardia long before hypotension is apparent. A child
with multiple injuries should undergo placement of
two large-bore intravenous catheters. If intravenous
access proves to be difficult, insertion of an intraosseous catheter can be life saving in any age group.
An intraosseous catheter can be used for fluid resuscitation and administration of medications.79 The
most common location is at least one finger breadth
below the tibial tuberosity to make certain the
physis is avoided. After the initial resuscitation has
been performed using an intraosseous catheter,
intravenous attempts are often successful.
Obtaining as much information as possible about
a child’s past medical history is always worthwhile
even in the abbreviated trauma history and examination. Medical conditions that affect a child’s neurological or developmental baseline are important to
obtain. A few examples that may make evaluation
more difficult include autism, cerebral palsy, or other
medical conditions that result in mental or physical
handicaps. Hemophilia patients or patients with
recent or concurrent Epstein-Barr virus infection
may have delayed splenic rupture and massive
bleeding from minor abdominal trauma.80
Fear and pain can complicate the management of
serious abdominal trauma in children. Children
tend to distend the stomach greatly with ingested
air and this can significantly decrease the diaphragmatic excursion by overdistention of the abdomen,
which can compromise respiratory efforts. Early
decompression via nasogastric or orogastric tube
insertion should therefore be considered. Children
in whom a stable pelvis has been established and
who are not at risk for urethral trauma should have
a Foley catheter inserted to decompress the bladder.
The clinician should then evaluate for the presence
of urinary retention and check for the presence of
blood in the urine.
Table 1. Pediatric Trauma Score
Patient features
+2
+1
-1
Size (kg)
Airway
Systolic BP
Mental status
Open wound
Extremity fracture
> 20
Patent
> 90
Awake
None
None
10-20
Maintainable
50-90
Obtunded
Minor
Close
< 10
Non maintainable
< 50
Comatose
Major
Open or multiple
Table 2. Revised Trauma Score.
Revised Trauma Glasgow
Score
Coma Scale
4
3
2
1
0
13-15
9-12
6-8
4-5
3
Systolic blood
Respiratory rate
pressure (mm Hg) (respirations/min)
> 89
76-89
50-75
1-49
0
Pediatric Emergency Medicine Practice©
10-29
> 29
6-9
1-5
0
6
March 2008 • EBMedicine.net
ED evaluation and management of blunt trauma
is guided primarily by the stability of the patient
and the presence of associated injuries. The blood
volume of a child is approximately 80 mL/kg. The
American College of Surgeons fluid resuscitation
guidelines recommend an initial bolus of 20 mL/kg
of warm isotonic fluids (0.9% normal saline or lactated Ringer’s) for the thermodynamically unstable
child. In addition, other life-threatening injuries
should be excluded. If the child remains hemodynamically unstable after 40 mL/kg of isotonic solution, administration of blood at 10-20 mL/kg should
be strongly considered, and a thorough evaluation
for the source of bleeding should be undertaken. It
is imperative that a pediatric surgeon or trauma surgeon be consulted at this point. If hypotension persists and intra-abdominal injury is suspected, additional blood and a laparotomy should be strongly
considered.
After completion of the primary survey, perform
a thorough secondary survey that consists of a
head-to-toe physical examination to identify all
traumatic injuries. Physical findings suggestive of
intra-abdominal injury include abrasions and contusions on the abdominal wall (seat belt sign), abdominal distention, and tenderness. Abdominal distention may be a sign of hemoperitoneum, but it can
also be the result of significant aerophagia leading
to massive gastric distention. Placement of a nasogastric or orogastric tube will decompress the stomach and reduce the risk of aspiration. Rectal examination is an important adjunct to the abdominal
examination, as is evaluation of the pelvis.
injury.86-90 Abdominal wall bruising has been associated with the use of suboptimal restraint, such as
the lap belt only restraint.91 Significant intraabdominal injury occurs in 6-16% of patients.86-90
Children with physical signs such as abrasions, contusions, pain and tenderness are more likely to have
abdominal injury.81,84,92
Laboratory Evaluation
Difficulties in the evaluation of the injured child and
the inherent risk for missed injuries and subsequent
morbidity have led to standardized management
protocols, including screening tests obtained during
resuscitation. Before CT was readily obtained,
“trauma panels” were performed as a means of predicting serious intra-abdominal pathology.82,93
Despite prior studies showing a limited use for
trauma panel, their use is still recommended but
controversial.82,83,94-97 The utility of the trauma panels, however, may be increased through use on
select subsets of injured patients. These panels may
include some or all of the following laboratory tests:
a complete blood cell count, serum chemistries, and
coagulation profiles along with organ-specific markers of injury such as liver function tests, amylase,
lipase, and urinalysis.
A retrospective review of the utility of a trauma
panel in children showed that no laboratory screen
was clinically significant for abdominal pathology.98
Elevated AST and ALT levels, in addition to microscopic hematuria and an abnormal physical examination, are associated with an intra-abdominal
injury.99 Elevation of glucose and white blood cell
(WBC) count may occur as a stress response to the
trauma and has no correlation with injury severity
or impact on patient management.100-102
Initial hemoglobin and hematocrit levels might
be normal in children with significant bleeding, as it
may take hours for body fluid spaces to equilibrate
and reflect the degree of hemorrhage. Serial hemoglobin and hematocrit levels are more useful tools
that reflect the presence of ongoing blood loss.
Coagulation studies, including platelet count,
prothrombin time (PT), and activated partial thromboplastin time (aPTT) are seldom useful acutely in
previously healthy children. A review of 830 pediatric blunt trauma victims found that during hospitalization, an elevated PT or aPTT developed in 37%
who were hypotensive, 18% with a PTS less than or
equal to 8, 17% with open or multiple fractures, 16%
with major open wounds, and 19% with a pediatric
Glasgow Coma Scale (GCS) score of less than or
equal to 13.103 Children who receive multiple units
of blood are also at risk for developing transfusionrelated coagulopathies. Patients with an isolated
intra-abdominal injury generally do not require
Physical Examination
Prompt and accurate assessment of injuries is necessary to optimize the outcome. However, children
sustaining blunt abdominal trauma pose a challenging dilemma because the initial abdominal examination is often unreliable and inaccurate, with a high
rate of missed abdominal injuries. The initial
abdominal examination may fail to show significant
abdominal pathology (up to 45%), and sequential
examinations are essential to exclude an evolving
abdominal problem.81 Studies have demonstrated
the difficulty in assessing abdominal tenderness on
physical examination of pediatric trauma
patients.8,9,81-84 In children with significant hemoperitoneum, 40% had no clinical abdominal signs.85
Delays in diagnosis can be fatal in some patients. In
addition, there are injuries that may develop symptoms very slowly, such as small gastrointestinal
perforations, pancreatic contusions, pseudocyst or
ductal injury, urinoma, obstructing duodenal hematoma, or hematobilia.
Bruising of the abdominal wall has been reported previously as an indicator of intra-abdominal
EBMedicine.net • March 2008
7
Pediatric Emergency Medicine Practice©
coagulation studies if one of the above factors does
not exist.
Electrolyte abnormalities are uncommon in acute
trauma. A multicenter prospective study of 715
children with electrolyte panels obtained in the ED
found that 1 of 42 children with trauma requiring
blood or fluid resuscitation in the ED had an electrolyte abnormality.104 However, in children with
shock caused by acute blood loss, metabolic acidosis
and an elevated serum lactate level are expected.105
Base deficit is a useful marker for the presence of
abdominal injury requiring surgery. A study of 3223
patients, mainly adults, with blunt abdominal
trauma found that patients with a normal base
deficit (-2 to 2) had a 4% probability of abdominal
injury requiring surgery.106 The probability of
abdominal trauma requiring surgery rose to 9% for
a mild base deficit (-3 to -5), to 28% for a moderate
base deficit (-6 to -14), and to 31% for a severe base
deficit (less than -15). Other electrolyte abnormalities that occur primarily following massive transfusions include hyperkalemia, metabolic alkalosis,
hyperphosphatemia, and hypocalcemia.
Hematuria is an important marker of serious
renal and non-renal trauma in children.107 In one
study, the most commonly injured organ in children
with hematuria was not the kidney (26%), but the
spleen (37%) and liver (33%).107 A study of 378 children evaluated after blunt abdominal trauma found
that splenic injury was present in 11% and liver
injury in 10% of patients with hematuria, while
renal injury occurred in only 8% of children with
hematuria.107 Renal trauma was found in 22% of
those with gross hematuria, splenic injury in 17%,
and liver injury in 8%. While the degree of hematuria correlated with a higher risk of abdominal
injury, all children with hematuria and organ injury
had other indications for CT, such as abdominal
pain or abnormal abdominal examination. Hematuria can indicate trauma at any location within the
genitourinary system. Conversely, hematuria might
be absent in up to 50% patients with renal pedicle
injuries.108 Blood in the urine may also come from
the placement of a Foley catheter. A study of 285
consecutive children with minimal to moderate
injury found that the abdominal examination combined with urinalysis detected 98% of all intraabdominal injuries.82
Children with hepatic transaminase abnormalities were more likely to have liver injury than children presenting with normal levels.102,109 Only
transaminases in excess of 400 IU/L, however, were
predictive of liver injury identifiable with abdominal imaging. Of note, in each child presenting with
a transaminase level in excess of 400 IU/L,
abdominal imaging was deemed necessary because
of either injury mechanism or physical examination
findings, such as decreased level of consciousness,
Pediatric Emergency Medicine Practice©
abdominal tenderness, or shock, and was not influenced by these laboratory results. Another study
showed that a serum AST greater than 400 IU/L
and/or ALT greater than 250 IU/L predicted hepatic
injuries.109,110 In addition, the degree of elevation of
hepatic transaminases does not correlate with the
degree of injury or outcome.110 Since CT is recommended to identify and grade suspected liver
injuries, liver function tests are generally not
required in managing liver injuries. Their main use
might be to identify unsuspected injuries in children
who do not undergo CT.
Elevated serum amylase and lipase may suggest
pancreatic injury. However, serum values alone are
not reliable as screening studies for pancreatic
injury in the pediatric trauma population. Elevation
of serum amylase has some correlation with injury
to the pancreas in children. Some studies have
noted elevated serum amylase levels in children
with pancreatic injury, yet others do not.111-115 These
tests have poor sensitivity in detecting pancreatic
injury, with elevations reported in only 25-77% of
CT or laparoscopic proven cases.113,116,117 Sensitivity
might be increased if repeated values are obtained,
especially in those with increasing abdominal
pain.111,113 The magnitude of serum amylase elevation, however, does not predict the severity of injury
to the pancreas.113 Serum amylase levels may be
normal even in cases of major injury to the pancreatic duct.118 Serum amylase levels do not alter the
management of patients with abdominal trauma in
several large series and were felt to be of limited
value in predicting pancreatic trauma.81,119 Amylase
and lipase also are poor at discriminating between
pancreatic and non-pancreatic trauma. In one study,
45 patients (53%) had an elevation of one of these
tests and only one (1%) had a pancreatic injury.
Furthermore, several studies have shown that
severe head injury in the absence of pancreatic
injury may result in hyperamylasemia in the early
post-injury period.120 Therefore, inclusion of amylase and lipase values as a part of a trauma screening panel results in a significant number of elevated
values that do not correlate with abdominal
injury.121
In addition to the laboratory evaluation early in
the resuscitation process, any multiply injured child
should have blood drawn and sent for cross-match.
Diagnostic Studies
Liberal use of diagnostic imaging has become an
integral part of the initial assessment of pediatric
blunt abdominal trauma because both the clinical
assessment and laboratory evaluation are considered unreliable.105 Many diagnostic methods currently exist, such as abdominal radiographs, abdominal ultrasonography, CT, diagnostic peritoneal
8
March 2008 • EBMedicine.net
lavage (DPL), and diagnostic laparoscopy (DL), for
the evaluation of abdominal injuries in traumatized
children. In spite of these technologies, it is still
often difficult to evaluate the presence of intraabdominal injuries in children.
in this physically active patient population. The
view of many experts is that injuries with no
intraperitoneal fluid require the same treatment as
injuries associated with fluid. Therefore, a screening test should identify both types of injury. At this
point, FAST may have a role as a screening tool, but
it is not a replacement for CT scan or visualization
with laparoscopy, if indicated. However, rather
than a tool for definitive diagnosis, ultrasound still
retains its function as an effective triage tool to
detect significant intra-abdominal injury requiring
immediate attention.
While ultrasound is fast, inexpensive, noninvasive, portable, easily repeated, fairly accurate at
identifying children requiring laparotomy, and does
not require contrast or radiation exposure, the role
of the FAST examination in the pediatric population
is less well-defined.131,132 FAST can be performed
during the primary survey of trauma resuscitation
and could provide timely information regarding the
presence of intraperitoneal fluid. Theoretically, children are ideal candidates for ultrasound examination. Their abdominal cavities are small and not
clouded by the large fat deposits so often seen in
adults. Some studies have supported the routine
use of ultrasound in evaluating the abdomen of
pediatric blunt trauma patients, but others question
the use of ultrasonography in this setting.129,133,134
The sensitivity of ultrasound for pediatric trauma
patients has been a point of criticism. The documented sensitivity rates range from 55% to 100%
and specificities range from 83% to 98%; it has a
positive predictive value of 86-91% and a negative
predictive value of 50-99% in detecting intraabdominal injuries.134-143 One limitation common to
many of these studies reporting high sensitivities,
however, is that patients frequently did not have
more definitive abdominal evaluations beyond
ultrasonography.139,140,144,145 It is, therefore, possible
that patients with negative ultrasound findings
without further definitive abdominal evaluations
Plain Abdominal Radiographs
Plain abdominal radiographs are primarily useful in
penetrating trauma to detect pneumoperitoneum
and foreign bodies. Their use in blunt trauma is less
useful since they are normal in greater than 95% of
cases and only serve to delay evaluation and management of these patients.122
Focused Abdominal Sonography For Trauma
(FAST)
The use of ultrasound for abdominal trauma was
described initially by Kristensen and colleagues in
1971.123 The term Focused Assessment with Sonography for Trauma (FAST) was coined by Rozycki et
al in 1996.124 Examination of Morrison’s pouch (the
potential space between Gerota’s fascia of the kidney and Glisson’s capsule covering the liver), the
pouch of Douglas (retrovesical pouch), the left flank
to include the perisplenic anatomy (splenorenal
recess), and the subxiphoid view to visualize the
pericardium, is the standard four-view focused
abdominal sonography for trauma examination.
Others have included a six-view examination, which
adds visualization of the right and left paracolic
gutters.
In detecting intra-abdominal injuries in trauma
patients, the governing paradigm has always been
to quickly recognize those patients who require
laparotomy and to prevent further morbidity and
mortality. In the child with multiple injuries who is
hemodynamically unstable, one must quickly determine whether an intra-abdominal injury is an important source of bleeding. Historically, DPL had
been used to determine the presence of hemoperitoneum in such children.125,126 However, a FAST
examination quickly performed in the ED might be
more efficient and less prone to complications (Figure 2). The bedside examination may be useful as a
rapid screening study, particularly in patients too
unstable to undergo an abdominal CT scan.127,128
FAST is poor at identifying organ-specific injury and
may under-diagnose intra-abdominal injuries,
which is a serious limitation in the context of nonoperative management of abdominal injuries.129,130
Because most intra-abdominal injuries in children
can be managed non-operatively, the mere presence
of free fluid alone in the peritoneal cavity is not
enough to warrant operative exploration. In addition, accurate assessment of injuries is critical if nonoperative management is to be used. Unrecognized
injuries could have potentially serious consequences
EBMedicine.net • March 2008
Figure 2. A Positive FAST Examination
Showing Free Fluid In The Pelvis
Image courtesy of Dr. Antonio Muñiz.
9
Pediatric Emergency Medicine Practice©
had unidentified intra-abdominal injury. This may
have falsely elevated the sensitivity of ultrasound
scan in these studies. However, the injuries that are
missed are generally grade I or II solid organ
injuries that usually require no treatment. Although
ultrasound may have a limited sensitivity, it has
proven to be very specific in the detection of intraperitoneal fluid.134,136,139,145,146 Because the negative
predictive value of sonography for free fluid is too
low for routine screening and the lack of free fluid
on sonography does not negate serious organ injury,
sonography is not reliable as a screening tool in the
evaluation of hemodynamically stable children with
blunt abdominal trauma.
The use of ultrasound appears to be accurate in
those children who present to the ED with hypotension because it identified intraperitoneal fluid in all
patients with hypotension and hemoperitoneum in
a retrospective review.147 Most important, none of
the patients with hypotension and negative abdominal ultrasound findings had hemoperitoneum or an
intra-abdominal injury that required emergent therapy. In these cases, ultrasound scan likely provided
crucial information for further management of the
hypotensive child.
A consensus paradigm for ultrasound use can be
included in hemodynamically unstable patients. A
positive FAST examination may increase the chance
of the need for a therapeutic laparotomy; a negative
FAST examination warrants examination for an
extra-abdominal source of hemorrhage.138,148 In
hemodynamically stable patients, a positive FAST
examination should be followed by an abdominal
CT scan to better define the injury, and a negative
FAST examination should be followed with serial
examinations for six hours and a follow-up
ultrasound or abdominal CT scan, depending on the
clinical scenario.149 However, variations in this
practice are commonplace since there is no validation of this paradigm. For example, given a significant mechanism of injury and a negative FAST
examination, a stable patient may still undergo CT
scanning.150 An unconscious patient with severe
head injury requiring operative intervention who
has a negative FAST examination may also still
undergo CT scanning to provide preoperative clearance. Suffice it to say that stable patients with a
negative FAST examination are a more ambiguous
population. Patients can have significant intraabdominal injuries without free fluid or they may
have delayed fluid accumulation, especially if the
examination is performed shortly after the injury.
Up to 45% of pediatric abdominal injuries have no
identifiable free fluid on CT.139,140,142 In one study of
hepatic injuries, CT scans showed 25% had no free
fluid, and the majority were grade I or II injuries.150
Yet the detection of solid organ injuries has therapeutic implications, such as the need for
Pediatric Emergency Medicine Practice©
hospitalization, duration of bed rest, resumption of
activity, and need for follow-up.
False-positive FAST results can occur when the
examination shows a small amount of retrovesical
fluid. This fluid can be either physiologic in pubertal girls after ovulation or due to incorrect interpretation of the sonogram. In one series, a small
amount of pelvic fluid was noted in 31% of children
with blunt abdominal trauma, and organ injury was
detected in only 3.5% of these children.151 However,
in the presence of peritoneal fluid outside the pelvic
cavity, an organ injury was detected in 92.3% of the
cases.
Computed Tomography (CT) Scanning
In recent years, abdominal CT scanning has
emerged as the diagnostic modality of choice for the
evaluation of pediatric abdominal trauma. The purpose in imaging injured children is not to look for
fluid, but to look for a specific organ injury, and CT
is decidedly better in this regard than the FAST
examination.131 Specifying the lesion could provide
information about prognosis, risk stratification, and
length of stay. On the other hand, CT is not without
drawbacks. Sedation, gastric tubes, lack of portability, and contrast material may create problems.
Deterioration of the patient during the study is a
real consideration. Despite these limitations, 86% of
pediatric surgeons in the U.S. prefer the CT scan as
their modality of choice in assessing abdominal
injuries.152 It is considered the gold standard in
assessing the extent and severity of intra-abdominal
injuries in children.153 It is noninvasive and an
accurate method for identifying and qualifying the
extent of abdominal injury and has reduced the incidence of nontherapeutic exploratory laparotomy.
Solid organ injury is clearly defined by CT
scanning154 (Figure 3). Unfortunately, bowel injury
is often difficult to diagnose by CT scan. Extravasation of oral contrast or free intraperitoneal air is
diagnostic for injury to a hollow viscous.155 Bowel
wall thickening, multiple fluid-filled loops of bowel,
and free fluid in the pelvis without solid organ
injury are suggestive of, but not pathognomonic for,
intestinal injury.155 Extraluminal air has been found
in only 47% of children with gastrointestinal perforation following trauma.156 Others have confirmed
that extraluminal air is present in only a minority of
children with gastrointestinal perforation, with completely normal CT findings in up to 25% of cases.157159 The diagnosis of intestinal injuries requires a
combination of strong clinical suspicion, serial physical examinations, and careful evaluation of CT scan
results.
CT is even less accurate in diagnosing pancreatic
trauma, with normal scans in 33-53% of patients
with laparoscopically proven pancreatic
10
March 2008 • EBMedicine.net
Interestingly, water has been shown to be just as
effective, less expensive, and more quickly administered than contrast in pediatric trauma patients
undergoing CT scanning.177 Water also offers
another advantage since aspiration of contrast can
lead to chemical pneumonitis.
Disadvantages of the use of CT scan include
moving the patient to the radiology suite, requiring
expensive equipment, use of ionizing radiation, use
of contrast and potential allergic reaction or subsequent renal dysfunction, use of sedation in children,
and results are dependent on the experience of the
interpreter.
An increased risk of cancer, estimated at 1 per
1000 CT examinations, has been reported in the
pediatric population exposed to low-dose radiation
during CT examination.178 It has been estimated
that 600,000 pediatric CT scans are performed each
year, and 500 of these children will die secondary to
cancer attributed to CT radiation.179 To minimize
radiation exposure, it is suggested that hospitals
implement the “as low as reasonably achievable”
(ALARA) concept.180 This consists of limiting the
number of CT examinations obtained routinely and
making size-based adjustments of the radiation
exposure scanning parameters. A trauma patient
may receive multiple scans on admission followed
by repeat scanning to evaluate progression of the
trauma during their hospitalization. This can lead
to a rapid accumulation of doses, placing these children at increased risk for such cancers.179 Unfortunately, approximately 67-73% of CT scans of the
abdomen in children were found to be normal.180,181
Figure 3. CT Scan Showing A Grade III
Splenic Laceration
Image courtesy of Dr. Antonio Muñiz.
trauma.111,160,161 The most common CT finding in
pancreatic trauma is nonspecific and includes intraperitoneal, lesser sac, peripancreatic, and retroperitoneal fluid.161 Less common findings include thickened Gerota’s fascia, mesenteric fluid or hematoma,
fluid separating the pancreas from the superior
mesenteric vein or duodenum, and fluid surrounding the superior mesenteric and periportal
veins.111,160,161 Mesenteric, bladder, and diaphragmatic trauma are other injuries that might present
with normal CT findings.158,162,163
Indications for abdominopelvic CT scanning
after blunt abdominal trauma are shown in Table
3.164-166
Use of intravenous contrast is essential to provide optimal vascular and parenchymal enhancement. The practice of administering oral contrast
material to pediatric patients undergoing abdominal
CT for blunt trauma is controversial.167 The administration of an oral contrast agent is generally
accepted as useful in the CT evaluation of abdominal trauma. Proponents of oral contrast use argue
that oral contrast is safe, and opacification of the
bowel may help to identify bowel and pancreatic
injuries.168,169 The use of oral contrast increases
scanning times, increases the number of potentially
unnecessary nasogastric tube, may lead to vomiting
of contrast, and can cause aspiration of contrast
with development of pneumonitis.170-174 Moreover,
contrast reaches the small and large bowel in less
than half the cases and may not help identify intestinal perforation, mesenteric injury, and pancreatic
injuries. Furthermore, pediatric trauma centers that
have omitted oral contrast report similar rates of
detecting perforations and other abdominal injuries
compared to centers that use oral contrast.175,176 In
addition, due to the lack of a large prospective randomized study with a definitive finding that oral
contrast agents are not useful for CT of pediatric
blunt abdominal trauma, most institutions continue
to administer oral contrast to these patients.
EBMedicine.net • March 2008
Diagnostic Peritoneal Lavage (DPL)
DPL is a technique that involves the insertion of a
catheter under direct visualization into the peritoneal cavity. Aspiration of blood indicates a positive tap; if no blood is detected, saline is infused
Table 3. Indications For Abdominopelvic CT
After Blunt Abdominal Trauma
• Suspected blunt intra-abdominal injury based on injury pattern.
• Significant initial fluid resuscitation requirement without obvious blood loss.
• Multisystem trauma, such as severe pelvic, thoracic, or cranial
injury.
• Inability to perform adequate abdominal examination, such as
altered mental status, suspected head injury, or alcohol or drug
intoxication.
• Hemoglobin less than 10 g/dL without obvious blood loss.
• Positive screening laboratory tests (elevated AST or ALT).
• Spinal cord injury.
• Ecchymosis on the abdominal wall (lap belt or handle bar
injuries).
• Hematuria greater than 50 RBC/HPF or associated with additional signs and symptoms of intra-abdominal injury.
• Child abuse suspected.
• Slowly declining hematocrit or requirement for persistent fluid
resuscitation.
• Require general anesthesia for other injuries.
11
Pediatric Emergency Medicine Practice©
through the catheter at a volume of 10 mL/kg. The
effluent is allowed to drain passively and is then
sent for cell count and chemistries. A positive DPL
is shown in Table 4.
DPL is rarely used in the pediatric population.
This procedure will identify abnormalities in more
than 98% of patients with intra-abdominal injury,
and in fact, DPL is more sensitive than CT and US at
identifying abdominal injury.182,183 DPL can provide
useful information in children with injuries that are
often undetectable with CT, such as bowel, pancreatic, and mesenteric trauma. However, DPL will be
falsely positive in a significant number of children
with blunt trauma, leading to an unnecessary
laparotomy rate of 42-63%.184,185
The limitations of DPL, besides its invasive
nature, are similar to those of a FAST examination.
A positive DPL for blood simply indicates the presence of hemoperitoneum, with no information
regarding the source of the bleeding. Since many
solid-organ injuries may be successfully managed
non-operatively in children, the mere presence of
blood in the abdomen is not an indication for operation in the hemodynamically stable child. Because
of these drawbacks, several pediatric centers rarely
use this procedure. In addition, there are complications inherent to the procedure, such as bladder or
bowel perforation or mesenteric or iliac vessel perforation. It also does not provide information about
the specific organ injured, does not identify
retroperitoneal injury, and introduces fluid and air
into the abdominal cavity, potentially altering future
abdominal examination and diagnostic tests.182
DPL may be utilized to exclude abdominal
trauma in children requiring immediate surgical
intervention for life-threatening cranial and thoracic
injuries when no time exists to perform an abdominal CT scan or when a FAST examination is not
available. DPL should be considered in injured
children who require ongoing blood products when
CT or US are unavailable.
stable patient with blunt abdominal trauma who
either has a suspicious physical examination and
laboratory evaluation with developing peritonitis or
declining hematocrit.194 It has been considered by
some as the gold standard for the evaluation of hollow viscous injury.194
Drawbacks may include the inability to completely assess the small bowel and to evacuate hemorrhage.195 This procedure is not without risks.
These risks include a 20% morbidity rate, 0-5% mortality, and a 3% long-term risk for bowel obstruction.196 Therefore, most pediatric trauma centers
will still use less invasive tests, such as CT or ultrasound, for most initial evaluations of abdominal
injuries.
Intravenous Pyelography (IVP)
IVP is primarily reserved for a few select situations.
It can be used preoperatively in unstable children
selected for laparotomy to identify major renovascular injuries.197 It might be indicated in children suspected of only having renal contusion and not
deemed at risk for abdominal injury. Renal imaging
is indicated if greater than or equal to 50 RBC/HPF
or gross hematuria is present or there is persistence
or worsening of lesser degree of hematuria. Even in
this group, CT scan is more accurate at identifying
renal lesions.
Treatment
Since the beginning of modern surgery, splenectomy
had been the procedure of choice for splenic injury.
To do otherwise was believed to invite disaster as
the spleen could not heal on its own and there was a
tendency to rupture in a delayed fashion.198 In
1952, the immunologic dangers of removing the
spleen were demonstrated, although this did not
alter management.199 It was not until 1973, when
data on incidence and mortality from sepsis from
splenectomy became available, that the ramifications of this practice became evident.200 Indeed,
overwhelming sepsis occurs in children who have
undergone splenectomy at more than 85 times the
rate of the normal population and may result in a
50% mortality rate.201 This new information led to
the revolutionary concept of splenic preservation
after splenic injury and has become the priority in
children after blunt abdominal trauma.202 This
approach is particularly important in children who
face a lifelong risk of overwhelming post-splenectomy infections of 3-5%.203
In 1968, successful nonoperative treatment of
select children presumed to have splenic injury was
first demonstrated.202 By the 1980s, nonoperative
management became the treatment of choice for
pediatric blunt splenic trauma.204-206 Simultaneously, the expanding introduction and use of CT
Diagnostic Laparoscopy (DL)
DL has been shown to be both diagnostic and therapeutic in the setting of abdominal trauma.186,187
However, there is a paucity of data on the role of
laparoscopy in pediatric abdominal trauma. The
literature is restricted to mainly case reports.188-193
Indications for DL may include a hemodynamically
Table 4. Criteria For Positive Diagnostic
Peritoneal Lavage
•
•
•
•
Greater than 100,000 red blood cells/mL.
Greater than 500 white blood cells/mL.
Gram-satin with bacteria present.
Presence of feces, vegetable fibers, bile, alkaline phosphatase
( greater than 6 IU/L), or amylase ( greater than 175 IU/L).
Pediatric Emergency Medicine Practice©
12
March 2008 • EBMedicine.net
Clinical Pathway For Management Of Pediatric Blunt Abdominal Trauma
Initial Assessment
• Airway
• Breathing
• Circulation
• Disability
• Exposure
Vital signs stable
YES
NO
Abdominal Examination
• Non tender
• No distracting injuries
• GCS score 15 or normal for age
20 mL/kg crystalloids
Vital signs stable?
YES
NO
YES
Serial examinations
FAST
CT scan
NO
CT scan
20 mL/kg crystalloids
Vital signs stable?
NO
YES
10-20 mL/kg packed red blood cells (PRBCs)
Pediatric or trauma surgery consult
Vital signs stable?
YES
NO
Exploratory laparotomy
More packed red blood cells (PRBCs)
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a
patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2008 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of
EB Practice, LLC.
EBMedicine.net • March 2008
13
Pediatric Emergency Medicine Practice©
scanning opened up a new avenue for diagnosis
and observation of splenic injuries, providing additional confidence in the nonoperative management
of solid organ injury. It was not a great leap, therefore, for pediatric surgeons to apply the approach to
another commonly injured pediatric organ, the liver,
as well as the kidney and pancreas.207
Nonoperative management has been shown to
be safe, with success rates by pediatric surgeons of
89-99%.208-210 There has, however, been a disparity
in non-pediatric trauma or non trauma centers to
reach the same results as those encountered in pediatric trauma centers.211 The Trauma Committee of
the American Pediatric Surgical Association (APSA)
developed evidence-based guidelines for the nonoperative management of hemodynamically stable
children with blunt splenic or liver injury.208 Their
recommendations were based on analysis of patient
data collected from 32 pediatric surgical groups,
nonrandomized trials, historical controls from the
literature, expert clinical experience, and a consensus conference. But non-pediatric trauma or non
trauma hospitals fail to achieve nonoperative success rates commensurate with that of pediatric
trauma centers for blunt splenic injuries.211,212 Management of children by non-pediatric surgeons or in
non-pediatric trauma centers is known to have a
negative effect on transfusion rates, length of stay,
and mortality of pediatric patients who undergo a
laparotomy.213-215 The aggregate conclusions of
these authors were that training, experience, and
available resources, such as intensivists, blood banking, and a pediatric intensive care unit, were the
measures of differences between pediatric surgeons
and adult surgeons caring for pediatric patients.
Therefore, to be successful in the nonoperative management of pediatric abdominal blunt organ injury
requires the following:
• Frequent examinations.
• Close monitoring of vital signs.
• Frequent laboratory tests (done with microvalve technique).
• Close monitoring by nursing personnel experienced in the pediatric intensive care unit
(PICU).
overall 5% nonoperative management failure rate in
solid organ injuries, including spleen, liver, kidney,
and pancreas.217 Multivariate analysis logistic
regression analysis controlling of Injury Severity
Scores (ISSs) and Glasgow Coma Scales scores
(GCSs) found five variables associated with a significantly increased risk for failure of nonoperative
management; these included:
• Bicycle-related injury mechanism.
• Isolated pancreatic injury.
• One solid organ injury.
• Summary Abbreviated Injury Scale (sAIS)
greater than or equal to 4.
• Isolated grade 5 injury.
Other factors that predict the likelihood of failure of nonoperative management of solid organ
injury include the degree of hemoperitoneum noted
on physical examination or radiographic studies,
the hemodynamic response to fluid therapy, or the
finding of contrast blush on CT scans.150,218-220
Angioembolization has been shown to diminish
nonoperative management failure rate in blunt
splenic and hepatic injuries.221-223 However, there
may be an increase in complications, including
bleeding, bile duct injuries, abdominal compartment
syndrome, and abscesses.224,225 The ideal candidate
for angioembolization is the patient with active
solid organ bleeding who is hemodynamically
stable.221
Analgesics should be considered in children
with significant pain. Trauma patients and
especially children receive less analgesia than do
adults.226,227 Many excuses have been used as reasons to not give analgesics to pediatric trauma
patients. One is the belief that localized pain assists
in diagnosis and that the masking of the patient’s
symptoms may lead to a delay in diagnosis. Others
fear the potential harmful side effects from opioid
analgesics, including respiratory depression, hypotension, and altered level of consciousness. Pain
control may also not be a priority among trauma
medical personnel.228,229 The surgical literature is
full of studies that demonstrate that analgesics do
not significantly alter the abdominal examination.230,231 While these studies are mostly concerned
with non traumatic causes of abdominal pain, they
still have some validity in the trauma patient.
If a small bowel perforation is suspected, the
child should receive appropriate antibiotics (Table
5). A pediatric surgeon should be consulted for
definitive repair of their injury.
The decision to operate in pediatric patients is
based not on the anatomy or radiographic grade of
the injury, but on the physiologic response to the
injury and the evolution of the physiological
response to resuscitation. Indications to operate
after blunt abdominal trauma are shown in Table 6.
Laparoscopic exploration and repair of traumatic
If these requirements are followed, there should
be an increase in nonoperative management of
children who are admitted to non-pediatric trauma
centers with better outcomes, lower complication
rates, and lower transfusion rates.215 There must
also be a wider dissemination of the APSA guidelines for management of the pediatric trauma victim
to these non-pediatric trauma hospitals.216 This is
especially important since most children with
splenic injuries are treated in non-pediatric trauma
centers.209
Nonoperative management of injury to solid
organs is not without complications. There is an
Pediatric Emergency Medicine Practice©
14
March 2008 • EBMedicine.net
abdominal injuries offers many conceptual advantages over the traditional trauma laparotomy in
carefully selected patients and is becoming more
popular in children.232 A minimally invasive
approach to the traumatized patient maintains the
intestines within the peritoneal cavity, preventing
tissue desiccation and minimizing fluid and temperature shifts that may result in ileus and may adversely affect the postoperative course.233,234 Theoretically, patients who have a laparoscopic approach
to the repair of bowel injuries may have less pain,
more rapid return of intestinal function, earlier hospital discharge, reduced total health care costs, and
an earlier return to out-of-hospital activities.232,235,236
Furthermore, a minimally invasive procedure may
allow for quicker recovery after an exploration with
negative findings. Finally, inspection of the abdominal contents with magnification during laparoscopy
may aid in the detection of subtle injuries.
typically results from a direct blow to the left upper
quadrant. The most common mechanism is motor
vehicle collisions, but other mechanisms include
pedestrians hit by cars, falls, bicycle accidents,
assaults, sports-related injuries, blows to abdomen,
and motorcycle accidents. Diseases that increase the
size of the spleen, such as infectious mononucleosis,
lymphoproliferative disorders, or systemic lupus
erythematosus, predispose patients to rupture, even
with minor trauma.
A number of patients will complain of left shoulder pain at the time of presentation. This phenomenon is known as Kehr’s sign (referred pain to the
left shoulder) and is the result of diaphragmatic irritation by blood released from the ruptured spleen.
Findings that suggest splenic trauma on physical
examination include left upper-quadrant abrasions,
tenderness, and abdominal distention. Because of
the elasticity of the chest wall, rib fractures are
uncommon in children with splenic trauma. Findings such as marked tachycardia, weak pulses,
decreased capillary refill, or pallor suggest significant blood loss and incipient hemorrhagic or hypovolemic shock.
Chest radiographs are usually normal but may
have findings suggestive of splenic injury, such as
lower left rib fractures, elevation of the left hemidiaphragm, pleural effusion, or a medially displaced
gastric bubble. Stable children with suspected
splenic injury should undergo an abdominopelvic
CT scan. CT can accurately determine the degree of
splenic injury, associated intra-abdominal organ
injury, and the amount of free fluid in the abdomen
(hemoperitoneum). The American Association of
Trauma (AAST) adopted a classification of splenic
injuries based on a CT scan grade system
(Table 7).237
In the literature, the incidence of the “blush
sign” in blunt abdominal trauma varies between
less than 1% in early series to more that 30% in
more recent series.220,238-242 The radiologic “blush
sign” is the result of an active pooling of contrast
material within or around the injured organ. It is
seen during an intravenous contrast-enhanced CT
scan and is indicative of active bleeding from the
injured organ.241,243-245 This radiologic finding has
been described for various intra-abdominal organ
injuries, including the spleen, liver, kidney, adrenal,
and mesentery.245-247 In adult patients, the “blush
sign” could predict the failure of nonoperative management and warrants early embolization or
surgery.218,220,213,248,249 In children, management
decisions are based on the physiologic response to
the injury rather than the radiologic features of the
injury, calling into question the significance of a
“blush sign” in this population.242,250,251 However
worrisome the presence of a blush sign is, most
pediatric patients can still be treated successfully
Specific Circumstances
Splenic Injuries
The spleen is the most frequently injured intraabdominal organ in children. Injury to the spleen
Table 5. Antibiotics And Dosages For
Suspected Small Bowel Perforation
Antibiotics
Doses
Cefotaxime
150-200 mg/kg/day divided 3-4 times/day
(maximum 2 g/dose)
Pipercillin/tazobactam
300-400 mg/kg/day divided 3-4 times/day
(maximum 3.375 g/dose)
150-300 mg/kg/day divided 3-4 times per
day for infants less than 6 months
Ampicillin/sulbactam
200-400 mg/day divided 4-6 times/day
(maximum 3 g/dose)
Ticarcillin/clavulanate
200-300 mg/kg/day divided 4-6 times/day
(maximum 3.1 g/dose)
Table 6. Indications After Blunt Abdominal
Trauma For An Exploratory Laparotomy In
Children
• Children with hemodynamic instability despite aggressive
resuscitation or blood product transfusion requirement total
greater than 50% total blood volume (40 mL/kg) over the first
24 hours during the hospital course.
• Grade IV and V renovascular injury.
• Hollow visceral bowel injuries (pneumoperitoneum).
• Evisceration of abdominal contents.
• Rectal or vaginal lacerations.
• Peritoneal irritation on examination.
• Intraperitoneal bladder rupture.
• Large extraperitoneal bladder rupture associated with pelvic
fractures.
• Major pancreatic duct injury or pancreatic injury unresponsive
to conservative treatment (fistula, pseudocyst, or persistent
duodenal obstruction).
• Evidence of fecal or bowel contamination on DPL.
EBMedicine.net • March 2008
15
Pediatric Emergency Medicine Practice©
pediatric population is preservation of splenic
immune function and avoidance of overwhelming
post-splenectomy infection. The estimated incidence of overwhelming postsplenectomy infection
is 0.23-0.42% per year, with a lifetime risk of 3.25%.201,203 The mortality associated with overwhelming postsplenectomy infection ranges from 38% to
69%. Streptococcus pneumoniae is the most frequent
causative agent of overwhelming postsplenectomy
infection. Vaccination against encapsulated bacteria,
including S. pneumonia, Haemophilus influenzae type
b, and Neisseria meningitides, is recommended after
splenectomy or nonoperative management of a
severely damaged spleen.
The APSA’s Trauma Committee has developed a
series of evidence-based guidelines for the management of isolated splenic and hepatic injuries.
According to these guidelines, children can return to
their normal activities after a period consisting of
the grade of injury plus two weeks. Late complications of splenic injuries, while rare, can include
pseudoaneurysm formation, delayed rupture,
pseudocyst formation, wound infection, or intestinal
obstruction from adhesions.258,259
without operation.239,252 The role of angiographic
embolization in pediatric spleen injuries has yet to
be determined but may become useful in the hemodynamically stable child with active splenic
bleeding.221,253
Once the extent of injury has been defined, management depends upon the child’s hemodynamic
status and the presence of associated injuries. Children with hemodynamic instability, despite aggressive resuscitation, after blunt abdominal trauma
should be taken to the operating room for exploratory laparotomy after completion of the primary
and secondary surveys. Splenectomy is more likely
in children with splenic injury after motor vehicle or
bicycle accidents or who have an ISS greater than
15, a GCS score less than or equal to 8, or who have
a grade IV and/or V injury.254,255 Older children
and those presenting with hypotension or tachycardia also had an increase in splenectomy rate. Children with associated injuries, such as head, thorax,
non splenic, pelvic or extremity injuries, were more
likely to undergo splenectomy. At the time of exploration, attempts should be made to preserve the
spleen. Splenorrhaphy and partial splenectomy are
two techniques used to control bleeding while preserving splenic parenchyma. In the critically ill
child, or in the case of a completely shattered
spleen, splenectomy may be required. Laparoscopic
splenectomy with either the anterior or posterior
approach has been shown to be safe in children.256,257 Nonoperative management of isolated
splenic injuries has become the standard of care in
pediatric trauma centers and is successful in 90-95%
of cases. The ultimate goal of nonoperative or operative management of blunt splenic trauma in the
Liver Injury
The liver is the second most commonly injured
intra-abdominal organ. Liver injuries are generally
more severe than splenic injuries, are more likely to
re-bleed on a delayed basis, and are the most common lethal abdominal injury in blunt abdominal
trauma from hemorrhage.4 The right lobe is injured
slightly more frequently than the left, probably
because of its size. The dual blood supply of the
liver and its close proximity to the inferior vena
cava predisposes it to severe hemorrhage after blunt
trauma to the abdomen.
Mechanisms of injury include motor vehicle
crashes, pedestrians struck by motor vehicles, falls,
assaults, bicycle injuries, and child abuse.260,261
Trauma to the liver may result in subscapular or
intrahepatic hematoma, contusion, vascular injury,
or biliary disruption. The spleen is the most common associated injury, followed by the kidney.
Children who sustain injury to the liver occasionally complain of right shoulder pain (Kehr’s
sign). The majority exhibit right upper abdominal
or right lower chest pain and tenderness and have
associated injures, a reflection of the mechanism of
injury.
Elevated transaminases are highly suggestive of
a liver injury. The chest radiograph is often normal
but may show indirect signs of liver injury, such as
right lower rib fracture, elevation of right hemidiaphragm, and right pleural effusion. The mainstay
of diagnosis in the hemodynamically stable child is
CT scan. It can provide useful information
Table 7. Grades Of Splenic Injuries
Grade
Extent of Splenic Injury
1
Hematoma: subscapular, non expanding, < 10% of
surface area
Laceration: capsular tear, non bleeding, < 1 cm of
parenchymal depth
2
Hematoma: subscapular, non expanding, 10-50% of
surface area; intraparenchymal, non expanding, < 2 cm
in diameter
Laceration: capsular tear, active bleeding, 1-3 cm of
parenchymal depth that does not involve a trabecular
vessel
3
Hematoma: subscapular, > 50% of surface area or
expanding, ruptured subscapular hematoma with active
bleeding, intraparenchymal hematoma, > 2 cm or
expanding
Laceration: > 3 cm of parenchymal depth or involving
trabecular vessels
4
Hematoma: ruptured intraparenchymal hematoma with
active bleeding
Laceration: laceration involving segmental or hilar vessel
producing major devascularization (> 25% of spleen)
5
Hematoma: completely shattered spleen
Laceration: hilar vascular injury that devascularizes spleen
Pediatric Emergency Medicine Practice©
16
March 2008 • EBMedicine.net
regarding the severity of injury, associated injuries,
and the amount of free fluid (hemoperitoneum).
The AAST adopted a classification of liver injuries
based in a CT scan grade system; this is shown in
Table 8. 237 This classification has not correlated
with outcome. ISS and the presence of associated
injuries are the factors that correlate with outcome
in children with liver injuries.262
Management of liver injuries is usually nonoperative with careful repetitive physical examinations.
About 20 years ago, most liver injuries were treated
with surgical repair and approximately 70% spontaneously stopped bleeding with no intervention;
therefore, a selective nonoperative approach was
adopted.263 Today, the selective, nonoperative management of blunt liver trauma in hemodynamically
stable patients is well established and accepted in
most pediatric trauma centers, and nonoperative
management can be successful in 85-90% of hepatic
injuries.260-267 Indications for nonoperative management are the same as for splenic injuries: hemodynamic stability and absence of peritoneal signs.
Complications of nonoperative management may
include biliomas, risk of delayed bleeding, and
abscess formation.268 Most of these complications
will be amenable to nonoperative treatment such as
endoscopic retrograde cholangiopancreatography
(ERCP) or percutaneous drainage.269 Compared
with children who sustain splenic injuries, a greater
number of children with hepatic injuries will require
blood transfusion or operative intervention. However, in the setting of hemodynamic instability and
transfusion requirements of greater than 25-40
mL/kg/day, most would agree that surgical intervention is necessary.270 For patients who meet these
transfusion requirements but who maintain hemodynamic stability, selective hepatic arterial embolization may be considered.271 Children who sustain
higher grades of liver injury are more likely to
require exploratory laparotomy.272 Other risk factors for surgery include lower PTS owing to multisystem trauma, transfusion required within two
hours of presentation, and associated retrohepatic
vena cava or major hepatic vein trauma.269 Tamponade of the bleeding with laparotomy pads, temporary abdominal closure, and a planned second look
procedure is preferred over major hepatic resection.
Once the child has been stabilized and the coagulopathy and hypothermia have been corrected, the
child is returned to the operating room for re-exploration and removal of packing. Complications from
surgery may include abscess formation, pancreatic
fistula, hematemesis from hemobilia, biliary
obstruction, bilioma, stress gastric ulceration, sympathetic pleural effusion, abdominal compartment
syndrome, delayed bleeding, wound infection, and
bowel obstruction from adhesions.261,273
Similar to the guidelines for splenic trauma, children who sustain an isolated hepatic injury are
restricted from contact sports and strenuous physical activity for a period consisting of the grade of
injury plus two weeks.
Pancreatic Injury
Injuries to the pancreas occur in 1.7-12% of children
sustaining blunt abdominal trauma.111,118,161,274,275
Major pancreatic ductal injury is rare.113,275-277 Diagnosis of pancreatic injuries is difficult because of its
retroperitoneal location and is based on clinical,
radiographic, and laboratory data. About twothirds of children with traumatic pancreatitis are
diagnosed within the first 24 hours.146 Pancreatic
injury frequently is underestimated or missed initially.111-113,278 Delay in diagnosis is associated with
increased morbidity and mortality rates.275,276
The mechanism of injury most commonly
involves compression of the pancreas against the
rigid spinal column or by discrete intrusion forces.
Young children with flatter diaphragms, thinner
abdominal walls, and higher costal margins sustain
pancreatic injuries from blows to the abdomen,
which are less likely to cause pancreatic injury in
adults. Mechanisms of pancreatic injuries have
included motor vehicle crashes, cars striking pedestrians, bicycle crashes, direct blows to abdomen
from objects, bicycle injuries, falls, sports-related
injuries, and child abuse.111,121 Associated injuries
occur in 25-68% of children with pancreatic injuries
and include liver, spleen, kidney, stomach, and
small bowel.113,275,277 Non abdominal injuries
involve the head, chest, and extremities.
Clinical examination and a history suggestive of
Table 8. Grades Of Splenic Injuries
Grade
Extent of Liver Injury
1
Hematoma: subscapular, non expanding, < 10% of
surface area
Laceration: capsular tear, non bleeding, with < 1 cm deep
parenchymal disruption
2
Hematoma: subscapular, non expanding, hematoma
10-50%, intraparenchymal non expanding, < 2 cm in
diameter
Laceration: < 3 cm of parenchymal depth, < 10 cm in
length
3
Hematoma: subscapular, > 50% of surface area or
expanding, ruptured subscapular hematoma with active
bleeding, intraparenchymal hematoma > 2 cm
Laceration: > 3 cm of parenchymal depth
4
Hematoma: ruptured central intraparenchymal hematoma
Laceration: parenchymal disruption involving 25-75% of
the hepatic lobe
5
Hematoma: parenchymal disruption > 75% of
hepatic lobe
Vascular: juxta-hepatic venous injury (retrohepatic
cava/major hepatic veins)
6
Vascular: hepatic avulsion
EBMedicine.net • March 2008
17
Pediatric Emergency Medicine Practice©
trauma to the upper abdomen can increase suspicion of injury to the pancreas and help direct diagnostic studies. Although children with pancreatic
and other internal organ injuries may present with
obvious abdominal tenderness, those with isolated
pancreatic injury may experience a delay of hours or
even days before the onset of abdominal symptoms.
Although the post-traumatic symptoms of abdominal pain, nausea, vomiting, and fever are nonspecific, they should heighten the level of suspicion for
pancreatic injury in the setting of blunt abdominal
trauma. A slowly enlarging abdominal mass may
occur after the development of a pseudocyst.
Elevations of amylase greater than 200 IU/L and
lipase of greater than 1800 IU/L correlate with a
major pancreatic injury. However, serum values
alone are not reliable as screening studies for pancreatic injury in the pediatric trauma population.
Abdominal radiographs are usually normal but
may show sentinel loops of dilated intestines over
the area of the pancreas. CT scans identified traumatic injury to the pancreas with a sensitivity of
85%.278 Findings on CT scan indicative of acute
pancreatic injury include a visualized transection,
thickening of the gland with accompanying edema,
peri-pancreatic fluid collections, or ductal dilatation.
CT scan, on occasion, may miss major pancreatic
injuries, especially pancreatic ductal injuries.111,113,279
A grading system has been described to grade the
severity of pancreatic injuries (Table 9).275 Other
radiographic studies, such as ERCP and magnetic
resonance cholangiopancreatography (MRCP), have
been shown to be effective in the diagnosis of injury
to the pancreas, especially ductal injuries, but are
costly and not readily adaptable in the acute trauma
setting.111,280-283
The management of pancreatic injuries continues
to be controversial. Management strategies for pancreatic injuries largely have been determined by
injury severity, injury location, and the presence or
absence of associated abdominal injures. While
some authors advocate aggressive nonoperative
management for most pancreatic injuries
irrespective of grade, others recommend a lower
threshold for operation relative to standard management protocols for other solid organ injuries.111,283,284
Pancreatic injuries do not behave as other solid
organ injuries and have been shown to have a nine
fold increase in need for operative management.286
It may well be that the pancreas should not be
included as a standard solid organ in nonoperative
management protocols. However, pancreatic
injuries without a major ductal injury usually
resolve with nonoperative management using bowel
rest and parenteral nutrition, with a low prevalence
of subsequent pseudocyst formation.285
Early operative therapy is warranted for the
treatment of a distal transection of the pancreas.
The spleen-preserving distal pancreatectomy is
associated with lower rates of complications and
shorter hospitalization than nonoperative management.287,274 Treatment of major ductal injuries
involving the head of the pancreas is controversial.
The adult literature describes early radical interventions such as pancreaticoduodenectomy, pancreaticojejunostomy, onlay Roux-en-Y loop to cover damaged tissue, pyloric exclusion, and duodenal
diverticulization; however, they are associated with
significant morbidity.288-290 There is no clear recommendation in pediatric patients. Many use nonoperative management of these injuries and later
drainage of any pseudocyst that develops.113 However, this plan of management usually involves prolonged hospitalization with bowel rest and hyperalimentation, waiting for the pseudocyst to develop
over four to six weeks.118 Delayed diagnosis of pancreatic duct injury may also result in other complications such as recurrent pancreatitis, fistula, or
abscess.280 Others will perform ERCP with stent
placement.118,291 ERCP is a very accurate technique
for determining the location and type of duct disruption, and it allows appropriate therapeutic intervention with endoscopic placement of stents.292
ERCP can be indicated in children if the results of
enhanced CT show low attenuation in the pancreatic parenchyma and heterogeneous staining of the
pancreas.293,294 The advantages of therapeutic ERCP
for ductal injury are the avoidance of a major
abdominal operation with potential risk to the
spleen, elimination of the waiting period for
pseudocyst development from continuing pancreatitis, shortened hospital stay, and faster return to normal activity.295,296
Pseudocyst formation is the main complication
of nonoperative management of pancreatic injuries.
Therefore, repeat imaging by CT, ultrasonography,
or ERCP should be obtained if a pancreatic injury is
found. A pseudocyst is a loculated collection of
pancreatic juice from a ductal injury. Occasionally,
small pseudocysts will resolve with bowel rest and
parenteral nutrition. Octreotide (somatostatin) has
been used to accelerate resolution of traumatic
pseudocysts in children.297,298 Large cysts that have
been present for 4-6 weeks will likely require
drainage. The standard for management of posttraumatic pancreatic pseudocyst is internal drainage, either into the stomach or duodenum via a
Table 9. Classification Of Pancreatic Injuries
Classes
Description
Class I
Contusion or laceration without duct injury
Class II
Distal transaction or parenchymal injury with probable
duct injury
Class III
Proximal transaction or parenchymal injury with
probable duct injury
Class IV
Combined pancreatic and duodenal injury
Pediatric Emergency Medicine Practice©
18
March 2008 • EBMedicine.net
Roux-en-Y limb into the intestine. Percutaneous
and endoscopic drainage procedures have also been
successful but may have higher failure rates.299
Another complication is the development of acute
pancreatitis.276
the extent, associated injuries, and the amount of
retroperitoneal contamination. Relatively small,
fresh injuries can be effectively treated with simple
closure of the perforation and drainage. More complicated injuries, particularly if they involve a large
segment of the duodenal wall or pancreas, may
require pyloric exclusion and creation of a gastrojejunostomy to allow for adequate healing. Other
newer techniques may include duodenal decompression by a lateral duodenostomy tube, placement
of a retrograde jejunostomy tube, or pyloric exclusion and proximal tube decompression without gastrojejunostomy.301,302 Mortality from duodenal perforations, particularly if there is a delay in diagnosis
of greater than 24 hours, is significant. Mortality in
the 1970s was approximately 25%, which has been
decreased to 19% with the use of pyloric exclusion
with gastrojejunostomy.303,304 Complications of surgery may include fistula formation, anastomosis
leak, and infection.
Duodenal hematomas are the result of blunt
force trauma to the epigastrium. In addition to
abdominal pain and tenderness, children with this
type of injury often present with bilious emesis, the
result of obstruction of the duodenal lumen by the
hematoma. The diagnosis can be made by CT scanning, upper gastrointestinal contrast studies (which
show the “coiled-spring” sign), or by ultrasound.
Most duodenal hematomas can be successfully
managed non operatively with nasogastric decompression and parenteral nutrition. Most resolve by
10 days but may take up to three weeks. If the
hematoma has not resolved after three weeks of
bowel rest, operative evacuation of the hematoma is
indicated.
Duodenal Injuries
Injuries of the duodenum are rare. They present in
two forms: perforation and hematoma. The duodenum has an increased vascular blood supply, resulting in larger amounts of blood loss when traumatized. The force disrupts the vessels between
submucosa and muscularis, causing development of
an intramural hematoma that can almost obstruct
the duodenal lumen. Similar to other intestinal
injuries, duodenal perforations can be difficult to
diagnose. Mechanisms of injuries include motor
vehicle accidents, bicycle accidents, contact-sport
injuries, falls onto blunt objects, and child abuse.300
Symptoms at the time of presentation include
abdominal pain, nausea, vomiting, hematemesis,
and abdominal distention. If the perforation is into
the retroperitoneum, peritoneal irritation will not be
obvious upon presentation and free air may not be
seen on radiographs, resulting in diagnostic delay.
Associated injuries may include injury to the pancreas, spleen, or liver, hollow viscous injury, rib fractures, and thoracic vertebral fractures. A high output in the nasogastric tube is suggestive of a
duodenal injury.
Elevation of serum transaminases, amylase, and
lipase may be seen. CT scanning is diagnostic in
only 60% of cases of duodenal perforation. CT scanning can be used to determine the extent of injury
(Table 10).300 Persistent abdominal pain or development of peritonitis in a child with signs of upper
abdominal trauma, especially in the face of CT findings of free fluid without evidence of solid-organ
injury, necessitates abdominal exploration. Operative management of these injuries is dependent on
Small Intestine Injury
The small intestine is injured much less frequently
than either the spleen or liver and only 2-5% of children with blunt abdominal trauma will have intestinal injury.305,306 However, in restrained occupants
of motor vehicle collisions with sufficient force to
produce visible abdominal wall ecchymosis and
vertebral column fracture, the incidence of intestinal
injury may exceed 50%.307-309 The jejunum is the
most commonly injured segment of the bowel, followed by the duodenum and the ileum. However,
intestinal injuries can often pose a diagnostic
dilemma, resulting in a delay in diagnosis. Injuries
occur because of direct blows over a fixed point,
such as the ligament of Treitz or ileocecal valve, or
from a sudden deceleration resulting in a shearing
force at the mesenteric attachment. In the latter,
trauma may cause only local injury to the small
bowel or its mesenteric supply. This may result in
either a very small perforation or delayed perforation owing to necrosis.310 Blunt trauma to the
Table 10. Grading System For Duodenal
Injuries
Grade
Extent of Duodenal Injury
1
Hematoma involving single portion of wall
Laceration: partial thickness, no perforation
2
Hematoma involving more than 1 portion
Laceration: < 50% circumference disruption
3
Laceration: disruption of 50-75% circumference of
second portion
Disruption of 50-100% circumference of first, third, or
fourth portions
4
Laceration: disruption of > 75% circumference of second
portion
Involvement of ampulla or distal common duct
5
Laceration: massive disruption of duodenopancreatic
complex
Duodenal devascularization
EBMedicine.net • March 2008
19
Pediatric Emergency Medicine Practice©
abdomen results in transmission of shearing forces
to the small bowel causing injury. The most typical
injury is a seromuscular tear where the submucosa
is torn from the inner circular muscular layer.311
This can result in mesenteric bleeding and can
progress to delayed perforation when the underlying submucosa and mucosa subsequently lose viability. Other injuries that can occur include closed
loop perforation, complete transaction of the bowel,
or crushing of the bowel against the spine.311-313
Mechanisms for small bowel injury include motor
vehicle crashes, lap-belt injuries, struck pedestrians,
bicycle accidents, blunt object impacts, motor cycle
accidents, sports-related injuries, falls, and child
abuse.314 Up to 14-51% of patients with hollow viscous organ injury will have associated intra-abdominal solid organ injury.312,315 Other associated extraabdominal injuries include head injuries, extremity
fractures, fracture pelvis, and pneumothorax.316
Small bowel injuries are difficult to diagnose.
Serial examination in the non-head-injured pediatric
patient has been shown to be accurate in the diagnosis of hollow viscous injury.317,318 Peritoneal signs
are initially present in only 30-38% of patients with
bowel injury.305,319 The neutral pH, low bacterial
concentration, and low enzymatic activity of the
small bowel contents cause minimal inflammatory
reaction, resulting in few clinical signs at early
stages after blunt abdominal trauma. In addition,
functional closure of small perforations by bowel
spasm and/or omentum also leads to delay in diagnosis. Free air may not be seen for several hours or
more, and sometimes never in the course. Associated head and spinal cord injury or other distracting
injuries, such as long bone fractures, are other factors making physical examination difficult and misleading.305,315,320,321 Although initial physical examination findings are often mild, all children with
hollow viscous injury will develop progressive features suggesting bowel injury, such as peritonitis,
fever, tachycardia, and diminished urine output
over the ensuing 12-24 hours.305 However, time to
laparotomy is likely to be increased using a conservative approach.
Laboratory investigations, including WBC count
and blood biochemistry, may be helpful in the diagnosis. The peripheral WBC count is routinely elevated following trauma, and a progressive rise in
serial measurements may give indirect evidence of
bowel injury.316 In addition, serial measurement of
liver transaminases may also demonstrate an elevation but are nonspecific findings.316
Plain films may show intra-abdominal air in 1050%.312,316,319,320,322 The presence of pneumoperitoneum can occur from bowel injury but also may
occur from air dissection from the pleura or mediastinum into the abdomen via the retroperitoneum.
Ultrasound examination may show free pelvic fluid
Pediatric Emergency Medicine Practice©
but will not tell where this fluid came from, which
could include solid organ injury or hollow viscous
injury.323 CT findings following bowel injury can be
nonspecific. In one study where hollow viscous
injury was proven during celiotomy, five of the six
children had normal CT scan and the contrast material was only in the proximal portion of bowel.324
This finding may represent an ileus or not enough
time elapsing between administration of the
contrast and obtaining of the CT scan, making the
CT scan less effective in identifying bowel injury.
Free air initially may be present in CT scan in only
23-47% (Figure 4).314,325 Improved specificity (96%)
and sensitivity (95%) of CT scanning can be
achieved by looking for the presence of one or more
of:314,326
• Moderate-to-large amounts of unexplained
fluid.
• Unexplained extraluminal air.
• Bowel wall enhancement.
• Bowel wall thickening.
• Bowel dilatation.
• Extravasation of contrast.
• Multiple fluid-filled loops of bowel.
However, in one study, CT scan findings suggested injuries to the bowel, but one-third of those
studied did not have any injury upon laparotomy.158
Free fluid alone, however, is not pathognomonic for
intestinal injury and does not necessarily mandate
immediate surgical exploration. This fluid can be
either physiologic in pubertal girls after ovulation or
due to incorrect interpretation of the sonogram.
Other conditions that have free fluid with no obvious solid-organ or hollow viscous injury include
mesenteric injury not affecting the bowel lumen or
hypovolemic shock syndrome resulting in transudation of intraperitoneal and retroperitoneal fluid. In
children with free intraperitoneal fluid with no solid
organ damage, only 6-25% will need a therapeutic
laparotomy.324,327,328 The probability of bowel injury
Figure 4. CT Scan Showing Free Air From A
Jejunal Perforation
Image courtesy of Dr. Antonio Muñiz.
20
March 2008 • EBMedicine.net
increases when the free fluid is associated with seat
belt ecchymosis on the abdominal wall and when
the peritoneal fluid is in more than one location.
Therefore, the mere finding of free intraperitoneal
fluid does not dictate immediate surgical exploration in children. Identification of intestinal injuries
requires a combination of strong clinical suspicion,
serial physical examinations, and thoughtful interpretation of the results of CT scanning. If a DPL is
performed, the presence of bile or amylase is indicative of an injury.
Once a small bowel perforation is suspected, the
child should receive appropriate antibiotics (Table 5
on page 15) and should have adequate resuscitation
with intravenous fluids. A pediatric surgeon should
be consulted for definitive repair of their injury.
Delay in the diagnosis of hollow viscous injury
and a delay in laparotomy might increase morbidity
and mortality, prolong hospitalization, increase
complications, and may result in death.307,329,330 The
risk of delayed diagnosis or missed injury has led
some to advocate an aggressive diagnostic approach
using DPL, exploratory laparotomy, or empiric
laparotomy in selected patients.331,332 Some series
have found worse outcomes in patients with a
laparotomy more than 24 hours post injury.317,333,334
Other pediatric series have found no increase in
morbidity and mortality with delayed
laparotomy.305,321 However, mortality is usually due
to another associated injury, such as head injury or
major vessel injury.314,319,321,329
Admit patients with an isolated finding of peritoneal fluid who do not undergo immediate surgery
based on physical findings, and perform sequential
abdominal examinations and serial hematocrit evaluations. When the abdominal examination and
hematocrit level remain stable, begin oral intake.
Those with bowel injury should have worsening
abdominal tenderness and will require surgical
repair. Operative management generally involves
either simple surgical closure or segmental resection
with primary anastomosis. Creation of a proximal
colostomy is less common. Laparoscopic exploration and repair of traumatic bowel injuries is now
more commonly used in children and offers many
advantages over traditional trauma laparotomy in
carefully selected children. Complications after surgery may include delayed abscess, delayed obstruction, superficial wound infection, fistula formation,
later onset of small bowel obstruction, pneumonia,
pleural effusion, peritonitis, sepsis, acute respiratory
distress syndrome, and death.316,321,328
abdominal injuries in children. Blunt abdominal
trauma is responsible for more than 90% of pediatric
renal injuries.336 Minor injuries account for 85% of
the total renal injuries, lacerations occur in 10%, and
severe injuries (such as renal rupture, fractures, or
pedicle injuries) occur in 3% of cases.337 One should
consider renal injury with a blow to the flank or
abdomen, deceleration injury, hematuria, or pelvic
fracture. In children, the kidney is at greater risk for
injury because of its proportionally greater size, limited thoracic cage and perirenal fat protection,
weaker abdominal wall musculature, and more flexible thoracic cage.338 In addition, pediatric kidneys
may retain fetal lobulations, permitting easier
parenchymal laceration after blunt trauma.339 Preexisting or congenital renal abnormalities, such as
hydronephrosis, tumors, or abnormal position, may
predispose the kidney to trauma despite relatively
mild traumatic forces. Historically, congenital abnormalities in injured kidneys have been reported to
vary from 1% to 21%. However, most recent reviews have shown a decreased incidence of 1-5%.340
The most common mechanisms include motor
vehicle collisions, falls, pedestrians struck by cars,
bicycle crashes, sports-related injuries, crush
injuries, animal kicks, and inflicted injuries.341,342
Usually there is direct flank trauma or rapid deceleration that crushes the kidneys against the ribs or
vertebral column.
Only 88.1% of patients with known renal injury
have either microscopic or macroscopic hematuria.341 Up to 4.2% have underlying congenital
renal anomalies, including ureteropelvic junction
obstruction, polycystic kidney disease, horseshoe
kidney, or ureteroceles.343 Half of the injuries occur
in one kidney.364 Renal trauma was associated with
multiple other injuries in 51-80%; head injuries and
skeletal fractures are the most common, accounting
for 70% of all associated injuries.338,342,344
The AAST adopted a classification of renal
injuries based on a CT scan grade system (Table
11).262
Due to the retroperitoneal location of the
Table 11. Renal Injury Grades
Renal Trauma
Injury to the kidney from blunt or penetrating
trauma is the most common urinary tract injury.335
Renal trauma accounts for about 10% of blunt
EBMedicine.net • March 2008
21
Grade
Extent of renal injury
1
Contusion: microscopic or gross hematuria, no depiction
of injury with any imaging method
Hematoma: subscapular hematoma with no parenchymal
laceration
2
Nonexpanding perirenal hematoma or cortical laceration
less than 1 cm deep with no urinary extravasation
3
Parenchymal laceration extending greater than 1 cm into
the cortex with no urinary extravasation
4
Parenchymal laceration extending through the corticomedullary junction and into the collecting system
5
Multiple major lacerations resulting in a shattered kidney
or avulsion of renal hilum that devascularizes the
kidney
Pediatric Emergency Medicine Practice©
kidneys, clinical manifestations are less obvious.
Dull flank tenderness, flank hematoma, abdominal
tenderness, and hematuria are often the only clues
to renal injury.
In the pediatric population, gross hematuria is
the most reliable indicator for serious urologic
injury; therefore, any child presenting with gross
hematuria requires radiographic evaluation.345 The
need for imaging in the pediatric patient with blunt
trauma and microscopic hematuria is not as clear.
The degree of hematuria does not always correlate
with the degree of injury.252,324 Renal vascular pedicle avulsion or acute thrombosis of segmental
arteries can occur in the absence of hematuria in up
to 40%,252 whereas mild renal contusions can present with gross hematuria.346,347 Detection of significant renal injury was found to increase to 8% with
significant microhematuria (greater than 50 RBC/
HPF) and to 32% in those with gross hematuria.95
The presence of multisystem trauma significantly
increases the risk for significant renal damage.
Gross hematuria, shock, or significant deceleration
injury are reliable indicators for the presence of
renal injuries.96 Patients with blunt abdominal
trauma, microscopic hematuria, and no associated
injuries are unlikely to have significant renal
injury.336 Significant renal injuries are more likely in
patients with multiple intra-abdominal injuries and
hematuria. A review of 12 studies with 1048 total
children who had radiographic imaging following
blunt trauma showed that 32% of children with
gross hematuria, 8% with greater than or equal to 50
RBC/HPF, and 2% with less than 50 RBC/HPF had
significant renal injuries. Most importantly, all children with significant renal injuries and less than 50
RBC/HPF were seriously ill and all had other indications for abdominal CT scan.348 Therefore, imaging is not recommended in the initial evaluation in
patients with insignificant microscopic hematuria
(less than 50 RBC/HPF) without associated organ
injury, but it should be performed when there is
persistent microscopic hematuria.348 The chest radiograph may suggest a renal injury when there is
obliteration of the renal and psoas shadows, scoliosis with concavity toward the injured side, fractures
of lower posterior ribs, or adjacent transverse spinous process or pelvic fractures. Renal ultrasound
has been recommended in screening of renal
injuries, but its efficacy has not been yet proven.336
In addition to determining the severity of renal
injuries, CT scan can demonstrate or exclude other
intra-abdominal injuries.349 The CT scan can determine degree of renal parenchymal injury, evaluate
presence of nonviable tissue, demonstrate extravasation and perirenal collections, and diagnose most
pedicle injuries. Intravenous pyelography (IVP) has
traditionally been the imaging study of choice for
suspected renal trauma.258 However, it has been
Pediatric Emergency Medicine Practice©
reported that the IVP is interpreted as normal in up
to 20% of patients with major renal injuries. When
compared with CT scan, the sensitivity of IVP may
be as low as 50%.348 However, IVP is 100% sensitive
in grade IV and V injuries on showing the urinary
extravasation and a nonfunctioning kidney. It may
be used preoperatively in unstable children selected
for laparotomy to identify major renovascular
injury. IVP findings suggestive of renal injury
include delayed excretion of contrast by injured kidney, nonvisualization of caliceal system, or extravasation of contrast into the perinephric tissues. It
may miss injuries, but its importance lies in rapidly
assessing overall function and anatomical integrity
of the kidney, as well as the presence of congenital
anomalies. When the CT scan does not show excretion of contrast agent in to the renal collecting system, magnetic resonance angiography or digital
subtraction angiography should be performed.350
The indications for CT in the evaluation of renal
injuries are shown in Table 12.
The management of children with suspected
renal trauma, especially major renal injuries, remains controversial.344 Non operative management
can be accomplished in up to 95% of children.341
Older studies have shown a nonoperative success
rate of 84-89%.344,351,352 Prior reported high rates of
failure of nonoperative therapy for renal injuries
may have been related to historical management
bias, particularly the inclusion of patients before the
broad application of routine nonoperative management protocols for solid organ injury. In addition, it
is now generally considered safer to manage the
complications associated with nonoperative therapies, such as urinoma, than to risk excessive intraoperative hemorrhage or renal parenchymal loss by
intervening in cases that might otherwise heal spontaneously. Complicated lacerations with urinary
extravasation may be amenable to adjunctive
techniques, such as urethral stenting or percutaneous nephrostomy, to decompress the urinoma and
allow spontaneous healing of the leak.354,355 Persistent urinary extravasation has successfully been
managed by percutaneous drainage. Adjunctive
interventions may be required in 7.4% of cases.341
Although 5% require surgical repair or nephrectomy, the overall renal salvage rate is 98.9%.341
Table 12. Indications For CT Scanning For
Suspected Renal Injuries
•
•
•
•
•
•
Hematuria greater than 50 RBC/HPF.
Microscopic hematuria with shock.
Gross hematuria.
Penetrating trauma to abdomen.
Physical findings consistent with renal trauma.
Significant mechanism that warrant genitourinary tract
evaluation.
• Hematuria after a minor mechanism (exclude congenital
abnormality or tumor).
22
March 2008 • EBMedicine.net
Risk Management Pitfalls For Pediatric Abdominal Trauma
an increased chance of a liver injury. However,
normal liver functions tests do not exclude a
small liver injury.
1. “I didn’t think I had to evaluate for intraabdominal organ injury after the child fell off
the bicycle handle.”
Children have intra-abdominal organs that are
proportionally larger and not well protected by
their weaker abdominal musculature and cartilaginous ribs. Therefore, minor traumatic forces
can easily cause injury to these intra-abdominal
organs.
7. “The FAST examination shows free fluid in
the peritoneal cavity; this child must go to the
operating room for an exploratory
laparotomy.”
The decision to take a child to the operating
room for a solid organ injury depends on the
hemodynamic status of that child. If after
appropriate fluid and/or blood resuscitation,
the child remains hemodynamically unstable
then the decision to go to the operating room
must be addressed.
2. “I didn’t get a lumbar x-ray of that child
involved in a car accident who was restrained
in a lap-belt.”
Children in motor vehicle accidents who wear a
lap-only seat belt are prone to intra-abdominal
solid organ, hollow viscous, and lumbar spine
injuries. Due to their underdeveloped pelvis,
the seat belt rides higher on the abdomen and
rapid deceleration causes the child to sustain a
hyperflexion injury of the upper lumbar spine
and compression of the abdominal organs
between the seat belt and the spine.
8. “The FAST examination is normal; there is no
need for an abdominal CT scan in this child
who was kicked in the abdomen by a horse.”
The FAST examination is intended to detect
abnormal fluid collections in the peritoneum. It
is very limited in the accuracy of detecting solid
organ injury that is not actively bleeding.
Therefore, in a child with a significant injury
mechanism that may result in intra-abdominal
trauma with a normal FAST examination, a CT
scan of the abdomen should be ordered.
3. “I didn’t suspect that child would go into
shock from her inflicted abdominal injuries.”
Children who sustain intra-abdominal injuries
from abuse are usually younger. The injuries
are usually severe and because the history is
inadequate and the time to presentation is usually delayed, these children frequently present
in shock.
9. “I didn’t call the pediatric surgeon until the
child became hypotensive.”
A pediatric or trauma surgeon should be consulted early in the management of any child
who may have a significant intra-abdominal
injury, especially if not responding to
intravenous crystalloid solution. The hemodynamically unstable child has a higher chance of
requiring surgical repair of injuries.
4. “The emergency medical technician told me
the child had a PTS score of 4, and I told him
it was okay to bring the child to my level 3
hospital.”
A PTS score less than 8 is the recommended
threshold for diverting children to a designated
trauma center. Children with a PTS score
greater than 8 have virtually no mortality. Significantly injured children have a better
outcome in a dedicated trauma center.
10. “I didn’t think this child had a pancreatic
injury because the CT scan was normal, but he
did have an elevated lipase.”
The accuracy of the CT scan is poor for certain
types of pancreatic injuries. It does very well in
detecting major pancreatic duct injuries but is
poor at detecting minor contusions. If the lipase
is elevated, serial lipase determinations will
clarify if there is a pancreatic injury.
5. “I didn’t think the child was in shock since his
blood pressure was normal.”
The heart rate is the most sensitive indicator of
intravascular volume status in infants and
young children. Hypovolemic shock is
heralded by tachycardia long before hypotension becomes apparent.
6. “I didn’t think he had a liver injury because
his liver function tests were normal.”
If the liver function tests are elevated, there is
EBMedicine.net • March 2008
23
Pediatric Emergency Medicine Practice©
Angiographic embolization is an alternative to surgery in a hemodynamically stable patient in whom
persistent gross hematuria signifies persistent lowgrade hemorrhage from the injured kidney. Minor
renal injuries constitute most blunt renal injuries
and usually resolve without incident.337 When conservative management is chosen, supportive care
with bed rest, hydration, and serial hemoglobin and
vital sign monitoring are required for uneventful
healing. After gross hematuria resolves, limited
activity is allowed for 2-4 weeks until microscopic
hematuria ceases.
Complications of managing grade IV and V
injuries non operatively are recurrent hemorrhage,
extravasation, urinoma, infection, infarction, or segmental hydronephrosis. Hypertension is a rare but
reported complication of renal injury and the true
risk is unknown, but earlier studies have shown an
incidence rate of 0-9.4%.351,355,356 Hypertension in
most instances is treated medically. Renal insufficiency may also occur.357 Other complications may
include delayed nephrectomy or infection.344,358
by adequate resuscitation, including blood product
administration. The hemodynamically stable child
is evaluated using laboratory and imaging studies.
Stable children with solid organ injuries are almost
always managed nonoperatively, whereas small
bowel perforations and pancreatic injuries with
main ductal disruption require laparotomy.
References
Evidence-based medicine requires a critical
appraisal of the literature based upon study
methodology and number of subjects. Not all references are equally robust. The findings of a large,
prospective, randomized, and blinded trial should
carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such
as the type of study and the number of patients in
the study, will be included in bold type following
the reference, where available. In addition, the most
informative references cited in this paper, as
determined by the authors, will be noted by an
asterisk (*) next to the number of the reference.
Summary
1. National Center for Injury Prevention and Control WISQUARS fatal
injuries: leading causes of death reports. Available at
http://webapp.cdc.gov/sasweb/ncipc/leadcaus.html (Registry of
injuries)
2. National Pediatric Trauma Registry. Available at: http://www.npr.org
(Registry of trauma—No longer available)
3. Tyroch AH, Kaups KL, Sue LP, O’Donnell-Nicol S. Pediatric restraint use
in motor vehicle collisions. Arch Surg 2000; 135(10): 1173-1176.
(Retrospective review, 600 patients)
4. Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury:
the pediatric perspective. J Pediatr Surg 1994; 29(1): 33-38 (Prospective
data collection, 301 patients)
*5. Cantor RM, Leaming JM. Evaluation and management of pediatric major
trauma. Emerg Med Clin North Am 1998; 16: 229-256 (Review)
6. Stein JP, Kaji DM, Eastham J, Freeman JA, Esrig D, Hardy BE. Blunt
renal trauma in the pediatric population: indications for radiographic
evaluation. Urology 1994;44(3): 406-410 (Retrospective review, 412
patients)
Timely diagnosis and a systematic approach to non
operative versus operative management of intraabdominal injuries in children are critical in providing the best pediatric trauma care. Suspicion of
intra-abdominal injury is based on mechanism of
injury and findings on clinical examination. Subsequent evaluation and management of intra-abdominal injury is dictated by the patient’s hemodynamic
status and the presence of other extra-abdominal
injuries. The hemodynamically unstable child with
suspected intra-abdominal injuries may require
emergent laparotomy if the child’s hemodynamic
status continues to be unstable and not correctable
Key Points
• The PTS and the RTS are useful in determining
which injured child should be transported to a
trauma center.
• The physical examination of a child sustaining
blunt abdominal trauma is unreliable and may
initially fail to show significant abdominal
pathology.
• The laboratory evaluation is unreliable in predicting which child has significant abdominal injuries.
• The CT scan is the radiographic procedure of
choice for detecting significant abdominal injury.
• The decision to perform an exploratory laparotomy in children sustaining abdominal organ
injuries is dependent on their hemodynamic
status.
• Significant abdominal trauma occurs in 25% of
children sustaining multisystem trauma.
• Children’s anatomically unique features predispose them to abdominal injuries that are rarely
seen in adults.
• The most common mechanism for producing
abdominal injuries includes motor vehicle
accidents, pedestrians struck by cars, falls, and
bicycle accidents.
• Incorrectly placed lap belts can predispose children to injuries to solid organs, hollow viscous
fractures, and lumbar spine fractures (Chance
fracture).
• Children with abusive abdominal injuries are
younger and may have severe injuries with high
mortality rates.
Pediatric Emergency Medicine Practice©
24
March 2008 • EBMedicine.net
7. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and
children: prompt identification and early management of serious and
life-threatening injuries. Part 1: injury patterns and initial assessment.
Pediatr Emerg Care 2000; 16(3): 106-115 (Review)
*8. Holmes JF, Sokolove PE, Brant WE, Palchak MJ, Vance CW, Owings JT, et
al. Identification of children with intra-abdominal injuries after blunt
trauma. Ann Emerg Med 2002; 39(5): 500-509 (Retrospective review, 1095
patients)
*9. Taylor GA, O’Donnell R, Sivit CJ, Eichelberger MR. Abdominal injury
score: a clinical score for the assignment of risk in children after blunt
trauma. Radiology 1994; 190(3): 689-694 (Retroactive review, 793
patients)
10. Siegel JH, Mason-Gonzalez SM, Dischinger P, et al. Safety belt restraints
and compartment instructions in frontal and lateral motor vehicle
crashes: mechanisms of injuries, complications, and acute care costs. J
Trauma 1993; 34: 736-758 (Prospective review, 121 patients)
11. Tyroch AH, Kaups KL, Sue LP, O’Donnell-Nicol S. Pediatric restraint use
in motor vehicle collisions. Arch Surg 2000; 135(10): 1173-1176
(Retrospective review, 600 patients)
12. Reath DB, Kirby J, Lynch M, Maull KI. Patterns of maxillofacial injuries
in restrained and unrestrained motor vehicle crash victims. J Trauma
1989; 29(6): 806-809 (Prospective review, 613 patients)
13. Aräjarvi E, Santavirta S. Chest injuries sustained in traffic accidents by
seat belt wearers. J Trauma 1989; 29(1): 37-41 (Retrospective review, 3468
patients)
14. Reath DB, Kirby J, Lynch M, Maull KI. Injury and cost comparison of
restrained and unrestrained motor vehicle crash victims. J Trauma 1989;
29(8): 1173-1176 (Prospective review, 613 patients)
15. Hoffman MA, Spence LJ, Wessons DE, Armstrong PF, Williams JI, Filler
RM. The pediatric passenger: trends in seatbelt use and injury patterns. J
Trauma 1987; 27(9): 974-976 (Prospective review, 91 patients)
16. Valent F, McGwin G Jr, Hardin W, Johnston C, Rue LW 3rd. Restraint use
and injury patterns among children involved in motor vehicle collisions.
J Trauma 2002; 52(4): 745-751 (Retrospective review, 1.5 million patients)
17. Osberg JS, Di Scala C. Morbidity among pediatric motor vehicle crash
victims: the effectiveness of seat belts. Am J Public Health 1992; 82(3): 422425 (Retrospective review, 413 patients)
18. Nance ML, Lutz N, Arbogast KB, Cornejo RA, Kallan MJ, Winston FK, et
al. Optimal restraint reduces the risk of abdominal injury in children
involved in motor vehicle crashes. Ann Surg 2004; 239(1): 127-131
(Retrospective cross sectional study, 10,927 patients)
19. Durbin DR, Elliot MR, Winston FK. Belt positioning booster seats and
reduction in risk of injury among children in vehicle crashes. JAMA 2003
Jun 4; 289(21): 2835-2840 (Retrospective cross sectional study, 3616
patients)
20. Traffic Safety Facts 2001:Children (DOT HS 809 471). Available at wwwnrd.nhtsa.dot.gov/Pubs/809471.PDF (Registry)
21. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma
is associated with increased incidence of abdominal injury. Am Surgeon.
1997 Oct; 63(10): 885-888 (Prospective review, 117 patients)
22. Asbun HJ, Irani H, Roe EJ, Bloch JH. Intra-abdominal seatbelt injury. J
Trauma. 1990; 30(2): 189-193 (Review)
23. Rutledge R, Thomason M, Oller D, Meredith W, Moylan J, Clancy T, et al.
The spectrum of abdominal injuries associated with the use of seat belts.
J Trauma. 1991; 31(6): 820-825 (Review)
24. Garrett JW, Braunstein PW. The seat belt syndrome. J Trauma 1962; 2:
220-238 (Review)
25. Shepherd M, Hamill J, Segedin E. Paediatric lap-belt injury: a 7 year
experience. Emerg Med Australas 2006;18(1): 57-63 (Case report)
26. Chance GQ. Note on a type of flexion fracture of the spine. Br J Radiol
1948; 21: a452-a453 (Case report)
27. Vandersluis R, O’Connor HM The seat-belt syndrome. CMA J 1987;
137(11); 1023-1024 (Review)
28. Denis R, Allard M, Atlas H, Farkouh E. Changing trends with abdominal
injury in seatbelt wearers. J Trauma 1983; 23(11): 1007-1008 (Retrospective
review, 38 patients)
29. Newman KD, Bowman LM, Eichelberger MR, Gotschall CS, Taylor GA,
Johnson DL, et al. The lap belt complex: intestinal and lumbar spine
injury in children. J Trauma 1990; 30(9): 1133-1138 (Retrospective review,
395 patients)
30. Kong LB, Lekawa M, Navarro RA, McGrath j, Cohen M, margulies DR, et
al. Pedestrian motor vehicle trauma: an analysis of injury profiles by
age. J Am Coll Surg 1996; 182(1): 17-23 (Retrospective review, 273
patients)
31. Agran PF, Winn DG, Anderson CL. Differences in child pedestrian injury
events by location. Pediatrics 1994; 93(2): 284-288 (Survey, 345 patients)
32. Waddell JP, Drucker WR. Occult injuries in pedestrian accidents. J Trauma
1971; 11(10): 844-852 (Retrospective review, 23 patients)
33. LeMaster T., Tuchfarber B., Garcia VF, Ruddy R. Pediatric Pedestrian
Injury Patterns: A Closer Look at Waddell’s Triad. Journal of Emergency
Medical Services (21)3, 1996.
34. Orsborn R, Haley K, Hammond S, Falcone RE. Pediatric pedestrian
versus motor vehicle patterns of injury: debunking the myth. Air Med J.
1999; 18(3): 107-110 (Retrospective review, 4444 patients)
35. US Consumer Product Safety Comission National Electronic Surveillance
System (NEISS). Bethesda, MD: US Consumer Product Safety
Commission; 1999 http://www.cpsc.gov/neiss/2000d015.pdf (Review)
36. Winston FK, Shaw KN, Kreshak AA, Schwarz DF, Gallagher PR, Cnaan
A. Hidden spears: handlebars as injury hazards to children. Pediatrics
1998; 102: 596-601 (Prospective cross sectional, 107 patients)
EBMedicine.net • March 2008
37. Nadler EP, Potoka DA, Shultz BL, Morrison KE, Ford HR, Gaines BA.
The high morbidity associated with handlebar injuries in children. J
Trauma 2005; 58(6): 1171-1174 (Retrospective review, 221 patients)
38. Krishnan SG, Rathjen KE. Open iliac wing fractures caused by
penetrating injury from a bicycle handlebar. J Ortho Trauma 2002; 16(4):
277-279 (Review)
39. Erez I, Lazar L Gutermacher M, Katz S. Abdominal injuries caused by
bicycle handlebars. Eur J Surg 2001; 167(5): 331-333 (Retrospective
review, 76 patients)
40. Clarnette TD, Beasley SW. Handlebar injuries in children: patterns and
prevention. Aust N Z J Surg 1997; 67(6): 338-339 (Retrospective review, 32
patients)
41. Levenson M. All-terrain 2001 injury and exposure studies. Washington
(DC): US Consumer Product Safety Commission: 2003
http://www.cpsc.gov/cpscpub/pubs/cpsr_nws29.pdf (Review)
42. American Academy of Pediatrics, Committee on Injury and Poison
Prevention: All-terrain vehicle injury prevention: two, three-, and fourwheeled licensed motor vehicles. Pediatrics 2000; 10: 1352-1354 (Position
paper)
43. Hargarten SW. All terrain vehicle mortality in Wisconsin: a case study in
injury control. Am J Emerg Med 1991; 9(2): 149-152 (Retrospective review,
52 patients)
44. Su W, Hui T, Shaw K. All-terrain vehicle injury patterns: are current
regulations effective? J Pediatr Surg 2006; 41(5): 931-934 (Retrospective
review, 50 patients)
45. Bhutta ST, Greenberg SB, Fitch SJ, Parnell D. All-terrain vehicle injuries
in children: injury patterns and prognostic mortality. Pediatr Radiol 2004;
34(2): 130-133 (Retrospective review, 141 patients)
46. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Guzzetta PC,
Anderson KD, et al. Patterns of injury in children. J Pediatr Surg 1990;
25(1): 85-91 (Retrospective review, 3472 patients)
47. Roshkow JE, Haller JO, Hotson GC, Sclafani SJ, Mezzacappa PM, Rachlin
S. Imaging evaluation of children after falls from a height: review of 45
cases. Radiology 1990; 175: 359-363 (Retrospective review, 45 patients)
48. Wan J, Corvino TF, Greenfield SP, DiScala C. The incidence of
recreational genitourinary and abdominal injuries in the Western New
York pediatric population. J Urol 2003; 170(4 Pt 2): 1525-1527
(Retrospective review, 4921 patients)
49. Trokel M, Discala C, Terrin NC, Sege RD. Patient and injury
characteristics in abusive abdominal injuries. Pediatr Emerg Care 2006;
22(10): 700-704 (Retrospective review, 664 patients)
*50. Cooper A, Floyd T, Barlow B, Niemirska M, Ludwig S, Seidl T, et al.
Major blunt abdominal trauma due to child abuse. J Trauma 1988; 28(10):
1483-1487 (Retrospective review, 10,000 patients)
51. Caniano DA, Beaver BL, Boles ET Jr. Child abuse: an update on surgical
management in 256 cases. Ann Surg 1986; 203: 219-224 (Retrospective
review, 1512 patients)
52. Sivit CJ, Taylor GA, Eichelberger MR. Visceral injury in battered children:
a changing perspective. Radiology 1989; 173(3): 659-661 (Retrospective
review, 69 patients)
53. McCort J, Vaudagna J. Visceral injuries in battered children. Radiology
1964; 82: 424-428 (Retrospective review, 42 patients)
54. Fossum RM, Descheneaux KA. Blunt trauma of the abdomen in
children. J Forensic Sci 1991; 36(1): 47-50 (Review)
55. Ledbetter DJ, Hatch EI Jr, Feldman KW, Fligner CL, Tapper D.
Diagnostic and surgical implications of child abuse. Arch Surg 1988;
123(9): 1101-1105 (Retrospective review, 156 patients)
56. Canty TG Sr., Canty TG Jr., Brown C. Injuries of the gastrointestinal tract
from blunt abdominal trauma in children: a 12-year experience at a
designated pediatric trauma center. J Trauma 1999; 46(2): 234-240
(Retrospective review, 79 patients)
57. Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal
Sara H. A population-based study of inflicted traumatic brain injury in
young children. JAMA 2003; 290: 621-626 (Retrospective review, 152
patients)
58. Wood J, Rubin DM, Nance ML, et al. Distinguishing inflicted versus
accidental abdominal injuries in young children. J Trauma 2005; 59(5):
1203-1208 (Retrospective review, 1221 patients)
59. Roaten JB, Partrick DA, Bensard DD, Hendrickson RJ, Vertrees T,
Sirotnak AP, et al. Visceral injuries in nonaccidental trauma: spectrum of
injury and outcomes. Am J Surg 2005; 190(6): 827-829 (Retrospective
review, 3705 patients)
60. Rutledge R, Smith CY, Azizkhank RG. Population-based multivariate
analysis of the association of county demographic and medical system
factors with per capita pediatric trauma deaths. Ann Surg 1994; 219(2):
205-210. (Retrospective review, 941 medical examiner patients)
61. Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal
intubations in rural pediatric trauma patients. J Pediatr Surg 2004; 39:
1376-1380 (Retrospective review, 121)
62. Sing RF, Reilly PM, Rotondo MF, Lynch MJ, McCans JP, Schwab CW.
Out-of-hospital rapid-sequence induction for intubation of the pediatric
patient. Acad Emerg Med 1996; 3(1): 41-45 (Retrospective review, 41
patients)
63. Wang HE, O’Conner RE, Megargel RE, Bitner M, Stuart R, Bratton-Heck
B, et al. The utilization of midazolam as a pharmacologic adjunct to
endotracheal intubation by paramedics. Prehospital Emerg Care 2000; 4:1418 (Retrospective review, 683 patients)
64. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich
SM,et al. Effect of out of hospital pediatric endotracheal intubation on
survival and Neurologic outcome. JAMA 2000; 283: 783-790 (Prospective
controlled clinical trial, 830 patients)
25
Pediatric Emergency Medicine Practice©
65. Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann
Emerg Med 1992; 21(12): 1430-1434 (Retrospective review, 300 patients)
66. Pepe PE, Eckstein M. Reappraising the pre-hospital care of the patient
with major trauma. Emerg Med Clin North Am 1998; 16(1): 1-14 (Review)
67. Tepas JJ, Mollitt DL, Talbert JL, Bryant M. The pediatric trauma score as
a predictor of injury severity in the injured child. J Pediatr Surg 1987; 22:
14-18 (Prospective cohort, 120 patients)
68. Tepas JJ, Ramenofsky ML, Mollitt DL, Gans BM, DiScala C. The pediatric
trauma score as a predictor of injury severity: an objective assessment. J
Trauma 1988; 28(4): 425-429 (Retrospective review, 615 patients)
69. Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, et al.
Immediate versus delayed fluid resuscitation for hypotensive patients
with penetrating torso injuries. N Engl J Med 1994; 331(17): 1105-1109
(Prospective, 598 patients)
70. Ramenofsky M, Luterman A, Quindlen E, Riddick L, Curreri PW.
Maximum survival in pediatric trauma: the ideal system. J Trauma 1984;
24(9): 818-823 (Retrospective review, 100 patients)
71. Eichelberger MR, Gotschall CS, Sacco WJ, Bowman LM, Mangubat EA,
Lowenstein AD. A comparison of the trauma score, the revised trauma
score, and the pediatric trauma score. Ann Emerg Med 1989(10); 18: 10531058 (Retrospective review, 1334 patients)
72. Kaufmann CR, Maier RV, Kaufmann EJ, Rivara FP, Carrico CJ. Validity of
applying adult Triss analysis to injured children. J Trauma 1991; 31: 691697 (Retrospective cohort, 792 patients)
73. Nayduch DA, Moylan J, Rutledge R, Baker CC, Meredith W, Thomason
M, et al. Comparison of the ability of adult and pediatric trauma scores
to predict pediatric outcome following major trauma. J Trauma 1991; 31:
452-457 (Retrospective review, 2604 patients)
74. Saladino R, Lund D, Fleisher G. The spectrum of liver and spleen injuries
in children: failure of the pediatric trauma score and clinical signs to
predict isolated injuries. Ann Emerg Med 1991; 20(6): 636-640
(Retrospective review, 77 patients)
75. Hall JR, Reyes HM, Meller JL, Loeff DS, Dembek R. The outcome for
children with blunt trauma is best at a pediatric trauma center. J Pediatr
Surg 1996; 31(1): 76-77 (Retrospective review, 1797 patients)
76. Knudson MM, Shagoury C, Lewis FR. Can adult trauma surgeons care
for injured children? J Trauma 1992; 32(6): 729-739 (Retrospective review,
353 patients)
77. Rhodes M, Smith S, Boorse D. Pediatric trauma patients in an ‘adult’
trauma center. J Trauma 1993; 35(3): 384-393 (Retrospective review, 1115
patients)
78. Keller MS, Vane DW. Management of pediatric blunt splenic:
Comparison of pediatric and adult trauma surgeons. J Pediatr Surg 1995;
30(2): 221-225 (Retrospective review, 817 patients)
79. Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric
trauma patient. J Pediatr Surg 1993; 28(2): 158-161 (Retrospective review,
32 patients)
80. Fort DW, Bernini JC, Johnson A, Cochran CJ, Buchanan GR. Splenic
rupture in hemophilia. Am J Pediatr Hematol Oncol 1994; 16(3): 255-259
(Case series, 5 patients)
*81. Jaffe D, Wesson D. Emergency management of blunt trauma in children.
N Engl J Med 1991; 324(21): 1477-1482 (Review)
82. Isaacman DJ, Scarfone RJ, Kost SI, Gochman RF, Davis HW, Bernardo
LM, et al. Utility of routine laboratory testing for detecting
intraabdominal injuries in the pediatric patient. Pediatrics 1993; 92: 691694
83. Rodiguez A, DuPriest RW, Shatney CH. Recognition of intraabdominal
injury in blunt trauma victims: a prospective study comparing physical
examination with peritoneal lavage. Am Surg 1982; 48(9): 457-459
(Prospective study, 221 consecutive patients)
84. Cotton BA, Beckert BW, Smith MK, Burd RS. The utility of clinical and
laboratory data for predicting intraabdominal injury among children. J
Trauma 2004; 56(5): 1068-1074 (Retrospective review, 351 patients)
85. Rosoff L, Cohen JL, Telfer N, Halpern M. Injuries of the spleen. Surg Clin
North Am 1972; 52(3): 667-685 (Review)
86. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma
is associated with increased incidence of abdominal injury. Am Surg
1997; 63(10): 885-888 (Prospective cross sectional, 117 patients)
87. Stassen NA, Lukan JK, Carillo EH, Spain DA, Richardson JD. Abdominal
seat belt marks in the era of focused abdominal sonography for trauma.
Arch Surg 2002; 137: 718-723 (Retrospective review, 23 patients)
88. Velmahos GC, Tatevossian R, Demetriades D. The “seat belt mark” sign:
A call for increased vigilance among physicians treating victims of motor
vehicle accidents. Am Surg 1999; 65(2): 181-185 (Prospective, 650
consecutive patients)
89. Wotherspoon S, Chu K, Brown AF. Abdominal injury and the seat belt
sign. Emerg Med 2001; 13(1): 61-65 (Retrospective review, 99 patients)
90. Eray O, Oktay C, Cete Y, Bozan H, Colak T, Akyol C, et al. Is seat belt
sign a predictor for physicians in management of trauma patients in
emergency settings? Ulus Travma Derg 2001; 7(3): 139-141 (Retrospective
review, 213 patients)
91. Lutz N, Nance ML, Kallan MJ, Arbogast KB, Durbin DR, Winston FK.
Incidence and clinical significance of abdominal wall bruising in
restrained children involved in motor vehicle crashes. J Pediatr Surg
2004; 39(6): 972-975 (Retrospective review, 147 patients)
92. Chui WC, Cushing BM, Rodriguez A, Ho SM, Mirvis SE,
Shanmuganathan K, et al. Abdominal injuries without hemoperitoneum:
a potential limitation of focused abdominal sonography for trauma
(FAST). J Trauma 1997; 42(4): 617-623 (Retrospective review, 986 patients)
Pediatric Emergency Medicine Practice©
93. Lieu TA, Fleisher GR, Mahboubi S, Schwartz JS. Hematuria and clinical
findings as indications of intravenous pyelography in pediatric blunt
renal trauma. Pediatrics 1988; 82(2): 216-222 (Retrospective review, 78
patients)
94. Hashmi A, Klassen T. Correlation between urinalysis and intravenous
pyelography in pediatric abdominal trauma. J Emerg Med 1995; 13(2):
225-258 (Retrospective review, 41 patients)
95. Bryant MS, Tepas JJ, Talbert JL, et al. Impact of emergency room
laboratory studies on the ultimate triage and disposition of the injured
child. Am Surg 1988; 54(4): 209-211 (Retrospective review, 626 lab tests)
96. Namias N, McKenney MG, Martin LC. Utility of admission chemistry
and coagulation profiles in trauma patients: a reappraisal of traditional
practice. J Trauma 1996; 41(1): 21-25 (Prospective, 772 patients)
97. Ford EG, Karamanoukian HL, McGrath N, Mahour GH. Emergency
center laboratory evaluation of pediatric trauma victims. Am Surg 1990;
56(12): 752-757 (Prospective, 500 consecutive patients)
98. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory
studies as screening tools in pediatric abdominal trauma. Pediatr Emerg
Care 2006; 22: 480-484 (Retrospective review, 382 patients)
99. Keller MS, Coln CE, Trimble JA, Green MC, Weber TR. The utility of
routine laboratories in pediatric trauma resuscitations. Am J Surg 2004;
188(6): 671-678 (Retrospective review, 240 patients)
100. Wilmore DW. Carbohydrate metabolism in trauma. Clin Endocrinol Metab
1976; 5(3): 731-745 (Review)
101. Abramson N, Melton B. Leukocytosis: basics of clinical assessment. Am
Fam Physician 2000; 62(9): 2053-2060 (Review)
102. Keller MS, Coln CE, Trimble JA, Green MC, Weber TR. The utility of
routine trauma laboratories in pediatric trauma resuscitations. Am J Surg
2004; 188(6):671-678 (Retrospective review, 240 patients)
103. Holmes JF, Goodwin H, Land C, Kupperman N. Coagulation studies in
pediatric blunt trauma patients. Pediatr Emerg Care 2001; 17(5): 324-328
(Retrospective review, 830 patients)
104. Rothrock SG, Green SM, MacArthur CL, DelDuca K. Detection of
electrolyte abnormalities in children presenting to the emergency
department: a multicenter prospective analysis. Acad Emerg Med 1997;
4(11): 1025-1031 (Retrospective review, 488 patients)
105. Bagwell CE, Ferguson WW. Blunt abdominal trauma: exploratory
laparotomy or peritoneal lavage? Am J Surg 1980; 140(3): 368 (Review)
106. Davis JW, Mackersie RC, Holbrook TL, Hoyt DB. Base deficit as an
indicator of significant abdominal injury. Ann Emerg Med 1991; 20(8): 842844 (Retrospective review, 3011 patients)
107. Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of
abdominal injury in children after blunt trauma. Ann Surg 1988; 208(6):
688-693 (Retrospective review, 378 consecutive patients)
108. Boone TB, Gilling PJ, Husmann DA. Ureteropelvic junction disruption
following blunt abdominal trauma. J Urol 1993; 150(1): 33-36 (Case series,
8 patients)
109. Hennes HM, Smith DS, Schneider K, Hegenbarth MA, Duma MA, Jona
JZ. Elevated liver transaminase levels in children with blunt abdominal
trauma: a predictor of liver injury. Pediatrics 199; 86(1): 87-90
(Retrospective review, 43 patients)
110. Purnik SR, Hayes JS, Long J, Mata M. Liver enzymes as predictors of
liver damage due to blunt abdominal trauma in children. South Med J
2002; 95(2): 203-206 (Retrospective review, 44 patients)
111. Shilyansky J, Sena LM, Kreller M, Chait P, Babyn P, Filler RM, et al.
Nonoperative management of pancreatic injuries in children. J Pediatr
Surg 1998; 33(2): 343-349 (Retrospective review, 35 patients)
112. Firstenberg MS, Volsko TA, Sivit C, et al. Selective management of
pediatric pancreatic injuries. J Pediatr Surg 1999; 34(7): 1142-1147
(Retrospective review, 12 patients)
113. Jobst MA, Canty TG Sr, Lynch FP. Management of pancreatic injury in
pediatric blunt abdominal trauma. J Pediatr Surg 1999; 34(5): 818-824
(Retrospective review, 56 patients)
114. Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children:
mechanism of injury. J Trauma 1997; 42(1): 49-53 (Retrospective review,
26 patients)
115. Takishima T, Sugimoto K, Asari Y, Kikuno T, Hirata M, Kakita A, et al.
Characteristics of pancreatic injury in children: a comparison with such
injury in adults. J Pediatr Surg 1996; 31(7): 896-900 (Case series, 8
patients)
116. Smith SD, Nakayama DK, Gantt N, Lloyd D, Rowe MI. Pancreatic
injuries in children due to blunt trauma. J Pediatr Surg 1988; 23(7): 610614 (Retrospective review, 22 patients)
117. Buechter KJ, Arnold M, Steele B, Martin L, Byers P, Gomez G, et al. The
use of serum amylase and lipase in evaluating and managing blunt
abdominal trauma. Am Surg 1990; 56(4): 204-208 (Retrospective review,
45 patients)
118. Canty TG Sr, Weinman D. Management of major pancreatic duct injuries
in children. J Trauma 2001; 50(6): 1001-1007 (Retrospective review, 18
patients)
119. Simon HK, Muehlberg A, Linakis JG. Serum amylase determinations in
pediatric patients presenting to the ED with acute abdominal pain or
trauma. Am J Emerg Med 1994; 12(3): 292-295 (Retrospective review, 656
patients)
120. Vitale GC, Larsop GM, Davidson PR, Bouwman DL, Weaver DW.
Analysis of hyperamylasemia in patients with severe head injury. J Surg
Res 1987; 43(3): 226-233 (Retrospective review, 60 patients, 10 controls)
121. Adamson WT, Hebra A, Thomas PB, Wagstaff P, Tagge EP, Biemann
Ohersen H. Serum amylase and lipase alone are not cost-effective
screening methods for pediatric trauma. 2003; 38(3): 354-357
(Retrospective review, 1821 patients)
26
March 2008 • EBMedicine.net
122. Rothrock SG, Green SM, Hummel CB. Plain abdominal radiography in
the detection of major disease in children: a prospective analysis. Ann
Emerg Med 1992; 21(12): 1423-1429 (Retrospective review, 354 patients)
123. Kristensen JK, Beumann B, Kühl E. Ultrasonic scanning in the diagnosis
of splenic haematomas. Acta Chir Scand 1971; 137(7): 653-657
(Retrospective review, 41 patients)
124. Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, et
al. A prospective study of surgeon-performed ultrasound as the primary
adjuvant modality for injured patient assessment. J Trauma 1995; 39(3):
492-498 (Prospective, 371 patients)
125. Rothenburg S, Moore EE, Marx JA, Moore FA, McCroskey BL. Selective
management of blunt abdominal trauma in children- The triage role of
peritoneal lavage. J Trauma 1987; 27(10): 1101-1106 (Retrospective review,
16 patients)
126. Powell RW, Green JB, Ochsner MG, Barttelbort SW, Shackford SR, Sise
MJ. Peritoneal lavage in pediatric patients sustaining blunt abdominal
trauma: A reappraisal. J Trauma 1987; 27(1): 6-9 (Retrospective review,
128 patients)
127. Tafl F, Ceran C, Atalar MH, Bulut S, Selbefl B, Iflik AO. The efficacy of
ultrasonography in hemodynamically stable children with blunt
abdominal trauma: a prospective comparison with computed
tomography. Eur J Radiol 2004; 51(1): 91-96 (Prospective, 96 patients)
128. Ong AW, McKenney MG, McKenney KA, Brown M, Namias N, MaCloud
J, et al. Predicting the need for laparotomy in pediatric trauma patients
on the basis of the ultrasound score. J Trauma 2003; 54(3): 503-508
(Retrospective review, 96 patients)
129. Benya EC, Lim-Dunham JE, Landrum O, Statter M. Abdominal
sonography in the examination of children with blunt abdominal trauma.
Am J Roentgenol 2000; 174(6); 1613-1616 (Prospective, 51 patients)
130. Miller MT, Pasquale MD, Bromberg WJ, et al. Not so FAST. J Trauma
2003; 54(1): 52-59 (Prospective, 372 patients)
131. Sivit CJ, Kaufman RA. Commentary: Sonography in the evaluation of
children following blunt trauma: is it to be or not to be? Pediatr Radiol
1995; 25(5): 326-328 (Review)
132. Filiatrault D, Garel L. Commentary: Pediatric blunt abdominal trauma—
to sound or not to sound? Pediatr Radiol 1995; 25(5): 329-331 (Review)
133. Agkur FM, Tanyel FC, Akhan O, et al. The place of ultrasonographic
examination in the initial evaluation of children sustaining blunt
abdominal trauma. J Pediatr Surg 1993; 28: 78-81 (Retrospective review,
109 patients)
134. Katz S, Lazar L, Rathaus V, et al. Can ultrasound replace computed
tomography in the initial assessment of children with blunt abdominal
trauma? J Pediatr Surg 1996; 31: 649-651 (Retrospective review, 124
patients)
135. Akgür FM, Aktug T, Olguner M, Kovanlikaya A, Hakgüder G.
Prospective study investigating routine usage ultrasonography as the
initial diagnostic modality for the evaluation of children sustaining blunt
abdominal trauma. J Trauma 1997; 42(4): 626-628 (Prospective, 217
patients)
136. Corbett SW, Andrews HG, Baker EM, Jones WG. ED evaluation of the
pediatric trauma patient by ultrasonography. Am J Emerg Med 2000; 18(3):
244-249 (Prospective, 47 patients)
137. Akgür FM, Aktu_ T, Kovanlikaya A, Erda_ G, Olguner M, Ho_gör M, et
al. Initial evaluation of children sustaining blunt abdominal trauma
ultrasonography vs. diagnostic peritoneal lavage. Eur J Pediatr Surg 1993;
3(5): 278-280 (Prospective, 68 patients)
138. Luks FI, Lemire A, St-Vil D, Di Lorenzo M, Filiatrault D, Ouimet A. Blunt
abdominal trauma in children: the practical value of ultrasonography. J
Trauma 1993; 34(5): 607-611 (Prospective, 259 patients)
139. Partrick DA, Bensard DD, Moore EE, Terry SJ, Karrer FM. Ultrasound is
an effective triage tool to evaluate blunt abdominal trauma in the
pediatric population. J Trauma, 1998; 45(1): 57-63 (Prospective, 98
patients)
*140. Taylor GA, Sivit CJ. Posttraumatic peritoneal fluid: is it a reliable
indicator of intraabdominal injury in children? J Pediatr Surg 1995; 30(12):
1644-1648 (Retrospective review, 1486 patients)
141. Krupnick AS, Teitelbaum DH, Geiger JD, Strouse PJ, Cox CS, Blane CE, et
al. Use of abdominal ultrasonography to assess pediatric splenic trauma
potential pitfalls in the diagnosis. Ann Surg 1997; 225(4): 408-414
(Retrospective review, 32 patients)
142. Coley MG, Mutabagni KH, Martin LC, Zumberge N, Cooney DR,
Caniano DA,et al. Focused abdominal sonography for trauma (FAST) in
children with blunt trauma. J Trauma 2000; 48(5): 902-906 (Retrospective
review, 32 patients)
143. Ingemen JE, Plewa MC, Okansinski RE, King RW, Knotts FB. Emergency
physician use of ultrasonography in blunt abdominal trauma. Acad
Emerg Med 1996; 3(10): 931-937 (Prospective, 97 patients)
144. Thourani VH, Pettit BJ, Schmidt JA, Cooper WA, Rozycki GS. Validation
of surgeon-performed emergency abdominal ultrasonography in
pediatric trauma patients. J Pediatr Surg 1998; 33(2): 322-328
(Prospective, 172 patients)
145. Patel JC, Tepas JJ 3rd. The efficacy of focused abdominal sonography for
trauma (FAST) as a screening tool in the assessment of injured children. J
Pediatr Surg 1999; 34(1): 44-47 (Retrospective review, 94)
146. Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, et al.
Practice management guidelines for the evaluation of blunt abdominal
trauma: the EAST practice management guidelines work group. J Trauma
2002; 53(3): 602-615 (Review)
EBMedicine.net • March 2008
*147. Holmes JF, Brant WE, Bond WF, Sokolove PE, Kuppermann N.
Emergency department ultrasonography in the evaluation of
hypotensive and normotensive children with blunt abdominal trauma. J
Pediatr Surg 2001; 36(7): 968-973 (Retrospective review, 224 patients)
148. Scalea TM, Rodriguez A, Chui WC, Brenneman FD, Fallon WF Jr, Kato K,
et al. Focused Assessment with Sonography for Trauma (FAST): results
from an international consensus conference. J Trauma 1999; 46(3): 466-472
(Review)
149. Rose JS. Ultrasound in abdominal trauma. Emerg Med Clin North Am
2004; 22: 581-599 (Review)
150. Nance ML, Mahboubi S, Wickstrom M, Prendergast F, Stafford PW.
Pattern of abdominal free fluid following isolated blunt spleen or liver
injury in the pediatric patient. J Trauma 2002; 52(1): 85-87 (Retrospective
review, 134 patients)
151. Rathaus V, Zissin R, Werner M, Erez I, Shapiro M, Grunebaum M, et al.
Minimal pelvic fluid in blunt abdominal trauma in children: the
significance of this sonographic finding. J Pediatr Surg 2001; 36(9): 13871389 (Retrospective review, 662 patients)
152. Fallat ME, Casale AJ. Practice patterns of pediatric surgeons caring for
stable patients with traumatic solid organ injury. J Trauma 1997; 43(5):
820-824 (Survey, 87 patients)
153. Meyer DM, Thal ER, Coln D, Weigelt JA. Computed tomography in the
evaluation of children with blunt abdominal trauma. Ann Surg 1993; 217:
272-276 (Retrospective review, 60 patients)
*154. Ruess L, Sivit CJ, Eichelberger MR, Gotschall CS, Taylor GA. Blunt
abdominal trauma in children: impact of CT on operative and
nonoperative management. AJR Am J Roentgenol 1997; 169(4): 1011-1014
(Prospective, 1500 patients)
155. Donohue JH, Federle MP, Griffiths BG, Trunkey DD. Computed
tomography in the diagnosis of blunt intestinal and mesenteric injuries. J
Trauma 1987; 27(1): 11-17 (Retrospective review, 24 patients)
156. Jamieson DH, Babyn PS, Pearl R. Imaging gastrointestinal perforation in
pediatric blunt abdominal trauma. Pediatr Radiol 1996; 26(3): 188-194
(Retrospective review, 43 patients)
157. Brown RA, Bass DH, Rode H, Millar AJ, Cywes S. Gastrointestinal tract
perforation in children due to blunt abdominal trauma. Br J Surg 1992;
79(6): 522-524 (Retrospective review, 29 patients)
158. Graham JS, Wong AL. A review of computed tomography in the
diagnosis of intestinal and mesenteric injury in pediatric blunt
abdominal trauma. J Pediatr Surg 1996; 31: 754-756 (Retrospective review,
145 patients)
159. Mirvis SE, Gens DR, Shanmuganathan K. Rupture of the bowel after
blunt abdominal trauma: diagnosis with CT. AJR Am J Roentgenol 1992;
159(6): 1217-1221 (Retrospective review, 17 patients)
160. Smith SD, Nakayama DK, Gantt N, Lloyd D, Rowe MI. Pancreatic
injuries in children due to blunt trauma. J Pediatr Surg 1988; 23(7): 610614 (Retrospective review, 22 patients)
161. Sivit CJ, Eichelberger MR, Taylor GA, Bulas DI, Gotschall CS, Kushner
DC. Blunt pancreatic trauma in children: CT diagnosis. AJR Am J
Roentgenol 1992; 158(5): 1097-1100 (Retrospective review, 18 patients)
162. Catasca JV, Siegel MJ. Posttraumatic diaphragmatic herniation: CT
findings in two children. Pediatr Radiol 1995; 25: 262-264 (Case report, 2
patients)
163. Rehm CG, Mure AJ, O’Malley KF, Ross SE. Blunt traumatic bladder
rupture: the role of retrograde cystogram. Ann Emerg Med 1991; 20(8):
845-847 (Retrospective review, 21 patients)
164. Allshouse MJ, Rouse T, Eichelberger MR. Childhood injury: a current
perspective. Pediatr Emerg Care 1993; 9(3): 159-164 (Review)
165. Taylor GA, Eichelberger MR, O’Donnell R, Bowman L. Indications for
computed tomography in children with blunt abdominal trauma. Ann
Surg 1991; 213(3): 212-218 (Retrospective review, 375 patients)
166. Taylor GA, Imaging of pediatric blunt abdominal trauma: what have we
learned in the past? Radiology 1995; 195(3): 600-601 (Communication)
167. Sivit CJ, Eichelberger MR, Taylor GA. CT in children with rupture of the
bowel caused by blunt trauma: diagnostic efficacy and comparison with
hypoperfusion complex. AJR Am J Roentgenol 1994; 163: 1195-1198
(Retrospective review, 21 patients)
168. Federle MP, Yagan N, Peitzman AB, Krugh J. Abdominal trauma: use of
oral contrast material for CT is safe. Radiology 1997; 205(1): 91-93
(Prospective 510 patients)
169. Nghiem HV, Jeffrey RB Jr, Mindelzum RE. CT of blunt trauma to the
bowel and mesentery. AJR Am J Roentgenol 1993; 160(1): 53-58 (Review)
170. Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast
administration for abdominal computed tomography in the evaluation of
acute blunt trauma. Ann Emerg Med 1997; 30(1): 7-13 (Retrospective
review, 297 patients)
171. Lim-Dunham JE, Narra J, Benya EC, Donaldson JS. Aspiration after
administration of oral contrast material in children undergoing
abdominal CT for trauma. AJR Am J Roentgenol 1997; 169(4): 1015-1018
(Retrospective review, 50 patients)
172. Donnelly LF, Frush DP, Frush KS. Aspirated contrast material
contributing to respiratory arrest in a pediatric trauma patient. AJR Am J
Roentgenol 1998; 171(2): 471-473 (Case report, 1 patient)
173. Donnelly LF. Oral contrast administration for abdominal CT: reevaluating the benefits and disadvantages in the pediatric patient.
Pediatr Radiol 1997; 27(9): 770-772 (Commentary)
174. Jamieson DH. Abdominal CT: clear fluids can replace water-soluble oral
contrast media. Pediatr Radiol 2002; 32(6): 462-463 (Prospective, 18
patients)
27
Pediatric Emergency Medicine Practice©
175. Bulas DI, Eichelberger MR, Sivit CJ, Wright CJ, Gotschall CS. Hepatic
injury from blunt trauma in children: follow-up evaluation with CT. AJR
Am J Roentgenology 1993; 160(2): 347-351 (Retrospective review, 45
patients)
176. Haftel AJ, Lev R, Mahour GH, Senac M, Akhtar Shah SI. Abdominal CT
scanning in pediatric blunt trauma. Ann Emerg Med 1988; 17(7): 684-689
(Retrospective review, 90 patients)
177. Halsted MJ, Racadio JM, Emery KH, Kreymerman P, Poe SA, Bean JA, et
al. Oral contrast agents for CT of abdomen trauma in pediatric patients:
a comparison of dilute hypaque and water. AJR Am J Roentgenol 2004;
182: 1555-1559 (Retrospective review, 74 patients)
178. Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation
risks: what pediatric health care providers should know. Pediatrics 2003;
112(4): 951-957. (Review)
179. Brenner DJ, Elliston CD, Hall EJ, Berdon W. Estimated risks of radiationinduced fatal cancer from pediatric CT. Am J Roentgenol 2001; 176(2): 289296 (Review)
180. Fenton SJ, Hansen KW, Meyers RL, et al. CT scan and the pediatric
trauma patient – are we overdoing it? J Pediatr Surg 2004; 39(12): 18771881 (Commentary)
181. Kane NM, Cronan JJ, Dorfman GS, DeLuca F. Pediatric abdominal
trauma: evaluation by computed tomography. Pediatrics 1988; 82(1): 11-15
(Retrospective review, 73 patients)
182. Davis JW, Hoyt DB, Mackersie RC, McArdle MS. Complication in
evaluation abdominal trauma: diagnostic peritoneal lavage versus
computerized axial tomography. J Trauma 1990; 30(12): 1506-1509
(Retrospective review, 2809 patients)
183. Liu M, Lee CH, P’eng FK. Prospective comparison of diagnostic
peritoneal lavage, computed tomographic scanning, and
ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma
1993; 35(2): 267-270 (Prospective, 55 patients)
184. Nagy KK, Fildes JJ, Sloan EP, et al. Aspiration of free blood from the
peritoneal cavity does not mandate immediate laparotomy. Am Surg
1995; 61: 790-795 (Prospective, 566 patients)
185. Powell RW, Green JB, Ochsner G, Barttelbort SW, Shackford SR, Sise MJ.
Peritoneal lavage in pediatric patients sustaining blunt abdominal
trauma: a reappraisal. J Trauma 1987; 27(1): 6-9 (Retrospective review, 129
patients)
186. Rossi P, Mullins D, Thal E. Role of laparoscopy in the evaluation of
abdominal trauma. Am J Surg 1993; 166(6): 707-711 (Prospective, 32
patients)
187. Iannelli A, Fabiani P, Karinmdjee BS, Baque P, Venissac N, Gugenheim J.
Therapeutic laparoscopy for blunt abdominal trauma with bowel
injuries. J Laparoendosc Adv Surg Tech A 2003; 13(3): 189-191 (Case
report)
188. McKinley AJ, Mahomed AA. Laparoscopy in a case of pediatric blunt
abdominal trauma. Surg Endosc 2002; 16(2): 358 (Case report)
189. Alaish SM, Stylianos S. Diagnostic laparoscopy. Curr Opin Pediatr 1998;
10(3): 323-327 (Review)
190. VanderKolk WE, Garcia VF. The use of laparoscopy in the management
of seat belt trauma in children. J Laparoendosc Surg 1996; 6: S45-S49 (Case
series, 4 patients.
191. Namias N, Schmidt J, Oiticica C, Kirton O, Davison M. Diagnostic
laparoscopy for dog bite wounds to the abdomen. J Laparoscopy Surg
1996; 6(6): 435-436 (Case report)
192. Ghandhi RR, Stringel G. Laparoscopy in pediatric abdominal trauma.
JSLS 1997; 1(4): 349-351 (Case report)
193. Hasegawa T, Miki Y, Yoshioka Y, Mizutani S, Sasaki T, Sumimura J.
Laparoscopic diagnosis of blunt abdominal trauma in children. Pediatr
Surg Int 1997; 12(2/3): 132-136 (Case series, 5 patients)
194. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic
laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006; 41(1): 7277 (Retrospective review, 32 patients)
195. Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk KA.
A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg
1993; 217(5): 557-565 (Prospective, 182 patients)
196. Ross SE, Dragon GM, O’Malley KF, Rehm CG. Morbidity of negative
celiotomy in trauma. Injury 1995; 26: 393-394 (Retrospective review, 50
patients)
197. Morey AF, Bruce JE, McAninch JW. Efficacy of radiologic imaging in
pediatric blunt renal trauma. J Urol 1996; 156(6): 2014-2018 (Retrospective
review, 180 patients)
198. Peitzman AB, Ford HR, Harbrecht BG, Potoka DA, Townsend RN. Injury
to the spleen. Curr Probl Surg 2001; 38: 932-1008 (Review)
199. King H, Shumacker HB Jr. Splenic studies: I Susceptibility to infection
after splenectomy performed in infancy. Ann Surg 1952; 136(2): 239-242
(Case series, 5 patients)
200. Singer DB. Postsplenectomy sepsis. Perspect Pediatr Pathol 1973; 1: 285311 (Review)
201. Francke EL, Neu HC. Postsplenectomy infection. Surg Clin North Am
1981; 61(1): 135-155 (Review)
202. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol
Obstet 1968; 126(4): 781-790 (Retrospective review, 51 patients)
203. Bisharat N, Omari H, Lavi I, Raz R. Risk of infection and death among
post-splenectomy patients. J Infect 2001; 43(3): 182-186 (Retrospective
review, 19680 patients)
*204. Upadhyaya P. Conservative management of splenic trauma: history and
current trends. Pediatr Surg Int 2003; 19(9/10): 617-627 (Review)
Pediatric Emergency Medicine Practice©
205. Thompson SR, Holland AJ. Evolution of nonoperative management for
blunt splenic trauma in children. J Paediatr Child Health 2006; 42(5): 231234 (Review)
206. Richardson JD. Changes in the management of injuries to the liver and
spleen J Am Coll Surg. 2005 May;200(5):648-69 (Review)
207. Nance ML, Lutz N, Carr MC, Canning DA, Stafford PW . Blunt renal
injuries in children can be managed nonoperatively: outcome in a
consecutive series of patients. J Trauma 2004; 57: 474-478 (Retrospective
review, 95 patients)
208. Stylianos S, and the APSA Liver/Spleen Trauma Study Group.
Prospective validation of evidence-based guidelines for resource
utilization in children with isolated spleen or liver injury. J Pediatr Surg
2002; 37(3): 453-456 (Review)
209. Mooney DP, Forbes PW. Variation in the management of pediatric splenic
injuries in New England. J Trauma 2004; 56(2): 328-333 (Retrospective
review, 2191 patients)
210. Haller JA Jr, Papa P, Drugas G, Colombani P. Nonoperative management
of solid organ injuries in children- Is it safe? Ann Surg 1994; 219(6): 625631 (Retrospective review, 28 patients)
211. Stylianos S. Outcomes from pediatric solid injury: role of standardized
care guidelines. Curr Opin Pediatr 2005; 17(3): 402-406 (Review)
212. Bowman SM, Zimmerman FJ, Christakis DA, Sharar SR, Martin DP.
Hospital characteristics associated with the management of pediatric
splenic injuries. JAMA 2005; 294(20): 2611-2617 (Retrospective cohort,
2851)
213. Davis DH, Localio AR, Stafford PW, Helfaer MA, Durbin DR. Trends in
operative management of pediatric splenic injury in a regional trauma
system. Pediatrics 2005; 115(1): 89-94 (Retrospective review, 3245
patients)
214. Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR.
Impact of pediatric trauma centers on mortality in a statewide system. J
Trauma 2000; 49(2): 237-245 (Retrospective review, 13351 patients)
215. Pratrick DA, Bensard DD, Moore EE, Karrer FM. Nonoperative
management of solid organ injuries in children results in decreased blood
utilization. J Pediatric Surg 1999; 34(11): 1695-1699 (Retrospective review,
161 patients)
*216. Stylianos S, Egorova N, Guice KS, Arons RR, Oldham KT. Variation in
treatment of pediatric spleen injury at trauma centers versus nontrauma
centers: a call for dissemination of American Pediatric Surgical
Association benchmarks and guidelines. J Am Coll Surg 2006; 202(2): 247251 (Retrospective review, 3232 patients)
217. Holmes JH, Wiebe DJ, Tataria M, et al. The failure of nonoperative
management in pediatric solid organ injury: a multiinstitutional
experience. J Trauma 2005; 58: 1309-1313 (Retrospective review, 1880
patients)
218. Omert LA, Salyer D, Dunham CM, Porter J, Silva A, Protetch J.
Implications of the “contrast blush” finding on computed tomographic
scan of the spleen in trauma. J Trauma 2001; 51(2): 272-277 (Retrospective
review, 324 patients)
219. Shanmuganathan K, Mirvis SE, Sover ER. Value of contrast-enhanced CT
in detecting active hemorrhage in patients with blunt abdominal or
pelvic trauma. Am J Roentgenol 1993; 161(1): 65-69 (Retrospective review,
26 patients)
220. Schurr MJ, Fabian TC, Gavant M, Croce MA, Kudsk KA, Minard G,.
Management of blunt splenic trauma: computed tomographic contrast
blush predicts failure of nonoperative management. J Trauma 1995; 39(3):
507-512 (Retrospective review, 309 patients)
221. Wahl WL, Ahrns KS, Chen S, Hemmila MR, Rowe SA, Arbabi S. Blunt
splenic injury: operation versus angiographic embolization. Surgery
2004; 136(4): 891-899 (Retrospective review)
222. Christmas AB, Wilson AK, Manning B, Franklin GA, Miller FB,
Richardson JD, et al. Selective management of blunt hepatic injuries
including nonoperative management is a safe and effective strategy.
Surgery 2005; 138(4): 606-611 (Retrospective review, 561 patients)
223. Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G,t al.
Improved success in nonoperative management of blunt splenic injuries:
embolization of splenic artery pseudoaneurysms. J Trauma 1998; 44(6):
1008-1113 (Retrospective review, 180 patients)
224. Kozar RA, Moore JB, Niles SE, Holcomb JB, Moore EE, Cothren CC, et al.
Complications of nonoperative management of high grade blunt hepatic
injuries. J Trauma 2005; 59(5): 1066-1071 (Retrospective review, 337
patients)
225. Ekeh AP, McCarthy MC, Woods RJ, Haley E. Complications arising from
splenic embolization after blunt splenic trauma. Am J Surg 2005; 189(3):
335-339 (Retrospective review, 284 patients)
226. Schechter NL, Allen DA, Hanson K. Status of pediatric pain control: a
comparison of hospital analgesic usage in children and adults. Pediatrics
1986; 77(1): 11-15 (Retrospective cohort, 180 patients)
227. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency
department analgesia for fracture pain. Ann Emerg Med 2003; 42(2): 197205 (Retrospective review, 2828 patients)
228. Zohar Z, Eitan A, Halperin P, Stolero J, Hadid S, Shemer J, et al. Pain
relief in major trauma patients: an Israeli perspective. J Trauma 2001;
51(4): 767-772 (Survey, 115 responses)
229. Silka PA, Roth MM, Geiderman JM. Patterns of analgesic use in trauma
patients in the ED. Am J Emerg Med. 2002; 20(4): 298-302 (Retrospective
review, 1381 patients)
230. LoVecchio F, Oster N, Strurrman K, Nelson LS, Flashner S, Finger R. et al.
The use of analgesics in patients with acute abdominal pain. J Emerg Med
1997; 15(6): 775-779 (Prospective, randomized, 49 patients)
28
March 2008 • EBMedicine.net
231. Thomas S, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN,et al.
Effects of morphine analgesia on diagnostic accuracy in emergency
department patients with abdominal pain: a prospective, randomized
trial. J Am Coll Surg 2003; 196(1): 18-31 (Prospective, double-blind,
randomized, 74 patients)
232. Streck CJ, Lobe TE, Pietsch JB, Lovvorn HN 3rd. Laparoscopic repair of
traumatic bowel injury in children. J Pediatr Surg 2006; 41(11): 1864-1869
(Retrospective review, 50 patients)
233. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg
2000; 87(11): 1480-1493 (Review)
234. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg
2000; 87: 1480-1493 (Review)
235. Renz BM, Feliciano DV. The length of hospital stay after an unnecessary
laparotomy for trauma: a prospective study. J Trauma 1996; 40(2): 187-190
(Retrospective review, 254 patients)
236. Streck CJ, Lobe TE, Pietsch JB, Lovvorn HN 3rd. Laparoscopic repair of
traumatic bowel injury in children. J Pediatr Surg 2006; 4(11)1: 1864-1869
(Retrospective review, 50 patients)
237. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD,
Champion HR, et al. Organ injury scaling: spleen, liver, kidney. J Trauma
1989; 29(12): 1664-1666 (Review)
238. Nwomeh BC, Nadler EP, Meza MP, Bron K, Gaines BA, Ford HR.
Contrast extravasation predicts the need for operative intervention in
children with blunt splenic trauma. J Trauma 2004; 56(3): 537-541
(Retrospective review, 343 patients)
239. Lutz N, Mahboubi S, Nance ML, Stafford PW. The significance of
contrast blush on computed tomography in children with splenic
injuries. J Pediatr Surg 2004; 39(3): 491-494 (Retrospective review, 133
patients)
240. Coutier DR, Baird TB, Gromley P, et al. Pediatric splenic injuries with a
contrast blush: successful nonoperative management without
angiography and embolization. J Pediatr Surg 2004; 39(6): 969-971
(Retrospective review, 107 patients)
241. Willmann JK, Roos JE, Platz A, Pfammatter T, Hilfiker PR, Marincek B, et
al. Multidetector CT: Detection of active hemorrhage in patients with
blunt abdominal trauma. AJR Am J Roentgenol 2002; 179(2): 437-442
(Retrospective review, 165 patients)
242. Cox CS Jr, Geiger JD, Liu DC, et al. Pediatric blunt abdominal trauma:
role of computed tomography vascular blush. J Pediatr Surg 1997; 32:
1196-1200 (Case series, 5 patients)
243. Sivit CJ, Peclet MH, Taylor GA. Life-threatening intraperitoneal
bleeding: demonstration with CT. Radiology 1989; 17(2): 430-432 (Case
report)
244. DiGiacomo JC, McGonigal MD, Haskal ZJ, Audu PB, Schwab CW.
Arterial bleeding diagnosed by CT in hemodynamically stable victims of
blunt trauma. J Trauma 1996; 40(2): 249-252 (Case report)
245. Yao DC, Jeffrey RB Jr, Mirvis SE, Weekes A, Federle MP, Kim C, et al.
Using contrast-enhanced helical CT to visualize arterial extravasation
after blunt abdominal trauma: incidence and organ distribution. AJR Am
J Roentgenol 2002; 178(1): 17-20 (Prospective, 565 patients)
246. Taylor GA, Kaufman RA, Sivit CJ. Active hemorrhage in children after
thoracoabdominal trauma: clinical and CT features. AJR Am J Roentgenol
1994; 162(2): 401-404 (Case series, 7 patients)
247. Strouse PJ, Close BJ, Mayshall KW, Cywes R. CT of bowel and
mesenteric trauma in children. Radiographics 1999; 19(5): 1237-1250
(Review)
248. Fang JF, Chen RJ, Wong YC, Lin BC, Hsu YB, Kao JL, et al. Pooling of
contrast material on computed tomography mandates aggressive
management of blunt hepatic injury. Am J Surg 1998; 176(4): 315-319
(Retrospective review, 194 patients)
249. Wong YC, Wang LJ, Fang JF, Chen CJ, Lin BC, Chen RJ. Perisplenic
extravasation of contrast medium on enhanced helical computed
tomography: a reliable indicator for early surgical management in blunt
splenic injuries. Chang Gung Med J 2002; 25(6): 381-387 (Retrospective
review, 80 patients)
250. Gandhi RR, Keller MS, Schwab CW, Stafford PW.Pediatric splenic injury:
pathway to play? J Pediatr Surg 1999; 34(1): 55-59 (Prospective cohort, 49
patients)
251. Bond SJ, Eichelberger MR, Gotschall CS, Sivit CJ, Randolph JG.
Nonoperative management of blunt hepatic and splenic injury in
children. Ann Surg 1996; 223(3): 286-289 (Retrospective review, 179
patients)
252. Eubanks JW III, Meier D, Hicks B, Joglar J, Guzzetta PC. Significance of
“blush” on computed tomography scan in children with liver injury. J
Pediatr Surg 2003; 38(3): 363-366 (Retrospective review, 105 patients)
253. Sclafini SJ, Baker CC, Scalea T, Phillips TF, Duncan AO. Blunt splenic
injuries: nonsurgical treatment with CT, arteriography, and transcatheter
arterial embolization of the splenic artery. Radiology 1991; 181(1): 189-196
(Retrospective review, 44 patients)
254. Cogbill TH, Moore EE, Jurkovich GJ, Morris JA, Mucha P Jr, Shackford
SR, et al. Nonoperative management of blunt splenic trauma: a
multicenter experience. J Trauma 1989; 29(10): 1312-1317 (Retrospective
review, 112 patients)
255. Potoka DA, Schall LC, Ford HR. Risk factors for splenectomy in children
with blunt splenic trauma. J Pediatr Surg 2002; 37(3): 294-299
(Retrospective review, 754 patients)
*256. de Laguasie P, Bonnard A, Benkerrou M, Rorlich P, de Ribier A, Aigrain
Y. Pediatric laparoscopic splenectomy: benefits of the anterior approach.
Surg Endosc 2004; 18(1): 80-82 (Retrospective review, 54 patients)
EBMedicine.net • March 2008
257. Esposito C, Corcione F, Ascione G, Garipoli V, Di Pietto F, De Pasquale
M. Splenectomy in childhood. The laparoscopic approach. Surg Endosc
1998; 12(12): 1445-1448 (Case report)
258. Jugenburg M, Haddock G, Freeman MH, Ford-Jones L, Ein SH. The
morbidity and mortality of pediatric splenectomy: does prophylaxis
make a difference? J Pediatr Surg 1999; 34(7): 1064-1067 (Retrospective
review, 264 patients)
259. Sjövall A, Hirsch K. Blunt abdominal trauma in children: risks of
nonoperative treatment. J Pediatr Surg 1997; 32(8): 1169-1174
(Retrospective review, 29 patients)
260. Pryor JP, Stafford PW, Nance ML. Severe blunt hepatic trauma in
children. J Pediatr Surg 2001; 36(7): 974-979 (Retrospective review, 30
patients)
261. Hackan DJ, Potoka D, Meza M, Pollock A, Gardner M, Abrams P, et al.
Utility of radiographic hepatic injury grade in predicting outcome for
children after blunt abdominal trauma. J Pediatr Surg 2002; 37(3): 386-389
(Retrospective review, 152 patients)
262. Landau A, van As AB, Numanoglu AJ, Millar AJ, Rode H. Liver injuries
in children: the role of selective non-operative management. Injury 2006;
37(1): 66-71 (Retrospective review, 311 patients)
263. Cywes S, Rode H, Millar AJ. Blunt liver trauma in children:
nonoperative management. J Pediatr Surg 1985; 20(1): 14-18
(Retrospective review, 23 patients)
264. Karp MP, Cooney DR, Pros GA, Newman BM, Jewett TC Jr. The
nonoperative management of pediatric hepatic trauma. J Pediatr Surg
1983; 18(4): 512-518 (Prospective cross sectional, 17 patients)
265. Gross M, Lynch F, Canty T Sr, Peterson B, Spear R.Management of
pediatric liver injuries: a 13-year experience at a pediatric trauma center.
J Pediatr Surg 1999; 34(5): 811-817 (Retrospective review, 328 patients)
266. Galat JA, Grisoni ER, Gauderer MW. Pediatric blunt liver injury:
establishment of criteria for appropriate management. J Pediatr Surg
1990; 25(11): 1162-1165 (Retrospective review, 41 patients)
267. Bond SJ, Eichelberger MR, Gotschall CS, et al. Nonoperative
management of blunt hepatic and splenic injury in children. Ann Surg
1996; 223: 286-289 (Retrospective review, 179 patients)
268. Sjövall A, Hirsch K. Blunt abdominal trauma in children: risks of
nonoperative treatment. J Pediatr Surg 1997; 32: 1169-1174 (Retrospective
review, 203 patients)
269. Poli ML, Lefebvre F, Ludot H, Bouche-Pillon MA, Daoud S, Tiefin G.
Nonoperative management of biliary tract fistulas after blunt abdominal
trauma in children. J Pediatr Surg 1995; 30(12): 1719-1721 (Case report)
270. Moulton SL, Lynch FP, Hoyt DB, Kitchen L, Pinckney L, Canty TG, et al.
Operative intervention for pediatric liver injuries: avoiding delay in
treatment. J Pediatr Surg 1992; 27(8): 958-963 (Retrospective review, 106
patients)
271. Ciraulo DL, Luk S, Palter M, Cowell V, Welch J, Cortes V, et al. Selective
hepatic arterial embolization of grade IV and V blunt hepatic injuries: an
extension of resuscitation in the nonoperative management of traumatic
hepatic injuries. J Trauma 1998; 45(2): 353-359 (Retrospective review)
272. Smith RS. Nonoperative management of pediatric blunt hepatic trauma.
Am Surg 2001; 67: 138-142 (Retrospective review, 48 patients)
273. Fisher JC, Moulton SL. Nonoperative management and delayed
hemorrhage after pediatric liver injury: new issues to consider. J Pediatr
Surg 2004; 39(4): 619-622 (Case report)
274. Wales PW, Shuckett B, Kim PC. Long-term outcome of non-operative
management of complete traumatic pancreatic transaction in children. J
Pediatr Surg 2001; 36(5): 823-827 (Retrospective review, 10 patients)
275. Jurkovich GJ, Carrico CJ. Pancreatic trauma. Surg Clin North Am 1990;
70(3): 575-593 (Review)
276. Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children:
mechanism of injury. J Trauma 1997; 42: 49-53 (Retrospective review, 26
patients)
277. Takishima T, Sugimoto K, Asari Y, Kikuno T, Hirata M, Kakita A, et al.
Characteristics of pancreatic injury in children: a comparison with such
injury in adults. J Pediatr Surg 1996; 31(7): 896-900 (Case series, 8
patients)
278. Keller MS, Stafford PW, Vane DW. Conservative management of
pancreatic trauma in children. J Trauma 1997; 42(6): 1097-1100
(Retrospective review, 154 patients)
279. Akhrass R, Kim K, Brandt C. Computed tomography: an unreliable
indicator of pancreatic trauma. Am Surg 1996; 62(8): 647-651.259
(Retrospective review, 72 patients)
280. Kim HS, Lee DK, Kim IW, Baik SK, Kwon SO, Park JW, et al. The role of
endoscopic retrograde pancreatography in the treatment of traumatic
pancreatic duct injury. Gastrointest Endosc 2001; 54(1): 49-55
(Retrospective review, 23 patients)
281. Fulcher AS, Turner MA, Yelon JA, McClain LC, Broderick T, Ivatury
RR,et al. Magnetic resonance cholangiopancreatography (MRCP) in the
assessment of pancreatic duct trauma and its sequelae: preliminary
findings. J Trauma 2000; 48(6): 1001-1007 (Case series, 10 patients)
282. Chandler C, Waxman K. Demonstration of pancreatic ductal integrity by
endoscopic retrograde pancreatography allows conservative surgical
management. J Trauma 1996; 40(3): 466-468 (Case report)
283. Hall R, Lavelle M, Venables C. Use of ERCP to identify the site of
traumatic injuries of the main pancreatic duct in children. Br J Surg 1986;
73(5): 411-412 (Case report, 2 patients)
284. Nadler EP, Gardner M, Schall LC, Lynch JM, Ford HR. Management of
blunt pancreatic injury in children. J Trauma 1999; 47(6): 1098-1103
(Retrospective review, 51 patients)
29
Pediatric Emergency Medicine Practice©
285. Jobst MA, Canty TG Sr, Lynch FP. Management of pancreatic injury in
pediatric blunt abdominal trauma. J Pediatr Surg 1999; 34(5): 818-823
(Retrospective review, 56 patients)
286. Holmes JH, Wiebe DJ, Tataria M, Mattix K, Mooney, D, Scaife, E. et al.
The failure of nonoperative management in pediatric solid organ injury:
a multiinstitutional experience. J Trauma 2005; 59(6): 1309-1313
(Retrospective review, 1818 patients)
287. Cogbill TH, Moore EE, Morris JA, et al. Distal pancreatectomy for
trauma: a multicenter experience. J Trauma 1991; 31(12): 1600-1606
(Retrospective review, 74 patients)
288. McGahren ED, Magnuson D, Schaller RT, Tapper D. Management of
transected pancreas in children. Aust N Z J Surg 1995; 65(4): 242-246
(Case report, 5 patients)
289. Gentilello LM, Cortes V, Buechtner KJ, Gomez GA, Castro M, Zeppa R.
Whipple procedure for trauma: is duct ligation a safe alternative to
pancreaticojejunostomy? J Trauma 1991; 31(5): 661-668 (Retrospective
review, 13 patients)
290. Heimansohn DA, Canal DF, MaCarthy MC, Yaw PB, Madura JA, Broadie
TA. The role of pancreaticoduodenectomy in the management of
traumatic injuries to the pancreas and duodenum. Am Surg 1990; 56(8):
511-514 (Case series, 6 patients)
291. Huckfeldt R, Agee C, Nichols W, Barthel J. Nonoperative treatment of
traumatic pancreatic duct disruption using an endoscopically placed
stent. J Trauma 1996; 41(1): 143-144 (Case report)
292. Cattaneo SM, Sedlack JD, Kalloo AN, Lillemoe KD. Management of a
pancreatic duct injury with an endoscopically placed stent. Surgery 2004;
135(6): 690-692 (Case report)
293. Richieri JP, Chapoy P, Bertolino JG, Salducci J, Grimaud JC. Endoscopic
retrograde cholangiopancreatography in children and adolescents.
Gastroenterol Clin Biol 1994; 18(1): 21-25 (Retrospective review, 19
patients)
294. Dítè P, Vacek E, Stefan H, Koudelka J, Pozler O, Králová M. Endoscopic
retrograde cholangiopancreatography in childhood. Hepatogastroenterolgy
1992; 39(4): 291-293 (Retrospective review, 19 patients)
295. Çay A, Imamoglu M, Bektafl O, Ozdemir O, Arslan M, Sarihan H.
Nonoperative treatment of traumatic pancreatic duct disruption in
children with an endoscopically placed stent. J Pediatr Surg 2005; 40(12):
e9-E12 (Case report)
296. Canty TG Sr, Weinman D. Treatment of pancreatic duct disruption in
children by an endoscopically placed stent. J Pediatr Surg 2001; 36(2):
345-348 (Case report, 2 patients)
297. Bosman-Vermeeren JM, Veereman-Wauters G, Broos P, Eggermont E.
Somatostatin in the treatment of a pancreatic pseudocyst in a child. J
Pediatr Gastroentol Nutr 1996; 23(4): 422-425 (Case report)
298. Mulligan C, Howell C, Hatley R, Martindale R, Clark J. Conservative
management of pediatric pancreatic pseudocyst using octreotide acetate.
Am Surg 1995; 61(3): 206-209 (Case report, 2 patients)
299. Ford EG, Hardin WD, Mahour GH, Woolley MM. Pseudocysts of the
pancreas in children. Am Surg 1990; 56(6): 384-387 (Review)
300. Ladd AP, West KW, Rouse TM, Scherer LR 3rd, Rescorla FJ, Engum SA, et
al. Surgical management of duodenal injuries in children. Surgery 2002;
132(4): 748-753 (Retrospective review, 12 patients)
301. Shilyansky J, Pearl RH, Kreller M, Sena LM, Babyn PS. Diagnosis and
management of duodenal injuries in children. J Pediatr Surg 1997; 32(6):
880-886 (Retrospective review, 27 patients)
302. Ginzburg E, Carrille EH, Sosa JL, Hertz J, Nir I, Martin LC. Pyloric
exclusion in the management of duodenal trauma: is concomitant
gastrojejunostomy necessary? Am Surg 1997; 63(11): 964-966
(Retrospective review, 45 patients)
303. Corley RD, Norcross WJ, Shoemaker WC. Traumatic injuries to the
duodenum. Ann Surg 1975; 181(1): 92-98 (Retrospective review, 98
patients)
304. Vaughan GD 3rd, Frazier OH, Graham DY, Mattox KL, Petmecky FF,
Jordan GL Jr. The use of pyloric exclusion in the management of severe
duodenal injuries. Am J Surg 1977; 134(6): 785-790 (Retrospective review,
75 patients)
305. Bensard DB, Beaver BL, Besner GE, Cooney DR. Small bowel injury in
children after blunt abdominal trauma: is diagnostic delay important? J
Trauma 1996; 41(3): 476-483 (Case series, 9 patients)
306. Cobb LM, Vincour CD, Wagner CW, et al. Intestinal perforation due to
blunt trauma in children in an era of increased nonoperative treatment. J
Trauma 1986; 26(5): 461-463 (Retrospective review, 12 patients)
307. Newman K, Bowman L, Eichelberger M, Gotschall CS, Taylor GA,
Johnson DL, et al. The lap belt complex: intestinal and lumbar spine
injury in children. J Trauma 1990; 30(9): 1133-1140 (Retrospective review,
29 patients)
308. Asburn H, Irani H, Roe E, Bloch JH. Intra-abdominal seatbelt injury. J
Trauma 1991; 30(2): 189 (Case series, 8 patients)
309. Anderson PA, Rivara FP, Maier RV, Drake C. The epidemiology of
seatbelt-associated injuries. J Trauma 1991; 31(1): 60 (Retrospective
review, 303 patients)
310. Mercer S, Legrand L, Stringel G, Soucy P. Delay in diagnosing
gastrointestinal injury after blunt abdominal trauma in children. Can J
Surg 1985; 28(2): 138 (Retrospective review, 12 patients)
311. Slavin RE, Borzotta AP. The seromuscular tear and other intestinal
lesions in the seatbelt syndrome: a clinical and pathological study of 29
cases. Am J Forensic Med Pathol 2002; 23(3): 214-222 (Retrospective
review, 29 patients)
312. Grosfeld JL, Rescorla FJ, West KW, Vane DW. Gastrointestinal injuries in
childhood: analysis of 53 patients. J Pediatr Surg 1989; 24(6): 580-583
(Retrospective review, 53 patients)
Pediatric Emergency Medicine Practice©
313. Kovacs GZ, Davies MR, Saunders W, Fonseca J, Gose C. Hollow viscous
rupture due to blunt trauma. Surg Gynecol Obstet 1986; 163(6): 552-554
(Retrospective review, 56 patients)
314. Albanese CT, Meza MP, Gardner MJ, Smith SD, Rowe MI, Lynch JM. Is
computed tomography a useful adjunct to the clinical examination for
the diagnosis of pediatric gastrointestinal perforation from blunt
abdominal trauma in children? J Trauma 1996; 40(3): 417-421
(Retrospective review, 30 patients)
315. Allen GS, Moore FA, Cox CS Jr, et al. Hollow visceral injury and blunt
trauma J Trauma 1998; 45(1): 69-78 (Retrospective review, 35 patients)
316. Ciftci AO, Tanyel FC, Salman AB, Büyükpamukcu N, Hiçsönmez A.
Gastrointestinal tract perforation due to blunt abdominal trauma. Pediatr
Surg Int 1998; 13(4): 259-264 (Retrospective review, 35 patients)
317. Jerby BL, Attori RJ, Morton D Jr. Blunt intestinal injury in children: the
role of the physical examination. J Pediatr Surg 1997; 32(4): 580-584
(Retrospective review, 32 patients)
318. Moss RL, Musemeche CA. Clinical judgment is superior to diagnosis
tests in the management of pediatric small bowel injury. J Pediatr Surg
1996; 31(8): 1178-1182 (Retrospective review, 48 patients)
319. Brown RA, Bass DH, Rode H, et al. Gastrointestinal tract perforation in
children due to blunt abdominal trauma. Br J Surg 1992; 79: 522-524
(Retrospective review, 29 patients)
320. Schimpl G, Schmidt B, Sauer H. Isolated bowel injury in blunt
abdominal trauma in childhood. Eur J Pediatr Surg 1992; 2(6): 341-344
(Retrospective review, 21 patients)
321. Canty TG Sr, Canty TG Jr, Brown C. Injuries of the gastrointestinal tract
from blunt trauma in children: a 12-year experience at a designated
trauma center. J Trauma 1999; 46(2): 234-240 (Retrospective review, 79
patients)
322. Emanuel B, Zlotnik P, Raffensperger JG. Perforation of the
gastrointestinal trauma in infancy and childhood. Surg Gynecol Obstet
1978; 146(6): 926-928 (Retrospective review, 88 patients)
323. Stassen NA, Lukan JK, Carillo EH, Spain DA, Richardson JD,.
Abdominal seat belt marks in the era of focused abdominal sonography
for trauma. Arch Surg 2002; 137(6): 718-722 (Retrospective review, 23
patients)
324. Hulka F, Mullins RJ, Leonardo V, Harrison MW, Silberberg P. Significance
of peritoneal fluid as an isolated finding on abdominal computed
tomographic scans in pediatric trauma patients. J Trauma 1998; 44(6):
1069-1072 (Retrospective review, 259 patients)
325. Jamieson DH, Babyn PS, Pearl R. Imaging gastrointestinal perforation in
pediatric blunt abdominal trauma. Pediatr Radiol 1996; 26: 188-194
(Retrospective review, 43 patients)
326. Sivit CJ, Eichelberger MR, Taylor GA. CT in children with rupture of the
bowel caused by blunt trauma. Am J Roentgenol 1994; 163(5): 1195-1198
(Retrospective review, 43 patients)
327. Beirele EA, Chen MK, Whalen TV, Doolin EJ. Free fluid on abdominal
computed tomography scan after blunt trauma does not mandate
exploratory laparotomy in children. J Pediatr Surg 2000; 35(6): 990-992
(Retrospective review, 34 patients)
328. Peters E, LoSasso B, Foley J, Rodarte A, Duthie S, Senac MO Jr. Blunt
bowel and mesenteric injuries in children: do nonspecific computed
tomography findings reliably identify these injuries? Pediatr Crit Care
Med 2006; 7(6): 551-556 (Retrospective review, 2114 patients)
329. Dauterive AH, Flancbaum L, Cox EF. Blunt intestinal trauma. A modernday review. Ann Surg 1985; 201(2): 198-203 (Retrospective review, 196
patients)
330. Schenk WG 3rd, Lonchyna V, Moylan JA. Perforation of the jejunum
from blunt abdominal trauma. J Trauma 1983; 23(1): 54-56 (Case series, 13
patients)
331. Burney R, Mueller G, Coon W, Thomas EJ, Mackenzie JR. Diagnosis of
isolated small bowel injury following blunt abdominal trauma. Ann
Emerg Med 1983; 12(2): 71-74 (Retrospective review, 29 patients)
332. Rothenburg S, Moore E, Marx J, Moore FA, McCroskey BL. Selective
management of blunt abdominal trauma in children: the triage role of
peritoneal lavage. J Trauma 1987; 27(10): 1101-1106 (Retrospective review,
16 patients)
333. Fakhry SM, Brownstein M, Watts DD, Baker, Christopher C. MD; Oller,
Dale. Relatively short diagnostic delays (< 8 h) produce morbidity and
mortality in blunt small bowel injury: an analysis of time to operative
intervention in 198 patients from a multicenter experience. J Trauma 2000;
48(3): 408-415. (Review 198 patients)
334. Holland AJ, Cass DT, Glasson MJ, Pitkin J. Small bowel injuries in
children. J Pediatr Child Health 2000; 36(3): 265-269 (Retrospective review,
198 patients)
335. Stein JP, Kaji DM, Eastham J, Freeman JA, Esrig D, Hardy BE. Blunt
renal trauma in the pediatric population: indications for radiographic
evaluation. Urology 1994; 44(3): 406-410 (Retrospective review, 48
patients)
336. Brown SL, Haas C, Dinchman KH, Elder JS, Spirnak JP. Radiographic
evaluation of pediatric blunt renal trauma in patients with microscopic
hematuria. World J Surg 2001; 25(12): 1557-1560 (Retrospective review,
1200 patients)
337. Ford EG, Karamanoukian HL, McGrath N, Mahour GH. Emergency
center laboratory evaluation of pediatric trauma victims. Am Surg 1990;
56(12): 752-757 (Retrospective review, 100 patients)
338. Miller RC, Sterioff S Jr, Drucker WR, Persky L, Wright HK, Davis JH. The
incidental discovery of occult abdominal tumors in children following
blunt abdominal trauma. J Trauma 1966; 6(1): 99-106 (Case series, 14
patients)
30
March 2008 • EBMedicine.net
339. Kuzmarov IW, Morehouse DD, Gibson S. Blunt renal trauma in the
pediatric population: a retrospective study. J Urol 1981; 126(5): 648-649
(Retrospective review, 22 patients)
340. Abou-Jaoude WA, Sugarman JM, Fallat ME, Casale AJ. Indicators of
genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J
Pediatr Surg 1996; 31(1): 86-89 (Retrospective review, 100 patients)
341. Nance ML, Lutz N, Carr MC, Stafford PW. Blunt renal injuries in
children can be managed nonoperatively: outcome in a consecutive series
of patients. J Trauma 2004; 57(3): 474-478 (Retrospective review, 101
patients)
342. Ceylan H, Gunsar C, Etensel B, Sencan A, Karaca I, Mir E. Blunt renal
injuries in Turkish children: a review of 205 cases. Pediatr Surg Int. 2003;
19(11): 710-714 (Retrospective review, 205 patients)
343. Lieu TA, Fleisher GR, Mahboubi S, Schwartz JS. Hematuria and clinical
findings as indications for intravenous pyelography in pediatric blunt
renal trauma. Pediatrics 1988; 82(2): 216-222 (Retrospective review, 78
patients)
344. Bass DH, Semple PL, Cywes S. Investigation and management of blunt
renal injuries in children: a review of 11 years’ experience. J Pediatr Surg
1991; 26(2): 196-200 (Retrospective review, 333 patients)
345. Herschorn S, Radomski SN, Shoskes DA, Mahoney J, Hirshberg E, Klotz
L. Evaluation and treatment of blunt renal trauma. J Urol 1991; 146(2):
274-276 (Retrospective review, 126 patients)
346. Mee SL, McAninch JW. Indications for radiographic assessment in
suspected renal trauma. Urol Clin North Am 1989; 16(2):187-192 (Review)
347. Smith EM, Elder JS, Spirnak JP. Major blunt renal trauma in the pediatric
population: is a nonoperative approach indicated? J Urol 1993; 149(3):
546-548 (Retrospective review, 22 patients)
*348. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in
pediatric blunt renal trauma. J Urol 1996; 156(6): 2014-2018 (Retrospective
review, 180 patients)
349. Rance CH, Singh SJ, Kimble R. Blunt abdominal trauma in children. J
Paediatr Child Health 2000; 36(1): 2-6 (Review)
350. Ku JH, Jeon YS, Kim ME, Lee NK, Park YH. Is there a role for magnetic
resonance imaging in renal trauma. Int J Urol 2001; 8(6): 261-267 (Case
series, 12 patients)
351. Margenthaler JA, Weber TR, Keller MS. Blunt renal trauma in children:
experience with conservative management at a pediatric trauma center. J
Trauma 2002; 52(2): 928-932 (Retrospective review, 55 patients)
352. Nguyen MM, Das S. Pediatric renal trauma. Urology 2002; 59(5); 762767 (Retrospective review, 61 patients)
353. Haas CA, Reigle MD, Selzman AA, et al. Use of ureteral stents in the
management of major renal trauma with urinary extravasation: is there a
role? J Endourol 1998; 12(6): 545-549 (Case series, 5 patients)
354. Philpott JM, Nance ML, Carr MC, Canning DA, Stafford PW. Ureteral
stenting in the management of urinoma after severe blunt renal trauma
in children. J Pediatr Surg 2003; 38(7): 1096-1098 (Case report, 2 patients)
355. Russell RS, Gomelsky A, McMahon DR, Andrews D, Nasrallah PF.
Management of grade IV renal injury in children. J Urol 2001; 166(3):
1049-1050 (Retrospective review, 15 patients)
356. Delarue A, Merrot T, Fahkro A, Alessandrini P, Guys JM. Major renal
injuries in children: the real incidence of kidney loss. J Pediatr Surg 2002;
37(10): 1446-1450 (Retrospective review, 14 patients)
357. Wessel LM, Scholz S, Jester I, et al. Management of kidney injuries in
children with blunt abdominal trauma. J Pediatr Surg 2000; 35(9): 13261330 (Retrospective review, 69 patients)
358. Sagalowsky AI, McConnel JD, Peters PC. Renal trauma requiring
surgery: an analysis of 185 cases. J Trauma 1983; 23(2): 128-131
(Retrospective review, 185 patients)
4. Which injuries have not been associated with the
lap belt?
a. Lumbar fracture
b. Liver contusion
c. Small bowel perforation
d. Femur fracture
e. Kidney laceration
5. Which one of the following patients does not
need to be taken to a designated trauma center:
a. PTS = 4
b. GSC = 6
c. PTS = 10
d. RTS = 11
e. RTS = 3
6. The abdominal examination of a child who sustained blunt abdominal trauma is an accurate
assessment tool for detecting intra-abdominal
injury.
a. True
b. False
7. The FAST examination evaluates each of these
areas EXCEPT:
a. The gallbladder fossa
b. Morrison’s pouch
c. Pouch of Douglas
d. Splenorenal recess
e. Subxiphoid area
8. Which modality is the best at detecting and
deciding management for a child who sustained
an intra-abdominal injury?
a. Focused abdominal sonography for trauma
(FAST)
b. Computed tomography (CT)
c. Plain abdominal radiograph
d. Intravenous pyelography (IVP)
e. Diagnostic peritoneal lavage (DPL)
9. The majority of children who sustain an intraabdominal injury will require an exploratory
laparotomy.
a. True
b. False
10. Indications for an exploratory laparotomy after
blunt abdominal trauma in children include all
of the following EXCEPT:
a. Intraperitoneal bladder rupture
b. Peritoneal irritation on examination
c. Hemodynamic instability despite adequate
crystalloid and blood administration
d. Hollow viscous bowel injury
e. Grade IV liver injury
11. Splenectomy is more likely in all of these
patients EXCEPT:
a. Glascow Coma Scale score < 8
b. Injury Severity Score < 15
c. Injury occurred after a motor vehicle collision
d. Hemodynamically unstable
e. Injury occurred after a bicycle accident
CME Questions
1. The most common cause of mortality in children
is trauma.
a. True
b. False
2. All of the following anatomic features predispose children to intra-abdominal injuries
EXCEPT:
a. Smaller size of the child
b. Less fat
c. Strong abdominal wall musculature
d. Incomplete ossification of the ribs
e. Proportionally larger intra-abdominal organs
3. The most common cause of pediatric death from
trauma is from intra-abdominal injuries.
a. True
b. False
EBMedicine.net • March 2008
31
Pediatric Emergency Medicine Practice©
Credit Designation: The Mount Sinai School of Medicine designates this
educational activity for a maximum of 48 AMA PRA Category 1 Credit(s)TM
per year. Physicians should only claim credit commensurate with the extent
of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved
by the American College of Emergency Physicians for 48 hours of ACEP
Category 1 credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been
reviewed by the American Academy of Pediatrics and is acceptable for up to
44 AAP credits. These credits can be applied toward the AAP CME/CPD
Award available to Fellows and Candidate Fellows of the American Academy
of Pediatrics.
Needs Assessment: The need for this educational activity was determined by a
survey of medical staff, including the editorial board of this publication; review
of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and
evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine
physicians, physician assistants, and nurse practitioners.
Goals & Objectives: Upon completion of this article, you should be able to: (1)
demonstrate medical decision-making based on the strongest clinical
evidence; (2) cost-effectively diagnose and treat the most critical ED
presentations; and (3) describe the most common medicolegal pitfalls for
each topic covered.
Discussion of Investigational Information: As part of the newsletter, faculty
may be presenting investigational information about pharmaceutical products
that is outside Food and Drug Administration approved labeling. Information
presented as part of this activity is intended solely as continuing medical
education and is not intended to promote off-label use of any pharmaceutical
product. Disclosure of Off-Label Usage: This issue of Pediatric Emergency
Medicine Practice discusses no off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of Mount Sinai School of Medicine to ensure
objectivity, balance, independence, transparency, and scientific rigor in all
CME-sponsored educational activities. All faculty participating in the planning
or implementation of a sponsored activity are expected to disclose to the
audience any relevant financial relationships and to assist in resolving any
conflict of interest that may arise from the relationship. Presenters must also
make a meaningful disclosure to the audience of their discussions of
unlabeled or unapproved drugs or devices.
In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty
for this CME activity were asked to complete a full disclosure statement. The
information received is as follows: Dr. Muñiz, Dr. Vella, and Dr. Whiteman
report no significant financial interest or other relationship with the
manufacturer(s) of any commercial product(s) discussed in this educational
presentation.
Method of Participation:
• Print Subscription Semester Program: Paid subscribers with current and
valid licenses in the United States who read all CME articles during each
Pediatric Emergency Medicine Practice six-month testing period, complete
the post-test and the CME Evaluation Form distributed with the June and
December issues, and return it according to the published instructions are
eligible for up to 4 hours of CME credit for each issue. You must complete
both the post test and CME Evaluation Form to receive credit. Results will be
kept confidential. CME certificates will be delivered to each participant
scoring higher than 70%.
• Online Single-Issue Program: Current, paid subscribers with current and
valid licenses in the United States who read this Pediatric Emergency
Medicine Practice CME article and complete the online post-test and CME
Evaluation Form at EBMedicine.net are eligible for up to 4 hours of Category
1 credit toward the AMA Physician’s Recognition Award (PRA). You must
complete both the post-test and CME Evaluation Form to receive credit.
Results will be kept confidential. CME certificates may be printed directly
from the Web site to each participant scoring higher than 70%.
Hardware/Software Requirements: You will need a Macintosh or PC with
Internet capabilities to access the website. Adobe Reader is required to
download archived articles.
12. Liver injuries are more likely to necessitate an
exploratory laparotomy than splenic injuries.
a. True
b. False
13. Indications for computed tomography scan for
suspected renal injuries include all of the following EXCEPT:
a. Hematuria < 50 RBC/HPF
b. Severe flank pain after blunt trauma
c. Hematuria after a minor injury
d. Microscopic hematuria with shock
e. Gross hematuria
Free Report:
“Evidence-Based Medicine:
A Guide For Physicians”
Learn how practicing evidence-based medicine
can empower you to provide better patient care
in this free report.
Send an email to [email protected] with the
subject “FREE E-NEWS” to sign up for our free
email newsletter and we’ll email you a copy of
“Evidence-Based Medicine: A Guide For
Physicians.”
Your free e-newsletter will be delivered to your
email twice per month and includes case studies,
medico-legal pitfalls to avoid, conference
updates, job listings, and more. You can easily
opt out at anytime.
Best Of All: It’s Free!
Coming In Future Issues:
Myocarditis
Congenital Heart Disease in Infancy
Initial Assessment and Management of Knee, Ankle and
Wrist Injuries
Physician CME Information
Date of Original Release: March 1, 2008. Date of most recent review: February
10, 2008. Termination date: March 1, 2011.
Accreditation: This activity has been planned and implemented in accordance
with the Essentials and Standards of the Accreditation Council for Continuing
Medical Education (ACCME) through the joint sponsorship of Mount Sinai
School of Medicine and Pediatric Emergency Medicine Practice. The Mount
Sinai School of Medicine is accredited by the ACCME to provide continuing
medical education for physicians.
Pediatric Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.
CEO: Robert Williford
President and Publisher: Stephanie Williford Associate Editor & CME Director: Jennifer Pai
Director of Member Services: Liz Alvarez
Direct all editorial, subscription-related, customer
service, or copyright/reprint questions to:
Subscription Information
EB Medicine
1 year (12 issues) including evidence-based print issues, 48
AMA/ACEP Category 1, AAP Prescribed CME credits, and full
online access to searchable archives and additional CME: $299
1-800-249-5770
Outside the U.S.: 1-678-366-7933
Fax: 1-770-500-1316
5550 Triangle Parkway, Suite 150
Norcross, GA 30092
E-mail: [email protected]
Web Site: ebmedicine.net
1 year institutional/hospital/library rate: $899
Individual issues, including 4 CME credits: $30
(Call 1-800-249-5770 or go to www.empractice.com to order)
Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a
general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for
making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine
Practice is a trademark of EB Practice, LLC. Copyright © 2008 EB Practice, LLC. All rights reserved. No part of this publication may be reproduced in any format
without written consent of EB Practice, LLC.
Pediatric Emergency Medicine Practice©
32
March 2008 • EBMedicine.net