II. Precautions

  1. See Pediatric Trauma
  2. Children hide hemodynamic instability from Hemorrhage
    1. Children compensate even with Massive Hemorrhage until they precipitously, hemodynamically collapse
  3. Children are higher risk for serious injury following blunt Abdominal Trauma
    1. Compact torso with large organ to body mass ratios (concentrated in a tight Abdomen)
    2. Large organs not fully protected by rib margin, and minimal abdominal fat and musculature
  4. Communication challenges
    1. Preverbal children
    2. Crying or fearful
    3. Adolescents may not be forthcoming of all aspects of injury
  5. Consider Nonaccidental Trauma
    1. Findings not consistent with history of injury

III. History

  1. Mechanism of injury
  2. Restraints or protective equipment
  3. Site of impact (e.g. handlebar injury to the duodenum)
  4. Underlying conditions
    1. Bleeding Disorder (e.g. Hemophilia)
    2. Splenomegaly (e.g. Mononucleosis)
    3. Weak or absent abdominal muscles (e.g. Eagle-Barrett Syndrome)

V. Signs: Higher Risk Findings

  1. See Pediatric Trauma
  2. Low systolic Blood Pressure
    1. Ominious finding that may herald imminent cardiovascular collapse
    2. See Pediatric Vital Signs
  3. Kehr Sign
    1. Left Shoulder Pain referred from left upper quadrant and splenic region
  4. Decreased mental status
  5. Seat Belt Sign
    1. Erythema, Ecchymosis or abrasion across the Abdomen secondary to the Seat Belt restraint
    2. Mildly associated (RR 1.6) with intraabdominal hollow viscus injury (but not solid organ injury)
    3. Intraabdominal injuries in 5.7% of children without Abdominal Pain, tenderness (2% required surgery)
    4. Mahajan (2015) Acad Emerg Med 22(9): 1034-41 [PubMed]
  6. Peritoneal signs (abdominal distention, guarding, rebound, rigidity)
  7. Pelvic instability
  8. Femur Fracture
  9. Abdominal tenderness or pain
    1. Present in most children with Abdominal Trauma and typically non-specific
    2. Correlate with other abdominal findings
    3. Abdominal Pain and tenderness Test Sensitivity for intraabdominal injury drops with GCS
      1. Test Sensitivity 79% for GCS 15
      2. Test Sensitivity 51-57% for GCS 14
      3. Test Sensitivity 32-37% for GCS 13
      4. Adelgais (2014) J Pediatr 165(6): 1230-5 [PubMed]

VI. Labs: Higher Risk Findings

  1. Serum Lipase increased
  2. Increased transaminase Liver Function Tests
    1. AST >200
    2. ALT >125
  3. Hematocrit <30% (initial on presentation)
  4. Urinalysis with Microscopic Hematuria (or certainly Gross Hematuria)
    1. Urine Red Blood Cells (urine RBC) >5 rbc/hpf
      1. Otherwise well appearing child with benign exam
        1. Consider renal Ultrasound (or FAST Exam)
        2. Observe and repeat Urinalysis
      2. Other physical findings or lab abnormalities suggesting renal injury
        1. CT Abdomen
    2. Urine catheterization typically yields <5 rbc/hpf
      1. Sklar (1986) Am J Emerg Med 4(1): 14-6 [PubMed]
  5. Other testing to consider
    1. Urine Pregnancy Test (or serum Qualitative hCG)

VII. Imaging

  1. FAST Exam
    1. Helpful if positive (esp. hemoperitoneum)
    2. High False Negative Rate in children
      1. Of those with significant solid organ injury on CT Abdomen, 33% had no free fluid on FAST Exam
      2. Scaife (2013) J Pediatr Surg 48(6): 1377-83 [PubMed]
  2. CT Abdomen and Pelvis (with IV Contrast but no Oral Contrast)
    1. See Pediatric Blunt Abdominal Trauma Decision Rule for indications
    2. See CT-associated Radiation Exposure for risks
    3. Normal CT in blunt Abdominal Trauma is reassuring
      1. Negative Predictive Value: 99.8% for significant intraabdominal injury
      2. Lower Test Sensitivity for pancreatic injury or bowel injury
      3. Misses 2 cases in 1000 of intraabdominal injury requiring immediate intervention
      4. Misses 5 cases in 1000 of intraabdominal injury overall
      5. Kerrey (2013) Ann Emerg Med 62(4):319-26 +PMID:23622949 [PubMed]

VIII. Differential Diagnosis

  1. Early presentations
    1. Hemorrhagic Shock
    2. Liver Laceration
    3. Splenic Rupture
    4. Diaphragmatic Rupture
    5. Duodenal or jejunal Laceration (esp. handlebar injury)
    6. Pancreatic Laceration
    7. Bowel injury
  2. Delayed presentations
    1. Pancreatic Pseudocysts
      1. Surgery indicated for large cysts (>5 cm), Pancreas rupture, Hemorrhage, infection or gastric outlet obstruction
    2. Duodenal hematoma
      1. May present as Small Bowel Obstruction (confirmed with CT Abdomen)
      2. Nonoperative management with gastrointestinal decompression
    3. Hematobilia
      1. Presents up to 4 weeks after injury with Biliary Colic, Obstructive Jaundice and Upper GI Bleeding
      2. Confirmed with CT Abdomen and managed surgically

IX. Evaluation

  1. CT Imaging indications
    1. See Pediatric Blunt Abdominal Trauma Decision Rule
    2. Abnormal lab testing (e.g. AST, ALT, Lipase, UA)
  2. Hemodynamic instability findings indicating surgical intervention
    1. Altered Mental Status
    2. Significant Tachycardia
    3. Hypotension
    4. Capillary Refill prolonged
    5. Pallor
    6. Decreased urine output
    7. Altered pulse quality (e.g. weak and thready)
    8. Unresponsive to IV fluids
    9. Unresponsive to Blood Transfusions (esp. >40 ml/kg)

X. Management

  1. Blunt Abdominal Trauma (>90% of cases)
    1. Initial evaluation
      1. Trauma Primary Survey and Trauma Secondary Survey
      2. Focused Assessment with Sonography for Trauma (FAST Exam)
      3. Pediatric Blunt Abdominal Trauma Decision Rule
    2. Stable child with a negative FAST Exam and a negative decision rule
      1. Consider observation and serial abdominal exams
    3. Unstable child, positive FAST Exam or positive decision rule
      1. Consult surgery
      2. Consider CT Abdomen and Pelvis
  2. Penetrating Trauma (<10% of cases)
    1. Unstable patients
      1. Emergent exploratory laparotomy
    2. Stable patients
      1. Carefully explore local wounds for peritoneal perforation
      2. Consider Abdominal CT with IV contrast
      3. Consider selective laparoscopy of penetrating wounds

XI. Disposition: Indications for discharge

  1. Benign exam with reassuring evaluation (labs, decision rules) or
  2. Definitive testing (e.g. CT Abdomen) negative and serial exams, Vital Signs reassuring or
  3. Observation for 4 hours with reassuring serial examinations (and possibly serial labs)
    1. Observation duration is not evidence based

XII. References

  1. Kupperman and Claudius in Majoewsky (2013) EM:Rap 13(7): 1-2
  2. Olympia and Huyler (2017) Crit Dec Emerg Med 31(2): 19-25
  3. Park (2015) Crit Dec Emerg Med 29(8): 2-8
  4. Holmes (2002) Ann Emerg Med 39(5): 500-9 [PubMed]

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