Paediatric Abdominal Trauma LA Hodsdon Oct 09 UPDATE ON BURNS MANAGEMENT IN CHILDREN

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

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

Type of Injury: Blunt Abdominal Trauma: – 85% of paeds abdo trauma (US/UK) – > 50 due to MVA’s – Other common causes bicycles, sports, falls, NAI RSA ?% Penetrating Trauma – Likely to be >15%

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

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

History & Examination: Age dependant Often difficult for kids to localise / verbalise FEAR – Often hard to reassure – Fear of unknown / vague concepts – Separation – Fear of Medical Personnel

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

 2004 Poletti et al: Awake, haemodynamically stable (adults): abdo pain, tenderness & peritoneal signs more reliable physical signs & can be found in 90%  BUT significant injuries can be missed  No physical signs ≠ exclude intra-abdominal injury  7.1% pts with normal physical examination = intra-abdominal injuries on CT  Multiple small studies suggest normal examination excludes the need for therapeutic surgery

Plain X-Rays Free Air – Gastric, duodenal bulb & colonic perforation – Only 25-33% of jejunal & ileal perforations have FA – Better viewed on CT Foreign Bodies Projectory Paths

FAST Advantages: – Rapid ID of Intraperitoneal Haemorrhage – Non Invasive – Portable – Rapid (5min FAST) – Widespread (US) therefore not rely on Radiologists – Serial examinations possible – No side effects

FAST Disadvantages: – Not able to image extent of organ damage – Not able to visualise retroperitoneum – Operator dependant – Patient dependent – Can’t differentiate blood from ascites – Can’t pick up contained bleeding

FAST in ABDO Trauma Most studies: – sensitivity for haemoperitonium 86-89% – Depends on required end point (Intra-abdominal Injury / Intra-abdominal Injury requiring ø / Potentially Fatal intra-abdominal Injury) Ollerton et al: U/S & Trauma Management – Changed Mx decisions 32.8% of time – ↓ CT (47  34%) & ↓ DPL (9  1%) Branay et al: U/S key pathway – ↓CT (56  26%) & ↓DPL (17-4%)

FAST: Reliability in Kids: Holmes: 224 kids (mean age 9 yrs) – Prospective – Hypotension (13): 100% sens, 100% spec – All Patients (244): 82% sens, 95% spec Soudack: 313 kids (2months – 17yrs) – Retrospective – 275 Negative FASTs – 73 of Negative FASTs had abdominal signs & CTs: 3 Positive – Parenchymal Injuries, none requiring ø – 92.5% sens, 97.% spec

CT Scan Advantages – Define extent of injury & organ involvement – Non Invasive – Most Accurate S/I for Solid Organ injury – Evaluates retroperitoneum 3 Contrast Studies have 97% sens, 98% spec Velmahos et al achieved similar rates with IVI contrast alone.

CT Scan Disadvantages – Time consuming & unable to monitor patients – Requires IVI Contrast – Requires Sedation in most kids – Can’t visualise pancreas, diaphragm, small bowel or mesentery – Radiation Dose – Brenner et al 1 yr old child: lethal malignancy risk of 1 abdominal CT was ± 1 in 550

CT Scan in Kids High Sensitivity & Specificity for the solid organ pattern common in kids Radiation dose and need for sedation major drawback in kids, so CT scans should be considered not just ordered as ‘routine’

DPL  Rapidly reveals/excludes the abdomen as the source of hypotension  Advantages  May detect Bowel Injury (GIT matter)  Disadvantages  Invasive with complication rate of 0.3%  Operator dependant  Comparatively time consuming (vs. FAST) Widespread replacement by FAST

Other Diagnostic Modalities Local Wound Exploration: – Bedside surgical exploration of tract – Determine whether Peritoneal Violation has taken place – Patient Factors Contrast Studies Angiography ERCP Laparoscopy

Management Questions: Blunt Abdominal Trauma – Trauma vs. Medical component – Single vs. Multisystem trauma – Emergency Laparotomy vs. Dx workup – Single vs. Multiple Intraperitoneal Injury – Expectant vs. Necessary Laparotomy Paediatric patients tolerate expectant management better than adults. If paediatric patient is stable and adequate monitoring is available: normally follow expectant management.

Management Questions: Penetrating Trauma Trauma vs. Medical component Single vs. Multisystem trauma Emergency Laparotomy required? Peritoneal Violation? Intraperitoneal Injury? Stab Wounds – 70% have peritoneal violation but only 25-33% of those require surgery. Expectant: Shaftan 1960’s

Operative vs. Non-operative Management.  Successful: mod – high grade liver / spleen trauma  Failures  considerable morbidity / mortality  Balance between avoiding unnecessary laparotomy & preventing significant morbidity or mortality by waiting too long.  Requirements:  Patient – alert & co-operative, mild-mod MOA  Institution - experienced nursing staff, trauma surgeons, radiologists & facilities for urgent laparotomy

Pitfalls: 1) Hollow Viscera Injuries: missed 2) Increased use of blood products 3) Approach will fail if haemorrhage ≠ respond to Rx angiography + embolization or not abate from solid organs. Time from injury  operation: increase morbidity and mortality.

Resources:  Advances in Abdominal Trauma; J.L. Isenhour, MD, J Marx, MD; Emerg Med Clin N Am 25 (2007) 713–733  Pediatric Major Trauma: An Approach to Evaluation and Management; J.T. Avarello, MD, FAAP, R.M. Cantor, MD, FAAP, FACEP; Emerg Med Clin N Am 25 (2007) 803–836  Rosen’s Emergency Medicine  Emergency Medicine Manual, 6 th Ed; O.John Ma & Davis M Kline  Oxford Handbook of Trauma for Southern Africa; A Nicol & E Steyn