1. K. Guerra

2. A 10 year old was a rear seat passenger who was wearing a lap belt in a vehicle that was struck from behind while at a red light. He presents to the ED complaining of abdominal and lower back pain. vital signs BP 102/54mmHg, HR 105 bpm, RR 22 bpm. His airway is patent, he is comfortable on RA. Physical examination reveals lumbar spine tenderness and bilateral lower quadrant abdominal tenderness with a band like area of ecchymosis over the lower abdomen. Neurological examination is normal. CBC is WNL. Plain x-ray of lumbar spine is normal and a FAST scan is negative.

3. What is the most appropriate next step in management? discharge home with follow up in 24 hours observe patient in the ED for 4 hours obtain CT scan abdomen obtain KUB of abdomen Perform a DPL

4. discharge home with follow up in 24 hours observe patient in the ED for 4 hours obtain CT scan abdomen obtain KUB of abdomen Perform DPL

5. Seat belt sign is a clue for possible underlying abdominal injury – patient have 3 times greater chance of having an underlying abdominal injury – 13 times as likely to have a gastrointestinal injury It will be unsafe to discharge patient home even after 4 hours observation in ED. Plain radiographs of abdomen are not recommended in the trauma patient. DPL (diagnostic peritoneal lavage) is not indicated in a blunt trauma patient with normal vital signs. DPL no longer has a central role in the management of blunt abdominal trauma.

6. CT scan Reasonably well-supported indications Intubated children undergoing mechanical ventilation Altered mental status Children with spinal cord injuries resulting in loss of abdominal sensation Gross hematuria Abdominal tenderness Persistent complaints of abdominal pain Free fluid on bedside ultrasound FAST examination Abdominal or flank bruising Suspected non-accidental trauma to the abdomen Seat belt mark above the iliac crests Direct blow to the abdomen from bicycle handlebars or kicking

7. Controversial indications Microscopic hematuria Elevated liver transaminases Isolated femur fracture Preverbal children with mild-to-moderate injuries

8. Reasonably well-supported contraindications Persistent hemodynamic instability despite adequate fluid resuscitation* (especially in the setting of a positive FAST scan)—in this case, bypass CT and go to the operating room

9. Historically, CT scanning has not been considered sensitive in identifying mesenteric or bowel injuries. Newer helical CT scanning technology, however, has been reported to have an overall sensitivity of 94% in detecting bowel injury and 96% in detecting mesenteric injury. Radiation exposure has also been raised as a concern with CT scanning, but if proper machine settings are provided for the smaller size of pediatric patients, this risk can be minimized.

10. A 7 year old boy presented to the accident and emergency department with left upper quadrant abdominal pain 30 minutes after a road traffic accident. He had been the only passenger wearing a seat belt in the car, which had been involved in a head-on collision. On admission he was alert with a pulse rate of 90 beats/min, respiratory rate of 22 breaths/min, and a blood pressure of 120/82 mm Hg. Auscultation of the chest was unremarkable and examination of his abdomen revealed mild left upper quadrant tenderness but normal bowel sounds. There was no blood at the anus or the external urethral meatus. An erect chest radiograph did not reveal any free intraperitoneal gas. Computed tomography of his abdomen shows the following:

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12. What is most appropriate next step in patients treatment? laporatomy and splenectomy serial abdominal examinations and CBCs discharge home with 24 hour follow up transfer to a trauma center for further management

13. What is most appropriate next step in patients treatment? laporatomy and splenectomy serial abdominal examinations and CBCs discharge home with 24 hour follow up transfer to a trauma center for further management

14. The spleen is a commonly injured abdominal organ in children who sustain blunt abdominal trauma, and splenic trauma should be suspected in children with left upper quadrant tenderness to palpation, left lower rib fractures, or evidence of left lower chest/abdominal contusion

15. Grade 1: Subcapsular hematoma of less than 10% of surface area or capsular tear of less than 1 cm in depth Grade 2: Subcapsular hematoma of 10%–50% of surface area, intraparenchymal hematoma of less than 5 cm in diameter, or laceration of 1–3 cm in depth and not involving trabecular vessels Grade 3: Subcapsular hematoma of more than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma of more than 5 cm or expanding, or laceration of more than 3 cm in depth or involving trabecular vessels Grade 4: Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen Grade 5: Shattered spleen or hilar vascular injury

16. Because many of these injuries are self-limited in children, the management of splenic trauma has evolved to a point at which stable children are managed with bed rest, frequent examinations, serial hemoglobin monitoring, and close surgical supervision. Splenic preservation is the preferred modality to decrease the risk of postsplenectomy infection. The only absolute indication for performing a splenectomy in children is massive disruption and hemodynamic instability Conservative preservation management of splenic injuries in children has shown full recovery in 90% to 98% of patients.

17. Splenectomy is NOT indicated since patient is hemodynamically stable. Patient should not be discharged or transferred to trauma center. He can be admitted for serial abdominal examinations and CBC under surgical supervision.

18. References Pediatric Emergency medicine Pediatr Clin N Am 53 (2006) 243– 256 www.uptodate.com www.medscape.com