1. Pediatric Blunt Abdominal Trauma Stephen Wegner, MD James E
Pediatric Blunt Abdominal Trauma Stephen Wegner, MD James E.Colletti, MD Donald Van Wie, MD
Intern 林士森

2. Preface
Abdominal trauma is a leading cause of morbidity and mortality in children.
Discussing issues：
Key issues to help for efficiently and successfully evaluate and manage blunt pediatric abdominal trauma.
Select organ trauma
Disposition issues

3. Mechanisms of injury
Motor vehicle collisions and automobile versus pedestrian accidents and falls are associated with the greatest increased risk.
Children only wearing a lap belt restrains, automobile versus bicycle accidents, all-terrain vehicle accidents, handlebar injuries, sports or nonaccidental trauma.
Abdomen-to-handlebar collisions are associated with a high risk of small bowel and pancreatic trauma.

4. Past medical history
Medical conditions that affect children’s neurologic or developmental baseline are important.
Autism, cerebral palsy, or other medical conditions that result in mental or physical handicaps.
Hemophilia
Being anticoagulated or receiving antiplatelet therapy
EB virus infection

5. Physical examination
Abnormality in abdominal PE should be considered an indicator of IAI.
Other comorbid injuries or factors predict abdominal injury.
A negative examination and absence of comorbid injuries do not totally rule out
IAI.

6. Physical examination Holmes and colleagues： Cotton and colleagues：
Abdominal tenderness
Cotton and colleagues：
Abdominal tenderness, ecchymosis, and abrasions as positive findings of IAI.
Isaacman：
Abnormal PE findings plus an abnormal urine analysis to be a highly sensitive screen of IAI.

7. Physical examination Associated comorbid findings/injuries：
Femoral fracture (Holmes)
Low SBP (Holmes)
Decreased mental status
GCS<13：mild indicator of IAI (Holmes)
GCS<10：23% had significant IAI (Beaver)

8. Laboratory findings
The most valuable lab tast include the CBC, liver function tests，and urine analysis.
Amylase, lipase, coagulation studies, genaral chemistries.

9. Laboratory findings

10. Select organ trauma
Spleen and liver are the most commonly injured organ.
Hepatic trauma
Abdominal CT (enhanced) is accurate in localizing the site and extent of liver injuries and providng vital information.
Subcapsular, intrahepatic hematoma, contusion, cascular injury, biliary disruption.
American association for the surgery of trauma liver injury scale

11. Select organ trauma Grade Description I II III IV V VI
Subcapsular hematoma <1cm in maximal thickness, capsular avulsion, superficial laceration<1cm deep, and isolated periportal blood tracking II
Parenchymal laceration 1-3cm deep and parenchymal/subcapsular hematomas 1-3cm thick
III
Parenchymal laceration>3cm deep and parenchymal or subcapsular hematoma >3cm in diameter IV
Parenchymal/subcapsular hematoma >10 cm in diameter, lobar destruction, or devascularization V
Global destruction or devascularization of the liver VI
Hepatic avulsion

12. Select organ trauma Splenic trauma
LUQ abdominal tenderness, l’t lower rib fracture, or evidence of l’t lower chest/abdominal contusion.
managed with bed rest, frequent examination, serial Hb monitoring.
Massive disruption and hemodynamic unstability – absolute surgical indication.
Splenic rupture and EB virus infection.

13. Select organ trauma Grade Description I II III IV V
Subcapsular hematoma < 10% of surface area or capsular tear of < 1cm deep II
Subcapsular hematoma of <10-50% of surface area, intraparenchymal hematoma <5cm in diameter, or laceration of 1-3cm deep and not involve trabecular vesse
III
Subcapsular hematoma >50% surface area or expanding and ruptured and subcapsular or parenchumal hematoma, intraparenchymal hematoma >5cm or expanding, or laceration >3cm deep or involving trabecular vessels IV
Laceration involving segmental or hilar vessels with devascularization >25% of the spleen V
Shattered spleen or hilar vascular injury

14. Select organ trauma Intestinal trauma
Peforation, intestinal hematoma, and mesenteric tears with bleeding.
Seatbelt sign
CT with subtle signs such as bowel wall edema.
Abdominal pain that worsens or persists and persistent emesis must be investigated with serial examinations.

15. Select organ trauma Pancreatic trauma Renal trauma
Falls onto handlebar result in a crush force applied to upper abdomen.
Persistent tenderness should indicate further investigation.
Overall prognosis is good.
Renal trauma
Posterior abdomen and retroperitoneum blunt trauma
Significant flank/abdominal pain and hematuria is indication for CT scan.

16. Management and disposition
Stabilizing treatment with ATLS and PALS.
Immediate fluid resuscitation
CBC,LFTs,UA
Transfusion
Surgical consultation
Hemodynamically stable
Abnormal lab finding  CT scan

17. Length of hospitalization and return to activity
Spleen or liver injury grade
Hospital day
Activity day
Grade I-III
Injury grade +1 day
Injury grade+2weeks
Grade IV
1 day intensive care + injury grade

18. Thanks for your attention！