Jennifer E. Guyther, MD, FACEP, FAAP, Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Maryland School of Medicine, Baltimore.
Jeffrey F. Linzer Sr., MD, FAAP, FACEP, Professor of Pediatrics and Emergency Medicine, Emory University School of Medicine, Attending Physician, Children’s Healthcare of Atlanta at Egleston.
Statement of Financial Disclosure
To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Dietrich (editor in chief), Dr. Guyther (author), Dr. Linzer (peer reviewer), Ms. Behrens (nurse planner), Ms. Mark (executive editor), Ms. Coplin (executive editor), and Mr. Landenberger (continuing education and editorial director) report no relationships with companies related to this field of study.
Acute kidney injury, indicated by an elevated creatine kinase level, occurred in 13% of the pediatric trauma patients in the study by Talving and colleagues.76 Independent risk factors included creatinine kinase concentration > 3000 IU/L, Injury Severity Score ≤ 15, GCS < 9, three or fewer imaging studies with contrast, blunt mechanism of injury, and fluid requirement in the emergency department.76 Patients who are at high risk of developing acute kidney injury need to have aggressive fluid resuscitation and serial measurements of kidney function.
The pancreas is the fourth most injured intra-abdominal organ, accounting for 2-9% of abdominal injuries.77 Blunt trauma squeezes the pancreas against the spine.5 Pancreatic injury in children might have a delayed presentation, even up to several weeks. Patients with pancreatic injury present with abdominal pain, nausea, vomiting, and fever. Complications include fistula formation, pancreatitis, and pseudocysts. Most cases can be managed nonoperatively with bowel rest, nasogastric tube placement, and parenteral nutrition. Ductal injury is a predictor of failure of conservative management.77
Pancreatic enzymes rise slower in children than in adults.3 Initial serum amylase and lipase values are not sensitive at detecting injury.24 The amylase concentration might be normal at first and should be reevaluated if suspicion of injury is high. The peak level of amylase is associated with the development of pancreatic pseudocysts. The lipase concentration also can be checked to exclude amylase originating from the salivary glands. Although lipase is considered more specific for the pancreas, many of the pediatric studies evaluating for pancreatic injuries have used amylase, and only occasionally lipase, as the main laboratory marker for pancreatic injury.78 A normal pancreas on the initial CT scan does not exclude pancreatic injury; the patient might require repeat CT scan, evaluation with ultrasound, or endoscopic retrograde cholangiopancreatography (ERCP). ERCP is the most utilized test when a CT scan is inconclusive.77
Hollow viscus injuries occur in 1-5% of children with abdominal trauma. The jejunum is injured in 30% of these cases and the duodenum in 2-10%. The colon is injured in 2-5% of pediatric cases of blunt trauma. Gastric perforations are rare.5 Intestinal injuries are caused by NAT, handlebar injuries, falls, and MVCs.79 CT has a high false-negative rate for perforation, especially when completed within the first several hours after trauma, so a high level of suspicion based on mechanism of injury is required.80 Unlike solid organ injuries, hollow viscus injuries often require surgical intervention.3 Peritonitis caused by bowel perforation takes time to develop, which can lead to a delay in presentation and diagnosis.80
Patients with duodenal hematomas can present after 24-48 hours with bilious vomiting.5,6 The hematoma can cause partial or complete small bowel obstruction, which normally can be managed conservatively.5,6,79 Hematomas typically develop in the second part of the duodenum.79
The inferior vena cava (IVC) is the most commonly injured intra-abdominal vessel in blunt abdominal trauma, with a 64% mortality rate among patients who present hemodynamically unstable. Seatbelt injuries are directly associated with IVC injuries. The hepatic vein also can be injured, which is typically fatal if hemodynamics are affected. Abdominal venous injuries have a 60% mortality rate overall (a three times greater risk of death compared with isolated arterial injuries).81 Abdominal aortic injuries are rare.6 Their leading cause is an MVC. Aortic injury also is associated highly with thoracic and pelvic injuries.82 Patients with vascular injury require operative management.81
Given the location of the adrenal glands and the protection afforded by other organs, they have a low incidence of injury. The incidence of adrenal injury is similar between adults and children who have sustained blunt abdominal trauma, ranging from 0.15% to 4.95%.83 CT is the best modality for visualizing these injuries. The mortality rate and injury severity are high when this particular injury is encountered, likely due to the force required to damage the gland and the subsequent endocrine deficiency. The right adrenal gland is injured more often than the left, possibly due to increased pressure in the inferior vena cava and compression between the liver and the spine. Patients with bilateral adrenal injuries typically are injured more severely than those with unilateral injuries. All patients with adrenal injuries should be monitored closely. These injuries induce no specific symptoms and commonly are discovered when imaging is performed. For most patients, care is supportive and revolves around the associated injuries. Steroid therapy may be considered for patients with bilateral injuries.83
Pregnancy. Trauma is the leading cause of nonobstetric death during pregnancy. Abdominal trauma conveys an increased risk of placental abruption and abortion.3 In 2013, more than 273,000 girls between the ages of 15 to 19 years gave birth in the United States.84 The pregnant pediatric patient with suspected abdominal trauma requires special considerations. To prevent aspiration, a nasogastric tube should be inserted if the patient has a decreased level of consciousness. When the patient has a gravid uterus, the fetus should be displaced off the inferior vena cava. The fetal heart rate should be monitored, as should viability in general. Laboratory work should include assessment of coagulation factors, fibrinogen, and Rh factor. In Rh-negative patients, a Kleinhaur-Betke test can be requested to determine the amount of anti-D immunoglobulin that should be given. If fetal cells are present in the maternal circulation, multiple doses of anti-D immunoglobulin are required. CT scans should not be deferred solely over concern about fetal radiation — the decision should be based on the condition of the mother. All patients with a viable pregnancy and abdominal trauma should have fetal monitoring for a minimum of four hours.85
Obesity. The pediatric population has not escaped the obesity epidemic: 16.2% of American children have a body mass index (BMI) for age higher than the 95th percentile.86 Little is known about the impact of pediatric obesity on abdominal trauma. Vehicle restraints might not fit obese patients properly, and it is not known if this mismatch might lead to more significant injuries. Obesity makes the physical examination and ultrasound evaluation more difficult.3 Carter et al looked at BMI with regard to thorax and head injuries and concluded that age has a greater impact on injury than either gender or BMI.87 Studies have shown a higher rate of extremity fractures during MVCs in obese children, but more data are needed with regard to the abdomen.88 Incidentally, a recent study in adult patients revealed that a high BMI might be protective against severe injury inflicted by stabbings and might reduce the need for operative intervention.89 This correlation has not yet been studied in children. Several studies have yielded conflicting results regarding the correlation of BMI with intensive care unit stays, ventilator rate, and injury severity scores.86 More information is needed to determine if the obese pediatric trauma patient requires a specialized approach.
Pediatric trauma patients present challenges in the ED and can be anxiety provoking. Key information to obtain about a child suspected of having abdominal trauma includes the mechanism of injury, the treatment that was administered in the field, and the initial vital signs. Management of the patient should proceed similar to that for any trauma patient, with emphasis on fluid resuscitation, pain control, and the abdominal examination. Laboratory evaluation should include hematocrit, AST, ALT, and UA. FAST should be incorporated into the initial examination, because its findings can be very useful in conjunction with those of the physical exam and laboratory testing. (See Figure 5.) Clinical decision scores such as the one developed by Holmes et al or the BATiC score should be given significant weight in decisions regarding CT for a child with abdominal trauma. When the patient is hemodynamically stable, solid organ injuries can be managed mainly conservatively, but viscus perforations likely will require surgical intervention.
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