ABDOMINAL TRAUMA in pediatrics part one.

Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.

1. ABDOMINAL TRAUMA By: Dr. Hasan A. Rajab Superviser : Prof. Dr. Ali Egab consultant of pediatric surgery Central Child Teaching Hospital Department of Pediatric Surgery

2. Anatomic considerations that make children more susceptible to abdominal traumatic injury include the following: Compact torso with smaller anterior-posterior diameters with less surface area to dissipate injury force. Liver and spleen that extend below the protective costal margin. Less fat and abdominal musculature to protect intraabdominal structures. Anatomy

3. • Death from injury occurs in one of three time periods (trimodal). • First peak . Within seconds to minutes. Very few can be saved due to severity of their injuries. • Second peak . Within minutes to several hours. Deaths occur due to life-threatening injuries. • Third peak . After several hours to weeks. Deaths from sepsis and multiple organ failure. • The ‘ golden hour ’ refers to the period when medical care can make the maximum impact on death and disability. It implies the urgency and not a fixed time period of 60min. Blunt trauma

4. The advanced trauma life support (ATLS) system • Accepted as a standard for trauma care during the ‘golden hour’ and focuses on the ‘second peak’. • Primary survey ( ABCDEs ) with simultaneous resuscitation is emphasized. • Secondary survey, begin only after primary survey is complete and resuscitation is continuing successfully. • Take history. AMPLE ( A llergy, M edication, P ast medical history, L ast meal, E vents of the incident ). • Perform a head-to-toe physical examination. • Continue reassessment of all vital signs. • Perform specialized diagnostic tests that may be required.

5. What are Signs of abdominal injury in children? Abdominal distention Rebound tenderness Involuntary guarding Rigidity Pelvic instability Abdominal abrasions Seat belt sign (abdominal bruise) after a motor vehicle collision Handlbar mark

6. What are Signs of abdominal injury in children?

7. What are Signs of abdominal injury in children? Shock in children is often manifested by : poor perfusion , with hypotension occurring only after very significant blood loss has occurred. In fact, over half of children requiring blood transfusion for shock are not hypotensive. For hemodynamically unstable children with suspected abdominal injury, the initial assessment includes evaluating their response to transfusion. Crystalloid infusion is limited to 20 mL/kg before initiating transfusion.

8. Traditional resuscitation algorithms were sequentially based on crystalloid followed by red blood cells and then plasma and platelet transfusions and have been in widespread use since the 1970s. No quality clinical data supported this concept. WHY? Due to exacerbation of LETHAL TRIAD the combination of acute coagulopathy , hypothermia , and acidosis seen in exsanguinating trauma patients (fig). Schwartz_s_Principles_of_Surgery_9ed

9. Hypoperfusion leads to decreased oxygen delivery, a switch to anaerobic metabolism, lactate production, and metabolic acidosis. Anaerobic metabolism limits endogenous heat production, exacerbating hypothermia caused by exposure.

10. Shock index (maximum heart rate divided by minimum systolic blood pressure [normal <0.9]) . The pediatric adjusted shock index (SIPA) have a moderate ability to identify children with intra-abdominal injury needing transfusion or other intervention. For SIPA, the cut-off values by age are >1.22 (ages 4–6), >1.0 (ages 7–12), >0.9 (13 years and older).

11. Signs of Child Abuse Discrepancies in history and severity of injury Multiple visits to different hospitals or delayed presentation Different colored bruises indicating recurrent trauma Perioral, perianal, or genital injuries Sharp demarcation of burn injuries indicating intentional scald

12. Management—primary survey • Any patient persistently hypotensive despite resuscitation, for whom no obvious cause of blood loss has been identified by the primary survey, can be assumed to have intra-abdominal bleeding. • If the patient is stable, an emergency abdominal CT scan is indicated . • If the patient remains critically unstable, an emergency laparotomy is usually indicated.

13. Management—secondary survey of the abdomen History • Mechanism of injury. • Prehospital condition and treatment of patient. Physical examination • Inspect anterior & posterior abdomen Look for abrasions, contusions,lacerations , penetrating wounds, distension, evisceration of viscera. • Palpate abdomen for tenderness, involuntary muscle guarding, rebound tenderness, gravid uterus • Auscultate for BS • Percuss to elicit subtle rebound tenderness. • Assess pelvic stability. • Penile, perineum, rectal, vaginal examinations, and examination of gluteal regions.

14. Investigations CBC, GUE , Liver enzymes, S.amylase & lipase Raised serum amylase may indicate small bowel or pancreatic injury. X ray (chest + abd + pelvis) FAST ( Focused abdominal sonography for trauma ) • for four Ps. (Morrison’s pouch, pouch of Douglas (or pelvic), perisplenic , Pleural and pericardium . DPL ( Diagnostic peritoneal lavage ) Useful, when FAST & CT are inappropriate or unavailable. considered positive if contains the following: 5 mL of gross blood Enteric contents >100 000 RBCs per cc >500 WBCs per cc Elevated amylase level

15. Investigations CT The ‘gold standard’ for intra-abdominal diagnosis of injury in the stable patient. The scan can be performed using intravenous contrast. An entirely normal abdominal CT is usually sufficient to exclude intraperitoneal injury. The following points are important when performing CT: ● it remains an inappropriate investigation for unstable patients; ● if duodenal injury is suspected from the mechanism of injury, oral contrast may be helpful; ● if rectal and distal colonic injury is suspected in the absence of blood on rectal examination, rectal contrast may be helpful. Indications Stable patients + signs of trauma Stable + no signs of trauma but AST/ALT or transaminase or hematuria

16. Investigations

17. Investigations Laparoscopy or thoracoscopy Can be used in stable patients with penetrating trauma , to detect or exclude peritoneal penetration and/or diaphragmatic injury. Laparoscopy may be divided into: ●● Screening : exclude a penetrating injury with breach of the peritoneum. ●● Diagnostic : finding evidence of injury to viscera. ●● Therapeutic : used to repair the injury. In most institutions, evidence of penetration requires a laparotomy to evaluate organ injury, as it is difficult to exclude all intra-abdominal injuries laparoscopically. When used in this role laparoscopy reduces the non-therapeutic laparotomy rate. There is no place for laparoscopy in the unstable patient.

18. Indications for resuscitative laparotomy Blunt abdominal trauma >> Unresponsive hypotension despite adequate resuscitation and no other cause for bleeding found. Indications for urgent laparotomy • Blunt trauma with + ve DPL or free blood on ultrasound and an unstable circulatory status. • Blunt trauma with CT features of solid organ injury not suitable for conservative management. • Clinical features of peritonitis. • Any knife injury associated with visible viscera, clinical features of peritonitis, hemodynamic instability, or developing fever/signs of sepsis. free intraperitoneal air or extravasated contrast on imaging • Any gunshot wound.

19. 13 years old male, presented to ED with Hx of RTA before 30 minutes, complains from pain in left side of the abdomen which is sever in nature associated with Lt shoulder pain and nausea. O/E Cofused Pale restlessness Clear chest Abrasive wound about 10 cm in diameter in Lt UQ region Rigid abdomen Lt upper quadrent tenderness PR= 126 bpm SPo2= 93% BP = 85 / 40 mmHg Case study

20. Summary Children are more susceptible to abdominal traumatic injury than adults. The resuscitation of the pediatric trauma patient is guided by fundamental ATLS principles, including the primary (ABCDE), secondary (AMPLE). Unstable patients with concerns for ongoing intra-abdominal hemorrhage go to the OR. Remember the indications of Lapratomy and CT. DON’T forget Signs of child abuse. Shock index DCR

21. References Pediatric Surgery 7th ed 2020 / Holcomb and Ashcrafts Schwartz_s_Principles_of_Surgery_9ed Oxford Handbook of Clinical Surgery

22. Thank you