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1 In the Belly of the Whale: Surviving Thoracoabdominal Trauma Debra Esernio Jenssen, MD, FAAP I have no financial disclosures. Objectives Review epidemiology of abusive chest and abdominal trauma. Identify presentations, signs, and symptoms of chest and abdominal trauma. Understand mechanisms of various chest and abdominal injuries. Describe the diagnostic evaluation of these injuries. 1

2 Epidemiology Second leading cause of death due to physical abuse. Average age is older, approximately 2 years Boys outnumber girls 2:1 Approximately 50% mortality rate delay in seeking care misleading histories at presentation delaying appropriate diagnosis Prevalence Visceral (thoracoabdominal) injuries contribute to less than 2% of child abuse injuries Only 1% of hospitalized child abuse victims sustain intra abdominal injuries Ledbetter study 11% of 156 pediatric abdominal trauma were due to abuse 44% of children younger than 4 years were abused Abusive injuries more often involve multiple organs Epidemiology of Abusive Abdominal Trauma Hospitalizations in the US Lane, WG Child Abuse and Neglect 2012;36(2): National Data base of children admitted to hospital in the US using ICD 9 codes AAT higher for infants than any other age group (17.7 case per million in 2006) 25% of all abdominal trauma in children less than 1 y was abusive 2

3 Sites as per Lane study Liver 64% Kidney 19% Stomach/intestines 12% Abdominal injury due to child abuse Barnes PM et al. Lancet 2005 Jul 16 22;366(9481):234 5 Ascertained the incidence of abdominal trauma due to abuse in the UK in children 0 14 years 164 due to accidents 112 road traffic, 52 falls 20 abused 16 were less than 5 years rate 2.33 cases per million children per year in children younger than 5 6 died 11 injured gut (10 small bowel) vs. 5 (all older than 5) injured by a fall Barnes et al Conclusion Small bowel injuries can arise accidentally as a result of falls and road traffic accidents but they are significantly more common in abused children. Therefore, injuries to the small bowel in young children need special consideration, particularly if a minor fall is the explanation. 3

4 Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes Trokel M et al. Child Maltreat 2004 Feb;9(1): This study sought to evaluate injury causes and patient outcomes in young children with abdominal injuries Trokel et al. 972 children 0-4 years were extracted from NPTR Measured hospital utilization days hospitalized intensive care unit use surgery Measured patient outcome in-hospital fatality discharge to rehabilitation facility home rehabilitation home nursing Three most common mechanisms of abdominal injury Motor vehicles (61.27%) Child abuse (15.75%) Falls (13.59%) 4

5 Trokel et al. Patient outcomes were more severe in abused children or those with concomitant central nervous system (CNS) injury. Pediatric abdominal trauma leads to intense use of hospital resources and a high risk of inhospital mortality. Child abuse, compared to falls, is independently associated with a 6 fold increase in in hospital mortality. Organs Chest Esophagus Heart Lungs Abdomen Hollow organs Stomach Small bowel Large bowel Bladder Solid organs Liver Spleen Pancreas Kidneys Adrenals Thorax Trauma Sites Esophagus Rare Most iatrogenic during procedures with underlying disease (atresia, GE reflux) Forced foreign body or caustic ingestion Blunt or penetrating external trauma Heart Contusions Dysrhythmias Lung Forced foreign body Contusions 5

6 Abdominal Trauma Sites Stomach rare May be rupture or gastric hematoma Small Intestine rupture more common 60% jejunum, 30% duodenum, 10% ileum Signs of peritonitis may be first presenting symptom Intramural hematomas of the small bowel Duodenum is very susceptible due to fixation and location over spine Colonic injuries are rare, but reported, lower colon, recto sigmoid perforations consider sexual abuse Abdominal Continued Pancreas Acute pancreatitis, pain, distension, elevation of amylase, lipase Chronic development of pancreatic psuedocyst Liver usually due to direct blows Elevated transaminases may detect occult injury Extensive hepatic injuries can be associated with life threatening hemorrhage Spleen, adrenals, kidneys are rarely associated with abuse but can occur (more likely accidental) Patient and Injury Characteristics in Abusive Abdominal Injuries Trokel M et al. Pediatric Emergen006;22(10) Used the National Pediatric Trauma Registry ( ) 106,135 blunt abdominal injury (excluding MVAs) Children 0 4 years 664 cases analyzed 40.5% suspected abuse 36.6% fall 9.7% struck, not child abuse Trokel, M et al. Pediatric Emergency Care 2006 (22);10:

7 Comparison of abuse cases with other mechanisms of injury P <0.05 Intra abdominal injuries Hollow viscous Pancreatic injury Suspected Child Abuse (n = 262) 92 (77.3%) 37 (66.0%) All other mechanisms (n = 394) 27 (22.7%) 19 (34%) Patient characteristics Mortality Traumatic Brain Injury Undernourishment Age 60 (83.3%) 77 (65.85) 40 (64.5%) 21 (11 32 months) 12 (16.7%) 40 (34.2%) 18 (31.1%) 41 (26 51 months) Specificity of Abuse Injury to both solid and hollow organs highly specific for abuse More likely multiple injuries Small size of a young child s chest and abdomen High mortality Mortality Mortality rate in this population ranges from 45% to 50%, making abdominal trauma the second most common form of fatal child abuse Exsanguination: ruptured blood vessels Shock and sepsis: ruptured hollow organ 7

8 Mechanisms of Injury Crushing of solid organs against vertebral column/thorax Compression of hollow organs against vertebral column Shearing forces due to acceleration/deceleration of mobile structures Blow out (rare) Vulnerability of Young Children Flared ribs Protuberant organs Thin abdominal walls Small size of abdomen More elastic musculature and skeletal structures than adults Less protective fat surrounding pancreas and kidneys History Non offending caregiver may be unaware of the abuse Partial or misleading histories Often report that child fell Often nonspecific: poor appetite, lethargy, vomiting, abdominal discomfort 8

9 Delay in seeking care Clinical Presentation May have concomitant head trauma Often clinically silent chest/abdominal injuries Rarely find bruising Signs of peritonitis (fever, quiet bowel sounds, distension, tenderness) Apnea or seizures may be first symptom Shock Septic shock perforation and contents leak into cavity Hypovolemic shock blood loss Medical Evaluation History Complete physical examination External bruising on chest/abdomen may not be observed. If coexistent head trauma, diagnosis of some abdominal injuries may be delayed. Include careful genital and anal examinations. 9

10 Spectrum of Injuries: External Soft tissue injuries of chest or abdomen. Bruises, especially on posterior aspects, flank Burns Bruises of torso Patterned bruises Genital and buttock bruises Bruises may be correlated with underlying sites of visceral trauma Fractures Esophageal Perforations Clinical Presentations Hematemesis, gagging, choking, poor feeding, respiratory distress, cyanosis, fever Typically the result of forceful insertion of a foreign body into esophagus Radiographs Retropharyngeal, subcutaneous emphysema Mediastinitis common from oral bacteria Esophageal Perforation in Infancy Large abscess Rare Iatrogenic Causes: passing ET, NG vigorous suctioning digitally dislodge an impacted foreign body Abuse: direct penetrating trauma with object or digit Delays may cause sepsis/abscess 10

11 Diagnostic Modalities: Thoracic Injuries Chest x ray: pulmonary contusions and pleural effusions may be seen within hours of injury. Biomarkers: Cardiac Troponin Electrocardiogram: injuries to heart can result in electrical conduction abnormalities Echocardiogram Chest CT Cardiac and Pulmonary Injuries Inflicted blunt trauma to heart and lungs is less common than abdominal trauma Cardiac rupture Mechanism is compression of heart between sternum and spine External physical signs may not be present Fatal commotio cordis (fatal dysrhythmia) secondary to blow to chest during critical time in cardiac cycle Cardiac Injury Cardiac insult can be difficult to detect on clinical examination and is often occult Relatively compliant chest wall in children allows cardiac injury to occur without external or radiographic signs of injury Signs and symptoms of cardiac injury are often non specific and may be attributed to other injuries 11

12 Cardiac Troponin I Bennett BL et al. Pediatric Emergency Care 2011;27(10): Level I Trauma Center Cincinnati Children 1 month 5 years evaluated in ED, had CTnI obtained & at least one of the following: hx of blunt trauma to chest bruises or abrasions to chest rib, sternum, clavicle fractures 7/10 patients had elevated CTnI (levels > 0.04 ng/ml) 2 to 50 x elevated Declined at rate of ng/ml per hour All cardiac exams normal, 1 with low voltage on EKG Gastric Rupture Rare Rapid onset of symptoms caused by pain, gastric spasms, noxious effect of acid Spontaneous gastric rupture probably doesn t occur May be very rare complication of CPR. Gastric rupture leads to sepsis, shock, death Duodenum and other Small Intestine Only 0.3% of all trauma admissions More common in abuse Occurs from crushing or compressing forces trapping gut against spine Duodenum: risk of injury due to central and retroperitoneal (near spine) location May occur from shearing forces during deceleration 12

13 Intramural Hematoma Usually caused by child abuse Mechanisms Compression of bowel against spine Due to firm fixation in retroperitoneum As the hematoma enlarges causes partial or complete obstruction of intestine Delayed presentation as signs of obstruction develop over time Diagnostic tests Liver function tests: AST, ALT, bilirubin Lipase, amylase: may indicate pancreatic injury. CBC elevated WBC seen in acute peritonitis Low hemoglobin due to blood loss Low platelets suggest patient is developing septicemia, shock Abdominal X ray: flat, upright to look for air Contrast Enhanced CT of Abdomen Imaging study of choice Good detection of solid organ injury Detection of free air or free fluid Evaluates the retroperitoneal region Better for small bowel and mesenteric injuries than other modalities Late findings such as pancreatic pseudocyst 13

14 A tool for timing child abuse? Baxter AL et al. Child Abuse & Neglect 2008 (32): Blunt hepatic injuries (lacerations, contusions, hematomas) in non abused victims Trauma registries at 4 study sites children 0 18 years retrospective chart review 176 Children Generally older than abusive victim studies Majority victims of MVC (motor vehicle collisions) Evaluated paired transaminase levels Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) A tool continued Higher levels were associated with more severe injuries In adults ½ life of transaminase level is 24 hours In children, ½ life of transaminase level was faster in the first 12 hours and slower after 36 hours ALT>AST = injury older than 12 hours Persistently stable or increasing levels may indicate complications Utility of Hepatic Transaminases in Abused Children Lindberg et al. Pediatrics 2009;124; Prospective, multicenter, observational study Children < 5 years Had consultation for suspected physical abuse 1272 children had transaminase testing 54/1272 had identified abdominal injuries If either AST or ALT > 80 = accurately predicted abdominal injury 14/54 were clinically occult No abdominal bruising, tenderness, or distention 14

15 Lindberg Conclusion Abdominal injuries are not common but not rare Order an abdominal CT: If AST or ALT > 80 If the victim has abdominal bruising, distention, or tenderness Mildly elevated or normal transaminase levels do not exclude injury Liver Injuries CT is diagnostic imaging choice Follow potential injury by transaminase testing Contusions may be contained by liver capsule or bleeding may occur into peritoneal cavity Most liver injuries are treated nonsurgically Grading Liver Injury 15

16 Pancreas Direct blunt trauma to upper abdomen Pancreas is particularly vulnerable due to central location overlying spine Transection can occur Pancreatitis develops early or late Pseudocysts may develop later Elevated amylase/lipase not reliable indicators of injury Spleen Spleen is very rarely involved in abuse as it has relative protection by ribs Massive bleeding may lead to hypoperfusion and shock Contrast enhanced CT for diagnosis Urinary Tract Kidney and urinary tract are uncommon abusive injuries May be seen with other injuries Adrenal hemorrhage is a marker of significant blunt trauma to the abdomen Adrenal and kidney injuries are more common on right 16

17 Intraperitoneal bladder rupture as an isolated manifestation of nonaccidental trauma Lautz T et al. Pediatr Emerg Care 2009;25(4): year old home alone with stepmother Presents pale, vomiting, and with severe abdominal pain Unknown Cases Conclusion Thoracoabdominal injuries are uncommon in childhood from all causes. A high index of suspicion should be maintained When present, they may be life threatening. May present as a medical problem, bypassing trauma evaluation. Often injuries (especially slow bleeds, hollow organ tears) are survivable if the diagnosis is made in a timely manner Delay in presentation & in seeking medical care, misleading history, presence of other serious injuries, may delay diagnosis resulting in death. 17