Tummy Trauma: Evaluation and Management of the Injured Child Catherine J. Goodhue, CPNP Pediatric Nurse Practitioner Trauma Program/Division of
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1 Tummy Trauma: Evaluation and Management of the Injured Child Catherine J. Goodhue, CPNP Pediatric Nurse Practitioner Trauma Program/Division of Pediatric Surgery
2 Objectives 1. Discuss common mechanisms of injury in pediatric blunt abdominal trauma and likely subsequent injuries 2. Review common traumatic injuries and their management of both solid and hollow viscera 3. List 5 signs or symptoms that should warrant high index of suspicion for abdominal injury in a child 4. Describe return to sports guidelines for solid organ injury 2
3 4 year old Flipped over handlebars Abrasions to face Bruising on abdomen Joy 3
4 Brittany 7 year old Auto vs. peds Deformity left femur Crying 4
5 Helen 15 year old Kicked in abdomen Continued playing Now nauseous and dizzy Bruise on abdomen 5
6 Isaac 4 year old Motor vehicle crash Altered mental status 6
7 Epidemiology Abdominal Trauma 90% blunt 10% penetrating Impalement Gunshot Stabbing 7
8 Pediatric Differences 8
9 Assessing the Pediatric Trauma Patient 9
10 In the Trauma Bay History Mechanism of injury GCS/AVPU on scene Any death on scene (MVA) Illicit substances/etoh involved Interventions in field ABCs 10
11 Mechanism of Injury External Forces Internal Forces Blunt vs. Penetrating Forces 11
12 Waddell s Triad - Bumper vs femur and torso on same side - Child is thrown, lands on opposite side of head 12
13 Restraint Devices & Injuries 13
14 In the Trauma Bay History Mechanism of injury GCS/AVPU on scene Any death on scene (MVA) Illicit substances/etoh involved Interventions in field ABCs 14
15 A In the Trauma Bay B C D E 15
16 Pediatric Abdominal Exam Inspection Auscultation Percussion Palpation 16
17 Benign Abdominal Exam - No outward signs - Soft, NTND 17
18 Concerning Abdominal Exam - Tenderness - Ecchymosis - Distension - Rebound - Guarding - Kehr s sign - Blood urethral meatus or rectum - Pelvic instability 18
19 Hemodynamics 19
20 Intra-Abdominal Injuries Hollow Organs (<10%) Solid Organs (>90%) Intraperitoneal Bladder Pancreas? Colon Spleen Small Intestine Liver Stomach Kidneys 20
21 Ultrasound CT Scan Plain Film Imaging the Belly Able to identify fluid Unable to localize or identify solid organ injury Portable and Fast Excellent identification of solid organ injury Questionable sensitivity for hollow viscus injury Takes time Free Air Pelvic Fracture Portable and Fast Also remember: Serial abdominal exams NPO observation 21
22 With permission 22
23 To Scan or Not to Scan?? Streck et al 2012 High-risk Clinical Variables Hypotension Abnormal abdominal exam AST > 200 U/L Microhematuria HCT < 30% Amylase > 100 U/L CLINICAL PREDICTION MODEL Normal systolic Normal abdominal exam AST < 200 U/L HCT > 30% Normal CXR 23
24 Trauma Bay Study Multi-center study Data points collected from Trauma Bay Data points collected 1-2 months after injury 24
25 Re-imaging? 3819 patients with normal CT scan results 16 (0.4%) subsequently diagnosed with intraabdominal injury Physical exams, labs 25
26 Diagnosis Free air Unexplained free fluid on CT Peritonitis Serial Exams Fever Oliguria Tachycardia in absence of bleeding Management Operate Hollow Viscus Injury 26
27 Grading of Splenic Injury American Association for the Surgery of Trauma (AAST)
28 Grading of Liver Injuries American Association for the Surgery of Trauma (AAST)
29 Solid Organ Injury Management Operative Management - Refractory hemorrhagic shock - Concomitant TBI Non-Operative Management - ICU, serial exams (bowel injury), serial Hct - APSA Guidelines Grade plus 1 day 29
30 APSA Guidelines Isolated Spleen or Liver CT GRADE I II III IV ICU stay (days) None None None 1 Hospital stay (days) Pre-discharge imaging None None None None Post-discharge imaging None None None None Activity restriction (weeks) From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 35: ,
31 Revised bedrest: spleen & liver Protocol Grade I/II One night bedrest Grade III-V Two nights bedrest Ambulate after bedrest Hgb/Hct after 4 hours Discharge 31
32 Follow up bedrest protocol 249 patients 199 bedrest: mean grade of injury required transfusion due to solid organ injury Mean bedrest 1.6 days vs 3.6 if had followed current guidelines J Pediatric Surg,
33 APSA Guidelines Activity Restriction CT GRADE I II III IV ICU stay (days) None None None 1 Hospital stay (days) Activity restriction (weeks) From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 35: ,
34 4 year old Flipped over handlebars Abrasions to face Bruising on abdomen Joy 34
35 Brittany 7 year old Auto vs. peds Deformity left femur Crying 35
36 Helen 15 year old Kicked in abdomen Continued playing Now nauseous and dizzy Bruise on abdomen 36
37 Isaac 4 year old Motor vehicle crash Altered mental status 37
38 38
39 References Acker SN, Stewart CL, Roosevelt GE, Partrick DA, Moore EE, Bensard DD. When is it safe to forgo abdominal CT in blunt-injured children? Surgery. 2015;158: Adelgais KM, Kuppermann N, Kooistra J, Garcia M, Monroe DJ, Mahajan P, Menaker J, Ehrlich P, Atabaki S, Kent Page M, Kwok M, Holmes JF on behalf of Intra-Abdominal Injury Study Group of PECARN. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014;265: Dodgion CM, Gosain A, Rogers A, St. Peter SD, Nichol PF, Ostlie DJ. National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol. J Pediatr Surg. 2014;49:
40 References Golden J, Dossa A, Goodhue CJ, Upperman JS, Gayer CP. Admission hematocrit predicts the need for transfusion secondary to hemorrhage in pediatric blunt trauma patients. J Trauma Acute Care Surg. 2015;79: Kerry BT, Rogers AJ, Lee LK, Adelgais K, Tunik M, Blumberg SM, Quayle KS, Sokolove PE, Wisner DH, Miskin ML, Kuppermann N, Holmes JF, PECARN. A multicenter study of the risk of intraabdominal injury in children after normal abdominal computed tomography scan results in the emergency department. Ann Emerg Med. 2013;62:
41 References Le TV, Baaj AA, Deukmedjian A, Uribe JS, Vale FL. Chance fractures in the pediatric population. J Neurosurg Pediatrics. 2011;8: LeeVan, E, Zmora O, Cazzulino F, Burke RV, Zagory J, Upperman JS. Management of pediatric blunt renal trauma: a systematic review. J Trauma Acute Care Surg. In Press. Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M, Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N, Holmes JF, for the Intra-abdominal Injury Study Group of PECARN. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. J Trauma Acute Care Surg. 2014;77:
42 References Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38; Notrica DM. Pediatric blunt abdominal trauma: current management. Curr Opin Crit Care. 2015;21: Notrica DM, Eubanks III JW, Tuggle DW, Maxson RT, Letton RW, Garcia NM, Alder AC, Lawson KA, St. Peter SD, Megison S, Garcia- Filion P. Nonoperative management of blunt liver and spleen injury in children: evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015;79: Safavi A, Skarsgard ED, Rhee P, Zangbar B, Kulvatunyou, Tang A, O Keeffe T, Friese RS, Joseph B. Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury: a national trauma data bank analysis. J Pediatr Surg
43 References Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr Opin Pediatr. 2012;24: St. Peter SD, Sharp SW, Snyder CL, Sharp RJ, Andrews WS, Murphy JP, Islan S, Holcomb GW, Ostlie DJ. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2011;46: St. Peter SD, Aguayo P, Juang D, Sharp SW, Snyder CL, Holcomb GW, Ostlie DJ. Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2013;48: Streck CJ, Jewett BM, Wahlquist AH, Gutierrez PS, Russell WS. Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model? J Trauma Acute Care Surg. 2012;73:
44 References Stylianos and the APSA Trauma Committee. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg. 2000;35: Wisner DH, Kuppermann N, Cooper A, Menaker J, Ehrlich P, Kooistra J, Mahajan P, Lee L, Cook LJ, Yen K, Lillis K, Holmes JF. Management of children with solid organ injuries after blunt torso trauma. J Trauma Acute Care Surg. 2015;79:
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