ABDOMINAL TRAUMA IN CHILDHOOD G Humphrey

North West Major Trauma Network 1 July 2016

IF A DISEASE WERE KILLING OUR CHILDREN IN THE PROPORTIONS THAT ACCIDENTS ARE, PEOPLE WOULD BE OUTRAGED AND DEMAND THAT THIS KILLER BE STOPPED.

• C Everrett Koop

INTRODUCTION

• 90% of trauma admissions and 90% of trauma deaths are due to blunt trauma

• Road Traffic accidents account for 80% of patients

• Non accidental injury accounts for up to 5%

PREDISPOSING FACTORS

• Thin, protuberant abdominal wall

• Little pre peritoneal and retro peritoneal fat

• Increased compliance of rib margin

• Liver partially exposed

• Bladder an abdominal organ

• Short stature so abdomen closer to site of impact

FREQUENCY OF VISCERAL INJURY

• Blunt abdominal trauma is present in up to 80% of children with multiple injuries

• Renal injury accounts for approximately 60%

• Liver injury 40%

• Splenic injury 16%

• Pancreatic injury 7%

• Bowel injury 4.5%

• Bladder injury <1%

• Diaphragmatic injury <1%

KEY LEARNING POINT 1

• The key is to Suspect Abdominal Injury in any child who presents with trauma to the torso no matter how minor it may be

ASSOCIATION OF BLUNT ABDOMINAL TRAUMA WITH MECHANISM OF INJURY

Mechanism Minor trauma

Blunt trauma

Head injury/neurological impairment

Lap belt

Bicycle handle bar Pelvic fracture NON-ACCIDENTAL Chest trauma

Organ Kidney

Significant intra-abdominal injury

Multiple abdominal injury

Intestinal/pancreatic injury/extrahepatic bile duct injury

Pancreatic injury and Abdominal wall hernia Genitourinary

multi-organ injury – duodenum, pancreas, kidney, bowel, liver, spleen

Liver, spleen and diaphragm

Features Underlying congenital anomaly Incidence 30%

17% if GCS <8, 5% if GCS >8

Bruising to anterior abdominal wall

80% if multiple fractures to pelvis, 11% if simple fracture to pelvis Frequently fatal

MANAGEMENT – FOLLOWS APLS GUIDELINES

• A – with c spine

• B – beware associated thoracic injuries – a pneumothorax may cause cardiogenic shock as can myocardial contusion

• C – volume replacement with tranexamic acid – remember to consider the abdomen as a cause of circulatory compromise even in the presence of long bone and pelvic fractures

• D – full neurological assessment plus glucose

• E – remembering that distracting injuries may mean that abdominal injuries are masked

Absence of external evidence in the form of bruising/abrasions does not exclude the abdomen as a potential site of blood loss

KEY LEARNING POINT 2

• Children have good compensatory mechanism therefore signs of loss of circulatory volume occur late Conversely

• Absence of evidence of circulatory failure does not preclude significant visceral injury

IMMEDIATE LAPAROTOMY

• If patient remains haemodynamically unstable having required >40ml/kg volume replacement – a Blood Pressure of <80 in a child <5 or <90 in a child over 5 is evidence of hypovolaemia

• But, beware fractured cervical spine with spinal shock

QUESTIONABLE INDICATIONS FOR IMMEDIATE LAPAROTOMY

• Overt peritonitis – difficult to recognise

• Obvious injury requiring surgical intervention – CXR with ruptured diaphragm, plain film with free gas, penetrating injury, evisceration of organs

INVESTIGATIONS – DEPENDS ON CLINICAL SITUATION

• US

• Unstable patient

• Abdominal organ at risk through MOI

• 20-25% risk of missing splenic injuries

• Difficult if gastric distension

• If free fluid present mandates cross sectional imaging

• ABSENCE of free fluid does not exclude significant injury

• CT – Camp Bastion protocol

• Stable patient

• Should be targeted to reduce exposure to radiation

• Allows evaluation of entire abdominal cavity and thorax

• Localises injured solid viscus 92-98% of the time

• Not reliable at detecting injury to the gut

• Haemorrhage from the liver is the most common cause of death attributable to abdominal injury

• Non –operative treatment of haemodynamic injury standard practise

• Consideration of interventional radiology intervention for active bleeding

• Pneumovax, meningococcal immunisation for splenic injury

SPLEEN AND LIVER INJURY

APSA GUIDELINES - 1

• Grade 1 – 2 day admission to general ward, No further imaging, 3 weeks restriction of activity

• Grade 2 – 3 day admission to general ward, no further imaging, 4 weeks restriction of activity

APSA GUIDELINES 2

• Grade 3 – 4 day admission to general ward, no further imaging, 5 weeks restriction of activity

• Grade 4 – I day admission to ICU, 5 days inpatient stay, no further imaging 6 weeks restriction of activity

GRADE V LIVER INJURY

• High care admission

• Involve experienced hepatobiliary team

• May need interventional radiology for embolization of hepatic artery in order to gain haemodynamic stability

SEQUELAE OF LIVER INJURY

• Delayed haemorrhage 10-38 days post injury

• Liver abscess

• Bile leak – mainly managed by ERCP stenting in conjunction with adult gastroenterologists

• False aneurysm causing upper GI bleeding and colic – managed by embolization

SEQUELAE OF SPLENIC INJURY

• pseudocysts can be huge, cause pain and gastrointestinal symptoms

laparoscopic excision/marsupialization effective

• Pseudo-aneursyms – thought to resolve with time

angiographic embolization effective at preserving splenic parenchyma

PANCREATIC INJURY

• RTA, handle bar injury, play ground injuries

• Consider child abuse

• Abdominal pain, vomiting, tenderness

• Raised amylase

• CT gives best definition

• Conservative vs distal pancreatectomy

SEQUELAE OF PANCREATIC INJURY

• Pseudocysts occur in 38-78% - 50% resolve spontaneously internal drainage – ERCP preferable to percutaneous drain endoscopic cyst-gastrostomy if fail to resolve

• May need NJ tube to feed down stream

• May need TPN and Octreotide

• Manage with adult gastroenterologist

BOWEL INJURY

• EASILY MISSED

• Lap belt and handle bar injury

• Repeated clinical review with high level of suspicion required

• Plain films often not diagnostic

• May have multiple perforations

• May have injury to mesentery with out perforation.

RENAL INJURY 1

• High energy impact

• Proportionately larger and more mobile than in adult

• Loin pain/mass

• Haematuria does not correlate with injury and absence does not preclude injury

• CT allows assessment of function

RENAL INJURY 2

• Renal pedicle injuries (grade IV) are rare - <5%

• Attempted renal salvage with vascular repair is possible but success is poor <5%

• All patients with significant renal injury should have DMSA at 8 weeks and a BP check at 1 year

BLADDER INJURY

• Child’s bladder mainly intra-abdominal

• Pelvic fractures present in significant number BUT can occur in isolation

• Suspect it

• Look for perineal swelling, suprapubic tenderness, dysuria, inability to void

• Gross haematuria usual if child able to pass urine

• CT may show leak of contrast – cystogram may be needed

• Close and drain bladder

• Check adjacent organs not damaged

DIAPHRAGMATIC INURY

• May cause respiratory compromise

• May be identified on CXR

• Diagnosis frequently made at laparotomy for other injuries

• Compliance of ribs implicated as most ruptures are peripheral

• Consider haemo-pneumothorax

• Laparotomy to repair with drainage of thorax post operatively

SUMMARY

• Diagnosis of significant intra abdominal injury requires a high index of suspicion

• Care should follow APLS pathways

• Immediate surgical intervention is extremely rare

• Urgent Imaging should be carried out on all children with a significant mechanism of injury because the child is able to compensate for blood loss and may have minimal symptoms until they decompensate

• Liver and Splenic injuries are nearly always managed conservatively

• Children with Splenic injury should have immunisations against encapsulated organisms