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Paediatric Abdominal Trauma

Paediatric Abdominal Trauma

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Paediatric Abdominal Trauma

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  1. Paediatric Abdominal Trauma UPDATE ON BURNS MANAGEMENT IN CHILDREN UPDATE ON BURNS MANAGEMENT IN CHILDREN LA Hodsdon Oct 09

  2. Considerations • Incidence • Type • Anatomical Considerations • History & Examination • Diagnostic Modalities • Suggested Investigative Approaches

  3. Incidence: • Abdominal Trauma: • 8-10% admissions to Paediatric Trauma Centres • 3rd most frequent cause of death () • MOST COMMON UNRECOGNIZED FATAL INJURY • NAI – 5% admitted with Abdominal Trauma

  4. Type of Injury: • Blunt Abdominal Trauma: • 85% of paeds abdo trauma (US/UK) • > 50 due to MVA’s • Other common causes bicycles, sports, falls, NAI • RSA ?% Penetrating Trauma • Likely to be >15%

  5. Anatomical Considerations: • Solid Organs: proportionally larger & more anterior • Kidneys: larger, more mobile +/- foetal lobulations • Subcutaneous Fat: ↓ • Abdominal Musculature: ↓ • AP Diameter: ↓ • Flexible Cartilaginous Ribcage

  6. Increased Solid Organ Injury • Both Blunt & Penetrating Injury • GIT Trauma not uncommon • Duodenal & Small Bowel haematomas & perforation • Pancreatic injuries • Mesenteric lacerations

  7. History & Examination: • Age dependant • Often difficult for kids to localise / verbalise • FEAR • Often hard to reassure • Fear of unknown / vague concepts • Separation • Fear of Medical Personnel

  8. Haemodynamically stable child - who is alert and co-operative - able to communicate effectively history and examination approach reliability rates of adults

  9. 2004 Poletti et al: Awake, haemodynamically stable (adults): abdo pain, tenderness & peritoneal signs more reliable physical signs & can be found in 90% • BUT significant injuries can be missed • No physical signs ≠ exclude intra-abdominal injury • 7.1% pts with normal physical examination = intra-abdominal injuries on CT • Multiple small studies suggest normal examination excludes the need for therapeutic surgery

  10. Plain X-Rays • Free Air • Gastric, duodenal bulb & colonic perforation • Only 25-33% of jejunal & ileal perforations have FA • Better viewed on CT • Foreign Bodies • Projectory Paths

  11. FAST • Advantages: • Rapid ID of Intraperitoneal Haemorrhage • Non Invasive • Portable • Rapid (5min FAST) • Widespread (US) therefore not rely on Radiologists • Serial examinations possible • No side effects

  12. FAST • Disadvantages: • Not able to image extent of organ damage • Not able to visualise retroperitoneum • Operator dependant • Patient dependent • Can’t differentiate blood from ascites • Can’t pick up contained bleeding

  13. FAST in ABDO Trauma • Most studies: • sensitivity for haemoperitonium 86-89% • Depends on required end point (Intra-abdominal Injury / Intra-abdominal Injury requiring ø / Potentially Fatal intra-abdominal Injury) • Ollerton et al: U/S & Trauma Management • Changed Mx decisions 32.8% of time • ↓ CT (4734%) & ↓ DPL (91%) • Branay et al: U/S key pathway • ↓CT (5626%) & ↓DPL (17-4%)

  14. FAST: Reliability in Kids: • Holmes: 224 kids (mean age 9 yrs) • Prospective • Hypotension (13): 100% sens, 100% spec • All Patients (244): 82% sens, 95% spec • Soudack: 313 kids (2months – 17yrs) • Retrospective • 275 Negative FASTs • 73 of Negative FASTs had abdominal signs & CTs: • 3 Positive – Parenchymal Injuries, none requiring ø • 92.5% sens, 97.% spec

  15. CT Scan • Advantages • Define extent of injury & organ involvement • Non Invasive • Most Accurate S/I for Solid Organ injury • Evaluates retroperitoneum • 3 Contrast Studies have 97% sens, 98% spec • Velmahos et al achieved similar rates with IVI contrast alone.

  16. CT Scan • Disadvantages • Time consuming & unable to monitor patients • Requires IVI Contrast • Requires Sedation in most kids • Can’t visualise pancreas, diaphragm, small bowel or mesentery • Radiation Dose – Brenner et al 1 yr old child: lethal malignancy risk of 1 abdominal CT was ± 1 in 550

  17. CT Scan in Kids • High Sensitivity & Specificity for the solid organ pattern common in kids • Radiation dose and need for sedation major drawback in kids, so CT scans should be considered not just ordered as ‘routine’

  18. DPL • Rapidly reveals/excludes the abdomen as the source of hypotension • Advantages • May detect Bowel Injury (GIT matter) • Disadvantages • Invasive with complication rate of 0.3% • Operator dependant • Comparatively time consuming (vs. FAST) Widespread replacement by FAST

  19. Other Diagnostic Modalities • Local Wound Exploration: • Bedside surgical exploration of tract • Determine whether Peritoneal Violation has taken place • Patient Factors • Contrast Studies • Angiography • ERCP • Laparoscopy

  20. Management Questions:Blunt Abdominal Trauma • Trauma vs. Medical component • Single vs. Multisystem trauma • Emergency Laparotomy vs. Dx workup • Single vs. Multiple Intraperitoneal Injury • Expectant vs. Necessary Laparotomy Paediatric patients tolerate expectant management better than adults. If paediatric patient is stable and adequate monitoring is available: normally follow expectant management.

  21. Management Questions:Penetrating Trauma • Trauma vs. Medical component • Single vs. Multisystem trauma • Emergency Laparotomy required? • Peritoneal Violation? • Intraperitoneal Injury? Stab Wounds – 70% have peritoneal violation but only 25-33% of those require surgery. Expectant: Shaftan 1960’s

  22. Operative vs. Non-operative Management. • Successful: mod – high grade liver / spleen trauma • Failures  considerable morbidity / mortality • Balance between avoiding unnecessary laparotomy & preventing significant morbidity or mortality by waiting too long. • Requirements: • Patient – alert & co-operative, mild-mod MOA • Institution - experienced nursing staff, trauma surgeons, radiologists & facilities for urgent laparotomy

  23. Pitfalls: 1) Hollow Viscera Injuries: missed 2) Increased use of blood products 3) Approach will fail if haemorrhage ≠ respond to Rx angiography + embolization or not abate from solid organs. Time from injury  operation: increase morbidity and mortality.

  24. Resources: • Advances in Abdominal Trauma; J.L . Isenhour, MD, J Marx, MD; Emerg Med Clin N Am 25 (2007) 713–733 • Pediatric Major Trauma: An Approach to Evaluation and Management; J.T. Avarello, MD, FAAP, R.M. Cantor, MD, FAAP, FACEP; Emerg Med Clin N Am 25 (2007) 803–836 • Rosen’s Emergency Medicine • Emergency Medicine Manual, 6th Ed; O.John Ma & Davis M Kline • Oxford Handbook of Trauma for Southern Africa; A Nicol & E Steyn