1 / 29

Paediatric Abdominal Trauma

Paediatric Abdominal Trauma. UPDATE ON BURNS MANAGEMENT IN CHILDREN. UPDATE ON BURNS MANAGEMENT IN CHILDREN. LA Hodsdon Oct 09. Considerations. Incidence Type Anatomical Considerations History & Examination Diagnostic Modalities Suggested Investigative Approaches . Incidence:.

tejano
Télécharger la présentation

Paediatric Abdominal Trauma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related