Management of Blunt and Penetrating Abdominal Trauma in Children

1. Managementof Blunt and Penetrating Abdominal Traumain Children Department of pediatric surgery Kharkov State Medical University

2. Motivation • Trauma is the leading cause of death in the pediatric population, and injuries to the abdomen are the third leading cause of pediatric trauma death, after injuries to the head and thorax. • The abdomen is the most common site of unrecognized fatal injury in pediatric trauma.

3. Errors are still present: • Children often cannot adequately communicate their injuries to physicians • They are better able to compensate for significant injuries, which makes vital signs less helpful in identifying injuries early. Children can lose up to 45% of their total blood volume before showing any changes in blood pressure

4. Mechanisms for Intra-abdominal Trauma • Motor vehicle collisions, pedestrian strucks (50 %) • Falls (up to 45 % in developed countries) • Bumps, assaults • Handlebar injury from bicycle • Sports injuries • Non-accidental trauma (child abuse 5%)

5. The Waddell triad of injuries to head, torso, and lower extremity

6. The mechanism for the development of intestinaland vertebral injuries from lap belts

7. Children are predisposed because: • They are not small adults. • have much more pliable skeletal systems, which helps reduce their risk of fracture but in turn results in decreased protection of internal organs. • The bladder has not yet settled into the pelvis. • Children have less fat and muscle to protect them. Along with the loose attachments of the intestines, these put them at higher risk for deceleration injuries. • Children have a much smaller surface area over which to distribute the force of impact.

8. 1.In the hemodynamically unstable patient with a distended abdomen, immediate operative intervention is indicated after completion of the primary andsecondary surveys. 2.In less critically illpatients, further diagnostic evaluation foran intra- abdominal injury is indicated.

9. Primary survey: Quick, initial patient assessment to identify life-threatening injuries Occurs with active resuscitation Secondary survey: More detailed assessment of injuries

10. Primary Survey • A,B,C,D,E • Every trauma patient should arrive boarded and C-spine immobilized • Collar for school-age/adolescents • Rolls and tape for infants/toddlers • Immediate vitals signs

11. A,B,C,D,Es A = Airway & C-Spine precausions B = Breathing (H/PTX) C = Circulation D = Disability E = Exposure F = Foley catheter unless contraindicated G = Gastric tube unless contraindicated

12. A: Airway & C-Spine Protection • Check for airway patency and clear secretions, blood, foreign bodies, loose teeth • Open: jaw thrust/spinal stabilization • Clear: suction/remove particulate matter • Support: oropharyngeal/nasopharyngeal airway • Establish: orotracheal/nasotracheal intubation* • Maintain: primary/secondary confirmation • Bypass: needle/surgical cricothyroidotomy • Ensure adequate C-spine protection

13. Indications for intubation An airway unsecured because of coma, combativeness, shock, or direct airway burns / trauma requires endotracheal intubation. 1. Airway or breathing compromise (present or predicted) 2. Unprotected airway 3. GCS < 9 4. Combative 5. Uncooperative patients requiring CT, aortography etc.

14. B: Breathing • Check for adequacy of breathing • Effort, breath sounds, oxygenation • Apply oxygen by facemask or blowby • Consider need for intubation • If already intubated confirm ETT position with: • Chest x-ray if available • End tidal CO2 or pedi-cap if available • Oxygen saturation if available • Auscultate the lungs for equal air entry • Take a look with a laryngoscope

15. Breathing/Chest Wall • Ventilation: chest rise/air entry/effort/rate • Oxygenation: central color/pulse oximetry • Support: respiratory distress—NRB mask/respiratory failure—BVM ventilation • Chest wall: ensure integrity/expand lungs • Tension pneumothorax: needle decompression, chest tube* • Open pneumothorax: occlusive dressing, chest tube • Massive hemothorax: volume resuscitation, chest tube Do not wait for confirmatory chest radiograph! NRB, non-rebreather mask; BVM, bag valve mask.

16. C: Circulation • Most common cause of shock in pediatrics = hypovolemia • TBV of child = 80ml/kg • 2 large bore IV’s started • Xmatch or Type and screen ordered • 20 ml/kg IV crystalloid bolus (x 3 then PRBC’s) • Look for obvious and non-obvious sources of bleeding

17. Circulation/External Bleeding • Stop bleeding: direct pressure, avoid clamps; consider arterialtourniquets, topical hemostats • Shock evaluation: pulse, skin CRT, LOC • Blood pressure: avoid over/undercorrection Infant/child: low normal, 70 + (age x 2) mm Hg Adolescent: low normal, 90 mm Hg • Volume resuscitation: Ringer’s lactate (RL), then packed cells Infant/child: 20 mL/kg RL, repeat x 1-2 with 10 mL/PRBCs Adolescent: 1-2 L, repeat x 1-2 with 1-2 units PRBCs

18. D: Disability Pupils reactive? Equal? GCS (modified) or Verbal Score Spontaneously moving? Obvious deformities?

19. Pediatric Verbal Score From American College of Surgeons’ Committee on Trauma. Advanced Trauma Life Support for Doctors (ATLS) Student Manual. 7th ed. Chicago: American College of Surgeons; 2004.

20. Glasgow Coma Scale (GCS) Eye Opening • Spontaneous 4 • To voice 3 • To pain 2 • None 1 Verbal Response (Peds) • Appropriate 5 • Cries, consoles 4 • Persistently irritable 3 • Restless, agitated 2 • None 1 Motor Response • Obeys Commands 6 • Localizes pain 5 • Withdraws to pain 4 • Flexion with pain 3 • Extension to pain 2 • None 1

21. E: Exposure • Assess all surface areas (SBS!) • Log-roll with using spinal precautions • Examine the spine: note step deformities or pain • Assess rectal tone and sensation • Check for vaginal/urethral bleeding • Prevent hypothermia • Keep trauma room warm, use blankets and overhead warmer for infants

22. Primary Survey Goals

23. Secondary Survey Head to toe examination Tetanus status IV antibiotics if necessary AMPLE history: allergies, medications, past medical history, last meal, events surrounding injury

24. Vascular Access - The IO Needle • If unable to secure access in 90 seconds = IO • Provides immediate vascular access when needed • Safe to administer fluids, drugs, blood products • Can be left for up to 72h • Use until more secure vascular access

25. IO: Procedure • 14 to 20 gauge IO needle with stylus • Prepare area in sterile fashion and use local anesthetic • Landmarks: proximal medial aspect of tibial plateau, 1-2cm distal to tuberosity (aiming away from growth plate); distal femur, 1-2cm proximal to superior border of patella • Insert needle at 900 angle to bony surface • Avoid putting hand behind limb where IO inserted • Slowly twist after puncturing the skin until ‘release’ felt • Connect to IV tubing • Secure to skin with tape and gauze

26. IO Insertion http://emedicine.medscape.com/article/940993-overview

27. Tools Available For Abdominal Trauma • Physical exam • X-Rays • Ultrasound (FAST) • DPL • Computerized Tomography (CT) • Magnetic Resonance Imaging (MRI) • Diagnostic Laparoscopy • Exploratory laparotomy

28. The Abdomen is More Than Just the Abdomen • Abdomen: • Intraperitoneal cavity • Clinical exam • FAST • DPL • CT scan • Exploratory laparoscopy • Exploratory laparotomy • Retroperitoneal cavity & pelvis • Pelvic xray • CT scan • Exploratory laparotomy • Thorax (thoracoabdominal injuries) • CXR • Heart & Great Vessels (cardiac box injuries) • Cardiac FAST • CXR • Diaphragm & Bladder (innocent bystanders) • Diagnostic laparoscopy • CT cystogram

29. What Are We Worried About? • Bleeding: • Spleen • Liver • Kidneys • Mesentery • Bowel: • Contamination (rupture), haematoma, mesentery • Bladder: • Intraperitoneal rupture • Diaphragm: • Mainly on the left side

30. Abdominal bruisisng Frequency of Pediatric Blunt Abdominal Injuries • Spleen 37% • Kidney 27% • Liver 18% • Pancreas 2%

31. Physical Examination • Neither sensitive nor specific to rule out intra-peritoneal hemorrhage (Kulenkampff’s, Weinert’s, Rozanov’s “tilting doll” sign) • Excellent to watch for the development of peritonitis (contamination) • Very poor to detect bladder or diaphragmatic injury

32. Physical Examination • Generally unreliable due to distracting injury, spinal cord injury • Look for signs of intraperitoneal injury • abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension • entrance and exit wounds to determine path of injury. • Distention - pneumoperitoneum, gastric dilation, or ileus • Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhage • Abdominal contusions – eg lap belts and bruises • ↓bowel sounds suggests intraperitoneal injuries Rosen’s Emergency Medicine, 7th ed. 2009

33. X-RAY Patients with suspected intra-abdominal injuries should undergo radiographic evaluation of the lateral cervical spine, chest, and pelvis. Although these studies are unlikely to verify an intra-abdominal injury, they may reveal important other injuries. The chest radiograph may demonstrate massive gastric distention and the position of the nasogastric tube. Rarely free intraperitoneal air, foreign bodies and missiles can be elicited.

34. Initial chest radiograph of an injuredchild demonstrating massive gaseous distentionof the stomach.

35. Other imaging Angiography • To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable patient • Rarely used for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma

36. FAST The FAST (focused assessment with sonography in trauma) exam is an option in the initial evaluation of trauma patients, when a quick decision must be made (either to initiate immediate celiotomy or to continue resuscitation and evaluation for extra-abdominal hemorrhage or severe brain or spinal injury.). This quick bedside study evaluating for the presence of free fluid in: • perihepatic & hepato-renalrecess [Morison pouch], • splenorenal space, • pelvis (Pouch of Douglas/rectovesical pouch), • pericardial space(subxiphoid)

37. FAST

38. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). FAST - Morrison’s pouch (hepato-renal space)

39. FAST - Retrovesicle (Pouch of Douglas) Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid.

40. FAST • Advantages: • Portable, fast (<5 min), • No radiation or contrast • Less expensive • Disadvantages • Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. • Limited by obesity, substantial bowel gas, and subcut air. • Can’t distinguish blood from ascites. • high (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture

41. Diagnostic Peritoneal Lavage (DPL) • Described in 1965, standard of care • Open, semi-open or closed (Seldinger) approach • Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%) • Lead to a non-therapeutic laparotomy rate of 36% • Laparotomy when: • 10 cc gross blood • Enteric contents • 1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3 • High false positives with pelvic fractures • Do a supraumbilical approach • High Sn for hollow viscus injuries • Moreso than CT • Risk of visceral injury = 0.6% • Retroperitoneum can’t be assessed

42. Diagnostic Peritoneal Lavage In real life: 1. Good tool if FAST equivocal in the HD abnormal pt. in the setting of a pelvic fracture 2. FAST unavailable, pt. is HD abnormal

43. Diagnostic Peritoneal Lavage Largely replaced by FAST and CT In blunt trauma, used to triage pts who is HD unstable and has multiple injuries with an equivocal FAST examination In stab wounds, for immediate determination of hemoperitoneum, intraperitoneal organ injury, and detection of isolated diaphragm injury In GSW, not used much

44. Computerized Tomography • Imaging modality of choice only in HD normal patients • Pts crumping in CT a performance indicator in trauma centres • Sn = 92-97%, Sp = 99% for bleeding • Active arterial contrast extravasation, blush or pseudoaneyrysm • Only modality to directly detect retroperitoneal injury • Poor test to diagnose diaphragmatic injury • Less accurate for HVI • Still need serial physical exams • If pelvic fluid is present in absence of solid organ injury – exploratory laparotomy is mandated, especially if moderate or large amounts of free fluid

45. Computerized Tomography 1. CT is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple extra-abdominal injuries. Under these circumstances, patients with a negative CT should be admitted for observation 2. CT is the diagnostic modality of choice for non- operative management of solid visceral injuries (i.e. bleeding). If HD stable with a positive FAST, follow up CT permits nonoperative management of select injuries 3.In HD stable patients, DPL and CT are complementary diagnostic modalities

46. Computerized Tomography By minimizing the incidence of non-therapeutic laparotomies for self- limited injury to the liver or spleen, trauma centers are using CT with intravenous (IV) contrast only.

47. Non-operative management of solid organ injury is now more commonATLS - advanced trauma life supportPALS - pediatric advanced life support

48. Initial Management of the Bleeding Patient – European Guidelines; 2007 • Recommendation 1: • That time elapsed between injury and operation be minimized for pts. In need of urgent surgical control • Recommendation 2: • That a grading system be used to assess the clinical extent of hemorrhage • Recommendation 3: • pts. presenting in hemorrhagic shock AND an identified source of bleeding undergo an immediate bleeding control procedure UNLESS initial resuscitation measures are successful • Recommendation 4: • pts. with an unidentified source of bleeding in hemorrhagic shock should undergo immediate further assessment • Recommendation 5: • Trauma pts. should be resuscitated initially with crystalloid to a BP of 80-100 mmHg in the absence of TBI

49. Initial Management of the Bleeding Patient – European Guidelines; 2007 • Recommendation 6: • Early FAST for the detection of FF in patients with suspected torso trauma • Recommendation 7: • Pts. with significant FF on FAST with hemodynamic instability should undergo urgent surgery • Recommendation 8: • HD normal pts. with suspected head, chest and/or abdominal bleeding following high-energy injuries should undergo further assessment using CT • Recommendation 9: • Single Hct is not helpful; lactate or base deficit is helpful to estimate and monitor the extent of bleeding and shock