PEM GUIDE ABDOMINAL TRAUMA - OVERVIEW

INTRODUCTION
Trauma is the leading cause of morbidity and mortality in children older than one year of
age, and abdominal trauma is the third leading cause of death in this age group.
Children are more vulnerable than adults to intraabdominal injuries (IAI) after blunt
trauma because of their immature musculoskeletal system, less overlying fat, and
smaller area over which the force is distributed.

Blunt abdominal trauma can occur with seemingly minor falls, direct blows to the
abdomen (e.g. bicycle handlebars) or shearing forces that may cause lacerations (e.g.
head-on motor vehicle collisions). The types of injuries include but are not limited to
abdominal wall contusions, solid organ injuries, pancreatic injuries, and hollow
abdominal viscera injuries.

Penetrating abdominal trauma occurs with gunshot and stab wounds and are less
common than blunt IAI but are more lethal. These injuries include burst injuries of the
liver and spleen, vascular injuries, and peritoneal perforations.

Specific abdominal injuries are discussed in the PEM Guide Abdominal Trauma
Specific Injuries. An overview to the approach to abdominal trauma follows here.

PRIMARY SURVEY
The goal of the primary survey is to rapidly identify and manage life-threatening injuries.
It consists of a systematic approach using the mnemonic A-B-C-D-E for Airway,
Breathing, Circulation, Disability, and Exposure to evaluate the trauma patient in order
to avoid missing life-threatening injuries. The following discussion focuses on the
primary survey of an abdominal injury: (See PEM Guide Trauma Primary Survey for a
general approach to the primary survey) Intra-abdominal injuries may become apparent
during the primary survey in the assessment of circulation and in particular that patient
who are in shock with tachycardia, poor distal perfusion or hypotension. Intra-abdominal
injury may also become apparent during the exposure phase of the primary survey. A
more directed assessment of abdominal trauma will occur during the secondary survey.

CIRCULATION
Primary circulation survey should assess for possible external or internal hemorrhage
by evaluating the blood pressure, pulses, skin perfusion and external hemorrhage. The
body compensates for diminished perfusion from significant blood loss by increasing its
heart rate and total peripheral vascular resistance in order to maintain the systolic blood
pressure within the normal range. This is particularly true in children who can maintain
blood pressure until approximately 25% of blood volume is lost but then will drop their
blood pressure precipitously. The goal is to identify hemorrhagic shock in the
compensatory phase before the onset of hypotension.


EXPOSURE
During the exposure phase of the primary survey care must be taken to examine the
abdomen for external signs of trauma (eg seat belt sign), signs of penetration trauma,
abdominal tenderness and pelvic instability. The patient should be log rolled as a unit
and examination and palpation of the back and vertebral column should occur as well.

SECONDARY SURVEY
The secondary survey involves obtaining the patients history, a complete physical
exam, and additional diagnostic studies as indicated (laboratory and imaging).

HISTORY - The secondary survey should include a focused
history using the SAMPLE mnemonic. The mechanism of
injury should be explored as it may predict patterns of injury.
For example, Waddels Triad can aid in the prediction of
injury in a pedestrian struck by a motor vehicle. A pedestrian
is struck first on the legs (femur in child, tib/fib in adults) and
is thrown against the hood/windshield of the car hitting their
abdomen (spleen if hit on the left and liver if hit on the right).
They then hit their head on the car and are thrown hitting their
head a second time. A pedestrian struck who has head and
lower extremity injuries should raise suspicions for an
intra-abdominal injury.

PHYSICAL EXAMINATION - A secondary survey includes a complete head-to-toe
examination, but only findings pertinent to IAI will be discussed here. Life-threatening
abdominal injuries may be occult or manifest as the following exam findings.
CIRCULATION
Assessment
Mental status
Pulse quality (central and distal), rate, and regularity
Blood pressure
Skin, color, temperature, capillary refill
Rhythm on cardiac monitor
Sites of external hemorrhage
Management
IV access and fluid resuscitation; if peripheral IV difficult, place an IO
Send blood sample for type and cross
Fluid resuscitation crystalloid (normal saline) 20 cc/kg
If the patient remains hemodynamically unstable after 2-3 boluses of
crystalloid give packed RBC 10cc/kg
Give type and cross matched blood !
If not available give type specific blood!
If not available give O negative blood
Large volume transfusions may require FFP, platelets, and cryoprecipitate
Control of external hemorrhage direct compression

S Symptoms
A Allergies
M Medications
P Past Medical Hx
L Last Meal
E Events
Environment


Pelvic Examination - Evaluate pelvic stability by gently compressing inwards the iliac
wings in order not to displace fracture fragments or exacerbate injuries. Repeated
compressions should be avoided to avoid worsening bleeding.

Digital Rectal Exam (DRE) - Blood on the DRE may indicate perforation of bowel. A
boggy or high-riding prostate, blood at the urethral meatus, or a distended bladder may
represent urethral injury and bladder catheterization should be avoided until a
retrograde urethrogram is obtained. There is limited utility of the digital rectal examine
for guaiac testing. Absent rectal sphincter tone may indicate spinal cord injury.

RADIOLOGIC EVALUATION
FAST EXAM (Focused Assessment for Sonography in Trauma) allows for visualization
of free fluid in the potential spaces but does not identify specific solid organ injury. It has
reported sensitivity of up to 95% for distinguishing as little as 100cc of fluid and
specificity of 98% for detecting IAI. It can be performed serially to increase its sensitivity.
The FAST exam is a rule in test. A positive fast can rules in IAI but a negative FAST
exam cannot rule out IAI. The FAST examination and the patients hemodynamic
status can be used to determine the next steps in evaluation and treatment.

FAST (See PEM Guide FAST Exam in the procedures section)
1 Perihepatic (right upper quadrant Morrisons pouch)
2 Perisplenic (left upper quadrant)
3 Pelvic (Pouch of Douglas and retrovesicular pouch)
4 Pericardial (subxiphoid cardiac view).
5 Pulmonary views for hemothorax/pneumothorax (Extended or E-FAST)

MANAGEMENT BASED ON FAST AND HEMODYNAMIC STABILITY
FAST BP, HR, Perfusion Management
Positive Unstable Laparotomy
Positive Stable CT Scan
Negative Unstable ? DPL vs Laparotomy
Negative Stable Serial examination or CT*
*Consider CT in high risk mechanism of injury or unable to assess abdominal exam
SECONDARY SURVEY ABDOMINAL EXAMINATION
Vital
Signs
Hemoperitoneum may manifest as hypotension and tachycardia
Normal blood pressure and pulse do not exclude IAI
Inspection Abdominal ecchymoses, bruising, seat belt mark across the abdomen
Abdominal distension may be due to hemoperitoneum or peritonitis.
Difficult to differentiate distension due to air swallowed by a crying child.
Gastric decompression may facilitate exam and decrease aspiration.
Auscultate Absence of bowel sounds in the initial examination is not predictive.
Prolonged ileus (>4hours) may signify pathology.


Palpation Serial abdominal examinations. Abdominal/flank/back/pelvic tenderness.
DIAGNOSTIC PERITONEAL LAVAGE (DPL)
A DPL is an invasive procedure that involves a infraumbilical
abdominal incision, placement of a catheter and infusion of
fluid into the abdominal cavity. It is highly sensitive but poorly
specific. It also limits the use of serial abdominal exams. DPL
is rarely used and has largely been supplanted by the FAST
exam and abdominal/pelvic CT. One possible indication is in
children requiring immediate surgery for non-abdominal injury
when an abdominal CT scan or FAST exam are unavailable
Plain Radiographs - A chest radiograph may show rib fractures and mediastinal air and
may raise suspicion for coincident intra-abdominal injury. Free air under the diaphragm
strongly suggests hollow viscous perforation. Intra-abdominal contents on the chest
XRAY may suggest a diaphragmatic injury. Pelvic x-rays identify open fractures.

CT Scan - CT scan with IV contrast is the preferred diagnostic test in stable patients as
it allows for the detection of specific organ injury, active intraperitoneal hemorrhage,
evaluation of extra-abdominal structures and the retroperitoneal space.

INDICATIONS FOR ABDOMINAL COMPUTED TOMOGRAPHIC SCAN
High risk mechanism of injury suggesting abdominal injury
Physical examination findings suggesting abdominal injury
Severe multisystem trauma
Significant fluid or blood requirements not explained by other injuries
Inadequate abdominal examination altered mental status, distracting injury
Laboratory Hb < 10g/dl, UA > 50 RBC/hpf, increased AST, ALT, amylase
Positive FAST Exam in an hemodynamically stable patient
Requiring general anesthesia for another indication

LABORATORY EVALUATION

LABORATORY FINDINGS
CBC Initial hemoglobin and hematocrits will not reflect early blood
loss. CBC establishes baseline hemoglobin and hematocrit
Type and Cross Essential for possible packed red blood cell resuscitation
AST/ALT Associated with hepatic or injuries
Amylase/Lipase Suggestive of pancreatic or hollow viscous injury
Urinalysis Grossly bloody urine or microscopic hematuria (>50
RBCs/HPF) suggests renal trauma
Lactate Adequacy of perfusion






POSITIVE DPL
>10cc blood on initial aspirate
> 100,000 RBC/ml
> 500 WBC/ml
Gram stain (+) for bacteria
Feces, bile, vegetable fibers
Alkaline phosphatase > 6 IU/L
Amylase > 175 IU/L
CLINICAL DECISION RULES (CDR)
In 2013 The Pediatric Emergency Care Applied Research Network (PECARN) derived a
decision rule to identify pediatric patients at very low risk of intra-abdominal injury
requiring intervention. They identified 6 factors whose absence predicted a very low rate
of intra-abdominal injury requiring intervention predictive value of a negative test of
99.9% with a 95% confidence interval of 99.7 100%. The rule did not included
laboratory tests or focused abdominal Sonography for trauma as possible predictors

The rule is intended to be assistive in clinical decision making and not directive. If the
rule is followed there would be a 25% reduction in the rate of CT scans in those
considered rule negative. Unfortunately, the rate of CT would rise of all those with a
positive rule were scanned. The authors provided recommendations for possible
management strategies, which are appended below. This is a level 4 clinical decision
rule. It has been derived though not yet validated


PECARN BLUNT ABDOMINAL TRAUMA DECISION RULE - 2013

abdominal injury undergoing acute intervention who were
categorized as low risk by the current prediction rule had
laboratory abnormalities that would suggest the possibility of an
intra-abdominal injury and likely would not be missed in
practice. Furthermore, laboratory resources and particularly
FAST expertise are not immediately available to all clinicians
evaluating injured children, and therefore creating a prediction
rule with these variables would not be universally applicable. As
such, the prediction rule is based totally on history and physical
examination variables and is thus widely generalizable, which is
one of its strengths. All children with intra-abdominal injury
undergoing acute intervention missed by the decision rule,
however, had hemoperitoneum, highlighting the potential
utility of the FAST examination, and all also had distracting
painful injuries, alcohol intoxication, hematuria, or elevated
liver enzyme levels (Table 3), suggesting that the miss rate
would actually be much lower in practice. Screening those
children who are negative for the rule but whom the clinician
203/12,044 (1.7%)
IAI with intervenon
Evidence of abdominal wall
trauma or seatbelt sign
91/10081 (0.9%)
IAI with intervenon
GCS score
112/1963 (5.7%)
IAI with intervenon
Yes No or Unknown
3-13 14-15
53/9255 (0.6%)
IAI with intervenon
Degree of abdominal
tenderness
17/6723 (0.3%)
IAI with intervenon
Evidence of thoracic
wall trauma
11/5768 (0.2%)
IAI with intervenon
38/826 (4.6%)
IAI with intervenon
36/2532 (1.4%)
IAI with intervenon
6/955 (0.6%)
IAI with intervenon
None
Mild or Moderate or
Severe
Yes No
IAI with intervenon
Complaint of
abdominal pain
9/5463 (0.2%)
IAI with intervenon
Absent/Decreased
breath sounds
8/5429 (0.1%)
IAI with intervenon
IAI with intervenon
2/305 (0.7%)
IAI with intervenon
1/34 (2.9%)
IAI with intervenon
Yes No or Unable to assess
Yes No or Unknown
Voming
6/5034 (0.1%)
IAI with intervenon
2/395 (0.5%)
IAI with intervenon
Yes No or Unknown
IAI with
intervenon
No IAI with
intervenon Total
Any Predictors present 197 6813 7010
No Predictors present 6 5028 5034
Total 203 11841
Percent (95% CI)
Predicon rule sensivity 97.0%(93.7, 98.9)
Predicon rule specicity 42.5%(41.6, 43.4)
Negave predicve value 99.9%(99.7, 1.00)
Posive predicve value 2.8%(2.4, 3.2)
Negave likelihood rao 0.07 (0.03, 0.15)
Figure 4. Prediction tree for children with IAI undergoing acute intervention. The nal box identies the very-low-risk
population.
Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries Holmes et al
6 Annals of Emergency Medicine Volume xx, . x : Month







PECARN SUGGESTED MANAGEMENT BASED ON DECISION RULE

BLUNT ABDOMINAL TRAUMA
Evidence abdominal wall trauma/
seatbelt sign OR
GCS score < 14
YES (23%)
CT is warranted in many
IAI Intervention 5.4%
NO
Abdominal Tenderness
NO
Thoracic wall trauma OR
Complaints of abdominal pain OR
Decreased breath sounds OR
Vomiting
YES (21%)
Labs, FAST warranted
Consider CT
IAI Intervention 1.4%
YES (14%)
Consider Labs, FAST
Observation
IAI Intervention 0.7%
NO (42%)
CT generally unwarranted
Consider FAST, labs
IAI Intervention 0.1%




















MANAGEMENT
The primary etiology of shock in the trauma patient is hypovolemic shock in in particular
hemorrhagic shock from internal or external blood losses. Other causes of shock in the
trauma patient include distributive (spinal cord injury), cardiogenic (myocardial
contusion) and obstructive (tension pneumothorax, pericardial tamponade)

The initial priorities in the management of intra-abdominal injuries is to assess
hemodynamic stability, obtain intravenous access and send a type and cross.

FLUID RESUSCITATION
In the hemodynamically unstable patient the response to fluid and packed RBC
resuscitation will guide further management. An urgent laparotomy is indicated in the
patient who is fluid/blood refractory.

In the hemodynamically stable patient an abdominal and pelvic CT will better delineate
potential injuries. The majority of intra-abdominal injuries in the pediatric blunt trauma
patient are managed non-operatively.

BLOOD TRANSFUSION
In hemorrhagic shock refractory to crystalloid blood is infused in a bolus of 10 cc/kg.
Packed RBCs are infused in preference to whole blood because whole blood needs to
first be reconstituted from packed RBCs and plasma. One unit of PRBC will raise an
adults hemoglobin by 1gm/dl or hematocrit by 3%.

Ideally, fully typed and cross-matched PRBCs are given. If time permits, type specific or
O negative PRBCs are infused. When large volumes of blood are given a coagulopathy
develops and additional blood products will be needed. Massive transfusion protocols
may include platelets, fresh frozen plasma and cryoprecipitate.

PRBC - 250-300 ml/unit, HCT 60 %
Whole blood - 450 ml/unit, HCT 35-40 %





























BLUNT ABDOMINAL TRAUMA DECISION ALGORITHM