Abdominal trauma

Background

• Trauma / serious injury is a leading cause of death in children in Australia.
• Early ABCDE (airway, breathing, circulation, disability, exposure) interventions improve morbidity and mortality secondary to major trauma.

Key points^1,2,3

Primary survey (see Trauma - Serious injury guideline)

Vital signs 

• Complete and record a full set of observations on the observation and response tool and record additional information on the Clinical Comments chart.
  • include observation of peripheral perfusion.
• The trend and response to fluid therapy will reflect haemodynamic stability. 

Secondary survey 

• Includes examination of the abdomen, back, pelvis, genitalia and rectum. 

Examination of the abdomen

• Look for bruising (e.g. seat belt), abrasions, lacerations and abdominal distension.
• Aim to exclude tenderness, rebound, guarding or rigidity (which will require evaluation by a surgeon and/or a CT scan).
• In children with significant pain, carefully titrating parenteral opiates will decrease distress and allow a more accurate clinical assessment.
• In the intubated child with possible intra-abdominal injury, the value of clinical examination is limited, and these children will require a CT scan of the abdomen.
• In major trauma, rectal examination should be performed, assessing:
  • rectal tone (for possible spinal injury)
  • rectal blood

Investigations

Pathology

• Bloods: Group and crossmatch, full blood count, electrolytes, liver function tests, lipase, coagulation screen, blood gas and blood glucose. 
• Urinalysis

Imaging

Management of child with significant abdominal trauma

• High flow oxygen.
• Vascular access x 2.

If signs of shock or uncontrolled bleeding:

• Tranexamic acid: 15 mg/kg (max 1000 mg) IV over 10 minutes⁴
• Fluids:
  • Intravascular bolus of 10 mL/kg sodium chloride 0.9% or uncrossmatched blood (if readily available)³
  • Repeat 10 mL/kg if still shocked
  • Ongoing volume resuscitation with blood product beyond 20 mL/kg consider activating massive transfusion protocol. Refer to Critical Bleeding and ROTEM Algorithm (Transfusion Medicine Manual)
• Failure to respond to fluids and blood indicates a need for urgent laparotomy if no other obvious source of haemorrhage and spinal shock excluded.^1,2,3

Consider:

• Nasogastric tube: to decompress the stomach. May also detect blood in the stomach. Use an orogastric tube if concern for base of skull fracture.
• Urinary catheter: to monitor fluid resuscitation and to look for haematuria. If a urethral injury is suspected (see below), seek surgical advice before insertion.

• Ongoing management is dictated by the haemodynamic response of the child to fluid resuscitation. CT scan may not be possible in a very small number of exsanguinating children with deteriorating vital signs despite fluid resuscitation. In this situation, early surgical consultation regarding urgent laparotomy is required.

Penetrating trauma^2,3

• Usually requires exploration by laparoscopy or laparotomy.
• Remember to log roll the patient and examine the back to exclude other injuries and exit wounds.
• An erect abdominal x-ray or lateral decubitus film may indicate the presence of free air.

Pelvic fractures

• A child with a fractured pelvis has been exposed to severe trauma.
• Major differences to adult pelvic fractures:
  • Greater energy is required to cause fracture
  • Avulsion fractures
  • Single fractures
• Presence of a pelvic fracture suggests associated injuries – other skeletal, head, abdominal and pulmonary injuries. The management of these usually takes priority over the pelvic fracture management.
• Bladder injury can occur with straddle ‘fall-astride’ type mechanism.
• Vascular injury and exsanguination in children is rare.
• A pelvic binder should be used for all suspected pelvic fractures.

Disposition

1. All children with a significant abdominal or pelvic injury will require admission under an appropriate surgical unit.
2. Children with significant ongoing abdominal pain following trauma should not be discharged, regardless of negative imaging results. CT Scan is not 100% sensitive for all intra-abdominal injuries.
3. Visible abdominal wall bruising increases the risk of serious intra-abdominal injury and requires a surgical opinion and often admission for serial clinical examination of the abdomen.
4. A “handlebar” mechanism of upper abdominal injury poses a significant risk of intra-abdominal (particularly solid organ or duodenal) injury and should therefore lower the threshold for surgical referral and admission.
5. Young children with a significant mechanism of injury but who are apparently injury free or have only minor injuries should be considered for observation (12-24 hours) under the appropriate surgical unit.
6. Parents of discharged children should be given clear instructions to return should a child’s condition change.

References

1. Saladino RA & Conti K (2022) Pediatric blunt abdominal trauma: Initial evaluation and stabilization, UpToDate. Available from Pediatric blunt abdominal trauma: Initial evaluation and stabilization - UpToDate (health.wa.gov.au)
2. Advanced Paediatric Life Support: A Practical Approach to Emergencies, Samuels, M, Wieteska S 6th Edition 2017 Wiley Blackwell Available from: https://www.apls.org.au
3. Cameron P, Browne GJ, Mitra B, Dalziel S, Craig S. Textbook of Paediatric Emergency Medicine. 4th ed. Elsevier Australia; 2023
4. Tranexamic acid. In: UpToDate. [Internet]. [cited 2023 Dec 06]. Available from: Tranexamic acid: Drug information - UpToDate (health.wa.gov.au)