abdominal trauma in childhood - …nwchildrenstrauma.nhs.uk/_file/lmvtrtk0bc_270210.pdf ·...
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ABDOMINAL TRAUMA IN CHILDHOOD G Humphrey
North West Major Trauma Network 1 July 2016
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IF A DISEASE WERE KILLING OUR CHILDREN IN THE PROPORTIONS THAT ACCIDENTS ARE, PEOPLE WOULD BE OUTRAGED AND DEMAND THAT THIS KILLER BE STOPPED.
• C Everrett Koop
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INTRODUCTION
• 90% of trauma admissions and 90% of trauma deaths are due to blunt trauma
• Road Traffic accidents account for 80% of patients
• Non accidental injury accounts for up to 5%
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PREDISPOSING FACTORS
• Thin, protuberant abdominal wall
• Little pre peritoneal and retro peritoneal fat
• Increased compliance of rib margin
• Liver partially exposed
• Bladder an abdominal organ
• Short stature so abdomen closer to site of impact
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FREQUENCY OF VISCERAL INJURY
• Blunt abdominal trauma is present in up to 80% of children with multiple injuries
• Renal injury accounts for approximately 60%
• Liver injury 40%
• Splenic injury 16%
• Pancreatic injury 7%
• Bowel injury 4.5%
• Bladder injury <1%
• Diaphragmatic injury <1%
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KEY LEARNING POINT 1
• The key is to Suspect Abdominal Injury in any child who presents with trauma to the torso no matter how minor it may be
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ASSOCIATION OF BLUNT ABDOMINAL TRAUMA WITH MECHANISM OF INJURY
Mechanism Minor trauma
Blunt trauma
Head injury/neurological impairment
Lap belt
Bicycle handle bar Pelvic fracture NON-ACCIDENTAL Chest trauma
Organ Kidney
Significant intra-abdominal injury
Multiple abdominal injury
Intestinal/pancreatic injury/extrahepatic bile duct injury
Pancreatic injury and Abdominal wall hernia Genitourinary
multi-organ injury – duodenum, pancreas, kidney, bowel, liver, spleen
Liver, spleen and diaphragm
Features Underlying congenital anomaly Incidence 30%
17% if GCS <8, 5% if GCS >8
Bruising to anterior abdominal wall
80% if multiple fractures to pelvis, 11% if simple fracture to pelvis Frequently fatal
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MANAGEMENT – FOLLOWS APLS GUIDELINES
• A – with c spine
• B – beware associated thoracic injuries – a pneumothorax may cause cardiogenic shock as can myocardial contusion
• C – volume replacement with tranexamic acid – remember to consider the abdomen as a cause of circulatory compromise even in the presence of long bone and pelvic fractures
• D – full neurological assessment plus glucose
• E – remembering that distracting injuries may mean that abdominal injuries are masked
Absence of external evidence in the form of bruising/abrasions does not exclude the abdomen as a potential site of blood loss
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KEY LEARNING POINT 2
• Children have good compensatory mechanism therefore signs of loss of circulatory volume occur late Conversely
• Absence of evidence of circulatory failure does not preclude significant visceral injury
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IMMEDIATE LAPAROTOMY
• If patient remains haemodynamically unstable having required >40ml/kg volume replacement – a Blood Pressure of <80 in a child <5 or <90 in a child over 5 is evidence of hypovolaemia
• But, beware fractured cervical spine with spinal shock
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QUESTIONABLE INDICATIONS FOR IMMEDIATE LAPAROTOMY
• Overt peritonitis – difficult to recognise
• Obvious injury requiring surgical intervention – CXR with ruptured diaphragm, plain film with free gas, penetrating injury, evisceration of organs
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INVESTIGATIONS – DEPENDS ON CLINICAL SITUATION
• US
• Unstable patient
• Abdominal organ at risk through MOI
• 20-25% risk of missing splenic injuries
• Difficult if gastric distension
• If free fluid present mandates cross sectional imaging
• ABSENCE of free fluid does not exclude significant injury
• CT – Camp Bastion protocol
• Stable patient
• Should be targeted to reduce exposure to radiation
• Allows evaluation of entire abdominal cavity and thorax
• Localises injured solid viscus 92-98% of the time
• Not reliable at detecting injury to the gut
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• Haemorrhage from the liver is the most common cause of death attributable to abdominal injury
• Non –operative treatment of haemodynamic injury standard practise
• Consideration of interventional radiology intervention for active bleeding
• Pneumovax, meningococcal immunisation for splenic injury
SPLEEN AND LIVER INJURY
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APSA GUIDELINES - 1
• Grade 1 – 2 day admission to general ward, No further imaging, 3 weeks restriction of activity
• Grade 2 – 3 day admission to general ward, no further imaging, 4 weeks restriction of activity
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APSA GUIDELINES 2
• Grade 3 – 4 day admission to general ward, no further imaging, 5 weeks restriction of activity
• Grade 4 – I day admission to ICU, 5 days inpatient stay, no further imaging 6 weeks restriction of activity
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GRADE V LIVER INJURY
• High care admission
• Involve experienced hepatobiliary team
• May need interventional radiology for embolization of hepatic artery in order to gain haemodynamic stability
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SEQUELAE OF LIVER INJURY
• Delayed haemorrhage 10-38 days post injury
• Liver abscess
• Bile leak – mainly managed by ERCP stenting in conjunction with adult gastroenterologists
• False aneurysm causing upper GI bleeding and colic – managed by embolization
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SEQUELAE OF SPLENIC INJURY
• pseudocysts can be huge, cause pain and gastrointestinal symptoms
laparoscopic excision/marsupialization effective
• Pseudo-aneursyms – thought to resolve with time
angiographic embolization effective at preserving splenic parenchyma
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PANCREATIC INJURY
• RTA, handle bar injury, play ground injuries
• Consider child abuse
• Abdominal pain, vomiting, tenderness
• Raised amylase
• CT gives best definition
• Conservative vs distal pancreatectomy
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SEQUELAE OF PANCREATIC INJURY
• Pseudocysts occur in 38-78% - 50% resolve spontaneously internal drainage – ERCP preferable to percutaneous drain endoscopic cyst-gastrostomy if fail to resolve
• May need NJ tube to feed down stream
• May need TPN and Octreotide
• Manage with adult gastroenterologist
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BOWEL INJURY
• EASILY MISSED
• Lap belt and handle bar injury
• Repeated clinical review with high level of suspicion required
• Plain films often not diagnostic
• May have multiple perforations
• May have injury to mesentery with out perforation.
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RENAL INJURY 1
• High energy impact
• Proportionately larger and more mobile than in adult
• Loin pain/mass
• Haematuria does not correlate with injury and absence does not preclude injury
• CT allows assessment of function
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RENAL INJURY 2
• Renal pedicle injuries (grade IV) are rare - <5%
• Attempted renal salvage with vascular repair is possible but success is poor <5%
• All patients with significant renal injury should have DMSA at 8 weeks and a BP check at 1 year
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BLADDER INJURY
• Child’s bladder mainly intra-abdominal
• Pelvic fractures present in significant number BUT can occur in isolation
• Suspect it
• Look for perineal swelling, suprapubic tenderness, dysuria, inability to void
• Gross haematuria usual if child able to pass urine
• CT may show leak of contrast – cystogram may be needed
• Close and drain bladder
• Check adjacent organs not damaged
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DIAPHRAGMATIC INURY
• May cause respiratory compromise
• May be identified on CXR
• Diagnosis frequently made at laparotomy for other injuries
• Compliance of ribs implicated as most ruptures are peripheral
• Consider haemo-pneumothorax
• Laparotomy to repair with drainage of thorax post operatively
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SUMMARY
• Diagnosis of significant intra abdominal injury requires a high index of suspicion
• Care should follow APLS pathways
• Immediate surgical intervention is extremely rare
• Urgent Imaging should be carried out on all children with a significant mechanism of injury because the child is able to compensate for blood loss and may have minimal symptoms until they decompensate
• Liver and Splenic injuries are nearly always managed conservatively
• Children with Splenic injury should have immunisations against encapsulated organisms