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and emergency medical personnel Penetrating trauma is usually evident on careful inspection of both the anterior and posterior torsi In contrast, blunt abdominal trauma must be suspected from both historical information and careful physical examination Children with severe multiple trauma are obviously at risk for intra-abdominal injuries, but sufficient energy to injure may also be present in apparently minor falls, direct blows to the abdomen from balls, bats, bicycle handlebars, toys, and during contact sports or assault Clinical Considerations Clinical Recognition Life-threatening abdominal injuries may be occult or manifest in several ways: the presence of shock, abdominal tenderness, ecchymoses or distention, or external hemorrhage (e.g., from a penetrating injury) Historical information or physical examination findings are often subtle or lacking Children have the capacity to maintain a normal blood pressure level in the face of significant blood loss and hence major intra-abdominal bleeding may not be obvious Sustained tachycardia is often the first sign of significant hemorrhage The examining physician must always keep in mind that the abdomen is a large potential reservoir for blood loss Triage Considerations The American College of Surgeons suggests that triage of the trauma patient should be based on severity of the mechanism of injury and physiologic status of the patient Clearly the patient with a mechanism associated with high velocity or with abnormal vital signs must be immediately resuscitated and evaluated for injuries That said, even those patients with a lesser mechanism of injury and stable vital signs should be evaluated with great vigilance Clinical Assessment Physical examination A traumatized child is often difficult to examine; pain associated with extra-abdominal injuries may obscure abdominal findings In addition, the results of physical examination may be subtle or unreliable in an unconscious, developmentally delayed or autistic, intoxicated, agitated, or fearful child Vital signs, including blood pressure and pulse, may be normal for age, especially in children with isolated injuries of the liver and spleen Physical examination findings, such as external signs of injury, abdominal tenderness, and presence of long bone fractures are helpful in determining which children require more extensive evaluation