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Careful serial examinations are critically important in maintaining the index of suspicion necessary to proceed with more sophisticated testing when appropriate Inspection should note abrasions, lacerations, ecchymoses, penetrating wounds (including missile entry and exit sites), and telltale markings (e.g., seat belt and handlebar marks, tire tracks) Attention should be paid to the anterior and posterior abdomen and to both flanks, as well as to the lower thorax, when considering abdominal injuries Abdominal distention may be caused by hemoperitoneum or peritonitis but most often results from gastric distention from air swallowed by the crying child Early gastric decompression may assist the abdominal examination and prevent vomiting with aspiration of gastric contents The presence or absence of bowel sounds is generally not of much significance in the initial evaluation, but prolonged ileus may be a sign of intra-abdominal pathology Tenderness upon palpation, percussion, or shaking may be caused by abdominal wall contusion or may indicate intra-abdominal injuries Pelvic stability is evaluated by gently compressing and distracting the iliac wings Digital rectal examination should be performed; the presence of blood may indicate perforation of the bowel A boggy or high-riding prostate, blood at the urethral meatus, or a distended bladder may be present with urethral disruption and preclude bladder catheterization until a retrograde urethrogram has been performed (see Chapter 108 Genitourinary Trauma ) Diminished or absent rectal sphincter tone may indicate a spinal cord injury Laboratory assessment Blood should be obtained and sent for immediate baseline hemoglobin measurement and typing and crossmatching, not only in all instances of multiple trauma but also if isolated intra-abdominal injury is suspected Routine multipanel laboratory testing (the so-called “trauma panels”) historically has been standard for patients with trauma, but more recent studies have called into question this undifferentiated approach Nonetheless, laboratory studies that are commonly added include measurement of liver transaminases, lipase, and urinalysis Many recent studies indicate that, in combination with the presence of physical examination findings, abnormal laboratory findings contribute to the identification of children with intra-abdominal injuries Elevated serum liver transaminase levels may be associated with intra-abdominal trauma, especially hepatic injuries Screening for intra-abdominal injuries by evaluating transaminase levels is not universally accepted because sensitivity and specificity vary widely in the literature, but some data suggest that elevated transaminase levels (aspartate aminotransferase more than 200 U/L and alanine