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aminotransferase more than 125 U/L) correlate well with the presence of an intraabdominal injury Using thresholds such as these may allow for more judicious use of computerized tomographic (CT) scan of the abdomen for children with blunt abdominal trauma Examination of the urine may also play a role in an increased suspicion for intra-abdominal injury after blunt force trauma to the abdomen Grossly bloody urine indicates likely injury to the kidneys and has been shown to be associated with nonrenal intra-abdominal injuries in pediatric patients with trauma The predictive capacity of microscopic hematuria is controversial In one study, microscopic examination of urine that revealed more than 50 red blood cells (RBCs) per high-powered field (hpf) was 100% sensitive and 64% specific for the presence of an intra-abdominal injury (see Chapter 108 Genitourinary Trauma ) A more recent study suggests consideration of CT scan of the abdomen in the context of a urinalysis demonstrating as few as five or more RBCs per hpf when the history indicates a significant force has been applied to the abdomen In addition, clinicians must remember that major trauma may cause complete disruption of a renal pedicle and the absence of hematuria Management Basic principles of management Airway management and cervical spine stabilization are first priorities ( Fig 103.1 ) Supplemental oxygen should be administered to any child with significant injuries, regardless of whether obvious signs of shock are present Intravenous or intraosseous access should be obtained while the primary survey is completed Immediate life-threatening injuries should be treated promptly Hemorrhagic shock should be addressed with judicious administration of isotonic crystalloid solution A first intravenous administration of a bolus of 20 mL/kg may be given rapidly, and, if the pulse and blood pressure remain outside the physiologic range, administration of blood should be considered If the child has received more than a total of 40 cc/kg of crystalloid, including fluids received prehospital, and remains hemodynamically unstable, ongoing bleeding should be suspected and administration of blood strongly considered The initial blood product administered should be O-negative–packed RBCs; there is no justification for waiting for type-specific blood products to treat ongoing bleeding The incidence of trauma-induced coagulopathy in severely injured children is significant and associated with poor outcome Data supports an initial resuscitation strategy of 1:1:1 transfusion of red cells, plasma, and platelets, followed by goal-directed resuscitation according to either real-time viscoelastic testing (TEG or ROTEM) or traditional measure of coagulation
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