1412 SECTION XII Pediatric Critical Care Environmental Injury and Trauma infection 35 At pediatric trauma centers, operating on a child with an isolated splenic injury is rare The indications for oper[.]
1412 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma • Fig 120.3 Computed tomography scan of a patient with a grade IV splenic laceration demonstrating free fluid around the tip of the spleen • Fig 120.2 Computed tomography scan of a patient with a grade IV splenic laceration infection.35 At pediatric trauma centers, operating on a child with an isolated splenic injury is rare The indications for operative intervention are generally limited to persistent hypotension, greater than 50% blood volume replacement, or additional life-threatening abdominal injuries Current nonoperative management consists of large-bore venous access for fluid resuscitation, intensive care unit monitoring, serial physical examinations and hematocrit evaluations, and activity restrictions TABLE a 120.2 Abdominal Organ Injury Computed Tomography Grading Scales Injury Grade I Grade II Grade III Splenic hematoma Subcapsular, ,10% surface area Subcapsular, 10%–50% surface; intraparenchymal, ,5 cm diameter Subcapsular, 50% surface or expanding; intraparenchymal cm or expanding; ruptured Splenic laceration ,1 cm depth 1–3 cm depth cm depth or involving vessel Grade IV Grade V Segmental vessel 25% devascularization Shattered spleen Splenic vascular Hilar injury 100% devascularization Hepatic hematoma Subcapsular, ,10% surface area Subcapsular, 10%–50% surface; intraparenchymal, ,10 cm diameter Subcapsular, 50% surface or expanding; intraparenchymal 10 cm or expanding; ruptured Hepatic laceration Capsular tear, ,1 cm depth 1–3 cm depth, ,10 cm length cm depth Hepatic vascular Duodenum hematoma Grade VI Disruption 25%– 75% of lobe or 1–3 Couinaud segments in lobe Disruption 75% lobe or Couinaud segments in lobe Injury to cava or hepatic vein Single portion Avulsion portion Continued CHAPTER 120 Pediatric Abdominal Trauma 1413 TABLE 120.2 Abdominal Organ Injury Computed Tomography Grading Scales—cont’d Injury Duodenum laceration Grade I Grade II Grade III Grade IV Grade V Partial thickness ,50% circumference 50%–75% circumference second portion 75% circumference second portion, ampulla, or common bile duct Disruption duodenopancreatic complex Duodenal vascular Grade VI Devascularization of duodenum Pancreas hematoma Minor contusion Major contusion Pancreatic laceration Superficial Major Kidney contusion Hematuria Kidney hematoma Subcapsular, nonexpanding Kidney laceration Distal transaction or duct injury Proximal transaction or ampulla injury Massive disruption of head cm depth Through cortex, medulla, and collecting system Shattered kidney Confined to retroperitoneum ,1 cm depth Kidney vascular Avulsion a Add one grade for multiple injuries up to grade III From Moore EE, Cogbill TH, Malangoni MA, et al Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum J Trauma 1990;30:1427–1429; and Moore EE, Shackford SR, Pachter HL, et al Organ injury scaling: spleen, liver, and kidney J Trauma 1989;29:1664–1666 Injury to the Liver The liver is the second most commonly injured organ in blunt abdominal trauma Severe liver injuries are associated with high mortality and may require surgical correction of injuries to the hepatic veins or vena cava Liver injuries in stable patients can usually be managed nonoperatively Ecchymosis, bruising, or abrasions over the right upper quadrant suggest significant injury Liver injury is graded by appearance on CT scans (see Table 120.2) However, the clinical course of the patient, not the appearance on CT scans, should determine treatment (Figs 120.4 and 120.5) Elevated serum transaminase concentrations are associated with liver trauma and other intraabdominal injury.36 Late complications of liver injuries include bile peritonitis, abscess formation, hemorrhage, and hematobilia Operative treatment may be required for major hepatic trauma associated with hepatic vein or retrohepatic caval injuries Definitive repair is often not possible at the time of initial exploration, necessitating damage-control surgery with packing, maintaining an open abdomen, further resuscitation, stabilization, and repeat laparotomy Select patients with ongoing bleeding from a hepatic injury can be stabilized with embolization of hepatic blood vessels Injury to the Small Bowel Bowel injuries resulting from blunt trauma are relatively rare However, a high index of suspicion must be maintained to avoid a delayed diagnosis, which is more common in children The in- • Fig 120.4 Computed tomography scan of a patient with a grade II hepatic hematoma cidence of small-bowel injury increases with increasing number of other organs injured.37 The mechanisms of injury associated with blunt bowel trauma include motor vehicle/pedestrian collisions, handlebar injuries, lap belt injuries, and child abuse Deceleration injuries in children restrained with a lap belt may occur as a constellation that includes intestinal injury, abdominal wall ecchymosis, and flexion-distraction injury (Chance fracture) to the lumbar 1414 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma Injury to the Duodenum • Fig 120.5 Computed tomography scan of a patient with a grade IV hepatic laceration Duodenal injuries are rare in children but occur more commonly than in adults Children may have localized right upper quadrant tenderness, but the presentation may be subtle The majority of duodenal injuries in children result in a duodenal hematoma without disruption of the lumen When there is perforation, CT demonstrates extraluminal gas or oral contrast extravasation in the right anterior pararenal space Thickening of the duodenal wall is seen when a duodenal hematoma is present Duodenal injuries are classified from grades I to V based on severity (see Table 120.2) The majority of pediatric duodenal injuries are grades I and II A duodenal hematoma is treated with observation and parenteral nutrition Resolution generally occurs in to weeks In some cases of duodenal hematoma, placement of a nasojejunal tube will allow enteral feeding distal to the point of obstruction Repair of full-thickness duodenal injury may require duodenorrhaphy, pyloric exclusion, duodenoduodenostomy, duodenojejunostomy, pancreaticoduodenectomy, or simple drainage (Fig 120.7) The majority of injuries are treated with debridement and primary closure with drainage Pyloric exclusion is recommended for complex duodenal injuries Duodenostomy and regional drains are useful In children, pancreaticoduodenectomy is rarely required to treat a duodenal injury Injury to the Pancreas • Fig 120.6 Small-bowel contusion after blast injury spine Intestinal injuries include bowel disruption, mesenteric avulsion, and bowel wall contusion (Fig 120.6) Areas of the small bowel particularly prone to injury are the points of retroperitoneal fixation, such as the proximal jejunum at the ligament of Treitz or the terminal ileum near the junction with the cecum A perforation may be present even without free air or significant spillage of succus on DPL Delayed perforations may occur as a result of mesenteric disruptions and subsequent bowel necrosis In some instances, a prolonged ileus that fails to resolve may be the only evidence of intestinal injury The mechanism of injury and abdominal wall ecchymosis can suggest the diagnosis of intestinal injury Abdominal tenderness may be present on physical examination Findings on CT consistent with small-bowel injury are free fluid, contrast extravasation, focal bowel thickening, pneumoperitoneum, and fat stranding or fluid in the mesentery.38 Once diagnosed, bowel injuries are treated by laparotomy Excision of injury and primary anastomosis to reestablish gastrointestinal continuity are usually possible Morbidity and mortality are not increased if the delay in diagnosis is less than 24 hours Injuries to the pancreas may require operative intervention depending on severity of injury and integrity of the pancreatic duct (see Table 120.2) Upper abdominal tenderness, hyperamylasemia, edema of the gland, and unexplained fluid in the lesser sac on CT scan suggest pancreatic injury Handlebar injury, lap belt injury, direct blow to the abdomen, and motor vehicle crash are the most common mechanisms (Fig 120.8) When the gland is fractured, this generally occurs where it crosses the vertebral column (Fig 120.9) Pancreatic transection is best treated by early distal pancreatectomy and drainage When the main pancreatic duct is intact, nonoperative treatment with an extended course of bowel rest and parenteral nutrition may be attempted.39 Devascularization of the pancreas and duodenum in blunt abdominal trauma is rare in children When it does occur, laparotomy, pyloric exclusion, drainage, and repeated debridement • Fig 120.7 Grade III duodenal laceration blowout injury after a fall onto a handrail CHAPTER 120 Pediatric Abdominal Trauma 1415 • Fig 120.8 Handlebar injury in a patient who required distal pancreatectomy • Fig 120.10 Endoscopic retrograde cholangiopancreatography demonstrates pancreatic duct leak after a kick to the abdomen angiography may be required in some children Aortic injuries include contusion, intimal dissection, and complete disruption The most frequent site of disruption is at the inferior mesenteric artery or renal arteries Patients present with diminished or absent distal lower extremity pulses Neurologic deficits may result from aortic compromise Associated injuries are present in 65% of cases When blunt abdominal aortic injury is recognized early, surgical intervention can dramatically lower mortality A pseudo aneurysm can develop as a late complication Major abdominal venous injuries resulting from blunt trauma are usually fatal • Fig 120.9 Computed tomography scan of a patient with a grade III pancreatic laceration (Courtesy Martin Eichelberger, MD, and Patrick McLaughlin, MD.) with an open abdomen may be required After pancreatic injury, acute peripancreatic fluid collections may develop and evolve into true pseudocysts These pseudocysts may resolve with observation or may require internal or external drainage.40 Operative drainage of a pseudocyst to the stomach or a roux-en-Y loop of intestine should be delayed for at least weeks until the pseudocyst wall is mature An infected pseudocyst may require urgent percutaneous drainage Magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography is useful to diagnose pancreatic duct disruption A pancreatic stent can be placed across the disrupted duct, which potentially prevents pseudocyst formation41 (Fig 120.10) Blunt Abdominal Aortic Injury The majority of aortic injuries after blunt trauma are in the chest, with only 6% in the abdomen.42 Pedestrians struck by a motor vehicle and unrestrained passengers are more likely to have thoracic injuries, whereas passengers with lap belt injuries are more likely to injure the abdominal aorta.43 Injury to the renal artery or mesenteric artery is more common than aortic injury.44 CT angiography is capable of providing a definitive diagnosis; however, Renal Trauma Renal injury rarely occurs as an isolated injury Findings suggestive of renal injury include flank tenderness, flank or abdominal mass, or ecchymosis Hematuria, either gross or microscopic, is an indicator of serious renal injury However, serious injury, especially renal pedicle injuries, may be present even without hematuria In hemodynamically stable patients, CT with intravenous contrast allows for an accurate diagnosis of renal injury and function (Fig 120.11) Sonography also provides an accurate diagnosis of extrarenal fluid collections.45 Renal trauma can result in a hematoma, laceration, or vascular injury (see Table 120.2) Children who are hemodynamically stable may be safely managed nonoperatively Angiography with embolization can control hemorrhage when contrast extravasation is seen on CT scan.46 Exploration is warranted in children who are hemodynamically unstable, have an expanding hematoma, or have an associated abdominal injury necessitating exploration In unstable patients, nephrectomy is the safest choice; however, the surgeon must ensure that the contralateral kidney is present before proceeding Renal repair or partial nephrectomy is possible in select cases Isolated urinary extravasation is not an indication for emergent exploration, but delayed operation or percutaneous drainage may be required for persistent extravasation or infection If urinary extravasation is present, antibiotics should be administered Patients with extravasation and devascularized segments on CT scan 1416 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma TABLE 120.3 Associated Injury by Location of Pelvic Fracture Number (%) Number With Abdominal Injury (%) Number With Genitourinary Injury (%) Unifocal 44 (81.5) (11) Fracture Site Pubic ramus 32 (59.3) (6) Iliac/pelvic rim (16.7) (33) Sacrum (5.60) 0 Multiple 10 (18.5) (60) (40) 54 11 (20) (7.4) Total • Fig 120.11 Computed tomography scan of a patient with a grade IV renal laceration and vascular injury have a higher incidence of delayed complications Observation and bed rest usually result in excellent outcome, even with deep parenchymal lacerations associated with urinary extravasation Patients with gross hematuria are kept on bed rest until the urine is grossly clear Reevaluation is necessary for persistent hematuria, tenderness, or mass All patients with renal injuries, regardless of severity, should be monitored for the delayed onset of hypertension A captopril-furosemide technetium-99m diethylenetriamine pentaacetic acid renal scan is used to verify function after injury Renal pedicle injuries are rare and are suggested by a lack of renal contrast enhancement on CT scan Renal angiography definitively establishes the diagnosis and directs operative management Ureteral injuries require operative repair, but diagnosis of ureteropelvic junction disruption may be delayed because of a lack of clinical signs on presentation Absence of contrast in the ureter indicates that ureteral stent placement will likely be necessary.47 Bladder Injuries Bladder injuries are most often associated with blunt trauma The bladder is predominantly intraabdominal in children Therefore, burst injuries are more common than in adults Bladder rupture is associated with pelvic fractures Clinical presentation of bladder rupture may be subtle, with only mild suprapubic tenderness The severity of associated injuries may mask signs of a bladder injury Hematuria is the most consistent finding Recognizing the injury and identifying it as intraperitoneal or extraperitoneal are important Stress cystography is best for establishing the diagnosis Lack of extravasation on CT scan does not exclude a bladder injury Peritoneal fluid located in the lateral perivesical recess, superior to the bladder, and in the pouch of Douglas is suggestive of intraperitoneal bladder rupture Extraperitoneal bladder rupture is noted by fluid extending superior and anterior to the level of the umbilicus and by fluid in the retrorectal presacral space The distinction between intraperitoneal and extraperitoneal bladder rupture is important for treatment purposes Controlled extraperitoneal ruptures are treated nonoperatively with urinary catheter drainage Extensive extraperitoneal rupture and intraperitoneal injuries require operative intervention.48 Pelvic Fractures The most common mechanism resulting in pelvic fracture in children is being struck by a motor vehicle when taking a walk Data from Bond SJ, Gotschall CS, Eichelberger MR Predictors of abdominal injury in children with pelvic fracture J Trauma 1991;31:1169 Single fractures of the pelvis are rarely associated with significant abdominal injury, but children with multiple fractures of the pelvis are at significant risk for abdominal injury even if hemodynamically stable (Table 120.3) Pelvic fractures are usually evident on the initial physical examination Findings include abrasions, bruising, hemorrhage, instability, or swelling Asymmetry of the bony structure, pain on palpation, or crepitus can be present An anteroposterior radiograph of the pelvis is obtained in the trauma bay to determine the anatomy of the fracture After recognition, attention should be directed toward prompt stabilization with a sheet tightly wrapped around the pelvis and assessment of hemodynamic status Opening of the pelvic ring, associated with fracture at two points, should be stabilized with a sheet wrapped around the pelvis, a C-clamp, or an external fixator Vertical shear injuries are not usually amenable to this treatment and will require operative reduction Hemodynamically unstable patients should be aggressively resuscitated Early angiography and embolization of bleeding vessels help to stabilize patients and avoid the need for operative intervention Hemodynamically stable patients should undergo CT to evaluate for associated injuries Special attention should be directed toward the rectum, vagina, and urethra, which are especially susceptible to injury by bony fragments Key References Arbra CA, Vogel AM, Zhang J, et al Acute procedural interventions after pediatric blunt abdominal trauma: a prospective multicenter evaluation J Trauma Acute Care Surg 2017;83(4):597-602 Gates RL, Price M, Cameron DB, et al Non-operative management of solid organ injuries in children: an American Pediatric Surgical Association outcomes and evidence based practice committee systematic review J Pediatr Surg 2019;54(8):1519-1526 Holmes J: Identifying children at very low risk of clinically important blunt abdominal injuries Ann Emerg Med 2013;62(2):107-116.e2 Peter SD, Keckler SJ, Spilde TL, et al Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children J Pediatr Surg 2008;43:191-194 Streck CJ, Vogel AM, Zhang J, et al Identifying children at very low risk for blunt intra-abdominal injury in whom CT of the abdomen can be avoided safely J Am Coll Surg 2017;224(4):449-458.e3 The full reference list for this chapter is available at ExpertConsult.com ... Grading Scales—cont’d Injury Duodenum laceration Grade I Grade II Grade III Grade IV Grade V Partial thickness ,50% circumference 50%–75% circumference second portion 75% circumference second portion,... demonstrates extraluminal gas or oral contrast extravasation in the right anterior pararenal space Thickening of the duodenal wall is seen when a duodenal hematoma is present Duodenal injuries are... a nasojejunal tube will allow enteral feeding distal to the point of obstruction Repair of full-thickness duodenal injury may require duodenorrhaphy, pyloric exclusion, duodenoduodenostomy, duodenojejunostomy,