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Emiliana Lia Pediatric Surgery Division Hasan Sadikin Hospital – Padjadjaran University
Emiliana Lia Pediatric Surgery Division Hasan Sadikin Hospital – Padjadjaran University
Emiliana Lia
Pediatric Surgery Division
Hasan Sadikin Hospital – Padjadjaran University
What is the evidence for non operative in children with blunt abdominal trauma? What is
What is the evidence for non operative
in children with blunt abdominal
trauma?
What is the evidence for
one week bed rest in
children with liver
injury?
 Blunt abdominal trauma remains the commonest cause of abdominal injury in children  National

Blunt abdominal trauma remains the commonest cause of abdominal injury in children

National Trauma Registry in USA, 9% mortality

Liver, spleen and kidney injury each occurred in about 30%

GIT was injured in about 15%

in USA, 9% mortality  Liver, spleen and kidney injury each occurred in about 30% 
 Infant  non accidental injury  Toddlers  falls  Older children  road
 Infant  non accidental injury  Toddlers  falls  Older children  road

Infant non accidental injury

Toddlers falls

Older children road traffic accidents and sport injuries

 non accidental injury  Toddlers  falls  Older children  road traffic accidents and
Physiological  A stroke volume is relatively constant  tachycardia the only way to increase
Physiological  A stroke volume is relatively constant  tachycardia the only way to increase

Physiological

A stroke volume is relatively constant tachycardia the only way to increase heart minute volume

Children’s skin area relatively large hypothermia develop relatively rapidly

Anatomical

Relatively large size of the head more often suffer from brain injury

Less abdominal muscle or fat mass absorb some of the impact

A very elastic ribcage less protection to the liver and spleen

A small pelvis more intra-abdominally bladder, thus less protected

 less protection to the liver and spleen  A small pelvis  more intra-abdominally bladder,
Assessment  Airway  establishing a free airway  Breathing  adequate oxygenation/ventilation 

Assessment

Airway establishing a free airway

Breathing adequate oxygenation/ventilation

Circulation

Sign of shock : after a loss of > 15% total circulating volume

20 cc/kg warm isotonic cystalloid is administered, can be repeated first bolus comprises 25% of the circulating volume, second bolus 50% of the circulating volume

can be repeated  first bolus comprises 25% of the circulating volume, second bolus 50% of

Physical examination

Repeated physical examination

X-rays : chest pelvis and cervical spine

FAST

Blood samples

CT scan absence of hemodinamic instability when abdominal injury is suspected

FAST  Blood samples  CT scan  absence of hemodinamic instability when abdominal injury is
 Abdominal pain and tenderness during exam  Pelvic or femur fracture  Abdominal contusions
 Abdominal pain and tenderness during exam  Pelvic or femur fracture  Abdominal contusions

Abdominal pain and tenderness during exam

Pelvic or femur fracture

Abdominal contusions (seatbelt sign or handlebar mark)

Lower ribs fractures

Pneumothorax

Costal margin tenderness

Lumbar spine fracture

Hematocrit less than 30%

Hematuria

Positive fast

Costal margin tenderness  Lumbar spine fracture  Hematocrit less than 30%  Hematuria  Positive
 CBC  Hb/ht  Coagulation factors (PT, aptt, inr)  Liver function test 

CBC

Hb/ht

Coagulation factors (PT, aptt, inr)

Liver function test

AST/ALT

(AST>400 or ALT>250 indicated for CT)

>80 indicated abdominal imaging (Schonfeld and Lee, Blunt Abdominal TRAUMA in Children, emergency and critical care medicine, 2012)

Urine analysis

5 rbc/hpf, or > 20 RBC/hpf, or > 50 RBC/hpf

Wegner, et al. Pediatric Blunt Abdominal Trauma, Pediatr Clin N Am53 (2006) 243-256

> 20 RBC/hpf, or > 50 RBC/hpf Wegner, et al. Pediatric Blunt Abdominal Trauma, Pediatr Clin

FAST

Detect free intraperitoneal fluid (presumed to be blood in the setting of trauma)

BATiC

Result of abdominal doppler ultrasound with three physical exam findings and six laboratory values

a score of 7 or less CT Scan seems unnecessary (sensitivity 91%, specificity 84%)

CT SCAN

Diagnostic test of choice

of 7 or less CT Scan seems unnecessary (sensitivity 91%, specificity 84%)  CT SCAN 
 Abnormal Abdominal ultrasound  Abdominal pain  Peritoneal irritation  Hemodynamic instability 
 Abnormal Abdominal ultrasound  Abdominal pain  Peritoneal irritation  Hemodynamic instability 

Abnormal Abdominal ultrasound

Abdominal pain

Peritoneal irritation

Hemodynamic instability

AST >60 U/l

ALT > 25 U/l

WBC >10 x109/l

LDH >330 U/L

Amylase >100 U/L

Creatinine >110 umol/L

Score less than 7 CT scan seems unnecessary

U/L  Amylase >100 U/L  Creatinine >110 umol/L  Score less than 7  CT
 Associated with high energy trauma or violent compression of the abdominal or thoracic wall.

Associated with high energy trauma or violent compression of the abdominal or thoracic wall.

 Associated with high energy trauma or violent compression of the abdominal or thoracic wall.
No difference between ISS scores in the different age groups 25 cases (31%) were performed

No difference between ISS scores in the different age groups

25 cases (31%) were performed laparotomy

19 cases : liver injury

Mortality 8%

55 cases (69%) non-operative management

Nellenstenijn DR, Groningen, 2015

laparotomy 19 cases : liver injury Mortality 8% 55 cases (69%) non-operative management Nellenstenijn DR, Groningen,

The American Pediatric Surgical Association (APSA) Recommendation evidence- based guidelines

 The American Pediatric Surgical Association (APSA) Recommendation evidence- based guidelines
The percentage of patients treated Non-operative Management was significanly higher in the period after the

The percentage of patients treated Non-operative Management was significanly higher in the period after the year 2000, compared to the period before 2000 (63% vs

84%)

Success rate are over 95%.

higher in the period after the year 2000, compared to the period before 2000 (63% vs
 Emphasis the physiology and metabolic stability  Damage Control Surgery  After DC Surgery
 Emphasis the physiology and metabolic stability  Damage Control Surgery  After DC Surgery

Emphasis the physiology and metabolic stability

Damage Control Surgery

After DC Surgery vital sign monitoring, urine output, serum lactate level, base deficit, mixed venous oxygen saturation, and gastric pH

After rewarming, replacement of coagulation factor, optimalization of O2 delivery remove packing & go for definitive surgery

When ? depend on resusitation and body response + infection risks

Complication of perihepatic / pelvic packing abscess, intraabdominal sepsis, intraabdominal hypertension

risks  Complication of perihepatic / pelvic packing  abscess, intraabdominal sepsis, intraabdominal hypertension
 Hemostasis: manual compression, suture, topical hemostasis agent  Morbidity & mortality in severe hepatic

Hemostasis: manual compression, suture, topical hemostasis agent

Morbidity & mortality in severe hepatic injury

more likely due to massive blood loss and replacement of large volume of cold blood products

Hypotermia + Coagulopathy + Acidosis unlikely to survive

When there is hemodinamic instability need of blood transfusion > 25 ml / kg BW in 1-2 hour presentation strong indicator need for surgical management.

of blood transfusion > 25 ml / kg BW in 1-2 hour presentation  strong indicator
 Term to describe deleterious effect of increased intraabdominal pressure.  Syndrome:  Respiratory

Term to describe deleterious effect of increased intraabdominal pressure.

Syndrome:

Respiratory insufficiency

Hemodynamic compromise

Impaired renal function

Decrease cardiac output

Etiology: hemoperitoneum, retroperitoneal and bowel edema, packing

Measure by instilling 1 mL/kg saline into Foley catheter measure from symphisis pubis

IAP 20-35 cmH2O or 15-25 mmHg indication to decompress the abdomen.

 measure from symphisis pubis  IAP 20-35 cmH2O or 15-25 mmHg  indication to decompress
 A potentially severe injury with a relatively high incidence.  High trauma or violent

A potentially severe injury with a relatively high incidence.

High trauma or violent compression of the abdominal or thoracic wall.

Traffic related accidents accounts for the majority of blunt splenic injuries.

of the abdominal or thoracic wall.  Traffic related accidents accounts for the majority of blunt
Success rate of Non-operative treatment is 97%, and complications are rare.
Success rate of Non-operative treatment is 97%,
and complications are rare.
 Rare, the consequences can be severe.  Late onset of complaint.  Usually blunt

Rare, the consequences can be severe.

Late onset of complaint.

Usually blunt injury to the upper abdomen.

Laboratory test and imaging techniques non-spesific

of complaint.  Usually blunt injury to the upper abdomen.  Laboratory test and imaging techniques

Non-operative management

Total parenteral nutrition

Naso-gastric drainage

Proton pump inhibitors

Possible ocreotide

Complications :

Pseudopancreas

Surgical Intervention

Peritonitis, threatening hemodinamic or respiratory failure or infected necrosis

Surgical Intervention  Peritonitis, threatening hemodinamic or respiratory failure or infected necrosis
 Recent advances in the delivery of trauma and critical care in children have resulted

Recent advances in the delivery of trauma and critical care in children have resulted in improved outcome following major injuries.

The data addressing specific concerns about the nonoperative treatment of children with solid organ injuries and recent radiologic and endoscopic contributions have made pediatric trauma care increasingly nonoperative.

Although the trend is in this direction, the pediatric surgeon should remain the physician-of-record in multidisciplinary care of these critically injured children.

The decision not to operate is always a surgical decision.

care of these critically injured children.  The decision not to operate is always a surgical