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26: Abdominal Trauma

Mercedes Uribe; Halim Hennes

OVERVIEW

Abdominal trauma is the most common unrecognized fatal injury and the third leading cause of pediatric trauma death after injuries to head and thorax. The mortality rate is estimated to be as high as 8.5% and accounts for 8-12% of all deaths of children admitted with abdominal trauma.

Children have anatomic, physiologic, and psychological characteristics in contrast to adults that predispose them to a variety of injuries. Recognition of these characteristics plays a major role in the evaluation and management of pediatric trauma patient. The most pertinent characteristics related to abdominal trauma are outlined in (Table 26–1).

Table 26–1.Reasons for pediatric susceptibility in trauma.
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Table 26–1. Reasons for pediatric susceptibility in trauma.

  • The abdomen is wide and short especially in young children.

  • The thinner abdominal wall musculature, larger solid organs, and protuberant abdomen increase risk of direct injury.

  • The pliable and underdeveloped ribs and pelvis increase the risk of injury to liver, spleen, and urogenital system in the absence of skeletal fracture.

  • The internal organs have less insulation from fat, and are suspended by more elastic structures. This reduces the amount of energy absorption and contributes to damage to organs.

  • The first part of the duodenum is not well protected and children can have intramural hematoma even with mild trauma.

  • High jejunal tears and injuries near the ileocecal valve are also common in children.

  • Abdominal distention is more common following trauma due to air swallowing from pain and crying, making examination more difficult.

  • Children can maintain blood pressure with up to 25-40% blood volume loss before hypotension results.

  • Children have small anteroposterior abdominal cavity diameter and when poorly restrained, the fulcrum of a flexion injury would be at the body of the spine, which exposes it to a flexion-distraction injury (Chance fracture).

  • A child’s smaller body size leads to traumatic forces that are often distributed over a smaller body mass, increasing the number of systems injured during trauma.

  • The larger relative surface area promotes hypothermia complicating shock.

TYPES OF INJURY

BLUNT ABDOMINAL INJURY

More than 80-90% of traumatic abdominal injuries in children result from blunt mechanism. The most common causes of injury are traffic accidents (49%), falls (22%), direct impact trauma (20%), and being run over by a vehicle (9%). Other mechanisms include all-terrain vehicle (ATV) accidents, handlebar injuries from bicycles, and sport or non-accidental trauma. Incidences of solid organ injuries associated with blunt trauma are spleen (46.7%), liver (33.3%), renal (17.5%), and pancreas (2.5%).

Children with non-accidental trauma have the highest risk for morbidity and mortality.

PENETRATING INJURIES

Penetrating abdominal trauma accounts for 4-15% of all pediatric abdominal trauma. In the United States, firearm-related injury and gunshot wounds (GSWs) are the most common causes of penetrating injuries in ...

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