Symposium on Trauma
Blunt Abdominal Trauma in Childhood Arvin 1. Philippart, M.D.*
Blunt abdominal trauma in childhood is a segment of the broader issue of pediatric trauma. Trauma is the major cause of mortality in the age group 1 to 14 years. 32 Furthermore, it may cause major chronic morbidity at great emotional and financial cost to families and to society. The mechanisms of injury frequently vary from those seen in the adult population. Because blunt abdominal trauma in childhood is so common, most general surgeons have some experience in the management of these children. The same basic surgical principles operative in the management of adult trauma apply in the management of the injured child. While principles of operative management are unchanged in the child, patterns of injury, patient evaluation, and nonoperative care may differ from that of the adult. The problems which arise most frequently originate in the physician's lack of comfort and familiarity with children. The result may be an inaccurate assessment of intraabdominal signs or inappropriate supportive management such as airway maintenance or fluid administration. The purpose of this article is not to list all the steps in recognition and management of pediatric trauma but to emphasize particularly the differences between the child and the adult. Appreciation of these dife ferences is necessary to provide optimal care.
INCIDENCE Accidents are the primary cause of mortality in children after the first year of life. 32 Automobile related events account for approximately 50 per cent of deaths. Although one can establish morbidity in adult injuries33 in the form of hospital days, lost days of employment, or financialloss, no assessment of morbidity, particularly long-term disability, is available for children . ., Attending Surgeon and Director of Surgical Education, Children's Hospital of Michigan; As· sistant Professor of Surgery, Wayne State University School of Medicine, Detroit, Michigan
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Trauma is one of the mechanisms by which the child learns in the exploration of his environment. Many social determinants affect the degree of supervision of any child. The degree of supervision, in turn, affects the incidence and severity of injury.
DETERMINANTS OF INJURY Age Trauma in the infant age group is infrequent. The toddler group (2 to 4 years) has the highest injury rate. 15 Most of these injuries occur in the home. After the age of 4, injuries occur outside the home with progressive frequency and the injury rate is stable. Season Trauma is a warm weather disease, particularly in the northern states. In our institution, approximately 50 per cent of trauma requiring hospitalization occurs in the three summer months. Mechanisms The automobile is clearly the primary agent of injury whether the child is an occupant or a pedestrian. 32 Other causes such as falls, bicycles or sleds, fights, or athletic endeavors vary with age or demographic differences. Trauma secondary to battering is largely a disease of infancy. Abuse occurs in all socioeconomic groups and all demographic categories. Three distinctive mechanisms of trauma are characteristic of the pediatric population and should be emphasized. The first is birth associated trauma. The second is the battered child syndrome. The third is the occurrence of major visceral injury after minor trauma in the child with a previously unrecognized congenital anomaly. Birth Injury The traumatic effects of birth are well recognized. However, birth trauma has been indicted as the primary cause in only 1 per cent of fetal and neonatal deaths at the Boston Hospital for Women. 27 Petechiae and edema of the presenting part and moulding of the skull are sufficiently frequent to be physiologic. Fetal presentation, duration of labor, and fetal size are all determinants of injury rate. Breech presentation, precipitous or prolonged labor, and increased fetal size all increase the risk of trauma. Head and neck, neurologic, and extremity injuries are most common. Abdominal visceral injury is less common. Potter26 reported autopsy findings in 2000 newborn deaths and related only 28 to laceration of solid intraabdominal viscera. Of these, 22 were hepatic lacerations. Splenic injury is less common and is associated with poor salvage because of late recognition, advanced hypovolemia with its attendant sequelae, and the frequent coexistence of a coagulopathy. Sieber re-
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ported the first survivors in 1958. 28 Since then, a total of 24 neonatal cases have been successfully treated by splenectomy or splenic repair. 22 In our experience, adrenal hemorrhage is more common than hepatic or splenic injuries. The important consideration is prompt recognition and the provision of steroid replacement therapy if necessary. The surgical significance of this disease is its late differentiation from neoplastic lesions that do require operation. Calcified adrenal hematomas do not. While intestinal perforations have been grouped with birth trauma previously, perforations are the result of intestinal ischeInia. The exception is rectal perforation secondary to the faulty insertion of a rectal thermometer.
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Battered Child Syndrome Physical abuse of children has existed since antiquity. In the last 15 years, this mechanism of injury has received increased attention. As a result, current conservative national estimates are that 250,000 children per year are abused. Of these, probably 15 per cent require hospitalization and the established mortality rate of these is at least 5 per cent.31 In our own institution, investigations into suspected abuse or neglect have plateaued at approximately 300 cases per year. Of this number, approximately 100 are evaluated by the surgical service for suspected abdoIninothoracic injury. Less than 5 per cent of these children require an operative procedure. Orthopedic or neurosurgical procedures are more frequently required than general surgical intervention. The environmental characteristics associated with battering have been well described. 18 The nuclear family may be intact, but relationships are disordered. The abusive parent frequently was an abused child. An awareness of this syndrome is necessary to recognition. The hallmark of the history is its misleading nature. The parents frequently deny any knowledge of the mechanism of injury. If trauma is implicated, the history describes a minor episode inconsistent with the extent of injury noted on physical examination. Suspicion may be reinforced by assessment of the child. Rather than loudly fearful of painful procedures, these patients are frequently passive and quiet. Surface evaluation commonly reveals signs of neglect. Ecchymoses, lacerations and abrasions of varied ages, or small burns, particularly cigarette burns, have been seen in the majority of our cases. All degrees of abdominal findings may be elicited by careful examination. The warning sign of the abused child is evidence of marked intraperitoneal pathology-more marked than the history would suggest. Clinical findings which are atypical or do not fit known syndromes should also raise suspicion. Supporting evidence of battering should be sought with a radiologic skeletal survey. The characteristic features are fractures in varied stages of repair. Callus formation frequently documents multiple episodes of trauma at different times prior to recognition.
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The abdominal visceral injuries seen in our most recent series of 27 cases include a predominance of central upper abdominal lesions in the duodenum, pancreas, and jejunum. This is characteristic and reflects the anatomy of the abdomen in the young child. The abdomen is prominent, the costal margins flare widely, the musculature gives inadequate protection against the delivered force, and the anteroposterior distance is small. The nature of the blow and its vectors account for the paucity of splenic and hepatic injuries. Traumatic pancreatitis is infrequent in children compared to adults and when it occurs is most often due to battering. The small bowel lesions occur adjacent to areas of retroperitoneal fixation but are frequently unusual in nature. Avulsion of the gut from the mesentery is more common than the usual simple antimesenteric perforation seen with handle bar injuries and similar traumatic agents. The need for recognition of the battered child is emphasized by the significant mortality previously mentioned. The major cause of mortality is irreversible head trauma or late arrival for medical care. In our own series, all operative cases have survived, but four children have been dead on arrival or within the first 24 hours. Three children have had siblings who previously had died of battering in other institutions. In many states, the onus of recognition and prevention has been placed on the physician. Statutes vary, but reporting of all cases of suspected abuse is required of the physician by many. Underlying Anomalies Another feature unusual to pediatric trauma is the occurrence of major clinical injury after minor trauma in children with underlying anomalies (Fig. 1). As in the battered child, the recognition of the underlying pathology requires an awareness of this possibility. The hallmark is the discrepancy between the history of a minor injury and the major clinical sequelae. The most widely appreciated example is the child with unrecognized obstructive hydronephrosis, such as ureteropelvic obstruction, who receives very minimal flank trauma, but presents with gross hematuria, colic, and acute obstruction. Frequently, acute flank symptoms after minor trauma will stimulate recognition of a Wilm's tumor. A major retroperitoneal hemorrhage may be the first mode of presentation of a retroperitoneal hemangioma or of a previously unrecognized coagulopathy, such as von Willebrand's disease, hemophilia variants, or idiopathic thrombocytopenic purpura. Splenic injury after minor trauma is frequently mentioned in infectious mononucleosis, leukemia, or portal venous hypertension. Splenic injury in these settings is a rare occurrence. Minor trauma with minimal acute sequelae may lead to an unplanned examination which reveals previously unrecognized pathology. This is particularly true of pediatric intraabdominal neoplasms such as Wilm's tumor, neuroblastoma, or hepatoblastoma.
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Figure 1. Two-year-old female presented with 2-day history of abdominal air and severe anemia after hyperextension over yoke of wagon. Large left flank mass extended into pelvis. IVP reveals hydronephrosis and displacement of bladder as well as displacement of gut. Minimal resolution in 3 weeks precipitated operative excision of retroperitoneal hemelymphangioma with recent hemorrhage.
EVALUATION The traumatized child must be evaluated in the same disciplined fashion as is done with the adult. Priorities are unchanged. Airway support is the first priority. If airway intubation is required, the initial procedure should be the insertion of a transoral endotracheal tube. The choice of size of tube is critical. Frequently, inappropriately large tubes are used resulting in subglottic stenosis as a result of mural injury. Tracheal stenosis is infrequent because cuffed tubes are rarely necessary. In the absence of appropriate experience, the width of the distal phalanx of the patient's fifth finger may be used as a guide to the size of tube to be chosen. If continued intubation is required after completion of the resuscitative phase, the orotracheal tube should be replaced by a nasotracheal tube by experienced personnel. Nasotracheal tubes can be more securely fixed, reducing iatrogenic airway injury. Tracheostomy is rarely required in the acute resuscitative phase. When later performed for prolonged airway support, it should be done over an indwelling tube for purposes of control and identification. Because the child's neck is short and thick, and the apical pleura more vulnerable, this procedure should be performed in the operating room and not at the bedside. Only a single vertical incision of one or two rings should be performed. No tracheal wall should be excised.
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Volume replacement should be accomplished expeditiously. The difficulty of venous access in small children frequently leads to the insertion of needles or cannulae of inadequate size by the inexperienced physician. Adequate access is always possible by venous cutdown if necessary. Central venous pressure monitoring is possible and, after the newborn period, requires no different interpretation than in the adult. Another common error too often encountered is the use of inappropriately small or large replacement volumes in the hypovolemic child. The only accurate approach to volume replacement is to calculate estimated blood volume CEBV) as 7 or 8 per cent of body weight. In the hypotensive child, 20 per cent of EBV should be given, with subsequent infusion based on clinical judgment. One frequently hears that children do not tolerate blood loss well but this statement is incorrect. When losses are calculated as percentage of blood volume, the child is shown to tolerate blood loss with fewer sequelae than the adult as the cardiovascular performance of the child is not compromised by the attrition of acquired disease. When the initial resuscitative maneuvers are completed, the same orderly assessment of injuries used in the adult is necessary. The history of the injury is frequently less accurate in the child than the adult. The only reliable way to overcome this limitation is to provide continuing reassurance and repetitive questioning. This must be combined with sequential examinations of the suspicious abdomen. The importance of repetitive examinations cannot be overemphasized. The abdomen of the child is thin and elastic compared to the adult. There is less subcutaneous tissue or muscle to interfere with evaluation. As a result, the physician skilled in the care of children can make an accurate assessment in the reassured and calmed child. It is very unusual to require either sedation or peritoneal aspiration or lavage in the awake child if one is patient. Paracentesis or lavage is used readily only in those children with both serious head injury and suspicious signs of intraabdominal injury. When lavage is used, the recommended volume of lactated Ringer's solution or normal saline is about 10 ml per kg. The radiologic evaluation of trauma is dictated both by the clinical status of the patient after the initial resuscitative maneuvers and by the nature of the injuries. The studies requested will be mentioned with the discussions of specific organ injuries. However, it may be stated as a generalization that plain films of the abdomen tend to provide fewer diagnostic clues in the injured child tJ;1an in the injured adult. A major reason for this disparity is that the child's inherent resilience results in fewer fractures for similar force patterns. However, when low thoracic rib fractures are seen in the child, serious visceral injury is more common.
UROLOGIC TRAUMA Although splenic laceration is the most common indication for operation,29 urinary tract injuries are the most frequent sequelae of
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blunt abdominal trauma.25 This difference in the operative rate reflects the conservative management used in renal injuries. Only head injury exceeds renal injury in frequency. Automotive trauma is the most common mechanism of injury in our series. Falls and athletic events account for a lesser number. Pre-existent renal anomalies are found in a significant number of children. A recent reporrt collated multiple series of pediatric renal injuries and established an incidence of 12 per cent with underlying anomalies such as obstructive hydronephrosis from ureteropelvic obstruction. However, in our recent series the most common pre-existent anomaly has been Wilm's tumor. The clinical presentation of flank trauma with cutaneous injury, flank tenderness, and hematuria is widely appreciated. Because low thoracic rib fractures are infrequent in children, their presence should further raise the index of suspicion. Associated with left renal injuries is a 25 per cent incidence of splenic injury25 which may complicate the evaluation. The efforts of Morse2 4 • 25 over a period of years have documented the nature and rational investigation of pediatric renal trauma. An infusion pyelogram (IVP) should be performed in all but the gravest situations. Better results are obtained with the earliest possible performance of the IVP before progressive increase in intracapsular pressure resulting from bleeding, sepsis, and edema. The advantages of the infusion IVP include a better nephrogram and visualization of a filled renal pelvis and ureter. This provides greater accuracy in assessment of the cortical injury,30 precludes the need for retrograde pyelograms in all but the rare case, and avoids the need for arteriography in many situations. Arteriograms are performed when there is anuria and when the infusion IVP reveals unilateral non visualization or a transection which may possibly be managed by a partial nephrectomy. In the latter circumstance, knowledge of renal arterial anatomy is very useful. Arteriograms are also performed when there is a significant concern that associated visceral injury may be present. The commonest example is the child with a recognized left renal injury in whom the possibility of concomitant splenic injury arises. We prefer arteriography to renal scans because they are more easily and rapidly obtained and provide greater information. Arteriography, well performed, has not been associated with complications in these patients. With the information obtained, classification of injury is possible,25 providing a useful guide to management. All management should be based on conservation of functioning nephrons. Indications for operation include renal pedicle injury, complete transection with marked extravasation, or lacerations of the pelvis. Lesser degrees of extravasation are treated without operation. Uncontrolled hemorrhage is rare in blunt trauma. With the above approach, 20 per cent or less of blunt renal injuries require operation. A more difficult problem is the management of renal trauma in the multiply injured child in profound shock despite resuscitative attempts. When urgent laparotomy has been performed to arrest blood loss from a
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major vascular or hepatic laceration, the approach to a renal hematoma represents a controversial problem. Once blood volume is restored, an IVP in the operating room is necessary to establish renal function. The technique may be simple or elaborate.3 Gerota's fascia, when intact, will tamponade renal hemorrhage. If exploration of the hematoma is embarked upon, the renal pedicle should first be exposed for later clamping should this become necessary.2. 3. 11 This approach will provide a dry field for parenchymal repair and a lower nephrectomy rate. While this technique is well accepted, it should not be overutilized; we concur with Holcroft et al./ 3 who open Gerota's fascia only when the hematoma is expanding, uncontained, or pulsatile. The survival of patients with renal trauma is determined by the presence or absence of associated injury. It is the rare circumstance where isolated renal injury results in death. When the patient with blunt renal trauma expires, death is almost invariably due to multisystem trauma and central nervous system injury is the commonest cause of mortality in these circumstances. The late sequelae of renal trauma include renal growth disturbances and hypertension. Reduced renal growth with contralateral compensatory hypertrophy occurs only in those patients with severe initial injury. An IVP 1 year after injury will reveal these changes. 14 The appearance of hypertension is late and infrequent and is not readily predictable by the nature of the initial injury.!O
SPLENIC TRAUMA Splenic laceration is the most frequent visceral injury reqUITIng laparotomy after blunt abdominal trauma in children. The additional number of splenic injuries treated successfully without operation is significant, but unknown. The mechanisms of splenic trauma, the association with other visceral injuries, and the clinical symptoms and signs are all well documented. Routine radiologic studies are occasionally helpful by revealing rib fractures or displacement of gastric or colonic gas. However, operative management has always been a clinical decision. Recently, the use of isotopic imaging of the spleen, as well as arteriography, has increased. There is little question that these techniques have improved diagnostic accuracy. Isotopic studies are noninvasive and more widely used. False negative and false positive scans have been reported.s. 21 False negatives commonly occur with lesser injuries. False positives may result from antecedent disease or anatomic variation. Splenic arteriograms are more accurate/' 9. 12 but are also associated with diagnostic errors. We have limited the use of splenic arteriography to those children with known left renal injury who also have clinical findings which suggest possible splenic injury. This group has been selected because of the frequency of simultaneous injury to both organs.
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Before discussing the implications of this improved diagnostic accuracy, it is necessary to realize the concern pediatric surgeons share about splenectomy for trauma. After the initial report of postsplenectomy septicemia by King and Shumaker in 1952,19 there was a period of years when the risk was strongly suspected but unproven. In 1972 Eraklis and Filler surveyed the partial experience of the members of the Surgical Section, American Academy of Pediatrics. 7 This study clearly demonstrated the late septic complications after pediatric splenectomy and asserted that increased risk of late fatal septicemia followed splenectomy performed in the first 2 years of life. While most physicians interested in this problem accept that statement, many feel the risk is also increased after 2 years of age. The authors also noted that deaths from sepsis occurred most often in patients with underlying hematologic or neoplastic disease. 7 They further stated that the 1 per cent incidence of fatal sepsis after splenectomy for trauma did not represent a clearly established risk. We do not concur with this as 1 per cent of the normal pediatric population with an intact spleen do not die of septicemia. It is probable that the estimate of 1 per cent is unduly low as a result of failures in recognition or reporting. Furthermore, this figure is based on mortality and does not include postsplenectomy septicemia successfully treated, of which we have a number of patients. While the role of the spleen in sepsis is poorly understood at this time, there is emerging evidence that supports the clinical impression of increased risk. It has been established that the spleen represents the major source of phagocytic function in pyogenic septicemia. While the balance of the reticuloendothelial system assumes this function after splenectomy, it is unclear whether there is a residual deficit. The report of a peptide, tuftsin, elaborated by the spleen and absent in splenectomized patients,5 provides further support for clinical concern. Tuftsin is the active peptide moiety in leucokinin which stimulates phagocytosis by the polymorphonuclear leukocyte. With these doubts emerging, attempts to salvage splenic function after trauma in the child are to be encouraged. Splenectomy remains the standard against which alternate forms of management must be measured. Hospital mortality in splenic trauma should be a result of associated organ injury and anesthetic risk only. On the other hand, the diagnosis of splenic trauma has been a purely clinical diagnosis until recently. As a result, many occult splenic lacerations have been successfully treated nonoperatively.6 Splenectomy solely on the grounds of an abnormal splenic scan or filling defects on arteriography should be questioned. Exploration should be based on clinical evidence of blood loss and peritoneal signs. Given those features, supporting studies may reinforce clinical judgment. Any mention of nonoperative management of splenic trauma raises the spectre of "delayed" rupture. The term "delayed" should be used only for those patients with splenic hemorrhage after the period of hospitalization and discharge. It should not be used for the patient in whom diagnosis is not made for 12 to 48 hours. When this definition is used, delayed rupture occurs very infrequently in children. 34
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If clinical signs necessitate exploration for splenic or other visceral injury, several courses may be followed. Splenectomy is the accepted and advised procedure in the presence of active bleeding. However, small, currently nonbleeding lacerations seen in the course of exploration for other injuries may be observed and left undisturbed while other lesions are attended to, much as is done for minor hepatic capsular lacerations. Bleeding lacerations have been sutured with Teflon pled gets more widely than reported. Partial splenectomies have been reported23 but caution and clinical judgment must be exercised. The goal of splenic salvage is appropriate but should never endanger patient survival. Postoperatively, the splenectomized child should be maintained on suppressive levels of penicillin. The optimal duration of adIninistration is unknown. We maintain prophylaxis in all children until 4 years of age. More importantly, parents are carefully and forcefully instructed to seek medical attention immediately when the child presents with any febrile illness, as overwhelming sepsis may occur in as little as 12 hours after the onset of symptom. Using these policies, we have successfully recognized and treated three cases of pyogenic septicemia or primary peritonitis in the past 5 years.
HEPATOBILIARY TRAUMA Trauma to the liver and bile ducts in children differs little from that seen in the adult population. Automotive injuries account for the majority and falls for many of the remaining cases. 12 ,17 Trauma to a mass lesion such as a hepatoblastoma or simple cyst is rare, but may produce contained hemorrhage and acute symptoms. Recognition of severe hepatic injury is frequently rapid as a result of hypotension, hemoperitoneum, and resultant urgent operation. In contrast, subclinical injury also occurs. As in splenic injuries, minor lacerations are treated on the basis of clinical rather than radiologic indications. Operative management of hepatic injuries differs little from the principles followed in the adult. Despite the difficulty of inserting large percutaneous intravenous lines in children, adequate routes for administration of blood must be established. A major difference in children occurs in the management of the common bile duct after hepatic resection, should this be necessary. The use of a T-tube choledochostomy in adults is a source of controversY,20 but in children T-tube decompression should not be used because of the small size of the duct, which adds to the risk. Furthermore, the benefit derived is highly questionable. Injury to the extrahepatic biliary tract is an unusual occurrence. In my experience, this has presented as a retroduodenal ductal transection which has been managed successfully with a Roux-en-Y choledochojejunostomy. "Spontaneous" perforations of the common duct occur rarely in infants and have been tentatively related to trauma. There is little evidence to support that etiology. Preferred management has been careful exploration of the bile pseudocyst and simple Penrose drainage.
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INTESTIN AL INJURIES Blunt intestinal trauma in children is less frequent than renal or splenic injury. The cause of perforations is related to age. Neonatal perforations are ischemic rather than traumatic with the exception of rectal perforations by thermometers. Because of thermometer perforations, many pediatric hospitals have discontinued rectal temperature monitoring. In infants and toddlers the usual cause of intestinal injury is physical abuse. The older more mobile child is most frequently injured by an automobile or a fall (Fig. 2). As in the adult, intestinal injuries occur in or adjacent to areas of retroperitoneal fixation. The pattern of injury resulting from abuse has already been described. The diagnosis of intestinal perforation is established by an appropriate history and repetitive examinations which reveal increasing peritoneal signs. Abdominal x-rays frequently fail to show free air, particularly in more distal perforations. When seen, free air is often a late finding. The operative management of the lesions does not differ from that used in the adult. One lesion seen more commonly in the pediatric age group is duodenal hematoma. The reasons for the disproportionate frequency is the anatomic variation described earlier. Most of these hematomas result from traumatic impingement of the duodenum against the vertebral bodies. They are also seen without an antecedent history of
Figure 2. Upper gastrointes· tinal series in 6-year-old male with duodenal hematoma following a fall. Note severe partial duodenal obstruction with "coiled spring" appearance. Successfully treated nonoperatively.
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trauma in children with bleeding disorders such as leukemia and hemophilia. Bilious vomiting may gradually increase over the first several days before obstruction is sufficient to cause parental concern. As a result, the history of trauma may be obscured unless sought. The physical examination is frequently normal. The diagnosis is established when an upper gastrointestinal ~eries reveals a significant partial obstruction of the duodenum with the characteristic "coiled spring" appearance of an intramural hematoma. In the absence of clinical signs of perforation, the management is nonoperative. Controversy arises in those cases where adequate oral alimentation cannot be maintained after 7 days of nonoperative care. 16 Proponents of operative management advise partial thickness duodenal incision with evacuation of the hematoma and careful closure of the seromuscular coat with drainage. Our preference is for continuation of nonoperative management in other than unusual circumstances. It is our experience that adequate oral alimentation occurs as soon with continued purely supportive care as it does with a duodenotomy performed at 7 days. This belief is buttressed by experience with children with hemorrhagic diatheses where operation is avoided. Furthermore, the availability of parenteral hyperalimentation obviates the need for early operation based on a projected later concern for adequacy of nutrition. Persistent obstruction without improvement documented by no decrease in nasogastric aspirate and no improvement on repeat barium studies after 10 or 12 days constitutes our indication for operation. The need for intervention will decrease significantly if these guidelines are used.
SUMMARY Blunt abdominal trauma in childhood is a common clinical occurrence. Accurate assessment requires an understanding of patterns of injury and the response of the child. Repetitive examinations in a comforting environment will yield superior clinical judgment. Renal trauma is frequent, requires thorough radiologic evaluation, and may be associated with an underlying anomaly. The goal of management is salvage of functioning nephrons. Definitive indications should exist prior to operative intervention. The goal of management of splenic injury should not be the justification of splenectomy. The operative decision should be based on clinical indications. Judgment should include a knowledge of the risks and alternatives.
REFERENCES 1. Awe, W. C., and Eidemiller, L.: Selective angiography in splenic trauma. Am. J. Surg., 126:171-17~ 1973. 2. Banowski, L. H., Wolfel, D. A., and Lackner, L. H.: Considerations, diagnosis, and management of renal trauma. J. Trauma, 10:587-597, 1970.
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3. Cass, A. S., and Ireland, G. W.: Management of renal injuries in the severely injured patient. J. Trauma, 12:516-522,1972. 4. Cass, A. S., and Ireland, G. W.: Renal injuries in children. J. Trauma, 14:710-722,1974. 5. Constantopoulos, A., Najjar, V. A., Wish, J. B., et al.: Defective phagocytosis due to tuftsin deficiency in splenectomized subjects. Am. J. Dis. Child., 125:663-665,1973. 6. Douglas, G. J., and Simpson, J. S.: The conservative management of splenic trauma. J. Ped. Surg., 6:565-570, 1971. 7. Erakiis, A. J., and Piller, R M.: Splenectomy in childhood: A review of 1413 cases. J. Ped. Surg., 7:382-388, 1972. 8. Gilday, D. L., and Alderson, P.O.: Scintigraphic evaluation of liver and spleen injury. Sem. Nucl. Med., 4:357-370,1974. 9. Gold, R E., and Redman, H. C.: Splenic trauma: Assessment of problems in diagnosis. Am. J. Roentgen., 116:413-418,1972. 10. Grant, R. P., Gifford, R P., Pudvan, W. R, et al.: Renal trauma and hypertension. Am. J. Cardiol., 27:173-176,1971. 11. Guerriero, W. G., Carlton, C. E., Scott, R., and Beall, A. C.: Renal pedicle injuries. J. Trauma, 11 :53-62, 1971. 12. Hartman, S. W., and Greaney, E. M.: Traumatic injuries to the biliary system in children. Am. J. Surg., 108:150-156, 1964. 13. Holcroft, J. W., Trunkey, D. D., Minagi, H., et al.: Renal trauma and retroperitoneal hematomas-Indications for exploration. J. Trauma, 15:1045-1052,1975. 14. Hutchinson, R J., and Norgrady, M. B.: Late sequelae of renal trauma in the pediatric age group. J. Can. Ass. Radiol., 24:3-11, 1973. 15. Izant, R J., and Hubay, C. A.: A limited study of childhood accidental injury and death. J. Trauma, 6:65-74,1966. 16. Jones, W. R, Hardin, W. J., Davis, J. T., and Hardy, J. D.: Intramural hematoma of the duodenum: A review of the literature and case report. Ann. Surg., 173 :534-544, 1971. 17. Kaufman, J. M., and Burrington, J. D.: Liver trauma in children. J. Ped. Surg., 6:585594, 1971. 18. Kemp, C. H., and Helfer, R E.: Helping the Battered Child and His Family. Philadelphia, J. B. Lippincott Co., 1972. 19. King, H., and Shumaker, H. B.: Splenic studies: I. Susceptibility to infection after splenectomy performed in infancy. Ann. Surg., 136:239-242, 1952. 20. Lucas, C. E., and Ledgerwood, A. M.: Controlled biliary drainage for large injuries of the liver. Surg. Gynec. Obstet., 137:585-589,1973. 21. Lutzker, L., Koenigsberg, M., Meng, C. H., and Freeman, L. M.: The role of radionuclide imaging in spleen trauma. Radiology, 110:419-425,1974. 22. Matsuyama, S., Suzuki, N., and Nagamachi, Y: Rupture of the spleen in the newborn: Treatment without splenectomy. J. Ped. Surg., 11: 115-116, 1976. 23. Mishalany, H.: Repair of the ruptured spleen. J. Ped. Surg., 9: 175-178, 1974. 24. Morse, T. S.: Infusion pyelography in the evaluation of renal injuries in children. J. Trauma, 6:693-700, 1966. 25. Morse, T. S.: Renal injuries. PED. CLIN. N. AM., 22:379-391, 1975. 26. Potter, E. L.: Fetal and neonatal deaths: Statistical analysis of 2,000 autopsies. J.A.M.A., 115 :996, 1940. 27. Potter, E. L., and Craig, J. M.: Pathology of the Fetus and the Infant, 3rd ed. Chicago, 1975, Yearbook Medical Publishers, Inc. 28. Sieber, W. K., and Girdany, B. R: Rupture of the spleen in newborn infants. N. Eng. J. Med., 259:1074-1076,1958. 29. Sinclair, M. C., and Moore, T. C.: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J. Ped. Surg., 9: 155-162, 1974. 30. Smalley, R H., and Banowski, L. H. W.: The evaluation of renal trauma in infusion urography. J. Urol., 105:620-622,1971. 31. Solomon, T.: History and demography of child abuse. Pediatrics, 51 :773-776,1973. 32. U.S. Depart. Health, Education and Welfare: National Center for Health Statistics, Health Services and Mental Health Administration, 1973. 33. U.S. Depart. Health, Education and Welfare: National Health Survey, DHEW Pub. (HRA) 76-1527, Sept. 1975. 34. Upadhyaya, P., and Simpson, J. S.: Splenic trauma in children. Surg. Gynec. Obstet., 126:781-790, 1968. Department of Surgery Children's Hospital of Michigan 3901 Beaubien Detroit, Michigan 48201
Blunt Abdominal Trauma in Childhood Arvin 1. Philippart, M.D.*
Blunt abdominal trauma in childhood is a segment of the broader issue of pediatric trauma. Trauma is the major cause of mortality in the age group 1 to 14 years. 32 Furthermore, it may cause major chronic morbidity at great emotional and financial cost to families and to society. The mechanisms of injury frequently vary from those seen in the adult population. Because blunt abdominal trauma in childhood is so common, most general surgeons have some experience in the management of these children. The same basic surgical principles operative in the management of adult trauma apply in the management of the injured child. While principles of operative management are unchanged in the child, patterns of injury, patient evaluation, and nonoperative care may differ from that of the adult. The problems which arise most frequently originate in the physician's lack of comfort and familiarity with children. The result may be an inaccurate assessment of intraabdominal signs or inappropriate supportive management such as airway maintenance or fluid administration. The purpose of this article is not to list all the steps in recognition and management of pediatric trauma but to emphasize particularly the differences between the child and the adult. Appreciation of these dife ferences is necessary to provide optimal care.
INCIDENCE Accidents are the primary cause of mortality in children after the first year of life. 32 Automobile related events account for approximately 50 per cent of deaths. Although one can establish morbidity in adult injuries33 in the form of hospital days, lost days of employment, or financialloss, no assessment of morbidity, particularly long-term disability, is available for children . ., Attending Surgeon and Director of Surgical Education, Children's Hospital of Michigan; As· sistant Professor of Surgery, Wayne State University School of Medicine, Detroit, Michigan
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Trauma is one of the mechanisms by which the child learns in the exploration of his environment. Many social determinants affect the degree of supervision of any child. The degree of supervision, in turn, affects the incidence and severity of injury.
DETERMINANTS OF INJURY Age Trauma in the infant age group is infrequent. The toddler group (2 to 4 years) has the highest injury rate. 15 Most of these injuries occur in the home. After the age of 4, injuries occur outside the home with progressive frequency and the injury rate is stable. Season Trauma is a warm weather disease, particularly in the northern states. In our institution, approximately 50 per cent of trauma requiring hospitalization occurs in the three summer months. Mechanisms The automobile is clearly the primary agent of injury whether the child is an occupant or a pedestrian. 32 Other causes such as falls, bicycles or sleds, fights, or athletic endeavors vary with age or demographic differences. Trauma secondary to battering is largely a disease of infancy. Abuse occurs in all socioeconomic groups and all demographic categories. Three distinctive mechanisms of trauma are characteristic of the pediatric population and should be emphasized. The first is birth associated trauma. The second is the battered child syndrome. The third is the occurrence of major visceral injury after minor trauma in the child with a previously unrecognized congenital anomaly. Birth Injury The traumatic effects of birth are well recognized. However, birth trauma has been indicted as the primary cause in only 1 per cent of fetal and neonatal deaths at the Boston Hospital for Women. 27 Petechiae and edema of the presenting part and moulding of the skull are sufficiently frequent to be physiologic. Fetal presentation, duration of labor, and fetal size are all determinants of injury rate. Breech presentation, precipitous or prolonged labor, and increased fetal size all increase the risk of trauma. Head and neck, neurologic, and extremity injuries are most common. Abdominal visceral injury is less common. Potter26 reported autopsy findings in 2000 newborn deaths and related only 28 to laceration of solid intraabdominal viscera. Of these, 22 were hepatic lacerations. Splenic injury is less common and is associated with poor salvage because of late recognition, advanced hypovolemia with its attendant sequelae, and the frequent coexistence of a coagulopathy. Sieber re-
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ported the first survivors in 1958. 28 Since then, a total of 24 neonatal cases have been successfully treated by splenectomy or splenic repair. 22 In our experience, adrenal hemorrhage is more common than hepatic or splenic injuries. The important consideration is prompt recognition and the provision of steroid replacement therapy if necessary. The surgical significance of this disease is its late differentiation from neoplastic lesions that do require operation. Calcified adrenal hematomas do not. While intestinal perforations have been grouped with birth trauma previously, perforations are the result of intestinal ischeInia. The exception is rectal perforation secondary to the faulty insertion of a rectal thermometer.
I II
Battered Child Syndrome Physical abuse of children has existed since antiquity. In the last 15 years, this mechanism of injury has received increased attention. As a result, current conservative national estimates are that 250,000 children per year are abused. Of these, probably 15 per cent require hospitalization and the established mortality rate of these is at least 5 per cent.31 In our own institution, investigations into suspected abuse or neglect have plateaued at approximately 300 cases per year. Of this number, approximately 100 are evaluated by the surgical service for suspected abdoIninothoracic injury. Less than 5 per cent of these children require an operative procedure. Orthopedic or neurosurgical procedures are more frequently required than general surgical intervention. The environmental characteristics associated with battering have been well described. 18 The nuclear family may be intact, but relationships are disordered. The abusive parent frequently was an abused child. An awareness of this syndrome is necessary to recognition. The hallmark of the history is its misleading nature. The parents frequently deny any knowledge of the mechanism of injury. If trauma is implicated, the history describes a minor episode inconsistent with the extent of injury noted on physical examination. Suspicion may be reinforced by assessment of the child. Rather than loudly fearful of painful procedures, these patients are frequently passive and quiet. Surface evaluation commonly reveals signs of neglect. Ecchymoses, lacerations and abrasions of varied ages, or small burns, particularly cigarette burns, have been seen in the majority of our cases. All degrees of abdominal findings may be elicited by careful examination. The warning sign of the abused child is evidence of marked intraperitoneal pathology-more marked than the history would suggest. Clinical findings which are atypical or do not fit known syndromes should also raise suspicion. Supporting evidence of battering should be sought with a radiologic skeletal survey. The characteristic features are fractures in varied stages of repair. Callus formation frequently documents multiple episodes of trauma at different times prior to recognition.
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The abdominal visceral injuries seen in our most recent series of 27 cases include a predominance of central upper abdominal lesions in the duodenum, pancreas, and jejunum. This is characteristic and reflects the anatomy of the abdomen in the young child. The abdomen is prominent, the costal margins flare widely, the musculature gives inadequate protection against the delivered force, and the anteroposterior distance is small. The nature of the blow and its vectors account for the paucity of splenic and hepatic injuries. Traumatic pancreatitis is infrequent in children compared to adults and when it occurs is most often due to battering. The small bowel lesions occur adjacent to areas of retroperitoneal fixation but are frequently unusual in nature. Avulsion of the gut from the mesentery is more common than the usual simple antimesenteric perforation seen with handle bar injuries and similar traumatic agents. The need for recognition of the battered child is emphasized by the significant mortality previously mentioned. The major cause of mortality is irreversible head trauma or late arrival for medical care. In our own series, all operative cases have survived, but four children have been dead on arrival or within the first 24 hours. Three children have had siblings who previously had died of battering in other institutions. In many states, the onus of recognition and prevention has been placed on the physician. Statutes vary, but reporting of all cases of suspected abuse is required of the physician by many. Underlying Anomalies Another feature unusual to pediatric trauma is the occurrence of major clinical injury after minor trauma in children with underlying anomalies (Fig. 1). As in the battered child, the recognition of the underlying pathology requires an awareness of this possibility. The hallmark is the discrepancy between the history of a minor injury and the major clinical sequelae. The most widely appreciated example is the child with unrecognized obstructive hydronephrosis, such as ureteropelvic obstruction, who receives very minimal flank trauma, but presents with gross hematuria, colic, and acute obstruction. Frequently, acute flank symptoms after minor trauma will stimulate recognition of a Wilm's tumor. A major retroperitoneal hemorrhage may be the first mode of presentation of a retroperitoneal hemangioma or of a previously unrecognized coagulopathy, such as von Willebrand's disease, hemophilia variants, or idiopathic thrombocytopenic purpura. Splenic injury after minor trauma is frequently mentioned in infectious mononucleosis, leukemia, or portal venous hypertension. Splenic injury in these settings is a rare occurrence. Minor trauma with minimal acute sequelae may lead to an unplanned examination which reveals previously unrecognized pathology. This is particularly true of pediatric intraabdominal neoplasms such as Wilm's tumor, neuroblastoma, or hepatoblastoma.
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Figure 1. Two-year-old female presented with 2-day history of abdominal air and severe anemia after hyperextension over yoke of wagon. Large left flank mass extended into pelvis. IVP reveals hydronephrosis and displacement of bladder as well as displacement of gut. Minimal resolution in 3 weeks precipitated operative excision of retroperitoneal hemelymphangioma with recent hemorrhage.
EVALUATION The traumatized child must be evaluated in the same disciplined fashion as is done with the adult. Priorities are unchanged. Airway support is the first priority. If airway intubation is required, the initial procedure should be the insertion of a transoral endotracheal tube. The choice of size of tube is critical. Frequently, inappropriately large tubes are used resulting in subglottic stenosis as a result of mural injury. Tracheal stenosis is infrequent because cuffed tubes are rarely necessary. In the absence of appropriate experience, the width of the distal phalanx of the patient's fifth finger may be used as a guide to the size of tube to be chosen. If continued intubation is required after completion of the resuscitative phase, the orotracheal tube should be replaced by a nasotracheal tube by experienced personnel. Nasotracheal tubes can be more securely fixed, reducing iatrogenic airway injury. Tracheostomy is rarely required in the acute resuscitative phase. When later performed for prolonged airway support, it should be done over an indwelling tube for purposes of control and identification. Because the child's neck is short and thick, and the apical pleura more vulnerable, this procedure should be performed in the operating room and not at the bedside. Only a single vertical incision of one or two rings should be performed. No tracheal wall should be excised.
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Volume replacement should be accomplished expeditiously. The difficulty of venous access in small children frequently leads to the insertion of needles or cannulae of inadequate size by the inexperienced physician. Adequate access is always possible by venous cutdown if necessary. Central venous pressure monitoring is possible and, after the newborn period, requires no different interpretation than in the adult. Another common error too often encountered is the use of inappropriately small or large replacement volumes in the hypovolemic child. The only accurate approach to volume replacement is to calculate estimated blood volume CEBV) as 7 or 8 per cent of body weight. In the hypotensive child, 20 per cent of EBV should be given, with subsequent infusion based on clinical judgment. One frequently hears that children do not tolerate blood loss well but this statement is incorrect. When losses are calculated as percentage of blood volume, the child is shown to tolerate blood loss with fewer sequelae than the adult as the cardiovascular performance of the child is not compromised by the attrition of acquired disease. When the initial resuscitative maneuvers are completed, the same orderly assessment of injuries used in the adult is necessary. The history of the injury is frequently less accurate in the child than the adult. The only reliable way to overcome this limitation is to provide continuing reassurance and repetitive questioning. This must be combined with sequential examinations of the suspicious abdomen. The importance of repetitive examinations cannot be overemphasized. The abdomen of the child is thin and elastic compared to the adult. There is less subcutaneous tissue or muscle to interfere with evaluation. As a result, the physician skilled in the care of children can make an accurate assessment in the reassured and calmed child. It is very unusual to require either sedation or peritoneal aspiration or lavage in the awake child if one is patient. Paracentesis or lavage is used readily only in those children with both serious head injury and suspicious signs of intraabdominal injury. When lavage is used, the recommended volume of lactated Ringer's solution or normal saline is about 10 ml per kg. The radiologic evaluation of trauma is dictated both by the clinical status of the patient after the initial resuscitative maneuvers and by the nature of the injuries. The studies requested will be mentioned with the discussions of specific organ injuries. However, it may be stated as a generalization that plain films of the abdomen tend to provide fewer diagnostic clues in the injured child tJ;1an in the injured adult. A major reason for this disparity is that the child's inherent resilience results in fewer fractures for similar force patterns. However, when low thoracic rib fractures are seen in the child, serious visceral injury is more common.
UROLOGIC TRAUMA Although splenic laceration is the most common indication for operation,29 urinary tract injuries are the most frequent sequelae of
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blunt abdominal trauma.25 This difference in the operative rate reflects the conservative management used in renal injuries. Only head injury exceeds renal injury in frequency. Automotive trauma is the most common mechanism of injury in our series. Falls and athletic events account for a lesser number. Pre-existent renal anomalies are found in a significant number of children. A recent reporrt collated multiple series of pediatric renal injuries and established an incidence of 12 per cent with underlying anomalies such as obstructive hydronephrosis from ureteropelvic obstruction. However, in our recent series the most common pre-existent anomaly has been Wilm's tumor. The clinical presentation of flank trauma with cutaneous injury, flank tenderness, and hematuria is widely appreciated. Because low thoracic rib fractures are infrequent in children, their presence should further raise the index of suspicion. Associated with left renal injuries is a 25 per cent incidence of splenic injury25 which may complicate the evaluation. The efforts of Morse2 4 • 25 over a period of years have documented the nature and rational investigation of pediatric renal trauma. An infusion pyelogram (IVP) should be performed in all but the gravest situations. Better results are obtained with the earliest possible performance of the IVP before progressive increase in intracapsular pressure resulting from bleeding, sepsis, and edema. The advantages of the infusion IVP include a better nephrogram and visualization of a filled renal pelvis and ureter. This provides greater accuracy in assessment of the cortical injury,30 precludes the need for retrograde pyelograms in all but the rare case, and avoids the need for arteriography in many situations. Arteriograms are performed when there is anuria and when the infusion IVP reveals unilateral non visualization or a transection which may possibly be managed by a partial nephrectomy. In the latter circumstance, knowledge of renal arterial anatomy is very useful. Arteriograms are also performed when there is a significant concern that associated visceral injury may be present. The commonest example is the child with a recognized left renal injury in whom the possibility of concomitant splenic injury arises. We prefer arteriography to renal scans because they are more easily and rapidly obtained and provide greater information. Arteriography, well performed, has not been associated with complications in these patients. With the information obtained, classification of injury is possible,25 providing a useful guide to management. All management should be based on conservation of functioning nephrons. Indications for operation include renal pedicle injury, complete transection with marked extravasation, or lacerations of the pelvis. Lesser degrees of extravasation are treated without operation. Uncontrolled hemorrhage is rare in blunt trauma. With the above approach, 20 per cent or less of blunt renal injuries require operation. A more difficult problem is the management of renal trauma in the multiply injured child in profound shock despite resuscitative attempts. When urgent laparotomy has been performed to arrest blood loss from a
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major vascular or hepatic laceration, the approach to a renal hematoma represents a controversial problem. Once blood volume is restored, an IVP in the operating room is necessary to establish renal function. The technique may be simple or elaborate.3 Gerota's fascia, when intact, will tamponade renal hemorrhage. If exploration of the hematoma is embarked upon, the renal pedicle should first be exposed for later clamping should this become necessary.2. 3. 11 This approach will provide a dry field for parenchymal repair and a lower nephrectomy rate. While this technique is well accepted, it should not be overutilized; we concur with Holcroft et al./ 3 who open Gerota's fascia only when the hematoma is expanding, uncontained, or pulsatile. The survival of patients with renal trauma is determined by the presence or absence of associated injury. It is the rare circumstance where isolated renal injury results in death. When the patient with blunt renal trauma expires, death is almost invariably due to multisystem trauma and central nervous system injury is the commonest cause of mortality in these circumstances. The late sequelae of renal trauma include renal growth disturbances and hypertension. Reduced renal growth with contralateral compensatory hypertrophy occurs only in those patients with severe initial injury. An IVP 1 year after injury will reveal these changes. 14 The appearance of hypertension is late and infrequent and is not readily predictable by the nature of the initial injury.!O
SPLENIC TRAUMA Splenic laceration is the most frequent visceral injury reqUITIng laparotomy after blunt abdominal trauma in children. The additional number of splenic injuries treated successfully without operation is significant, but unknown. The mechanisms of splenic trauma, the association with other visceral injuries, and the clinical symptoms and signs are all well documented. Routine radiologic studies are occasionally helpful by revealing rib fractures or displacement of gastric or colonic gas. However, operative management has always been a clinical decision. Recently, the use of isotopic imaging of the spleen, as well as arteriography, has increased. There is little question that these techniques have improved diagnostic accuracy. Isotopic studies are noninvasive and more widely used. False negative and false positive scans have been reported.s. 21 False negatives commonly occur with lesser injuries. False positives may result from antecedent disease or anatomic variation. Splenic arteriograms are more accurate/' 9. 12 but are also associated with diagnostic errors. We have limited the use of splenic arteriography to those children with known left renal injury who also have clinical findings which suggest possible splenic injury. This group has been selected because of the frequency of simultaneous injury to both organs.
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Before discussing the implications of this improved diagnostic accuracy, it is necessary to realize the concern pediatric surgeons share about splenectomy for trauma. After the initial report of postsplenectomy septicemia by King and Shumaker in 1952,19 there was a period of years when the risk was strongly suspected but unproven. In 1972 Eraklis and Filler surveyed the partial experience of the members of the Surgical Section, American Academy of Pediatrics. 7 This study clearly demonstrated the late septic complications after pediatric splenectomy and asserted that increased risk of late fatal septicemia followed splenectomy performed in the first 2 years of life. While most physicians interested in this problem accept that statement, many feel the risk is also increased after 2 years of age. The authors also noted that deaths from sepsis occurred most often in patients with underlying hematologic or neoplastic disease. 7 They further stated that the 1 per cent incidence of fatal sepsis after splenectomy for trauma did not represent a clearly established risk. We do not concur with this as 1 per cent of the normal pediatric population with an intact spleen do not die of septicemia. It is probable that the estimate of 1 per cent is unduly low as a result of failures in recognition or reporting. Furthermore, this figure is based on mortality and does not include postsplenectomy septicemia successfully treated, of which we have a number of patients. While the role of the spleen in sepsis is poorly understood at this time, there is emerging evidence that supports the clinical impression of increased risk. It has been established that the spleen represents the major source of phagocytic function in pyogenic septicemia. While the balance of the reticuloendothelial system assumes this function after splenectomy, it is unclear whether there is a residual deficit. The report of a peptide, tuftsin, elaborated by the spleen and absent in splenectomized patients,5 provides further support for clinical concern. Tuftsin is the active peptide moiety in leucokinin which stimulates phagocytosis by the polymorphonuclear leukocyte. With these doubts emerging, attempts to salvage splenic function after trauma in the child are to be encouraged. Splenectomy remains the standard against which alternate forms of management must be measured. Hospital mortality in splenic trauma should be a result of associated organ injury and anesthetic risk only. On the other hand, the diagnosis of splenic trauma has been a purely clinical diagnosis until recently. As a result, many occult splenic lacerations have been successfully treated nonoperatively.6 Splenectomy solely on the grounds of an abnormal splenic scan or filling defects on arteriography should be questioned. Exploration should be based on clinical evidence of blood loss and peritoneal signs. Given those features, supporting studies may reinforce clinical judgment. Any mention of nonoperative management of splenic trauma raises the spectre of "delayed" rupture. The term "delayed" should be used only for those patients with splenic hemorrhage after the period of hospitalization and discharge. It should not be used for the patient in whom diagnosis is not made for 12 to 48 hours. When this definition is used, delayed rupture occurs very infrequently in children. 34
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If clinical signs necessitate exploration for splenic or other visceral injury, several courses may be followed. Splenectomy is the accepted and advised procedure in the presence of active bleeding. However, small, currently nonbleeding lacerations seen in the course of exploration for other injuries may be observed and left undisturbed while other lesions are attended to, much as is done for minor hepatic capsular lacerations. Bleeding lacerations have been sutured with Teflon pled gets more widely than reported. Partial splenectomies have been reported23 but caution and clinical judgment must be exercised. The goal of splenic salvage is appropriate but should never endanger patient survival. Postoperatively, the splenectomized child should be maintained on suppressive levels of penicillin. The optimal duration of adIninistration is unknown. We maintain prophylaxis in all children until 4 years of age. More importantly, parents are carefully and forcefully instructed to seek medical attention immediately when the child presents with any febrile illness, as overwhelming sepsis may occur in as little as 12 hours after the onset of symptom. Using these policies, we have successfully recognized and treated three cases of pyogenic septicemia or primary peritonitis in the past 5 years.
HEPATOBILIARY TRAUMA Trauma to the liver and bile ducts in children differs little from that seen in the adult population. Automotive injuries account for the majority and falls for many of the remaining cases. 12 ,17 Trauma to a mass lesion such as a hepatoblastoma or simple cyst is rare, but may produce contained hemorrhage and acute symptoms. Recognition of severe hepatic injury is frequently rapid as a result of hypotension, hemoperitoneum, and resultant urgent operation. In contrast, subclinical injury also occurs. As in splenic injuries, minor lacerations are treated on the basis of clinical rather than radiologic indications. Operative management of hepatic injuries differs little from the principles followed in the adult. Despite the difficulty of inserting large percutaneous intravenous lines in children, adequate routes for administration of blood must be established. A major difference in children occurs in the management of the common bile duct after hepatic resection, should this be necessary. The use of a T-tube choledochostomy in adults is a source of controversY,20 but in children T-tube decompression should not be used because of the small size of the duct, which adds to the risk. Furthermore, the benefit derived is highly questionable. Injury to the extrahepatic biliary tract is an unusual occurrence. In my experience, this has presented as a retroduodenal ductal transection which has been managed successfully with a Roux-en-Y choledochojejunostomy. "Spontaneous" perforations of the common duct occur rarely in infants and have been tentatively related to trauma. There is little evidence to support that etiology. Preferred management has been careful exploration of the bile pseudocyst and simple Penrose drainage.
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INTESTIN AL INJURIES Blunt intestinal trauma in children is less frequent than renal or splenic injury. The cause of perforations is related to age. Neonatal perforations are ischemic rather than traumatic with the exception of rectal perforations by thermometers. Because of thermometer perforations, many pediatric hospitals have discontinued rectal temperature monitoring. In infants and toddlers the usual cause of intestinal injury is physical abuse. The older more mobile child is most frequently injured by an automobile or a fall (Fig. 2). As in the adult, intestinal injuries occur in or adjacent to areas of retroperitoneal fixation. The pattern of injury resulting from abuse has already been described. The diagnosis of intestinal perforation is established by an appropriate history and repetitive examinations which reveal increasing peritoneal signs. Abdominal x-rays frequently fail to show free air, particularly in more distal perforations. When seen, free air is often a late finding. The operative management of the lesions does not differ from that used in the adult. One lesion seen more commonly in the pediatric age group is duodenal hematoma. The reasons for the disproportionate frequency is the anatomic variation described earlier. Most of these hematomas result from traumatic impingement of the duodenum against the vertebral bodies. They are also seen without an antecedent history of
Figure 2. Upper gastrointes· tinal series in 6-year-old male with duodenal hematoma following a fall. Note severe partial duodenal obstruction with "coiled spring" appearance. Successfully treated nonoperatively.
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trauma in children with bleeding disorders such as leukemia and hemophilia. Bilious vomiting may gradually increase over the first several days before obstruction is sufficient to cause parental concern. As a result, the history of trauma may be obscured unless sought. The physical examination is frequently normal. The diagnosis is established when an upper gastrointestinal ~eries reveals a significant partial obstruction of the duodenum with the characteristic "coiled spring" appearance of an intramural hematoma. In the absence of clinical signs of perforation, the management is nonoperative. Controversy arises in those cases where adequate oral alimentation cannot be maintained after 7 days of nonoperative care. 16 Proponents of operative management advise partial thickness duodenal incision with evacuation of the hematoma and careful closure of the seromuscular coat with drainage. Our preference is for continuation of nonoperative management in other than unusual circumstances. It is our experience that adequate oral alimentation occurs as soon with continued purely supportive care as it does with a duodenotomy performed at 7 days. This belief is buttressed by experience with children with hemorrhagic diatheses where operation is avoided. Furthermore, the availability of parenteral hyperalimentation obviates the need for early operation based on a projected later concern for adequacy of nutrition. Persistent obstruction without improvement documented by no decrease in nasogastric aspirate and no improvement on repeat barium studies after 10 or 12 days constitutes our indication for operation. The need for intervention will decrease significantly if these guidelines are used.
SUMMARY Blunt abdominal trauma in childhood is a common clinical occurrence. Accurate assessment requires an understanding of patterns of injury and the response of the child. Repetitive examinations in a comforting environment will yield superior clinical judgment. Renal trauma is frequent, requires thorough radiologic evaluation, and may be associated with an underlying anomaly. The goal of management is salvage of functioning nephrons. Definitive indications should exist prior to operative intervention. The goal of management of splenic injury should not be the justification of splenectomy. The operative decision should be based on clinical indications. Judgment should include a knowledge of the risks and alternatives.
REFERENCES 1. Awe, W. C., and Eidemiller, L.: Selective angiography in splenic trauma. Am. J. Surg., 126:171-17~ 1973. 2. Banowski, L. H., Wolfel, D. A., and Lackner, L. H.: Considerations, diagnosis, and management of renal trauma. J. Trauma, 10:587-597, 1970.
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3. Cass, A. S., and Ireland, G. W.: Management of renal injuries in the severely injured patient. J. Trauma, 12:516-522,1972. 4. Cass, A. S., and Ireland, G. W.: Renal injuries in children. J. Trauma, 14:710-722,1974. 5. Constantopoulos, A., Najjar, V. A., Wish, J. B., et al.: Defective phagocytosis due to tuftsin deficiency in splenectomized subjects. Am. J. Dis. Child., 125:663-665,1973. 6. Douglas, G. J., and Simpson, J. S.: The conservative management of splenic trauma. J. Ped. Surg., 6:565-570, 1971. 7. Erakiis, A. J., and Piller, R M.: Splenectomy in childhood: A review of 1413 cases. J. Ped. Surg., 7:382-388, 1972. 8. Gilday, D. L., and Alderson, P.O.: Scintigraphic evaluation of liver and spleen injury. Sem. Nucl. Med., 4:357-370,1974. 9. Gold, R E., and Redman, H. C.: Splenic trauma: Assessment of problems in diagnosis. Am. J. Roentgen., 116:413-418,1972. 10. Grant, R. P., Gifford, R P., Pudvan, W. R, et al.: Renal trauma and hypertension. Am. J. Cardiol., 27:173-176,1971. 11. Guerriero, W. G., Carlton, C. E., Scott, R., and Beall, A. C.: Renal pedicle injuries. J. Trauma, 11 :53-62, 1971. 12. Hartman, S. W., and Greaney, E. M.: Traumatic injuries to the biliary system in children. Am. J. Surg., 108:150-156, 1964. 13. Holcroft, J. W., Trunkey, D. D., Minagi, H., et al.: Renal trauma and retroperitoneal hematomas-Indications for exploration. J. Trauma, 15:1045-1052,1975. 14. Hutchinson, R J., and Norgrady, M. B.: Late sequelae of renal trauma in the pediatric age group. J. Can. Ass. Radiol., 24:3-11, 1973. 15. Izant, R J., and Hubay, C. A.: A limited study of childhood accidental injury and death. J. Trauma, 6:65-74,1966. 16. Jones, W. R, Hardin, W. J., Davis, J. T., and Hardy, J. D.: Intramural hematoma of the duodenum: A review of the literature and case report. Ann. Surg., 173 :534-544, 1971. 17. Kaufman, J. M., and Burrington, J. D.: Liver trauma in children. J. Ped. Surg., 6:585594, 1971. 18. Kemp, C. H., and Helfer, R E.: Helping the Battered Child and His Family. Philadelphia, J. B. Lippincott Co., 1972. 19. King, H., and Shumaker, H. B.: Splenic studies: I. Susceptibility to infection after splenectomy performed in infancy. Ann. Surg., 136:239-242, 1952. 20. Lucas, C. E., and Ledgerwood, A. M.: Controlled biliary drainage for large injuries of the liver. Surg. Gynec. Obstet., 137:585-589,1973. 21. Lutzker, L., Koenigsberg, M., Meng, C. H., and Freeman, L. M.: The role of radionuclide imaging in spleen trauma. Radiology, 110:419-425,1974. 22. Matsuyama, S., Suzuki, N., and Nagamachi, Y: Rupture of the spleen in the newborn: Treatment without splenectomy. J. Ped. Surg., 11: 115-116, 1976. 23. Mishalany, H.: Repair of the ruptured spleen. J. Ped. Surg., 9: 175-178, 1974. 24. Morse, T. S.: Infusion pyelography in the evaluation of renal injuries in children. J. Trauma, 6:693-700, 1966. 25. Morse, T. S.: Renal injuries. PED. CLIN. N. AM., 22:379-391, 1975. 26. Potter, E. L.: Fetal and neonatal deaths: Statistical analysis of 2,000 autopsies. J.A.M.A., 115 :996, 1940. 27. Potter, E. L., and Craig, J. M.: Pathology of the Fetus and the Infant, 3rd ed. Chicago, 1975, Yearbook Medical Publishers, Inc. 28. Sieber, W. K., and Girdany, B. R: Rupture of the spleen in newborn infants. N. Eng. J. Med., 259:1074-1076,1958. 29. Sinclair, M. C., and Moore, T. C.: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J. Ped. Surg., 9: 155-162, 1974. 30. Smalley, R H., and Banowski, L. H. W.: The evaluation of renal trauma in infusion urography. J. Urol., 105:620-622,1971. 31. Solomon, T.: History and demography of child abuse. Pediatrics, 51 :773-776,1973. 32. U.S. Depart. Health, Education and Welfare: National Center for Health Statistics, Health Services and Mental Health Administration, 1973. 33. U.S. Depart. Health, Education and Welfare: National Health Survey, DHEW Pub. (HRA) 76-1527, Sept. 1975. 34. Upadhyaya, P., and Simpson, J. S.: Splenic trauma in children. Surg. Gynec. Obstet., 126:781-790, 1968. Department of Surgery Children's Hospital of Michigan 3901 Beaubien Detroit, Michigan 48201
