Peritoneal Lavage in Children With Blunt Abdominal Trauma By LCDR Randall W. Powell, MC, USNR, LCDR David E. Smith, MC, USN, LCDR Christopher K. Zarins, MC, USNR, LCDR Steve Parvin, MC, USN, and CDR Richard W. Virgilio, MC, USN
R A U M A is the leading cause of death and disability in children. Rapid diagnosis and prompt surgical therapy can help lower this morbidity and mortality. ~a A prospective study of the effectiveness of peritoneal lavage in diagnosing significant injury in patients with blunt abdominal trauma was conducted by the Trauma Research Unit, Naval Regional Medical Center, San Diego, from April 1972 to January 1974. 3 Included in this group of 500 patients were 52 children 15 yr of age or younger. The value of peritoneal lavage in these patients is the subject of this report.
T
MATERIALS AND METHODS Children sustaining blunt abdominal trauma were evaluated by the surgical resident and placed into four clinical categories based on physical examination: (1) surgical, patients requiring immediate operation; (2) equivocal, patients with inconclusive physical findings; (3) nonsurgical, patients requiring no operation; a n d (4) unconscious. Peritoneal lavage was then performed using the method of Root 4 as modified by Perry 5 after proper informed consent was obtained from the parents. A dialysis catheter was positioned in the pelvis through a small infraumbilical incision, and 20 ml/kg of normal saline was rapidly infused. The fluid was allowed to drain by gravity. The lavage was negative if the fluid in the collecting bottle was colorless. If blood was present, the fluid was thoroughly mixed and allowed to flow through standard intravenous infusion tubing. The amount of intraperitoneal blood in the lavage effluent was estimated by the quantitative colorimetric method of Olsen.6 If newsprint could be read through the tubing, the lavage was weakly positive. If newsprint could not be read, the lavage was considered to be strongly positive. Patients were placed into one of three treatment categories depending on results of the peritoneal lavage. (1) If a strongly positive lavage resulted, a prompt exploratory laparotomy was performed. (2) If the lavage was weakly positive, further diagnostic evaluation was carried out with echography, arteriography, and intravenous pyelography. Patients with positive findings underwent operation, while those with normal studies were closely observed. (3) If a negative peritoneal lavage resulted, close observation was carried out for 24 hr. RESULTS
Peritoneal lavage was performed in 52 children under the age of 15. Twenty patients had strongly positive, ten patients had weakly positive, and 22 patients had negative lavages (Table 1). All 20 patients (100~o) with strongly positive lavages had significant intraperitoneal injuries requiring operation. Nine of ten patients (90%) with a weakly positive lavage had normal ultrasound and ar-
From the Trauma Research Unit, Naval Regional Medical Center, San Diego, Calif. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department. Address for reprints: CDR Richard W. Virgilio, MC, USN, Trauma Research Unit, Naval Regional Medical Center, Park Boulevard, San Diego, Calif. 92134. 9 1976 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 11, No. 6 (December), 1976
973
974
POWELL ET AL.
Table 1. Correlation of Peritoneal Lavage Results and Initial Physical Examinations With the Incidence of Significant Intraperitoneal Injuries Lavage Results Strongly Positive Clinical Evaluation Surgical Equivocal Nonsurgical Total
No. No. P a t i e n t Injuries(%)
Weakly Positive No. Patient
Negative
No. Injuries(%)
No. Patient
Total
No. Injuries(%)
Total No. Patients Injuries(%)
14 3 3
14 3 3
100 100 100
2 2 6
0 1 0
0 50 0
2 9 11
0 0 0
0 0 0
18 14 20
14 4 3
78 29 12
20
20
100
10
1
10
22
0
0
52
21
40
teriographic studies and were safely observed. There were no significant intraperitoneal injuries in the 22 paUents with negative lavages. However, one patient with a negative lavage and gross hematuria underwent a partial nephrectomy after an intravenous pyelogram revealed a fractured kidney. Peritoneal lavage accurately predicted the need for operation. The initial physical examination was found to be much less accurate in determining the need for operation (Table 1). Eighteen patients were thought to have a surgical abdomen on admission. Fourteen of 18 (78~) had a strongly positive lavage, underwent operation, and were found to have significant injuries. Four patients had weakly positive or negative peritoneal lavages and did not undergo operation with good recovery. Thus, physical examination gave a 22~ false-positive rate and peritoneal lavage reliably prevented unnecessary laparotomy. In the clinically equivocal group, 4 of 14 patients (29~) sustained injuries requiring laparotomy. Three had strongly positive and one had a weakly positive lavage. Twenty patients were felt to have no significant abdominal injury on the basis of physical examination with negative findings. Peritoneal lavage revealed three to have a strongly positive lavage, and prompt operation revealed significant intraperitoneal injuries. Thus, physical examination had a 15~ false-negative rate. Peritoneal lavage accurately indicated significant injury and permitted prompt treatment. The intraabdominal and associated injuries are shown in Tables 2 and 3. Solid organ injury was most common, but two hollow viscus injuries occurred. Twenty-five patients (48~) had significant extraabdominal injuries. The youngest patient undergoing lavage was a 7-mo-old infant with multiple rib fractures and a large flank ecchymosis. His lavage was negative. Significant Table 2. Significant Intraabdominal Injuries Organs Injured
Total
Spleen Liver Pancreas Kidney Duodenum Jejunum Cisterna chyli Hepatic veins Vena cava
19 2 3 1 1 1 1 1 1
PERITONEAL LAVAGE
975
Table 3. Associated Injuries Chest Lung Contusion Pneumothorax
2 1 1
Head Concussion Skull fracture
Fractures Rib Spine Upper extremity Pelvis Femur Lower leg None
10 9 1
28 5 1 9 6 6 2 27
intraabdominal injuries were found in all age groups (Table 4). Peak incidence appeared in adolescence (ages 12-15), but a large number of injuries also occured between 6 and 8 yr of age. Twenty of 21 patients who required laparotomy were operated on within 4 hr of their initial evaluation. One patient underwent operation 6 hr after initial evaluation. He was a 9-yr-old boy with a weakly positive lavage and an elevated lavage amylase. Increasing abdominal tenderness and an associated elevated serum amylase led to a laparotomy, which revealed a pancreatic transection. Peritoneal lavage allowed immediate decision on the need for laparotomy in 42 of the 52 patients (strongly positive and negative lavages). Ten patients (18~o) had weakly positive lavages and underwent additional diagnostic evaluation. One patient, described above, had a pancreatic transection and underwent operation. Of the other nine patients, seven underwent abdominal echography. Five were negative, one was equivocal, and the other was positive, showing splenic enlargment. The latter two patients underwent visceral angiography with no abnormal findings in either. A third patient with a negative echogram and a weakly positive lavage underwent angiography to identify a possible bleeding point from her pelvic fracture, but none was identified. The two patients in this group who did not undergo screening echography had only a trace hemoperitoneum and hematuria and underwent intravenous pyelography. One had a minor renal laceration and the other was normal. Both were treated successfully nonoperatively. There were no major complications of either peritoneal lavage or arteriography in the entire group. There were several minor wound complications--hematoma and superficial wound separation, but these did not prolong hospitalization or recovery. No long-term morbidity of peritoneal lavage has been observed in these 52 children. All children recovered from their injuries, although several patients with multiple injuries had protracted hospital courses. Table 4. Distribution of Patients by Age Years
Number of Patients
Strongly Positive
0-2 2-6 6-8 8-10 10-12 12-15
4 2 10 4 14 18
I I 3 I 8 6
Weakly Positive I 0 I I 4 3
Negative 2 I 6 2 2 9
Totals
52
20
I0
22
976
POWELL ET AL.
DISCUSSION
The diagnosis of intraabdominal injury in children with blunt trauma is complicated by many factors not present in adults. Acute apprehension due to pain, anxiety transferred by parents, and fear of physicians and surroundings make evaluation of the child difficult.7,8 Serial abdominal examination has been recommended as a reliable means of diagnosing abdominal injury.9,~~However, we found physical examination to be unreliable. Twenty-two per cent of our patients diagnosed as ha~ing a surgical abdomen proved to have no injury. Of patients with equivocal abdominal findings, 71~ had no injury. Abdominal pain and tenderness may be caused by abdominal wall contusion or reflex spasm due to pelvic or thoracic trauma. A negative physical examination was also misleading in 12~ of our patients who proved to have a significant intraperitoneal injury. Four quadrant paracentesis has been utilized to detect hemoperitoneum.2'9,1~ However, this technique is of value only if positive. A negative paracentesis does not rule out intraabdominal injury) 2 Peritoneal lavage has been shown to be more reliable than paracentesis in identifying intraabdominal hemorrhage in children with splenic injuries.2''~ Our experience confirms that peritoneal lavage is an accurate, safe, and rapid diagnostic tool in children with abdominal injuries. All 20 patients with strongly positive lavages had sustained significant intraperitoneal injury confirmed at laparotomy. None of the 22 patients with negative peritoneal lavages were found to have significant injuries. Only one of ten patients in the weakly positive group was found to have a significant injury. Unnecessary laparotomy was avoided in four patients with definite clinical signs of an acute surgical abdomen. Peritoneal lavage has been criticized as being too sensitive for the detection of intraabdominal blood. If hemoperitoneum had been used as the sole indication for operation, nine patients would have undergone unnecessary laparotomy. The simple technique of quantitating the lavage by degree of opacity enabled us to avoid unnecessary laparotomy. Although lavage is very accurate in diagnosing intraperitoneal injuries, it may not be reliable for retroperitoneal injuries. Two patients with weakly positive lavages had significant retroperitoneal injury. One with a transected pancreas had a significant delay in operation. The other had a fractured kidney that was diagnosed by intravenous pyelography. Other diagnostic methods such as intravenous pyelography, arteriography, or gastrographic contrast studies must be considered when retroperitioneal injury is suspected. Rapid diagnosis and early operation significantly lowers morbidity and mortality in trauma. Peritoneal lavage allowed us to determine the need for operation within 15-20 rain of arrival to the emergency room in 42 of 52 patients. Definitive diagnosis was delayed in patients with weakly positive lavages, but only one patient had a preoperative delay of longer than 4 hr. No major complications due to peritoneal lavage occurred in our series, although others have reported bladder, bowel, and major vessel perforation) 3 These hazards may be minimized by complete evacuation of the bladder prior to lavage and careful surgical technique including direct visualization of the linea alba and countertraction on the fascia.
PERITONEAL LAVAGE
977
SUMMARY Q u a n t i t a t i v e p e r i t o n e a l lavage was p e r f o r m e d in 52 c h i l d r e n with b l u n t abd o m i n a l t r a u m a to d e t e r m i n e the presence o f i n t r a a b d o m i n a l injuries. A s t r o n g l y positive lavage was 100~o a c c u r a t e in d i a g n o s i n g an i n t r a a b d o m i n a l i n j u r y r e q u i r i n g o p e r a t i o n . A negative lavage d e m o n s t r a t e d a b s e n c e of a significant i n t r a p e r i t o n e a l i n j u r y with 100~o accuracy. A weakly positive lavage was n o t d i a g n o s t i c a n d r e q u i r e d a d d i t i o n a l e v a l u a t i o n i n c l u d i n g i n t r a v e n o u s p y e l o g r a p h y , e c h o g r a p h y , a n d a r t e r i o g r a p h y . D i a g n o s i s a n d t r e a t m e n t was p r o m p t , a n d in 20 of 21 cases, o p e r a t i o n was p e r f o r m e d w i t h i n 4 hr. P e r i t o n e a l lavage was f o u n d to be safe a n d m u c h m o r e a c c u r a t e t h a n physical e x a m i n a t i o n in d i a g n o s i n g significant i n t r a a b d o m i n a l i n j u r y . REFERENCES
1. Kakos GS, Grosfeld JL, Morse TS: Small bowel injuries in children after blunt abdominal trauma. Ann Surg 174:238, 1971 2. Orlando JC, Moore TC: Splenectomy for trauma in childhood. Surg Gynecol Obstet 134:94, 1972 3. Parvin S, Smith DE, Asher WM, et al: Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 181:255, 1975 4. Root HD, Hauser CW, McKinley CR et al: Diagnostic peritoneal lavage. Surgery 57:633, 1965 5. Perry JF Jr: Blunt and penetrating abdominal injuries. Curr Probl Surg 1970 p 5 6. Olsen WR, Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104:536, 1972 7. Hood JM, Smyth BT: Nonpenetrating intraabdominal injuries in children. J Pediatr Surg 9:69, 1974
8. Richardson JD, Belin RP, Griffen w e : Blunt abdominal trauma in children. Ann Surg 176:213, 1972 9. Kaufman JM, Burrington JD: Liver trauma in children. J Pediatr Surg 6:585, 1971 10. Halter BL, Gross RS: Non-penetrating wounds of the abdomen in children. Ann Surg 93:667, 1957 11. Sinclair MD, Moore TC: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J Pediatr Surg 9:155, 1974 12. Olsen WR, Hildreth DH: Abdominal paracentesis and peritoneal lavage in blunt abdominal trauma. J Trauma 1:824, 1971 13. Caffee HH, Benfield JR: Is peritoneal lavage for the diagnosis of hemoperitoneum safe? Arch Surg 103:4, 1971
R A U M A is the leading cause of death and disability in children. Rapid diagnosis and prompt surgical therapy can help lower this morbidity and mortality. ~a A prospective study of the effectiveness of peritoneal lavage in diagnosing significant injury in patients with blunt abdominal trauma was conducted by the Trauma Research Unit, Naval Regional Medical Center, San Diego, from April 1972 to January 1974. 3 Included in this group of 500 patients were 52 children 15 yr of age or younger. The value of peritoneal lavage in these patients is the subject of this report.
T
MATERIALS AND METHODS Children sustaining blunt abdominal trauma were evaluated by the surgical resident and placed into four clinical categories based on physical examination: (1) surgical, patients requiring immediate operation; (2) equivocal, patients with inconclusive physical findings; (3) nonsurgical, patients requiring no operation; a n d (4) unconscious. Peritoneal lavage was then performed using the method of Root 4 as modified by Perry 5 after proper informed consent was obtained from the parents. A dialysis catheter was positioned in the pelvis through a small infraumbilical incision, and 20 ml/kg of normal saline was rapidly infused. The fluid was allowed to drain by gravity. The lavage was negative if the fluid in the collecting bottle was colorless. If blood was present, the fluid was thoroughly mixed and allowed to flow through standard intravenous infusion tubing. The amount of intraperitoneal blood in the lavage effluent was estimated by the quantitative colorimetric method of Olsen.6 If newsprint could be read through the tubing, the lavage was weakly positive. If newsprint could not be read, the lavage was considered to be strongly positive. Patients were placed into one of three treatment categories depending on results of the peritoneal lavage. (1) If a strongly positive lavage resulted, a prompt exploratory laparotomy was performed. (2) If the lavage was weakly positive, further diagnostic evaluation was carried out with echography, arteriography, and intravenous pyelography. Patients with positive findings underwent operation, while those with normal studies were closely observed. (3) If a negative peritoneal lavage resulted, close observation was carried out for 24 hr. RESULTS
Peritoneal lavage was performed in 52 children under the age of 15. Twenty patients had strongly positive, ten patients had weakly positive, and 22 patients had negative lavages (Table 1). All 20 patients (100~o) with strongly positive lavages had significant intraperitoneal injuries requiring operation. Nine of ten patients (90%) with a weakly positive lavage had normal ultrasound and ar-
From the Trauma Research Unit, Naval Regional Medical Center, San Diego, Calif. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the Navy Department. Address for reprints: CDR Richard W. Virgilio, MC, USN, Trauma Research Unit, Naval Regional Medical Center, Park Boulevard, San Diego, Calif. 92134. 9 1976 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 11, No. 6 (December), 1976
973
974
POWELL ET AL.
Table 1. Correlation of Peritoneal Lavage Results and Initial Physical Examinations With the Incidence of Significant Intraperitoneal Injuries Lavage Results Strongly Positive Clinical Evaluation Surgical Equivocal Nonsurgical Total
No. No. P a t i e n t Injuries(%)
Weakly Positive No. Patient
Negative
No. Injuries(%)
No. Patient
Total
No. Injuries(%)
Total No. Patients Injuries(%)
14 3 3
14 3 3
100 100 100
2 2 6
0 1 0
0 50 0
2 9 11
0 0 0
0 0 0
18 14 20
14 4 3
78 29 12
20
20
100
10
1
10
22
0
0
52
21
40
teriographic studies and were safely observed. There were no significant intraperitoneal injuries in the 22 paUents with negative lavages. However, one patient with a negative lavage and gross hematuria underwent a partial nephrectomy after an intravenous pyelogram revealed a fractured kidney. Peritoneal lavage accurately predicted the need for operation. The initial physical examination was found to be much less accurate in determining the need for operation (Table 1). Eighteen patients were thought to have a surgical abdomen on admission. Fourteen of 18 (78~) had a strongly positive lavage, underwent operation, and were found to have significant injuries. Four patients had weakly positive or negative peritoneal lavages and did not undergo operation with good recovery. Thus, physical examination gave a 22~ false-positive rate and peritoneal lavage reliably prevented unnecessary laparotomy. In the clinically equivocal group, 4 of 14 patients (29~) sustained injuries requiring laparotomy. Three had strongly positive and one had a weakly positive lavage. Twenty patients were felt to have no significant abdominal injury on the basis of physical examination with negative findings. Peritoneal lavage revealed three to have a strongly positive lavage, and prompt operation revealed significant intraperitoneal injuries. Thus, physical examination had a 15~ false-negative rate. Peritoneal lavage accurately indicated significant injury and permitted prompt treatment. The intraabdominal and associated injuries are shown in Tables 2 and 3. Solid organ injury was most common, but two hollow viscus injuries occurred. Twenty-five patients (48~) had significant extraabdominal injuries. The youngest patient undergoing lavage was a 7-mo-old infant with multiple rib fractures and a large flank ecchymosis. His lavage was negative. Significant Table 2. Significant Intraabdominal Injuries Organs Injured
Total
Spleen Liver Pancreas Kidney Duodenum Jejunum Cisterna chyli Hepatic veins Vena cava
19 2 3 1 1 1 1 1 1
PERITONEAL LAVAGE
975
Table 3. Associated Injuries Chest Lung Contusion Pneumothorax
2 1 1
Head Concussion Skull fracture
Fractures Rib Spine Upper extremity Pelvis Femur Lower leg None
10 9 1
28 5 1 9 6 6 2 27
intraabdominal injuries were found in all age groups (Table 4). Peak incidence appeared in adolescence (ages 12-15), but a large number of injuries also occured between 6 and 8 yr of age. Twenty of 21 patients who required laparotomy were operated on within 4 hr of their initial evaluation. One patient underwent operation 6 hr after initial evaluation. He was a 9-yr-old boy with a weakly positive lavage and an elevated lavage amylase. Increasing abdominal tenderness and an associated elevated serum amylase led to a laparotomy, which revealed a pancreatic transection. Peritoneal lavage allowed immediate decision on the need for laparotomy in 42 of the 52 patients (strongly positive and negative lavages). Ten patients (18~o) had weakly positive lavages and underwent additional diagnostic evaluation. One patient, described above, had a pancreatic transection and underwent operation. Of the other nine patients, seven underwent abdominal echography. Five were negative, one was equivocal, and the other was positive, showing splenic enlargment. The latter two patients underwent visceral angiography with no abnormal findings in either. A third patient with a negative echogram and a weakly positive lavage underwent angiography to identify a possible bleeding point from her pelvic fracture, but none was identified. The two patients in this group who did not undergo screening echography had only a trace hemoperitoneum and hematuria and underwent intravenous pyelography. One had a minor renal laceration and the other was normal. Both were treated successfully nonoperatively. There were no major complications of either peritoneal lavage or arteriography in the entire group. There were several minor wound complications--hematoma and superficial wound separation, but these did not prolong hospitalization or recovery. No long-term morbidity of peritoneal lavage has been observed in these 52 children. All children recovered from their injuries, although several patients with multiple injuries had protracted hospital courses. Table 4. Distribution of Patients by Age Years
Number of Patients
Strongly Positive
0-2 2-6 6-8 8-10 10-12 12-15
4 2 10 4 14 18
I I 3 I 8 6
Weakly Positive I 0 I I 4 3
Negative 2 I 6 2 2 9
Totals
52
20
I0
22
976
POWELL ET AL.
DISCUSSION
The diagnosis of intraabdominal injury in children with blunt trauma is complicated by many factors not present in adults. Acute apprehension due to pain, anxiety transferred by parents, and fear of physicians and surroundings make evaluation of the child difficult.7,8 Serial abdominal examination has been recommended as a reliable means of diagnosing abdominal injury.9,~~However, we found physical examination to be unreliable. Twenty-two per cent of our patients diagnosed as ha~ing a surgical abdomen proved to have no injury. Of patients with equivocal abdominal findings, 71~ had no injury. Abdominal pain and tenderness may be caused by abdominal wall contusion or reflex spasm due to pelvic or thoracic trauma. A negative physical examination was also misleading in 12~ of our patients who proved to have a significant intraperitoneal injury. Four quadrant paracentesis has been utilized to detect hemoperitoneum.2'9,1~ However, this technique is of value only if positive. A negative paracentesis does not rule out intraabdominal injury) 2 Peritoneal lavage has been shown to be more reliable than paracentesis in identifying intraabdominal hemorrhage in children with splenic injuries.2''~ Our experience confirms that peritoneal lavage is an accurate, safe, and rapid diagnostic tool in children with abdominal injuries. All 20 patients with strongly positive lavages had sustained significant intraperitoneal injury confirmed at laparotomy. None of the 22 patients with negative peritoneal lavages were found to have significant injuries. Only one of ten patients in the weakly positive group was found to have a significant injury. Unnecessary laparotomy was avoided in four patients with definite clinical signs of an acute surgical abdomen. Peritoneal lavage has been criticized as being too sensitive for the detection of intraabdominal blood. If hemoperitoneum had been used as the sole indication for operation, nine patients would have undergone unnecessary laparotomy. The simple technique of quantitating the lavage by degree of opacity enabled us to avoid unnecessary laparotomy. Although lavage is very accurate in diagnosing intraperitoneal injuries, it may not be reliable for retroperitoneal injuries. Two patients with weakly positive lavages had significant retroperitoneal injury. One with a transected pancreas had a significant delay in operation. The other had a fractured kidney that was diagnosed by intravenous pyelography. Other diagnostic methods such as intravenous pyelography, arteriography, or gastrographic contrast studies must be considered when retroperitioneal injury is suspected. Rapid diagnosis and early operation significantly lowers morbidity and mortality in trauma. Peritoneal lavage allowed us to determine the need for operation within 15-20 rain of arrival to the emergency room in 42 of 52 patients. Definitive diagnosis was delayed in patients with weakly positive lavages, but only one patient had a preoperative delay of longer than 4 hr. No major complications due to peritoneal lavage occurred in our series, although others have reported bladder, bowel, and major vessel perforation) 3 These hazards may be minimized by complete evacuation of the bladder prior to lavage and careful surgical technique including direct visualization of the linea alba and countertraction on the fascia.
PERITONEAL LAVAGE
977
SUMMARY Q u a n t i t a t i v e p e r i t o n e a l lavage was p e r f o r m e d in 52 c h i l d r e n with b l u n t abd o m i n a l t r a u m a to d e t e r m i n e the presence o f i n t r a a b d o m i n a l injuries. A s t r o n g l y positive lavage was 100~o a c c u r a t e in d i a g n o s i n g an i n t r a a b d o m i n a l i n j u r y r e q u i r i n g o p e r a t i o n . A negative lavage d e m o n s t r a t e d a b s e n c e of a significant i n t r a p e r i t o n e a l i n j u r y with 100~o accuracy. A weakly positive lavage was n o t d i a g n o s t i c a n d r e q u i r e d a d d i t i o n a l e v a l u a t i o n i n c l u d i n g i n t r a v e n o u s p y e l o g r a p h y , e c h o g r a p h y , a n d a r t e r i o g r a p h y . D i a g n o s i s a n d t r e a t m e n t was p r o m p t , a n d in 20 of 21 cases, o p e r a t i o n was p e r f o r m e d w i t h i n 4 hr. P e r i t o n e a l lavage was f o u n d to be safe a n d m u c h m o r e a c c u r a t e t h a n physical e x a m i n a t i o n in d i a g n o s i n g significant i n t r a a b d o m i n a l i n j u r y . REFERENCES
1. Kakos GS, Grosfeld JL, Morse TS: Small bowel injuries in children after blunt abdominal trauma. Ann Surg 174:238, 1971 2. Orlando JC, Moore TC: Splenectomy for trauma in childhood. Surg Gynecol Obstet 134:94, 1972 3. Parvin S, Smith DE, Asher WM, et al: Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 181:255, 1975 4. Root HD, Hauser CW, McKinley CR et al: Diagnostic peritoneal lavage. Surgery 57:633, 1965 5. Perry JF Jr: Blunt and penetrating abdominal injuries. Curr Probl Surg 1970 p 5 6. Olsen WR, Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104:536, 1972 7. Hood JM, Smyth BT: Nonpenetrating intraabdominal injuries in children. J Pediatr Surg 9:69, 1974
8. Richardson JD, Belin RP, Griffen w e : Blunt abdominal trauma in children. Ann Surg 176:213, 1972 9. Kaufman JM, Burrington JD: Liver trauma in children. J Pediatr Surg 6:585, 1971 10. Halter BL, Gross RS: Non-penetrating wounds of the abdomen in children. Ann Surg 93:667, 1957 11. Sinclair MD, Moore TC: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J Pediatr Surg 9:155, 1974 12. Olsen WR, Hildreth DH: Abdominal paracentesis and peritoneal lavage in blunt abdominal trauma. J Trauma 1:824, 1971 13. Caffee HH, Benfield JR: Is peritoneal lavage for the diagnosis of hemoperitoneum safe? Arch Surg 103:4, 1971
