(APSA) Trauma Committee Guidelines are;
Abdominal
Trauma
Solid Organ Injuries
SPLEEN AND LIVER
The spleen and liver are the organs most
commonly injured in blunt abdominal trauma,
with each accounting for one third of the
injuries. Nonoperative treatment of isolated
splenic and hepatic injuries in stable children
has been universally successful and is now
standard practice.
Controversy exists regarding the utility of CT
grading and the finding of contrast blush as a
predictor of outcome in liver and spleen
injury.
The role and impact of angiographic
embolization in adults is still debated and
angiographic embolization seems to be safe
and effective in children.
The American Pediatric Surgical Association
Decision to operate for spleen or liver injury is
best based on evidence of continued blood
loss, such as low blood pressure, tachycardia,
decreased urine output, and falling hematocrit
unresponsive to crystalloid and blood
transfusion.
Nonoperative treatment of spleen or liver
injury is indicated even in the presence of
associated head injury if the patient is
hemodynamically stable.
Failure of nonoperative management
(NOM) can have serious consequences.
Pediatric patients who sustained pancreatic
injuries were more likely to fail nonoperative
management. Factors associated with
increased failure rate include bicycle-related
injury mechanism, isolated pancreatic injury,
more than one solid organ injury, and an
isolated grade 5 solid organ injury.
Continued surgical evaluation and assessment
during the entire hospital stay is required to
limit morbidity and mortality of the pediatric
trauma patient.
Operated patients are at higher risk for
overwhelming postsplenectomy sepsis and
complications related to laparotomy, such as
adhesive small bowel obstruction and
incisional hernia.
The major concerns are related to the potential
risks of increased transfusion requirements,
missed associated injuries, and increased
length of hospital stay.
Routine follow-up imaging studies have
identified pseudocysts and pseudoaneurysms
following splenic injury. Splenic
pseudoaneurysms often cause no symptoms
and appear to resolve with time.
Angiographic embolization techniques can
successfully treat these lesions, obviating the
need for open surgery and loss of splenic
parenchyma. Splenic pseudocysts can achieve
enormous size, leading to pain and GI
disturbance. Simple percutaneous aspiration

leads to a high recurrence rate. Laparoscopic

ASSOCIATED ABDOMINAL INJURIES excision and marsupialization are highly
Higher rates of hollow visceral injury were effective.
observed in assaulted patients and in those
with multiple solid visceral injuries or
pancreatic injuries. Differences in mechanism
of injury may account for the much lower
incidence of associated abdominal injuries in
children with splenic trauma. There is no
justification for an exploratory celiotomy
solely to avoid missing potential associated
injuries in children.

COMPLICATIONS OF NONOPERATIVE
TREATMENT
Fundamental to the success of a nonoperative
strategy is the early, spontaneous cessation
of hemorrhage. Recommended continued in-
house observation until symptoms resolve. SEQUELAE OF DAMAGE-CONTROL
The incidence of delayed bleeding after blunt STRATEGIES
splenic injury is very rare but life threatening.
Emergency laparotomy, embolization, or others, and the physiologic and metabolic
both are indicated in patients who are consequences often preclude completion of the
hemodynamically unstable despite fluid and procedure. Lethal coagulopathy from a
red blood cell transfusion. combination of tissue injury, dilution,
Most spleen and liver injuries requiring hypothermia, and acidosis can rapidly occur.
operation are amenable to simple methods of
hemostasis using a combination of;
1. Manual compression,
2. Direct suture,
3. Topical hemostatic agents, and
4. Mesh wrapping.

Acute coagulopathy of trauma and shock (ACoTS)

The infusion of activated recombinant factor

VII in children with massive hemorrhage and
maintains its effectiveness at hypothermic
temperatures.
Development of staged, multidisciplinary
treatment plans, including;
1. Abbreviated laparotomy,
2. Perihepatic packing,
3. Temporary abdominal closure,
4. Angiographic embolization, and
5. Endoscopic biliary stenting.
Total hepatic vascular isolation
Hepatic angioembolization can clearly be an
important adjunct in the treatment of patients
Children can tolerate periods of vascular
with major liver injury.
isolation for 30 minutes or longer, as long as
Abbreviated laparotomy with packing for
their blood volume is replenished.
hemostasis, allowing resuscitation before
Venovenous bypass may be useful but is rarely
planned reoperation, is an alternative in
available for such rare injuries.
unstable patients in whom further blood loss
Newer endovascular balloon catheters can
would be untenable. This damage-control
be useful for temporary vascular occlusion to
philosophy is a systematic, phased approach to
allow access to the juxtahepatic vena cava.
the management of exsanguinating trauma
The early morbidity and mortality of severe
patients.
hepatic injuries are related to the effects of
massive blood loss and replacement with large
volumes of cold blood products. The
consequences of prolonged operations with
massive blood-product replacement and lethal
triad include hypothermia, coagulopathy, and
acidosis.
Many of these critically ill patients are
unlikely to survive once their physiologic
reserves have been exhausted.
Maintenance of physiologic stability during
the struggle for surgical control of severe Once a patient is rewarmed, coagulation
bleeding is a formidable challenge even for the factors are replaced, and oxygen delivery is
most experienced surgical team, particularly optimized, he or she can be returned to the
when hypothermia, coagulopathy, and acidosis operating room for pack removal and
occur. This triad creates a vicious circle in definitive repair of injuries.
which each derangement exacerbates the
If closure of the abdomen becomes impossible
by abdominal packing, a Silastic silo is
constructed to accommodate the bowel until
the packing could be removed.
Preperitoneal pelvic packing for
hemodynamically unstable patients with pelvic
fracture is another unique use of pack
tamponade in life-threatening hemorrhage.
Abdominal packing may contribute to
significant morbidity, such as intraabdominal
sepsis, organ failure, and increased intra-
abdominal pressure. Laparotomy pad fluid
accumulating after damage-control laparotomy
can contribute to neutrophil dysfunction by
enhancing neutrophil respiratory burst and
inhibiting neutrophil responses to specific
chemotactic mediators needed to fight
infection. Thus the known propensity of such
patients to both intra-abdominal and systemic
infection may be related to changes in
neutrophil receptor status and effector function
related to the accumulation of inflammatory
mediators in the abdomen. Early washout,
repetitive packing, and other efforts to
minimize mediator accumulation deserve
consideration.
Abbreviated laparotomy and planned
reoperation depends on an early decision to
use this strategy before irreversible shock
occurs.
Physiologic and anatomic criteria as
indications for abdominal packing are;
1. pH (≈7.2),
2. Core temperature (<35 C), and
3. Coagulation values (prothrombin time
>16 seconds)
The optimal time for reexploration is
controversial, because neither the physiologic
end points of resuscitation nor the increased
risk of infection with prolonged packing are
well defined. The obvious benefits of
hemostasis provided by packing are also
balanced against the potential deleterious
effects of increased intra-abdominal pressure
on ventilation, cardiac output, renal function,
mesenteric circulation, and intracranial
pressure. Temporary abdominal wall
expansion is recommended in all patients
requiring packing, until hemostasis is obtained
and visceral edema subsides.
Intra-abdominal packing for control of
exsanguinating hemorrhage is a lifesaving
maneuver in highly selected patients in whom
coagulopathy, hypothermia, and acidosis
render further surgical procedures unduly
hazardous.
ABDOMINAL COMPARTMENT
SYNDROME
The deleterious effects of increased intra-
abdominal pressure. The syndrome includes;
1. Respiratory insufficiency from
worsening ventilation-perfusion
mismatch,
2. Hemodynamic compromise from
preload reduction resulting from
inferior vena cava compression,
3. Impaired renal function resulting from
renal vein compression,
4. Decreased cardiac output,
5. Intracranial hypertension resulting
from increased ventilator pressures,
6. Splanchnic hypoperfusion, and
7. Abdominal wall overdistention.
Intra-abdominal hypertension
1. Hemoperitoneum,
2. Retroperitoneal or bowel edema, and
3. Use of abdominal or pelvic packing.
The combination of tissue injury and
hemodynamic shock creates a cascade of
events, including capillary leak, ischemia-
reperfusion, and release of vasoactive
mediators and free radicals, which combine to
increase extracellular volume and tissue
edema. Once the combined effects of tissue
edema and intra-abdominal fluid exceed a
certain level, abdominal decompression must
be considered.
Intra-abdominal pressure can be determined
by measuring bladder pressure. This
involves instilling 1 mL/kg of saline into the
Foley catheter and connecting it to a pressure
transducer or manometer through a three-way
stopcock. The symphysis pubis is used as the
zero reference point, and the pressure is
measured in centimeters of water or
millimeters of mercury. Intraabdominal
pressures in the range of 20 to 35 cm H2O or
15 to 25 mmHg have been identified as an
indication to decompress the abdomen.
Abdominal decompression using pulmonary
artery catheters and gastric tonometry
improved preload, pulmonary function, and
visceral perfusion. Patch abdominoplasty
effectively decreased airway pressures and
oxygen requirements. Temporary patch
abdominoplasty, including Silastic sheeting,
Gore-Tex sheeting, intravenous bags,
cystoscopy bags, ostomy appliances, and
various mesh materials.
Nonspecific abdominal CT findings in
children with abdominal compartment
syndrome include narrowing of the inferior
vena cava, direct renal compression or
displacement, bowel wall thickening with
enhancement, and a rounded appearance of the
abdomen.
BILE DUCT INJURY
Nonoperative management of pediatric blunt
liver injury is highly successful. Radionuclide
scanning is recommended when biliary tree
injury is suspected.
Endoscopic retrograde cholangiopancreatography
(ERCP) with placement of transampullary
biliary stents for biliary duct injury following
blunt hepatic trauma. ERCP is invasive and
requires conscious sedation, it can pinpoint the
site of injury and allow treatment of the
injured ducts without open surgery.
Sphincterotomy during ERCP for persistent
bile leakage following blunt liver injury
decreases intrabiliary pressure and encourage
internal decompression. Endoscopic biliary
stents may migrate or become obstructed and
require specific treatment.
Injuries to the Duodenum
and Pancreas
The “protected” retroperitoneum both limits
the chance of injury and increases the
difficulty of early diagnosis.
DUODENUM
Clinical presentation with duodenal hematoma
versus perforation is similar. Extravasation of
air or enteral contrast into the
retroperitoneal, periduodenal, or prerenal
space is found in every child with a duodenal
perforation. The CT scans (or upper GI
contrast studies in equivocal cases) showing
duodenal narrowing, corkscrewing, or
obstruction without extravasation are
diagnostic.
Isolated duodenal injures should raise
suspicion if the history or mechanism of injury
described is inconsistent with the actual injury
as in child abuse.
Primary closure of a duodenal perforation is
recommended (whenever possible). Primary
closure can be combined with duodenal
drainage and either pyloric exclusion with
gastrojejunostomy or gastric drainage with
feeding jejunostomy. These surgical options
decrease the incidence of duodenal fistula,
reduce the time to GI tract alimentation, and
shorten hospital stay.
In complicated duodenal trauma, an effective
combination is the three-tube technique:
duodenal closure (primary repair, serosal
patch, or anastomosis) with duodenal
drainage tube for decompression (tube 1),
pyloric exclusion with an absorbable suture
through gastrotomy and gastric tube placement
(tube 2), and feeding jejunostomy (tube 3).
Several closed suction drains are placed
adjacent to the repair.When the duodenum is
excluded (by an absorbable suture for
temporary closure of the pylorus), complete
healing of the injury routinely occurs before
the spontaneous reopening of the pyloric
channel. Bioprosthetic repair is a new
strategy.
Protecting the duodenal closure (drain and
exclusion) and a route for enteral feeding
(gastrojejunostomy or feeding jejunostomy)
reduces morbidity and hospital length of stay.
Pancreaticoduodenectomy (the Whipple
procedure) is rarely required. Reserved for
the most severe injuries to the duodenum and
pancreas in which the common blood supply is
destroyed and reconstruction is impossible.
PANCREAS
Distal injuries should be treated with distal
pancreatectomy, proximal injuries with
observation, and pseudocysts with
observation or cystogastrostomy. Acute
ERCP management with stent placement is
safe and effective, and CT is suggestive but
not always diagnostic for the type and location
of pancreatic injuries.
CT is diagnostic, revealing five patterns of
injury:
1. Contusion,
2. Stellate fragmentation,
3. Partial fracture,
4. Complete transection, and
5. Pseudocyst
Following nonoperative management of
pancreatic blunt trauma, atrophy (distal) or
recanalization occurs in all cases with no long-
term morbidity. There is efficacy of early
ERCP intervention for diagnosis and treatment
with ductal stenting, and the use of
somatostatin to decrease pancreatic secretions
and promote healing.
Children undergoing operative treatment had
fewer pseudocysts but similar length of stay
because of nonpancreatic complications like
adhesive bowel disease.
Simple transection of the pancreas at or to
the left of the spine, spleen-sparing distal
pancreatectomy can provide definitive care
for this isolated injury, with short
hospitalization and acceptable morbidity.
Laparoscopic techniques may limit
perioperative morbidity.
Conservative therapy whenever possible,
including the following:
1. Early spiral CT with oral and
intravenous contrast in all patients
who, by history, physical examination,
or mechanism of injury, may have
blunt trauma to the pancreas
2. Documentation of injuries and early
ERCP to provide duct stenting in
selected cases
3. Nonoperative management with total
parenteral nutrition
4. Expectant management of pseudocyst
formation
5. Percutaneous drainage for
symptomatic, infected, or enlarging
pseudocyst