|Year : 2023 | Volume
| Issue : 1 | Page : 48-53
Blunt abdominal trauma in children: A review of 105 cases
Salsabil Mohamed Sabounji, Doudou Gueye, Gabriel Ngom
Department of Paediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
|Date of Submission||04-Aug-2021|
|Date of Decision||16-Jul-2022|
|Date of Acceptance||21-Aug-2022|
|Date of Web Publication||10-Jan-2023|
Salsabil Mohamed Sabounji
Department of Paediatric Surgery, Centre Hospitalier d'Enfants Albert Royer, Dakar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: The aim of the study is to identify the epidemiological, diagnostic, therapeutic, and evolutionary characteristics of patients admitted for blunt abdominal trauma (BAT) in a level 3 children's hospital.
Subjects and Methods: It was a retrospective and descriptive study on a series of 105 cases of BAT recorded over 8 years. The data were collected from patients' files. The analysis was done on Excel 2016. Several parameters were studied: frequency, age, sex, cause of trauma, circumstances, mechanism, mode of transportation, admission time, medical history, symptoms and signs, laboratory findings, radiological findings, injury assessment, associated injuries, type of treatment, and evolutionary modalities.
Results: The frequency was 13.1 cases/year. The mean age was 6.6 years. The sex ratio was 3.56. Road traffic accidents were the most frequent cause (54.3%). Abdominal tenderness (88.6%) was the most common physical sign. Associated lesions were found in 40% of cases. Abdominal sonography (85.7%) was the most common imaging tool followed by an abdominal computed tomography scan (34.4%). The liver was the most affected organ (24.7%) and contusion was the most frequent lesion (65.4%). The majority of patients had received nonoperative treatment (93.3%). The average length of hospitalization was 5.6 days. The outcome in all cases was favorable. No mortality was reported.
Conclusions: BAT in children is common in boys under the age of 10. They are caused by road accidents. Physical examination combined with abdominal ultrasound is very important in the therapeutic decision, which in most cases is a conservative one. Morbidity and mortality are almost nil.
Keywords: Blunt abdominal trauma, children, injury, nonoperative treatment, ultrasound
|How to cite this article:|
Sabounji SM, Gueye D, Ngom G. Blunt abdominal trauma in children: A review of 105 cases. J Indian Assoc Pediatr Surg 2023;28:48-53
|How to cite this URL:|
Sabounji SM, Gueye D, Ngom G. Blunt abdominal trauma in children: A review of 105 cases. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Feb 2];28:48-53. Available from: https://www.jiaps.com/text.asp?2023/28/1/48/367385
| Introduction|| |
Pediatric trauma accounts for approximately 14% of the overall trauma pathology. They are a major cause of death in children over 1 year of age., The abdomen is the third anatomical region affected in children, after the head and limbs, and accounts for approximately 25% of major trauma., Abdominal bruising (AB) or blunt abdominal trauma (BAT) represents approximately 80%–90% of abdominal trauma in children. Abdominal trauma is the most common cause of death due to undetected injuries. Nowadays, the progress made in resuscitation and imaging has allowed a revolution in their management with conservative nonoperative treatment in more than 95% of cases. Surgical treatment is restricted to well-defined situations of hemodynamic instability or rupture of a hollow organ or diaphragm. In the occident, abdominal contusions have been discussed in various publications in both adults and children. However, African literature remains quite limited on this subject, especially in children. Thus, the aim of this study is to identify the epidemiological, diagnostic, therapeutic, and evolutionary characteristics of patients admitted for BAT in a level 3 children's hospital in West Africa.
| Subjects and Methods|| |
It was a retrospective and descriptive study on a series of 105 patients admitted for BAT, recorded over 8 years from January 1, 2012, to December 31, 2019. Several parameters were studied: frequency, age, sex, cause of trauma, circumstances, mechanism, mode of transportation, admission time, medical history, symptoms and signs, laboratory findings, radiological findings, injury assessment, associated injuries, type of treatment, and evolutionary modalities. The data were collected from patients' files. The analysis was done on Excel 2016.
| Results|| |
In 8 years, 105 children were victims of BAT, representing a frequency of 13.1 cases/year and 2.99% of the admissions. Ages varied from 18 months to 15 years, with a mean of 6.6 years. Children between 5 and 10 years of age were the majority (46.6%). The sex ratio was 3.56. More than half of the patients were transferred (71.4%). Road traffic accidents (RTAs) were the most frequent cause (54.3%) [Figure 1]. The majority of patients did not benefit from emergency medical transportation (64.8%). Admission time was under 24 h in 78.1% of cases, with an average delay of 15.7 h. The majority of our patients did not have any significant history (91.4%). Abdominal pain was present in almost all cases (96.2%), only 27 patients presented vomiting (25.7%) and five patients had macroscopic hematuria (4.7%). On admission, altered consciousness was noted in one case, whereas the majority (98.1%) had a stable hemodynamic state. In eight patients, respiratory distress was noted (7.6%) in the context of an associated thoracic trauma and six patients presented a fever (5.7%).
Abdominal examination revealed: abdominal pain in 93 cases (88.6%), abdominal tenderness in 38 cases (36.2%), abdominal rigidity in six cases (5.7%), and distension in three cases (2.8%). Elsewhere, the examination revealed associated lesions (40%) [Table 1]. A biological assessment, namely, a blood count and a blood-Rhesus grouping, was performed on all our patients. Anemia was noted in 35 cases (33.3%), hyperleukocytosis in 32 cases (30.5%), and thrombocytopenia in five cases (4.8%). Elevated pancreatic enzymes were noted in three cases (2.8%).
A minimal radiological assessment was performed on all our patients. It consisted of an abdominal ultrasound in 90 cases (85.7%), an abdominal computed tomography (CT) scan in 36 cases (34.4%), and a full-body scan in nine cases (8.6%). Abdominal X-ray was performed in eight patients (7.6%). Ultrasound and/or CT scan allowed the following lesion assessment [Table 2].
Peritoneal effusions were found in 44.7% of cases. They were mostly of low abundance (49%) [Figure 2]. The liver was the most affected organ (n = 26/105) (24.7%) and contusion was the most frequent injury (n = 17/26) (65.4%) [Figure 3]. These injuries most often involved the right lobe (n = 21/26) (80.8%) and segment VII was the most represented (34.6%). The spleen came second (n = 14/105) (13.3%) with fracture as the most frequent lesion type (57.1%) [Figure 4]. The kidneys were affected in only six cases (5.7%) and finally the pancreas fracture in three cases (2.8%) [Figure 5] and [Figure 6]. In our study, 98 children (93.3%) benefited from nonoperative treatment with continuous clinical, radiological, and biological monitoring. Operative treatment was indicated in seven patients (6.7%) [Table 3]. The indication for surgery was decided either after the radiological assessment suggesting a visceral injury requiring surgery or was inconclusive, or in case of hemodynamic instability not responding to resuscitation measures. The postoperative follow-up in these patients was simple. The average length of hospitalization was 5.6 days with a range of 2 days and 26 days.
|Figure 4: Abdominal ultrasound showing a subcapsular hematoma of the spleen.|
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The outcome in all cases was favorable after a mean follow-up of 2.1 months.
One patient developed a pancreatic pseudocyst after 7 months. No mortality has been reported.
| Discussion|| |
AB or BAT accounts for about 80%–90% of abdominal trauma in children in the West. In Africa, no accurate epidemiological data have been identified and the exact frequency of BAT is not well documented. The average age varies between 7.1 and 9.5 years.,,, Most of these bruises occur in children with ages ranging from 5 to 9 years. The mean age of our series is below that of the literature but the most represented age range (between 5 and 10 years) is the same. Similar to the series reported in the literature, we noted a male prevalence., The restlessness and the great vivacity of boys could be the cause. In Africa as well as in the West, RTAs remain the first cause of intra-abdominal injuries in children.,, In developed countries, they are the leading cause of infant death. According to Naader, more than 50% of abdominal trauma (in adults and children) is due to RTAs. Spijkerman et al. found that RTAs were the first cause of injury in children over 12 years of age, followed by falls; the opposite was found in children under 12 years of age. In other studies, falls were the second most common cause of injury., The results of our series are consistent with those of the literature. Horse hoof strikes are not insignificant in our setting and remain absent in the international series that we have reviewed.
Physical examination is an important step in the evaluation of abdominal trauma. Abdominal tenderness is the first sign found in the literature with a prevalence that varies between 67% and 75%. It is followed by the defense (24%–39%) and contracture (16%–21%). Our results are similar to those in the literature., Physical examination and clinical judgment are of particular importance in cases of intestinal injury.,,
Although standard examinations still have a place in the emergency setting, it must be recognized that abdominal ultrasound and CT scans have considerably changed the facts of the problem: their availability in the emergency setting is now imperative in emergency centers. CT is the preferred imaging method in the evaluation of abdominal and pelvic injuries after blunt trauma in hemodynamically stable children.,, However, there are still concerns regarding radiation exposure and the risk of subsequent fatal malignancies. In addition, cost, need for contrast, and lack of portability are also considered limitations. Streck et al. retrospectively demonstrated that the use of a clinical prediction model based on six high-risk variables for intra-abdominal lesions for patients not limited to the abdominal examination can reduce the cost and radiation exposure of abdominal scans, potentially avoidable in children, without missing significant lesions. In our African setting, the limited access to this standard test, even in level 3 hospitals, is a real obstacle and contributes to a delay in management. Ultrasound remains the first-line diagnostic tool as it is less expensive, nonradiating, noninvasive, easier to perform, does not require any preparation or injection, and can be performed at the patient's bedside at the same time as first aid.,,,, It is also the key examination in the follow-up of patients with abdominal trauma. It allows assessment of the evolution of parenchymal contusions, approximate quantification and assessment of the evolution of a hemoperitoneum, and monitoring of the cystic evolution of a pancreatic fracture. Nowadays, focused assessment with sonography for trauma (FAST) is used more frequently in pediatric trauma management. Thus, it is performed in developed countries by both radiologists and nonradiologists and can be an alternative solution in our resource-limited countries, especially in regions without emergency CT. Indeed, institutional teaching of ultrasound is recommended by the American College of Emergency Physicians and the American College of Surgeons. These two colleges advocate initial ultrasound teaching as part of the curriculum for residents in both specialties.,, Smith et al., in a review of surgeon training for ultrasound in trauma patients, proposed that 10 examinations on healthy patients and 25 examinations on trauma patients were sufficient to qualify an operator in FAST., For this reason, we believe that it is essential to train physicians and surgeons to perform an emergency ultrasound for abdominal trauma. As in several recent literature series, we will discuss the most affected organs and their management. While in our study and that of Basaran and Ozkan, the liver is the most frequent location of visceral injuries, most studies find that the spleen is much more affected than the liver.,,, However, the liver and the spleen remain the two most affected organs.
The spleen is the most frequently affected organ in BAT. It is the most vascularized organ in the body. In fact, approximately 350 L of blood circulates through it every day; therefore, its injury is a potentially fatal situation, exposing the patient to massive hemoperitoneum. In the majority of cases, conservative treatment is sufficient. This is the case in our study. Splenectomy is necessary in case of continuous bleeding and if blood transfusion requirements exceed 40 ml/kg.
The lesions are often asymptomatic and in 70% of cases, they can be treated nonoperatively. Over the past decade, mortality associated with liver and spleen lesions has significantly decreased. Conservative treatment of these lesions has become a standard with more than 96% of isolated lesions managed without surgery.,,,
The third most affected organ, the kidney, is less frequently affected than the liver and spleen.,, Renal ultrasound and CT are useful modalities for assessing the degree of renal injury. However, CT is preferred for the evaluation of hematuria in a trauma patient, as it allows for simultaneous assessment of bladder injury and associated injury to intraperitoneal structures. The most specific sign is abundant hematuria, which is not always related to the severity of the trauma. A contusion is the most frequent injury. Renal parenchymal trauma can be safely treated conservatively., Failure of nonsurgical management occurs in only about 3% of cases, mainly high-grade injuries., Surgical treatment is necessary in hemodynamically unstable patients, or when there is either complete destruction of the pyeloureteral junction or renal artery or vein injury with devascularization of the kidney.,
Pancreatic trauma occurs in 3%–12% of AB injuries. The injury is rarely isolated, but in 60% of cases, it is usually associated with injuries of the liver, spleen, or duodenum. This means that in patients with pancreatic injury, morbidity, and mortality are increased.,,
Trauma is a significant cause of morbidity and mortality worldwide. Pediatric trauma in both Low and Middle Income Countries (LMICS) and High Income Countries (HICS) is shifting toward nonoperative management. As related to the literature, management should be done in the intensive care unit. This allows good monitoring which is essential to prevent possible complications.
Nonoperative management is optimal for children because their blood vessels are smaller than those of adults, and there is a major vasoconstrictive response so visceral bleeding tends to be self-limiting despite the severity of the trauma.,,
For years, conservative nonoperative treatment has become the standard for the management of abdominal visceral injuries. This is currently based on the patient's stable hemodynamic state and no longer on the grade of the visceral injury in question.,,, The majority of our patients were hemodynamically stable on admission and during monitoring, which justifies the high rate of conservative treatment in our series (93.3%).
| Conclusions|| |
BAT in children is common in boys under 10 years of age. They are caused by RTA. Physical examination combined with imaging, especially ultrasound, is important in the therapeutic choice, which is conservative in most cases. Morbidity and mortality are practically nil.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Snyder CL, Jain VN, Saltzman DA, Strate RG, Perry JF Jr., Leonard AS. Blunt trauma in adults and children: A comparative analysis. J Trauma 1990;30:1239-45.
Eppich WJ, Zonfrillo MR. Emergency department evaluation and management of blunt abdominal trauma in children. Curr Opin Pediatr 2007;19:265-9.
Mendelson KG, Fallat ME. Pediatric injuries: Prevention to resolution. Surg Clin North Am 2007;87:207-28, viii.
Lynch T, Kilgar J, Al Shibli A. Pediatric abdominal trauma. Curr Pediatr Rev 2018;14:59-63.
Wegner S, Colletti JE, Van Wie D. Pediatric blunt abdominal trauma. Pediatr Clin North Am 2006;53:243-56.
Miele V, Piccolo CL, Trinci M, Galluzzo M, Ianniello S, Brunese L. Diagnostic imaging of blunt abdominal trauma in pediatric patients. Radiol Med 2016;121:409-30.
Drexel S, Azarow K, Jafri MA. Abdominal trauma evaluation for the pediatric surgeon. Surg Clin North Am 2017;97:59-74.
Basaran A, Ozkan S. Evaluation of intra-abdominal solid organ injuries in children. Acta Biomed 2019;89:505-12.
Linard C, Germouty I, David CH, Pecquery R, Le Rouzic-Dartoy C, Fenoll B, et al
. Traumatisme abdominal mineur de l'enfant: Protocole de prise en charge aux urgences. J Eur Urgences Reanim 2012;24:2-8.
Chouayib N, Rafai M, Zerhouni H, Oubejja H, Ettayebi F. Traumatismes abdominaux fermés graves chez l'enfant. Expérience du Service des Urgences Chirurgicales Pédiatriques du CHU Ibn Sina rabat : à propos de 294 cas. Rev Mar Mal Enf 2013;31:27-30.
Cotte A, Guye E, Diraduryan N, Tardieu D, Varlet F, et al
. Prise en charge des traumatismes fermés de l'abdomen chez l'enfant. Arch Pediatr 2004;11:327-34.
Ameh EA, Chirdan LB, Nmadu PT. Blunt abdominal trauma in children: Epidemiology, management, and management problems in a developing country. Pediatr Surg Int 2000;16:505-9.
Spijkerman R, Bulthuis LC, Hesselink L, Nijdam TM, Leenen LP, de Bruin IG. Management of pediatric blunt abdominal trauma in a Dutch level one trauma center. Eur J Trauma Emerg Surg 2021;47:1543-51.
Chirdan LB, Uba AF, Yiltok SJ, Ramyil VM. Paediatric blunt abdominal trauma: Challenges of management in a developing country. Eur J Pediatr Surg 2007;17:90-5.
Beaver BL, Haller A. Epidemiology of trauma. In: Ashcraft KW, Holder TM, editors. Pediatric surgery, chap 10. Philadelphia, PA: WB Saunders; 1993. p. 103e9.
Naader SB. Pattern of abdominal injuries in Korle Bu teaching hospital. Accra Ghana Med J 1990;24:186-90.
Karamercan A, Yilmaz TU, Karamercan MA, Aytaç B. Blunt abdominal trauma: Evaluation of diagnostic options and surgical outcomes. Ulus Travma Acil Cerrahi Derg 2008;14:205-10.
Davis JJ, Cohn I Jr., Nance FC. Diagnosis and management of blunt abdominal trauma. Ann Surg 1976;183:672-8.
Jerby BL, Attorri RJ, Morton D Jr. Blunt intestinal injury in children: The role of the physical examination. J Pediatr Surg 1997;32:580-4.
Moss RL, Musemeche CA. Clinical judgment is superior to diagnostic tests in the management of pediatric small bowel injury. J Pediatr Surg 1996;31:1178-81.
Ortega Deballon P, Radais F, Benoit L, Cheynel N. L'imagerie médicale dans la prise en charge non opératoire des traumatismes abdominaux. J Chir 2006;143(4):212-20.
Weishaupt D, Grozaj AM, Willmann JK, Roos JE, Hilfiker PR, Marincek B. Traumatic injuries: Imaging of abdominal and pelvic injuries. Eur Radiol 2002;12:1295-311.
Streck CJ Jr., Jewett BM, Wahlquist AH, Gutierrez PS, Russell WS. Evaluation for intra-abdominal injury in children after blunt torso trauma: Can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model? J Trauma Acute Care Surg 2012;73:371-6.
Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr Opin Pediatr 2012;24:314-8.
Bahner D, Blaivas M, Cohen HL, Fox JC, Hoffenberg S, Kendall J, et al.
AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med 2008;27:313-8.
Katz S, Lazar L, Rathaus V, Erez I. Can ultrasonography replace computed tomography in the initial assessment of children with blunt abdominal trauma? J Pediatr Surg 1996;31:649-51.
Benya EC, Lim-Dunham JE, Landrum O, Statter M. Abdominal sonography in examination of children with blunt abdominal trauma. AJR Am J Roentgenol 2000;174:1613-6.
Richards JR, Knopf NA, Wang L, McGahan JP. Blunt abdominal trauma in children: Evaluation with emergency US. Radiology 2002;222:749-54.
Le Dosseur P, Dacher JN, Piétrera P. La prise en charge des traumatismes abdominaux de l'enfant. J Radiol 2005;86:209-21.
Adnet F, Galinski M, Lapostolle F. Fast echography in the emergency setting. JEUR 2014;13:465-70.
Allison EJ Jr., Aghababian RV, Barsan WG, Graff JG, Janiak BD, Kramer DA, et al.
Core content for emergency medicine. Task force on the core content for emergency medicine revision. Ann Emerg Med 1997;29:792-811.
Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: Lessons learned from 1540 patients. Ann Surg 1998;228:557-67.
Smith RS, Kern SJ, Fry WR, Helmer SD. Institutional learning curve of surgeon-performed trauma ultrasound. Arch Surg 1998;133:530-5.
Wisner DH, Kuppermann N, Cooper A, Menaker J, Ehrlich P, Kooistra J, et al.
Management of children with solid organ injuries after blunt torso trauma. J Trauma Acute Care Surg 2015;79:206-14.
Dodgion CM, Gosain A, Rogers A, St Peter SD, Nichol PF, Ostlie DJ. National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol. J Pediatr Surg 2014;49:1004-8.
Polites SF, Zielinski MD, Zarroug AE, Wagie AE, Stylianos S, Habermann EB. Benchmarks for splenectomy in pediatric trauma: How are we doing? J Pediatr Surg 2015;50:339-42.
Notrica DM. Pediatric blunt solid organ injury: Beyond the APSA guidelines. Curr Surg Rep 2015;3:1-6.
Buckley JC, McAninch JW. Pediatric renal injuries: Management guidelines from a 25-year experience. J Urol 2004;172:687-90.
Broghammer JA, Langenburg SE, Smith SJ, Santucci RA. Pediatric blunt renal trauma: Its conservative management and patterns of associated injuries. Urology 2006;67:823-7.
Graziano KD, Juang D, Notrica D, Grandsoult VL, Acosta J, Sharp SW, et al.
Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children. J Pediatr Surg 2014;49:198-200.
Siegel MJ, Balfe DM. Blunt renal and ureteral trauma in childhood: CT patterns of fluid collections. AJR Am J Roentgenol 1989;152:1043-7.
Carroll PR, McAninch JW, Klosterman P, Greenblatt M. Renovascular trauma: Risk assessment, surgical management, and outcome. J Trauma 1990;30:547-52.
Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008;43:72-82.
Lv F, Tang J, Luo Y, Nie Y, Liang T, Jiao Z, et al.
Emergency contrast-enhanced ultrasonography for pancreatic injuries in blunt abdominal trauma. Radiol Med 2014;119:920-7.
Bradshaw CJ, Bandi AS, Muktar Z, Hasan MA, Chowdhury TK, Banu T, et al.
International study of the epidemiology of paediatric trauma: PAPSA research study. World J Surg 2018;42:1885-94.
Ruess L, Sivit CJ, Eichelberger MR, Taylor GA, Bond SJ. Blunt hepatic and splenic trauma in children: Correlation of a CT injury severity scale with clinical outcome. Pediatr Radiol 1995;25:321-5.
Stylianos S. Outcomes from pediatric solid organ injury: Role of standardized care guidelines. Curr Opin Pediatr 2005;17:402-6.
St Peter SD, Aguayo P, Juang D, Sharp SW, Snyder CL, Holcomb GW 3rd
, et al.
Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg 2013;48:2437-41.
Mehall JR, Ennis JS, Saltzman DA, Chandler JC, Grewal H, Wagner CW, et al.
Prospective results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury. J Am Coll Surg 2001;193:347-53.
Fremgen HE, Bratton SL, Metzger RR, Barnhart DC. Pediatric liver lacerations and intensive care: Evaluation of ICU triage strategies. Pediatr Crit Care Med 2014;15:e183-91.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]