REVIEW
URRENT
C
OPINION
Blunt abdominal trauma in children
Deborah Schonfeld and Lois K. Lee
Purpose of review
This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical
exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intraabdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and
emergency department disposition after diagnosis.
Recent findings
The importance of the seat belt sign on physical examination and screening laboratory data remains
controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental
trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma
(FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with
concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial
abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed
emergently.
Summary
Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically
stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to
identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not
require routine hospitalization after blunt abdominal trauma.
Keywords
abdominal trauma, intra-abdominal injury, pediatrics
INTRODUCTION
Injuries continue to be a leading cause of death and
disability in children and adolescents less than 18
years old [1]. Abdominal trauma sustained from
motor vehicle crashes (MVC), falls, sports-related
injuries, or other causes can result in substantial
mortality from solid organ or hollow viscus injury
[2,3]. Despite the frequency with which abdominal
trauma occurs in children, there is still controversy
over the optimal evaluation strategy to identify
intra-abdominal injury (IAI). The purpose of this
review is to highlight the recent studies on the
utility of physical exam findings, laboratory testing,
and radiographic imaging in the assessment of the
pediatric abdominal trauma patient, and to examine
the recent literature regarding traumatic bowel
injuries and disposition after emergency department (ED) evaluation for abdominal trauma.
PHYSICAL EXAM FINDINGS IN THE
EVALUATION OF ABDOMINAL TRAUMA
Although physical exam findings of abdominal tenderness are an integral part of the decision making
in the evaluation of pediatric abdominal trauma, the
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importance of abdominal wall bruising associated
with a seat belt in the setting of a MVC varies among
studies. The ‘seat belt sign’ consists of a well-defined
area of ecchymosis, erythema or abrasions that
occurs on the abdomen of a restrained occupant
involved in a MVC. It may be seen in children
wearing an improperly fitted seat belt that crosses
the abdomen instead of the pelvis. In addition to
abdominal wall bruising, the ‘seat belt syndrome’
also includes vertebral Chance fractures resulting
from the flexion–distraction injury of the spine at
the fixed fulcrum site of the lap belt, and abdominal
injuries from compression of intra-abdominal
organs between the seat belt and the bony vertebral
column [4]. A porcine animal model of seat belt
related
injuries
demonstrated
that
direct
Division of Emergency Medicine, Children’s Hospital, Boston, Harvard
Medical School, Boston, Massachusetts, USA
Correspondence to Lois K. Lee, MD, MPH, Division of Emergency
Medicine, Children’s Hospital, Boston, 300 Longwood Ave, Boston,
MA 02115, USA. Tel: +1 617 355 5089; fax: +1 617 730 0335;
e-mail: [email protected]
Curr Opin Pediatr 2012, 24:314–318
DOI:10.1097/MOP.0b013e328352de97
Volume 24 Number 3 June 2012
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Blunt abdominal trauma in children Schonfeld and Lee
KEY POINTS
Screening laboratory values have not been well
established for the evaluation of pediatric intraabdominal injuries (IAI) after trauma; however, in the
evaluation of child abuse, screening with transaminases
is recommended to identify children at risk for occult
abdominal injury for definitive testing.
The Focused Assessment with Sonography for Trauma
exam has modest sensitivity for the identification of
hemoperitoneum or IAI in children with blunt abdominal
trauma, but may be useful in conjunction with physical
examination and laboratory results.
Children with a normal abdominal computed
tomography and normal physical exam findings after
blunt abdominal trauma may not require
routine hospitalization.
compression of the specific organ under the seat belt
was the mechanism causing the injuries, because the
solid organ injuries were only generated with belt
loading in the upper abdomen, whereas hollow
viscus organ and bladder injuries were associated
with lower abdomen belt loading [5].
A retrospective study of 331 children involved in
MVCs, 54 of whom had abdominal wall bruising,
determined that this finding had a sensitivity of
25% for identifying IAI and a specificity of 85%.
Even after addition of the presence of abdominal
tenderness, the relative risk of an abdominal injury
identified on computed tomography (CT) scan or
during surgery was not significant [relative risk (RR)
1.6, 95% confidence interval (CI) 0.546–4.68] [6].
In another retrospective study of children with
abdominal bruising after a MVC, a multivariate
logistic regression analysis determined that predictors for intestinal injuries included abdominal bruising when combined with a pulse rate of more than
120 per minute, presence of free intra-abdominal
fluid on ultrasound or CT, and an associated lumbar
fracture. The authors concluded that an abdominal
exploration should be considered for these patients
[4].
LABORATORY EVALUATION IN
ABDOMINAL TRAUMA
Laboratory studies are one potential adjunct in the
evaluation of children with abdominal trauma. Various cutoff values for liver transaminases to assess for
liver injury have been proposed to aid in the
decision making for CT evaluation after abdominal
trauma. A retrospective study of aspartate aminotransferase (AST) and alanine aminotransferase
(ALT) levels in the setting of blunt abdominal
trauma found a correlation between AST/ALT levels
and severity of liver injury; however, even among
patients with no discernable liver injury on CT, half
had elevated AST/ALT levels. Therefore, the authors
concluded cutoff values for AST/ALT under which
liver injury could be excluded could not be determined, as it is likely that elevated AST/ALT levels
may be due to moderate hepatic cytolysis in the
setting of trauma, even though a specific injury
may not be visualized on CT scan [7]. In contrast,
a study comparing 51 children with liver injury
with 65 children with other, nonliver, abdominal
injuries used the receiver operating characteristic
curve to determine that an ALT value of 104 IU/l
could identify the presence of liver injury with an
area under the curve of 0.945 (95% CI, 0.905–0985).
When using this level to identify clinically significant (grades III, IV, V) liver injuries the sensitivity
was 100% (95% CI 89–100%), specificity 70% (95%
CI 59–79%), positive predictive value (PPV) 57%,
and negative predictive value (NPV) 100% [8].
Given the varying methodologies and outcome
definitions for these studies analyzing the use of
laboratory values to screen for abdominal solid
organ injuries, the use of laboratory tests may be
most valuable when combined with other physical
exam and diagnostic test results, rather than in
isolation.
An exception to this may be the use of screening
transaminases in the evaluation of suspected nonaccidental trauma [9]. In a prospective study using
hepatic enzymes in the assessment of children with
potential physical abuse, an AST or ALT more than
80 IU/l had a sensitivity of 77% (95% CI 65–87%)
and a specificity of 82% (95% CI 80–84%) for
abdominal injury even in children with no abdominal bruising, tenderness, or distention. As a result
the authors recommended abdominal imaging at a
threshold level of 80 IU/l, as, in the evaluation of a
potentially abused child, the identification of occult
abdominal injuries may provide important forensic
information [10].
ABDOMINAL ULTRASOUND/FOCUSED
ASSESSMENT WITH SONOGRAPHY FOR
TRAUMA EVALUATION
Another tool in the evaluation of the pediatric
trauma patient is the Focused Assessment With
Sonography for Trauma (FAST), a rapid and noninvasive bedside ultrasound examination used for
the evaluation of blunt abdominal trauma. The
focus of this sonographic technique is to evaluate
the right upper quadrant, left upper quadrant, pelvis
and pericardial windows for free peritoneal fluid, as
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Emergency and critical care medicine
evidence of hemorrhage or other abnormal fluids
(e.g., bile, urine) [11]. The American College of
Surgeons in the Advanced Trauma Life Support
(ATLS), eighth edition, recognizes FAST as an
adjunct diagnostic option for the evaluation of
abdominal trauma in pediatric patients [12], but
the optimal use of FAST in pediatric trauma remains
controversial, with great variability in its use
[13–15].
FAST aims to detect free intraperitoneal fluid
(presumed to be blood in the setting of trauma),
but more than one-third of low-grade pediatric liver
or spleen injuries are not associated with free fluid
[2]. A meta-analysis to determine the test performance of FAST had a sensitivity of 66% (95% CI 56–
75%) for identifying children with hemoperitoneum, but the sensitivity decreased to 50% (95%
CI 41–59%) for identifying IAI, regardless of the
presence of hemoperitoneum [16]. A prospective
observational study of 357 pediatric patients
with blunt abdominal trauma determined that for
clinically important free fluid, defined as moderate
or greater amount of intraperitoneal free fluid on CT
or injury requiring surgery, FAST had a sensitivity of
52% (95% CI 31–73%), specificity 96% (95% CI
93–98%), PPV 48% (95% CI 28–69%), and NPV of
97% (95% CI 94–98%) [17 ].
In an effort to increase its utility as a screening
tool to detect solid organ injuries, the use of FAST
combined with other factors has been studied. The
combination of FAST with elevated liver transaminases (ALT or AST > 100 IU/l) was found in one
study to improve sensitivity (88%) and NPV (96%)
for free intraperitoneal fluid or IAI in pediatric
patients with blunt abdominal trauma [18]. The
Blunt Abdominal Trauma in Children (BATiC) score
combined the results of abdominal Doppler ultrasound with three physical exam findings and six
laboratory values to identify children with IAI without CT imaging. Each element in the score was
assigned a value, and a score of 7 or less had a
sensitivity of 91%, specificity 84%, PPV 64%, and
NPV 97% for the detection of intra-abdominal organ
injury [19]. To improve the ability of ultrasound to
identify solid organ injuries in children, contrast
enhanced ultrasound (CEUS), which uses intravenous contrast, has been shown to accurately
visualize intra-abdominal parenchymal injury
[20]. There is preliminary evidence which suggests
that CEUS may be more accurate than regular ultrasound in the detection of solid organ injuries in
children [21].
A positive FAST exam in the pediatric trauma
patient suggests hemoperitoneum from abdominal
injury, and, therefore, requires further evaluation to
delineate the specific nature and extent of IAI. If the
&&
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FAST exam is negative for free fluid; however, given
its modest sensitivity for the detection of intraperitoneal free fluid, it should not be used as the
sole diagnostic test to rule out the presence of IAI in
the hemodynamically stable patient. The FAST
exam may play a specific role in surgical decision
making in a subset of patients [22], including the
hemodynamically unstable child, in whom sonographic free fluid should prompt rapid blood transfusion and/or emergent laparotomy without further
imaging.
COMPUTED TOMOGRAPHY EVALUATION
Abdominal CT remains the diagnostic test of choice
for the evaluation of IAI. The CT diagnosis of
abdominal injury also guides nonoperative decisions such as duration of hospitalization, intensity
of care, length of activity restriction, and follow up
[3,23]. CT imaging, however, results in substantial
exposure to ionizing radiation, which may significantly increase a child’s lifetime risk of lethal malignancy [24,25,26 ]. Unfortunately, children who are
initially evaluated with abdominal CTs at community hospitals frequently undergo repeat CT
scans after transfer to pediatric trauma centers, further increasing their exposure to ionizing radiation
[27 ,28].
Given these radiation risks, there are ongoing
attempts to help clinicians risk stratify patients
for IAI with clinical prediction rules [19,29]. In
2009 Holmes et al. [29] prospectively validated
their previously derived clinical prediction rule for
the identification of children at very low risk for
IAI after blunt torso trauma. This rule included
six ‘high-risk’ variables, and the presence of any
of the variables indicated that the child was
not at low risk: low age-adjusted systolic blood
pressure, abdominal tenderness, femur fracture,
increased liver enzyme levels (serum AST
> 200 IU/l or ALT > 125 IU/l), microscopic hematuria (urinalysis > 5 red blood cells/high power field),
or initial hematocrit less than 30%. This rule had a
sensitivity of 95% (95% CI 90–98%) and specificity
of 37% (95% CI 34–40%). It ‘missed’ eight IAI,
none of whom required acute intervention. The
Pediatric Emergency Care Applied Research
Network (PECARN) recently conducted a multicenter prospective observational study of pediatric
blunt abdominal trauma to derive and validate a
clinical decision rule to identify children at low
risk for IAI who may not require CT evaluation.
The results of this study should result in a more
accurate and reliable decision rule and will hopefully limit the use of CT imaging to children with a
nonnegligible risk for IAI after trauma.
&
&
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Blunt abdominal trauma in children Schonfeld and Lee
BOWEL INJURY AND FREE
INTRAPERITONEAL FLUID ON COMPUTED
TOMOGRAPHY
Although CT is highly sensitive for the detection of
solid organ injury, it is not as accurate in the identification of hollow viscus injury. Blunt bowel injury
is much less common than solid organ injury after
trauma, occurring in fewer than 10% of children
with blunt abdominal trauma, and both the clinical
and CT diagnosis of a perforated bowel injury can be
challenging [2]. CT findings in the setting of bowel
injury can include peritoneal fluid without solid
organ injury, bowel wall enhancement and thickening, extraluminal gas, bowel wall discontinuity, and
mesenteric stranding [2,30]. To determine the
clinical significance of isolated ‘free intraperitoneal
fluid’ (free fluid without any solid parenchymal
injury or pelvic fracture), Christiano et al. [31] retrospectively analyzed 94 pediatric trauma patients
hospitalized with isolated free intraperitoneal fluid
on abdominal CT, and only three patients were
taken to surgery after developing peritonitis. The
only statistically significant predictors for abdominal surgery were the presence of abdominal tenderness on initial physical exam and the quantity of
free intraperitoneal fluid on initial CT. The authors
concluded that an initial nonoperative approach to
children with isolated intraperitoneal fluid on CT
with serial abdominal exams is justified.
The risk of expectant management, however, is
that delayed surgical intervention may lead to
adverse consequences. In a multi-institutional retrospective study of 214 patients diagnosed with
bowel injury after trauma, there were no statistically
significant differences in the early and late complications or total hospital length of stay based on the
time interval from injury to intervention (<6, 6–12,
12–24, and >24 h). The authors concluded that,
although operative management should be expeditiously pursued once a diagnosis of bowel injury is
established, in those children with unclear findings,
especially with other injuries (e.g., traumatic brain
injuries), observation and serial examinations may
be an appropriate alternative to emergency exploratory laparotomy or repeated CT scans [32].
DISPOSITION
For hemodynamically stable children with traumatic liver and spleen injuries, nonoperative management has increasingly become the standard of
care over the last few decades and is associated with
decreased morbidity and mortality [33,34]. Despite
the existence of several clinical practice guidelines
for pediatric solid organ injury management, there
are still varying degrees of familiarity with, and the
reported use of, these guidelines among adult general surgeons compared with their pediatric counterparts [35,36]. Strategies to ensure the widespread
adoption of spleen-conserving management are
needed to optimize management of the hemodynamically stable pediatric patient with blunt
abdominal trauma.
For children without an identifiable IAI after
blunt abdominal trauma, the disposition from the
ED is less clear. The current practice in many trauma
centers is to admit pediatric abdominal trauma
patients for serial abdominal exams and laboratory
measurements despite a normal ED abdominal CT,
because of the possibility of missed or delayed IAI. A
prospective observational study of 1085 children
less than 18 years old with abdominal CT imaging
after blunt abdominal trauma reported that 737
(68%) with normal ED abdominal CTs were admitted to the hospital. Only two of these children were
subsequently diagnosed with IAI, neither of whom
required acute intervention [37]. A review of three
prospective observational studies (including the
study discussed above) with a collective sample size
of 2596 patients determined that the NPV of
abdominal CT for diagnosing IAI was 99.8% (95%
CI 99.3–100%) with the primary outcome of prevalence of IAI after a negative CT. Overall, there were
five patients (0.19%) who required either a laparotomy or repeat abdominal CT after an initially negative abdominal CT, only one of whom required a
surgical intervention to repair a bowel injury
beyond 24 h of presentation. These studies suggest
that routine hospital admission for serial abdominal
exams and laboratory measurements after a normal
abdominal CT scan and a normal physical exam
may not be necessary [38 ].
&&
CONCLUSION
Abdominal trauma continues to be a substantial
cause of morbidity and mortality in children. CT
imaging remains the gold standard for the diagnosis
of IAI, but should be used judiciously due to the risk
of radiation-induced malignancy. The FAST exam
should not be used as the sole screening tool to rule
out IAI, but may be used in conjunction with
physical exam findings and laboratory results. The
majority of children with a normal ED abdominal
CT and normal physical exam may be discharged
home with close follow up.
Acknowledgements
L.K.L. receives funding support
Human Services Department of
Services Administration (HRSA,
through the Pediatric Emergency
Network (PECARN).
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from the Health and
Health Resources and
1H34MC193530100)
Care Applied Research
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Emergency and critical care medicine
Conflicts of interest
There are no conflicts of interest.
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This article is a literature review of children with blunt abdominal trauma
requiring an abdominal CT. It determined the prevalence of IAI after an initially
negative CT.
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