Fig. 1
Organ injury grading scale (Source of information in Table: Ernest E. Moore, MD, Thomas H. Cogbill, MD, Mark Malangoni, MD, Gregory J. Jurkovich, MD, and Howard R. Champion, MD. Scaling system for organ specific injuries. The American Association for the Surgery of Trauma. http://www.aast.org/library/traumatools/injuryscoringscales.aspx. Accessed 7 Dec 2013)
5.
Common patterns:
(a)
Seat belt trauma:
(i)
Seat belts must contact the body in the proper location. Children less than 6-years-old need a booster suit so that the lap belt crosses over the anterior superior ileac crests.
(ii)
When a lap belt is used without a shoulder strap, it can result in injury.
(iii)
In a head-on motor vehicle crash, if a child is using a lap belt only, the body is forcefully flexed at the waist.
(iv)
The lap belt crushes the viscera against the spine.
(v)
Organs at risk are colon, small bowel, mesentery, duodenum, pancreas, and aorta.
(vi)
Hyperflexion of the spine can result in a Chance fracture: transverse distraction fracture of the posterior portion of the vertebral body.
(b)
Handlebar injury:
(i)
In a bike crash, if the handlebars turn acutely, the child can receive a direct blow to the abdomen with the end of the handlebar.
(ii)
This can cause injury to pancreas, perforation of a hollow viscus, or traumatic hernia.
(c)
Waddell’s triad:
(i)
Constellation of injuries when a pedestrian is struck by a car.
(ii)
The components of the triad are femur fracture, splenic rupture, and subdural hematoma, but not all three injuries are always present.
(iii)
The bumper of the car strikes the left leg and causes a fracture of the femur or the tibia and fibula, depending on the height of the bumper relative to the child.
(iv)
When the child is thrown up on the hood of the vehicle, the spleen is ruptured.
(v)
When the vehicle brakes, the child is thrown to the ground, resulting in a subdural hematoma.
6.
Assessment:
(a)
Initial assessment follows Advanced Trauma Life Support assessment with stabilization of C-spine and evaluation of airway, breathing, and circulation.
(b)
Physical Examination: Abdomen is examined for ecchymosis, laceration, swelling, masses, and tenderness.
(c)
FAST:
(i)
Focused Abdominal Sonography for Trauma (FAST) is a rapid, noninvasive, and portable method to evaluate the abdomen.
(ii)
Sonographic windows examined are pericardium, Morrison’s pouch between liver and right kidney, space between spleen and left kidney, and the retrovesicular space in bladder.
(iii)
Right and left pleural spaces are evaluated for pneumothorax.
(iv)
The finding of free fluid in abdomen on FAST suggests solid organ injury and need for more diagnostic maneuvers.
(d)
Peritoneal lavage:
(i)
Used less frequency since FAST became available.
(ii)
Peritoneal cavity is entered via a small supraumbilical incision.
(iii)
Abdominal fluid is sampled for blood, amylase, or intestinal contents.
(iv)
Can diagnose injury to solid organ or perforated viscus.
(v)
Will not diagnose retroperitoneal injury with contained bleeding.
(e)
CT scan:
(i)
Requires ionizing radiation with risk of malignancy.
(ii)
Ensure that patient is hemodynamically stable before risking a trip to the scanner.
(iii)
Can diagnose and grade injury to solid organs.
(iv)
Able to diagnose free fluid and air from hollow viscus injury with 94 % sensitivity, but signs of perforation may require time to develop after injury.
(f)
MRI:
(i)
Used less frequently to evaluate trauma.
(ii)
Requires more time for images, and may require anesthetic for child to stay still.
(iii)
Can be used to evaluate for injury to the biliary tree through magnetic resonance cholangiopancreatography (MRCP).
(g)
ERCP:
(i)
Useful in evaluating pancreas injury.
(ii)
Endoscopic ultrasound can be performed at the same time.
(iii)
If a pancreatic duct injury is detected, as stent can be placed.
(h)
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Angiography:
(i)
Angiography with embolization offers an intermediate step for patients with hemorrhage from solid organ injury.
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