William A. Mize M.D.

University of Minnesota Hospital and Clinic

• A leading cause of death in children
• Traffic accidents most common
• Bicycle accidents
• Assaults
• Common in older (>2 years) abused children

• Abdominal tenderness
• Abdominal distention
• Abrasions
• Contusions
• Gross hematuria
• Suspected bleeding
• High-risk mechanism (e.g. lapbelt injury)
• Unreliable neurological exam (?)

• Hematuria is a marker for injury
• Most frequently injured organs:
  Liver (33%)
  Spleen (37%)
  Kidneys (26%)
• Significant number with hematuria abnormal CT, normal kidneys

• Asymptomatic hematuria = normal scan
• Good indication for no imaging

• Trauma score (TS) - physiologic
• Injury severity score (ISS) - anatomic
• TRISS - combines above
• Pediatric trauma score (PTS)
• Abdominal injury score (AIS)

• Developed for triage
• Lower (worse) scores correlate with significant injury

• Patient size
• Airway
• CNS evaluation
• Systolic blood pressure
• Open wounds
• Skeletal injury

• Mechanism of injury
  
  MVA passenger
  MVA pedestrian
  Fall
  Bicycle accident
  Abuse/assault
  Lap belt
• Trauma score
• Abdominal signs
  
  Tenderness
  Distention
  Absent bowel sounds
• Pelvic fracture
• Chest trauma
• Gross hematuria
• Low hematocrit

• Continued unstable vital signs
• Transfusion of > 1/2 estimated blood volume
• Peritonitis
• Massive abdominal distention with hypovolemia

• Evidence of bowel injury
• Renovascular injury
• Bladder rupture
• Ureteral transection
• Pancreatic injury
• Contrast extravasation

• Length/intensity of monitoring
• Length of hospitalization
• Length of bedrest
• Length of avoidance of physical activity
• Followup interval

• Stable vital signs
• IV access
• Appropriate monitoring equipment/personnel
• Cooperation/sedation

• Computed tomography
• Ultrasound
• Plain film radiography
• Excretory urography
• Cystography

• Panoramic view
• Solid organ survey
• Bowel injury (findings often subtle)
• Can be done concurrently with brain/spine imaging
• Lung imaging
• Skeletal trauma, particularly pelvis

• Radiation
• Iodinated contrast
• Cost
• Availability
• Lack of portability

• Lapbelt spine injury - do lateral scout
• Early pancreatic injury

• Scout images
• IV contrast
• GI contrast (?)
• Coordination with extra-abdominal CT (head, spine)
• Clamp Foley

• Topogram
  Assess degree of bowel distention
  Distribution of GI contrast, if used
  Metal artifacts
  Do ''ateral''if suspect spine injury
• Pre- IV contrast sections
  Assess field of view
  Assess positioning

• Nonionic contrast safer, less likely to cause vomiting
• 2-3cc/kg, maximum 100-120cc
• If hand-injecting - inject fast, start scan at end of injection
• If power-injecting - 1.5-2cc/sec, 70 sec delay from initiation

• May help distinguish bowel from nonbowel (such as hematoma)
• Potential to show extravasation

• Trauma patients seldom NPO
• Diluted luminal contrast may blend with enhancing wall
• Increased distention may lead to vomiting
• Often not time for good distribution
• Extravasation is a rare finding

• Portability
• Cost (?)
• No radiation

• You find what you look for
• Bowel gas hampers visibility
• Operator dependent
• Ever-increasing variety of operators
• Bowel/mesenteric injury
• Pancreatic injury
• Time/portability only an advantage if no other CT to be done

• Portable
• Simple way to detect large amount of pneumoperitoneum
• Skeletal injury
• Bowel distention

• Little or no role in pediatric abdominal trauma
• Similar iodine and radiation dose to CT
• ShouldnÕt do CT following EU
• Can readily get ''one-shot'' EU following CT
• Most listed indications for EU are either indications for CT or indications for no imaging

• CT with clamped Foley, delayed images probably better
• Can instill contrast via foley during CT if necessary
• Seldom indicated as a separate exam

• Hepatic injury
• Splenic injury
• Pancreatic injury
• Renal injury
• Bladder injury
• Bowel injury
• Hypoperfusion complex

• Common site of injury
• Hematoma vs. laceration/fracture
• Small vs. large
• Superficial vs. deep
• Simple vs. complex
• Vascular injury (devascularized areas)

• Bile leak
• AV fistula
• Major vessel laceration
• Poor correlation between initial imaging findings and outcome

• Common site of injury in accidental trauma
• Uncommon site of injury in abuse
• Imaging findings same as with liver
• Variety of grading systems
• Great majority managed nonoperatively in children
• Poor correlation between imaging grade and need for laparotomy
• Decision for laparotomy is clinical
• More severe injuries take longer to heal by imaging

• Most common cause of pancreatitis in childhood
• Common site of injury in abuse
• CT findings often subtle or absent initially
• If suspected, ERCP may be indicated - duct transection
• Focal areas of decreased enhancement
• Peripancreatic fluid - nonspecific
• Delayed development of fluid collections related to pancreatitis

• Contusion
• Laceration (cortex only)
• Fracture (extends to collecting system)
• Shattered kidney
• Pedicle injury
• Urine leak - delayed images

• Intraperitoneal - repair
• Extraperitoneal - conservative treatment
• Delayed CT images/clamped Foley
• May do CT cystography

• One of the few indications for exploration
• Mesenteric injury may lead to delayed perforation from ischemia
• Increased incidence in lapbelt injury and abuse
• Findings are subtle
• Free air - usually absent, may be tiny amount if present
• Unexplained peritoneal fluid
• Bowel wall thickening/enhancement
• Soft tissue infiltration of mesentery

• Seen in patients presenting in shock who seem to respond to initial resuscitation
• Carries extremely poor prognosis - 85% mortality
• Associated with:
  Severe head and/or spine injury
  Concurrent intra-abdominal injury

• Marked diffuse bowel dilatation
• Intense contrast enhancement of:
  bowel wall
  mesentery
  kidneys
  IVC/aorta
• Small caliber IVC and aorta

• Intense enhancement of:
  pancreas
  adrenals
  superior mesenteric artery and vein
• Decreased enhancement of:
  spleen
  pancreas
• Peritoneal fluid
• Bowel wall thickening

• Significant association with other injury
• When present without solid organ injury, pelvic fracture, or hypoperfusion complex, must suspect bowel injury
• Amount correlates with need for operation and mortality

• Lapbelts designed to anchor the adult pelvis at the anterior superior iliac spine (ASIS)
• Children have:
  Underdeveloped ASIS
  ÒSlouchedÓ posture
  Higher center of gravity
• Injury results from flexion about fulcrum produced by belt and compression of abdominal contents between belt and spine
• Three point harness does not eliminate problem
• Characteristic abrasion
• Flexion injury of the lumbar spine
• High incidence of associated bowel/mesenteric injury
• Some surgeons will explore with Chance fracture alone

• Spine injury often subtle/invisible on CT images and AP scout
• May see soft tissue bleeding in dorsal subcutaneous tissue, muscles
• Lateral scout useful if mechanism suspected

• Common sites of injury
  Left lobe of liver
  Pancreas
  Duodenum
  Small bowel
• Uncommon sites of injury
  Spleen
  Kidneys
  Colon

• Initially developed to select patients for exploration
• Now many injuries with positive lavage managed nonoperatively
• Many solid organ injuries have no peritoneal fluid on CT - probably would have false negative DPL
• Little/no role in evaluation of children with abdominal trauma
• Will produce small amounts of free air and unexplained peritoneal fluid - CT findings of bowel injury

• Imaging useful for documenting presence and extent of injuries
• CT best single imaging modality
• Most injuries managed nonoperatively
• Information used for treatment planning and followup

• Free air
• Unexplained peritoneal fluid
• Bowel wall thickening
• Hypoperfusion complex
• Contrast extravasation

The views and opinions expressed in this page are strictly those of the page author.
The contents of this page have not been reviewed or approved by the University of Minnesota.