Advanced Trauma Life Support ATLS Student Course Manual 2018

ABDOMINAL TRAUMA 201
surgical support and where transfer of injured children
is planned are justified in forgoing the CT evaluation
before transport to definitive care.
Injured children who require CT scanning as an
adjunctive study often require sedation to prevent
movement during the scanning process. Thus, a
clinician skilled in pediatric airway management and
pediatric vascular access should accompany an injured
child requiring resuscitation or sedation who undergoes
CT scan. CT scanning is not without risk. Fatal cancers
are predicted to occur in as many as 1 in 1000 patients
who undergo CT as children. Thus, the need for accurate
diagnosis of internal injury must be balanced against
the risk of late malignancy. Every effort should be made
to avoid CT scanning before transfer to a definitive
trauma center, or to avoid repeat CT upon arrival at a
trauma center, unless deemed absolutely necessary.
When CT evaluation is necessary, radiation must be
kept As Low As Reasonably Achievable (ALARA).
To achieve the lowest doses possible, perform CT
scans only when medically necessary, scan only
when the results will change management, scan
only the area of interest, and use the lowest radiation
dose possible.
Focused Assessment Sonography in Trauma
Although FAST has been used as a tool for the evaluation
abdominal injuries in children since the 1990s, the
efficacy of this modality has been the subject of debate
resulting from reports of relatively low sensitivity and
high false negative rates. However, FAST is widely used
as an extension of the abdominal examination in injured
children; it offers the advantage that imaging may be
repeated throughout resuscitation and avoids ionizing
radiation. Some investigators have shown that FAST
identifies even small amounts of intra-abdominal blood
in pediatric trauma patients, a finding that is unlikely to
be associated with significant injury. If large amounts
of intra-abdominal blood are found, significant injury
is more likely to be present. However, even in these
patients, operative management is indicated not by the
amount of intraperitoneal blood, but by hemodynamic
abnormality and its response to treatment. FAST is
incapable of identifying isolated intraparenchymal
injuries, which account for up to one-third of solid
organ injuries in children. Clinically significant intraabdominal
injuries may also be present in the absence
of any free intraperitoneal fluid. In summary, FAST
should not be relied upon as the sole diagnostic test
to rule out the presence of intra-abdominal injury.
If a small amount of intra-abdominal fluid is found
and the child is hemodynamically normal, obtain a
CT scan.
Diagnostic Peritoneal Lavage
Diagnostic peritoneal lavage (DPL) may be used to
detect intra-abdominal bleeding in children who have
hemodynamic abnormalities and cannot be safely
transported to the CT scanner, and when CT and FAST
are not readily available and the presence of blood
will lead to immediate operative intervention. This is
an uncommon occurrence, as most pediatric patients
have self-limited intra-abdominal injuries with no
hemodynamic abnormalities. Therefore, blood found
by DPL would not mandate operative exploration in a
child who is otherwise stable.
Use 10 ml/kg warmed crystalloid solution for the
lavage. The delicacy of the child's abdominal wall can
lead to uncontrolled penetration of the peritoneal
cavity and produce iatrogenic injury, even when an
open technique is used. DPL has utility in diagnosing
injuries to intra-abdominal viscera only; retroperitoneal
organs cannot be evaluated reliably by this technique.
Evaluation of the effluent from the DPL is the same in
children as it is in adults.
Only the surgeon who will ultimately treat the child
should perform the DPL, since this procedure can
interfere with subsequent abdominal examinations
and imaging upon which the decision to operate may
be partially based.
Nonoperative Management
Selective, nonoperative management of solid organ
injuries in children who are hemodynamically normal
is performed in most trauma centers, especially
those with pediatric capabilities. The presence of
intraperitoneal blood on CT or FAST, the grade of
injury, and/or the presence of a vascular blush does
not necessarily mandate a laparotomy. Bleeding from
an injured spleen, liver, or kidney generally is selflimited.
Therefore, a CT or FAST that is positive for
blood alone does not mandate a laparotomy in children
who are hemodynamically normal or stabilize rapidly
with fluid resuscitation. If the child’s hemodynamic
condition cannot be normalized and the diagnostic
procedure performed is positive for blood, perform a
prompt laparotomy to control hemorrhage.
For nonoperative management, children must
be treated in a facility with pediatric intensive care
capabilities and under the supervision of a qualified
surgeon. In resource-limited environments, consider
operatively treating abdominal solid organ injuries.
Angioembolization of solid organ injuries in children
is a treatment option, but it should be performed only
in centers with experience in pediatric interventional
procedures and ready access to an operating room. The
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