A 7-year-old boy is a restrained backseat passenger in a high-speed MVC. He presents with a GCS of 15 and complains of mild abdominal pain. He has no other injuries on primary or secondary survey. His initial FAST is negative. After appropriate fluid resuscitation, he is persistently tachycardic to the 140’s and has a seatbelt sign across the lower abdomen. He is tender along the seatbelt sign and in the lumbar region. A CT scan of the abdomen/pelvis shows moderate free fluid in the pelvis with a Hounsfield unit of 45. There is no evidence of solid organ injury. What is the best next step in management of this child?

 

 

[size=20px]A Discharge from the emergency room.

 

B Admit for observation.

 

C CT angiogram of the abdomen.

 

D Exploratory laparotomy/laparoscopy.

 

E Diagnostic peritoneal lavage.[/size]

Edited January 21, 20242 yr by Admin

D

D

the patient has an abdominal signs, with haemodynamic instability (tachycardic), with free intraabdominal fluids, so the next step in trauma patient is to explore dictated by the patient clinical condition. So I am going with D.

D

D

D

D - houndsfield 45 consistent with blood and tachycardia not responding to fluid resusitation in face of seat beat sign; dpl would miss retroperitoneal injury

B. Admit the patient. Get an upper GI contrast to rule out duodenal injury.

D

is the answer

B + Pain control, consider blood transfusion, observe & reassess..

E

D

C

B + pain management + Hemogram (+/- transfusion) then reevaluation

B

D

persistent tachy calls for exploration after optimization

B

D

D

correct answer

D Exploratory laparotomy/laparoscopy.

 

Blunt abdominal trauma is a relatively common source of traumatic injury in the pediatric patient. Most commonly, one sees injuries to the solid organs including the spleen, liver and kidney that may be treated nonoperatively based upon the grade of injury and clinical status of the patient. Injuries to the small intestine and mesentery are less commonly encountered but are treated operatively. These injuries may be missed on clinical exam due to the confounding findings of a seatbelt sign or other abdominal wall contusions. Additionally, patients may not present with peritonitis. CT scan has been shown to be effective in evaluating evidence of intestinal or mesenteric injuries with Graham and Wong commenting that it is a sensitive tool for the evaluation of intra-abdominal injury in children. Pneumoperitoneum, extraluminal oral contrast and evidence of mesenteric ischemia are clear signs of bowel or mesenteric injury. However, other findings may be more subtle and need to be recognized by the clinician on imaging. These findings include bowel wall thickening, mesenteric stranding, fluid at the mesenteric root, focal hematoma, and mesenteric pseudoaneurysm. Additionally, free fluid may be found in many trauma patients. A report in 2014 recommended that adult patients with blunt trauma who have moderate to large amounts of free fluid without solid organ injury on CT but have abdominal tenderness should undergo immediate operative exploration. They noted patients with neither of these findings may be observed.

 

Hounsfield units (HU) are a relative measure of radiodensity and can aid in the distinction of materials on CT, from soft tissue to blood to various fluids. For fluids, the density is largely dependent on the iron content of blood; therefore, plasma (iron-poor) will be hypodense and be associated with a much lower Hounsfield Unit than active bleeding. Uncoagulated blood typically measures 30 to 45 HU. Clotted (or concentrated) blood measures higher at 60 to 100 HU. Separated serum plasma is closer to water at 0 to 20 HU. Finally, ascites also has a Hounsfield measurement of around 0 to 20 HU. Recently, Perea et al. noted that pediatric patients with blunt trauma with isolated intraperitoneal free fluid with HU Units of 25 or less seen on CT and a non-peritonitic physical exam did not require operative exploration or further workup for intra-abdominal injury. Thus for patients with simple fluid as measured by Hounsfield units, observation with serial abdominal exams may be an appropriate option. The patient described has evidence of intra-abdominal bleeding with no obvious source and should undergo exploration for a possible bowel or mesenteric injury. This can be accomplished through laparoscopy or laparotomy.