Yesterday, I wrote about using ultrasound in place of CT for initial diagnosis of blunt abdominal injury in children. Although it looks good for identification of solid organ injury and free fluid, it may miss injury to the intestine. Is that bad?
Lets look at a recent study that examined the consequences of delayed laparotomy for blunt intestinal injury. The American Pediatric Surgical Association conducted an 18-center study of the management of intestinal injuries in children less than 16 years of age. They were stratified by time to treatment. There were 214 patients with complete data records for review.
The majority of the patients were involved in a motor vehicle crash or a bicycle accident. Demographics were similar in all time to treatment groups. Half were resuscitated at a referring hospital and then transferred to a pediatric trauma center, on average after 6 hours.
- The only deaths occurred in the 0-6hr and 6-12hr groups. The average Injury Severity Score of the children who died was significantly higher than survivors.
- Children operated on in the 0-6hr group had significantly higher ISS as well.
- There was no difference in early or late complications across all groups.
- Time to beginning oral intake and time in hospital were the same in all groups.
The authors concluded that observation and serial exam rather than urgent exploration or repeated CT scans is appropriate.
Bottom line: If you combine this study with the ultrasound study I reviewed yesterday, it seems appropriate to modify the usual (read: adult) way of evaluating blunt trauma to the abdomen. In place of automatically getting a CT scan of the abdomen in children, obtain a complete abdominal ultrasound to detect solid organ injury or free fluid. This will determine the degree of monitoring needed (e.g. ICU for higher grade liver or spleen injuries). Follow this with serial abdominal exam. If the child becomes symptomatic, it’s probably time to proceed to the OR. Note: I generally do not make children npo during the observation phase. They need to eat, and if they don’t want to, that tells you something.
Related post: Sonography in pediatric abdominal trauma
Reference: Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric patient. J Pediatric Surg 45(1):161-166, 2010.