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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 1090-1093

An epidemiological study of abdominal blunt trauma in pediatric population


1 Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Pediatric Surgery, SN Medical College, Jaipur, Rajasthan, India

Date of Submission12-Apr-2018
Date of Acceptance01-Jun-2018
Date of Web Publication17-Oct-2019

Correspondence Address:
Aditya P Singh
Near The Mali Hostel, Main Bali Road, Falna, Pali, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_157_18

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  Abstract 

Background
The management of abdominal blunt trauma in children has changed considerably. Nonoperative treatment is successful in more than 85% of the appropriately selected cases.
Aim
To evaluate the incidence of various modes of abdominal blunt trauma and the effectiveness of conservative treatment.
Patients and methods
A retrospective study of 101 cases of abdominal blunt trauma in children admitted to hospital in a 5-year period has been carried out. Of 101 patients, 67 patients had organ injury. Laparotomy was done in 14 patients based on clinical findings and investigations, and 90 patients were managed conservatively.
Results
The nonoperative management in abdominal blunt trauma was successful in more than 85% patients.
Conclusion
Nonoperative management is associated with lower morbidity and less hospital stay in paediatric patients with abdominal blunt trauma.

Keywords: abdominal blunt trauma, conservatively, laparotomy, liver injury, nonoperative management, splenic injury


How to cite this article:
Garg D, Singh AP, Mathur V, Barolia DK. An epidemiological study of abdominal blunt trauma in pediatric population. Menoufia Med J 2019;32:1090-3

How to cite this URL:
Garg D, Singh AP, Mathur V, Barolia DK. An epidemiological study of abdominal blunt trauma in pediatric population. Menoufia Med J [serial online] 2019 [cited 2019 Nov 12];32:1090-3. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/1090/268810




  Introduction Top


Trauma is a common cause of morbidity and mortality in children. Motor vehicle accidents are responsible for most blunt abdominal injuries, with slightly more occupant injuries (41%) than pedestrian injuries (33%). Falls make up the next highest group (8%) followed by bicycle injuries (7%) [1].

Mechanisms causing abdominal injuries are predominantly motor vehicle accidents, falls, and intentional injuries [2],[3]. Blunt trauma in the abdomen can produce solid organ injury, mainly to the spleen, liver, and kidneys. Early diagnosis of the nature and extent of abdominal injuries is important to reduce the mortality and morbidity secondary to these lesions.


  Patients and Methods Top


This retrospective study was conducted at a pediatric surgery center. All children (under 12 year of age) with abdominal blunt trauma owing to motor vehicle and motorcycle accidents, falls, automobile versus pedestrian, and bicycle injuries in 5 years were included. The clinical and imaging data of 101 patients admitted from 2011 to 2015 were reviewed retrospectively. Patients with only head injury were excluded from study.

All the cases of abdominal trauma were reviewed, and data were collected on age, sex, mechanism of trauma, imaging finding, associated injuries, management, and outcome. All patients had been evaluated clinically and had radiographs of the chest and ultrasound of the abdomen. Pulse and blood pressures were recorded. Abdominal findings were also recorded. All patients were managed in emergency department initially and after managing shifted to pediatric surgery ward. All the patients were admitted and investigated. Moreover, patients were resuscitated as per protocol [Figure 1] and [Figure 2].
Figure 1: Transaction at the duodeno-jejunal junction.

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Figure 2: Computed tomography image showing pancreatic laceration.

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  Results Top


Patients were divided into three age groups [Table 1].
Table 1: Age group

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Most patients were in age group of 5–8 years, the youngest was 1 year old, and the eldest one was 12 years old. Their mean age was 6.29 ± 3.17 (years). The mean age for male patients was 6.28 ± 3.19 years and for female patients was 6.34 ± 3.17 years, with P value of 0.93 (insignificant). Male to female ratio was 3 : 1. Most patients were injured owing to motor vehicle accident [Table 2]. Of 101 patients, 67 (66.3%) were admitted on the same day of injury, whereas 34 (33.6%) were admitted after 1 day or more after injury. Overall, 25 (24.7%) patients had associated injuries, 14 (13.8%) patients had chest injury, five (4.9%) patients had associated bony injury, three patients had head injury, two had perineal injury, and one had neck injury. Moreover, 20 patients had abrasions on the body after trauma. Pain in the abdomen was the predominant presenting symptom in 80 (79.2%) patients, whereas 10 (9.9%) patients were admitted with abdomen distension.
Table 2: Mode of injury

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Patient is considered unstable if blood pressure was low at the time of admission. Tachycardia was present in 90 cases. A total of 13 cases were unstable at the time of presentation. Of 13 patients, four patients were diagnosed as case of perforation of bowel, two patients had liver and splenic laceration, one had splenic and pancreatic laceration, three patients had liver injury, one had renal injury, one had bladder hematoma, and one had splenic laceration.

Of 101 patients, 67 had organ injury [Table 3]. The most common organ injured was liver. Moreover, five patients had multiple organ injury. Of these five patients, two had liver and spleen injury; one had spleen, renal, and pancreatic injury; one had spleen and pancreatic; and one had spleen and renal injury.
Table 3: Organ injury

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[Table 4] Abdominal ultrasound was done in all patients except when diagnosis of perforation was made on the basis of radiograph of the abdomen (four patients). In 32 patients, ultrasonography (USG) finding of the abdomen was normal, and in 54 patients, USG detected organ injury or hemoperitoneum. In 11 patients, USG abdomen was inconclusive.
Table 4: Comparison of ultrasonography

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Cases in which USG finding was reported normal or inconclusive but patient had clinical sign and symptom or had abnormal lab (laboratory) test reports, contrast-enhanced computed tomography (CT) of the abdomen was done (28 patients). Overall, 16 patients had same finding on USG and CT (computerized tomography) abdomen, but four patients had minimal free fluid in peritoneal cavity as USG finding but pancreatic injury on CT and two patients had no organ injury in USG but had liver injury in CT. Moreover, two patients diagnosed to have multiple organ injury on CT scan: one case of bowel perforation detected by CT scan and one case of renal injury missed by USG and diagnosed by CT. In addition, two patients had hemoperitoneum on USG but normal on CT scan result.

Of 101 patients, 67 patients had organ injury: 23 had liver injury, 11 patients had splenic injury, 11 patients had bowel injury, six patients had pancreatic injury, seven patients had renal injury, three had muscular hematoma, five patients had multiple organ injury, and one had bladder injury.

Management of patients

Overall, 90 patients were managed conservatively [Table 5]. This included regular pulse rate and blood pressure monitoring and clinical assessment. Blood investigations were done in all patients. Intercostal drainage was inserted in 11 patients for pneumothorax or hemothorax, and three patients had suturing of lacerated wound associated with trauma.
Table 5: Management of patients

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Laparotomy was done in 14 patients, with 11 patients operated for bowel injury and one each for liver, splenic trauma with hemoperitoneum, and bladder injury. In one hemodynamically unstable patient, drain was placed in ICU. One patient had abdominal wall injury with omental prolapse and underwent emergency laparotomy.

One patient died in ICU. Most common complication was fever. Of 90 patients managed conservatively, 23 (26.43%) patients developed fever, one (1.14%) patient developed gastrointestinal bleeding and one (1.14%) mortality. Three patients after conservative management transfer to orthopaedic department for further management. One patient having liver injury developed gastrointestinal bleeding during the course of hospital and was referred to higher center for hepatic artery embolization. The hospital stay was less in nonoperated cases as compared with operated cases. There was only one mortality in this study.


  Discussion Top


Blunt trauma in the abdomen is a common cause of morbidity and mortality in children. Treatment of blunt trauma in the abdomen has evolved significantly in last 25 years. Before the advent of CT and focused assessment with sonography for trauma, diagnostic peritoneal lavage (DPL) was the modality of choice for the assessment of the injured abdomen [6]. In current management algorithms, its use is significantly diminished. DPL may still be indicated when CT is unavailable or when a hemodynamically unstable child has suspected bleeding from an intra-abdominal injury [7]. Positive DPL is a indication for laparotomy.

Currently, nonoperative management of isolated blunt hepatic and splenic injuries is considered the standard of care for haemodynamically stable children. Laparotomy is indicated in cases of peritonitis or failure of conservative treatment.

In this study, most patients were male (74%), which is comparable to Ramesh (60%) [5]. Most patients were from the age group 5–8 years (41%). The most common mode of injury was vehicular accidents (47%) which is comparable to the studies by Chirdan et al. [8] and Ramesh [5]. Most of the patients presented on the same day of injury (66%). Other injuries associated with abdominal trauma can modify treatment result. The incidence of associated injury was 24.7%. Most common injury associated was chest injury (56%) which was comparable with study by Chirdan et al. [8].

All patients were initially evaluated clinically and radiologically. Radiographs play a key role in the diagnosis of pneumoperitoneum and chest injury. It is clear that emergency screening ultrasound is now a nationally accepted tool for the rapid assessment of the emergency patient bedside [9]. Ultrasound is considered the modality of choice in the initial evaluation of patients with blunt abdominal trauma as it is readily available, requires minimal preparation time, is not invasive, and may be performed with mobile equipment that allows greater flexibility in patient position [10]. USG is very sensitive in detecting free fluid. Presence of free fluid raises the suspicion of organ injury. USG is very sensitive to detect hemoperitoneum but poor in detecting organ injury.

USG can miss organ injury, especially pancreatic injury. In our study, four cases of pancreatic injury were missed by USG. CT scan is the investigation of choice to evaluate abdominal trauma [11]. It is safe and non invasive. The only contraindication is haemodynamically unstable cases. CT scan in our study detected 10 organ injuries missed by USG.

The most common organ of injury in this study is the liver (34.5%), whereas the most common organ involved was spleen in the study by Amulya (27%) [9]. Overall, 89.1% of the patients were managed conservatively. Except two patients, all were discharged uneventfully. Ramesh managed 76% patients conservatively. In addition, 14% of the patients were operated compare with 20% by Ramesh. Laparotomy was done in cases of peritonitis or when patient's condition deteriorated on conservative management. In one case, liver suturing was done and in one case splenectomy was done. There was one mortality in our study, and the primary cause of death was septicaemia.


  Conclusion Top


Nonoperative management of blunt trauma is successful in more than 85% cases. It is associated with reduce morbidity and less hospital stay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 1994; 29:33–38.  Back to cited text no. 1
    
2.
Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg 2002; 37:453–456.  Back to cited text no. 2
    
3.
Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 2000; 35:164–167; [discussion 167-9].  Back to cited text no. 3
    
4.
Thourani VH, Pettitt BJ, Schmidt JA, Cooper WA, Rozycki GS. Validation of surgeon performed emergency abdominal ultrasonography in pediatric trauma patients. J Pediatr Surg 1998; 33:322–328  Back to cited text no. 4
    
5.
Ramesh B. Hatti; study of blunt trauma abdomen in children. Sch J App Med Sci 2014; 2:332–335.  Back to cited text no. 5
    
6.
Krausz MM, Abbou B, Hershko DD, Mahajna A, Duek DS, Bishara B, et al. Laparoscopic diagnostic peritoneal lavage (L-DPL): a method for evaluation of penetrating abdominal stab wounds. World J Emerg Surg 2006; 1:3.  Back to cited text no. 6
    
7.
Willmann JK, Roos JE, Platz A, Pfammatter T, Hilfiker PR, Marincek B, et al. Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. Am J Roentgenol 2002; 179:437–444.  Back to cited text no. 7
    
8.
Chirdan LB, Uba AF, Yiltok SJ, Ramyil VM. Paediatric blunt abdominal trauma: challenges of management in a developing country. Eur J Pediatr Surg 2007; 17:90–95.  Back to cited text no. 8
    
9.
Sexana AK. Abdominal trauma. J Trauma 2006; 61:334–349.  Back to cited text no. 9
    
10.
Alwakil AM, Habib RM, Monem SA. Role of ultrasonography in blunt abdominal trauma. Menoufia Med J 2017; 30:876–879.  Back to cited text no. 10
    
11.
Clancy TV, Ragozzino MW, Ramshaw D, Churchil MP, Covington DL, Maxwell JG. Oral contrast is not necessary in the evaluation of blunt trauma abdomen by computed tomography. Am J Surg 1993; 166:680–685.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction
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