Management of pancreatic and duodenal injuries in pediatric patients

Diagnosis of duodenal and pancreatic injuries is frequently delayed, and optimal treatment is often controversial. Fourteen children with duodenal and/or pancreatic injuries secondary to blunt trauma were treated between 1980 and 1997. The pancreas was injured in all but 1 child. An associated duodenal injury was present in 4. The preoperative diagnosis was suspected in only 6 patients based on clinical signs and ultrasonography. One patient was treated successfully conservatively; all the others required surgical management. At operation, three procedures were used: peripancreatic drainage, suture of the gland or duodenum with drainage, and primary distal pancreatic resection without splenectomy. A duodenal resection with reconstruction by duodeno-duodenostomy was performed in 1 case. The overall complication rate was 14%: 1 fistula and 1 pseudocyst. Pancreatic ductal transection was recognized 3 days after the initial laparotomy by endoscopic retrograde cholangiopancreatography (ERCP). The mortality was 7%; 1 patient died from septic and neurologic complications. When the diagnosis of pancreatic ductal injuries is a major problem, ERCP may be a useful diagnostic procedure. Pancreatic injuries without a transected duct may often be treated conservatively. The surgical or conservative management of duodenal hematomas is still controversial; other duodenal injuries often need surgical treatment. Accepted: 26 April 1999     

Blunt renal injuries in Turkish children: a review of 205 cases

A retrospective analysis of the medical records of 205 children with renal injuries secondary to blunt abdominal trauma is used to make recommendations regarding the initial diagnostic and therapeutic approaches in this type of patient. It was found that the absence of hematuria on initial urinalysis does not exclude a serious renal injury. Thus, following blunt abdominal trauma, all children should undergo imaging procedures to exclude renal injury, whether they have hematuria or not. Ultrasound is a good initial screening procedure in all patients. Computed tomography is recommended for the definitive evaluation of suspected major renal injuries. Since even major renal injuries may heal without surgical intervention, conservative management is the recommended initial treatment of choice. Surgery is reserved for those children who are hemodynamically unstable and those that develop complications.     

Splenic injury in children: A 10 year experience

Abstract The aim of this report was to review retrospectively the management of splenic trauma at a major Australian tertiary referral centre (Westmead Hospital) over a 10 year period. Forty-nine patients (0-15 years of age) with documented blunt splenic trauma were identified. The causes of splenic injury were road trauma (73%) and falls (27%). There were 22 minor injuries (Injury severity score [ISS] <16) and 27 severe injuries (ISS ≥16). All nine deaths were related to road trauma (mean ISS = 59). The investigation most commonly used was CT scanning (47%). Peritoneal lavage was performed in six patients (12%). Management involved non-operative care in 29 patients (57%), exploratory laparotomy alone in 5 (10%), splenic salvage in 2 (4%) and splenectomy in 13 (26%). This experience supports the view that non-operative management of splenic injury in haemodynamically stable children is safe and is the preferred treatment. Experienced assessment and meticulous observation is necessary. Laparotomy is indicated if there is continuing haemodynamic instability despite resuscitation. Operative management is aimed at splenic salvage with splenectomy being reserved for uncontrolled haemorrhage.     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

Penetrating injuries in children: Is there a message?

OBJECTIVES: To determine the frequency, management and outcome of penetrating trauma in children. METHODS: A retrospective review of penetrating injuries in children under 16 years of age admitted to the Children's Hospital at Westmead (CHW), and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry, from January 1988 to December 2000. Patient details, circumstances of trauma, injuries identified, management and outcome were recorded. RESULTS: Thirty-four children were admitted to the CHW with penetrating injuries during the 13-year period. This represented 0.2% of all trauma admissions, but 3% of those children with major trauma. The injury typically involved a male, school-age child that fell onto a sharp object or was assaulted with a knife or firearm by a parent or person known to them. Twenty-five children (75%) required operative intervention for their injuries and 14 survivors (42%) suffered long-term morbidity. Thirty children were reported to the NPTD Registry over the same interval, accounting for 2.3% of all trauma deaths in New South Wales. Of these, a significant minority was injured by falls from a mower or a tractor towing a machine with blades. CONCLUSIONS: Penetrating injuries are uncommon, but cause serious injury in children. There are two clear groups: (i) those dead at the scene or moribund on arrival, in whom prevention must be the main aim; and (ii) those with stable vital signs. Penetrating wounds should be explored in the operating theatre to exclude major injury. Young children should not ride on mowers or tractors.     

Polytrauma in children

Polytrauma in children is rare, yet trauma is a leading cause of death in children. Clinicians with responsibility for the management of children suffering major trauma must recognise the conflict between these facts. Simulation and preparation can help to improve the quality of care at both individual and institutional levels. Children are not small adults, and their anatomic and physiological differences manifest themselves in different responses to major trauma than those seen in adults. This reality should be met with a tailored approach to assessment, investigation and management that accommodates the changes occurring from infancy, through childhood and adolescence to adulthood. This approach minimizes the risk of harm from inappropriate irradiation or intervention. Children have remarkable resilience and can make dramatic recoveries from seemingly irrecoverable situations. The appropriate treatment of musculoskeletal injuries should therefore not be compromised in the setting of polytrauma, and attention must be given to the optimal time for treatment. Damage control resuscitation and early appropriate care facilitate an individualised response. Outcomes for paediatric polytrauma are improved by management in a specialist centre, with early aggressive management of injuries that require surgical treatment by an experienced multidisciplinary team.     

Traumatic pelvic fractures in children and adolescents

Although traumatic pelvic fractures in children are relatively rare, these injuries are identified in about 5% of children admitted to level 1 trauma centers after blunt trauma.1, 2, 3, 4 Such injuries differ from adult pelvic fractures in important ways and require distinct strategies for management. While the associated mortality rate for children with pelvic fractures is much lower than that for adults, the patient may require urgent surgical intervention for associated life-threatening injuries such as head trauma and abdominal injury. Unstable pelvic ring fractures should be acutely managed using an initial approach similar to that used in adult orthopedic traumatology. Although very few pediatric pelvic fractures will ultimately need surgical treatment, patients with these injuries must be followed over time to confirm proper healing, ensure normal pelvic growth, and address any potential complications. The trauma team suspecting a pelvic fracture in a child must understand the implication of such a finding, identify fracture patterns that increase suspicion of associated injuries, and involve pediatric or adult orthopedic specialists as appropriate during the management of the patient.     

Pediatric thoracic trauma: Current trends

Pediatric thoracic trauma is relatively uncommon but results in disproportionately high levels of morbidity and mortality when compared with other traumatic injuries. These injuries are often more devastating due to differences in children׳s anatomy and physiology relative to adult patients. A high index of suspicion is of utmost importance at the time of presentation because many significant thoracic injuries will have no external signs of injury. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.     

Imaging evaluation of blunt renal trauma in children: Diagnostic accuracy of intravenous pyelography and ultrasonography

Forty-six consecutive children with blunt renal injury were evaluated retrospectively to assess the diagnostic accuracy of the different imaging methods, including ultrasonography (US), intravenous pyelography (IVP), and computed tomography (CT), and to determine the optimal radiologic management. Doppler ultrasonography was never performed in an emergency. Classification of the 46 renal injuries was as follows: 25 contusions, 4 lacerations, 11 ruptures, and 6 pedicle injuries. The diagnostic accuracy of IVP (80.8%) was superior to the diagnostic accuracy of US (41%) in all types of renal injuries. IVP should be performed as an emergency procedure when macroscopic hematuria is present, or when an isolated renal injury is clinically suspected. Microscopic hematuria alone is no longer an indication to perform IVP. Asymptomatic patients with microscopic hematuria should have US examination and should be observed with performance of serial urine analyses. Multiply injured and hemodynamically stable children should be evaluated by contrast-enhanced CT. Hemodynamically unstable children should undergo immediate exploratory laparotomy, if it is indicated after assessment by imaging.     

Anorectal injuries in children

 Anorectal injuries (ARI) are uncommon in children in civil practice. In developed countries the injuries are mainly due to sexual abuse and firearms. This report reviews the experience in tropical Africa. A retrospective study of children aged 12 years or less managed for ARI over 10 years was undertaken. There were seven children, four girls and three boys. Four injuries were due to blunt trauma and three to penetrating trauma. Six patients presented within 6 h of injury and one after 24 h. Five had rectal bleeding, which was associated with vaginal bleeding in one girl. One girl each had vaginal bleeding and vaginal discharge without rectal bleeding. Diagnosis was by rectal examination and proctoscopy. In three patients a laparotomy was necessary to exclude an intraperitoneal rectal injury (IRI); this was positive in one case. One patient with abdominal findings had a laparotomy as the primary procedure. Overall, five patients had rectal injuries (extraperitoneal 3, intraperitoneal 2), which were associated with an anal injury in three while one patient had only an anal injury. An IRI was missed at initial assessment in one girl. Associated injuries were to the vaginal wall (3), urethra (1) and head (1). IRIs were treated by repair and proximal colostomy. Extraperitoneal injuries were treated by colostomy and drainage; in two patients the injuries were accessible and were repaired. Anal and external-sphincter injuries were repaired in two cases. Vaginal lacerations were repaired and other associated injuries treated accordingly. Three patients had wound infections. Faecal continence was maintained in all patients who had anal and external-sphincter injuries. One girl died of peritonitis from a missed IRI. It is concluded that ARI remains uncommon in children. Morbidity and mortality can, however, be high. Meticulous rectal palpation and visualisation is necessary to avoid missing injuries. Accepted: 9 September 1999     

Management of blunt hepatic injury in children: usefulness of emergency transcatheter arterial embolization

We reviewed our experience to determine the usefulness of emergency transcatheter arterial embolization (TAE) for severe blunt hepatic injury (BHI) in children. Between 1978 and 2000, 21 children with BHI (14 boys and 7 girls, ranging in age from 2 to 14 years) were managed according to our protocol. The patients who were hemodynamically stable, and had no other associated injury requiring laparotomy, regardless of the hepatic injury grade, were managed nonsurgically. Emergency angiography and TAE performed after a CT scan revealed extravasation of the contrast medium. Of the 21 patients, 3 underwent emergency laparotomy; 2 due to hemodynamic instability despite fluid resuscitation (1 died), and the 3rd patient because of associated injury. The other 18 patients (86%) were initially managed nonsurgically; however, 2 underwent delayed laparotomy because of complications (1 each of suspected delayed hepatic hemorrhage and liver abscess). Nonsurgical management was completed in the remaining 16 (89%) with no morbidity and mortality. Two of the 16 returned to a hemodynamically stable condition with fluid resuscitation, but were compromised with persistent hepatic hemorrhage, and were successfully treated with emergency TAE. We propose that emergency TAE should be considered as an initial treatment for severe BHI in children.     

Blunt abdominal trauma in children: epidemiology, management, and management problems in a developing country

Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5–9 years. Falls were the cause of trauma in 36%, 60% of them aged 10–15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorhage, and a lacerated accesory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available. Accepted: 28 October 1999     

Pediatric Craniomaxillofacial Trauma

The management of fractures in the pediatric patient requires an understanding of craniofacial growth, anatomical differences of the pediatric craniofacial skeleton, and the special needs of the child and family. When possible, specialists trained in pediatric craniomaxillofacial trauma management should be consulted to help manage these complex injuries. For the emergency department physician, a familiarity with these injuries will allow for rapid triage, timely treatment, and favorable results.     

Paediatric post-injury management: A hospital-based review of deaths

In order to begin to evaluate the need for an integrated trauma management service for injured children, a retrospective review of deaths following admission to a suburban teaching hospital was conducted. The medical records and coroners' reports for 64 consecutive cases over 68 months were reviewed, looking for errors in care which may have contributed to fatal outcomes. There was a male predominance (64%). The main causes of death were pedestrian injuries (42%), drownings (20%), injuries to vehicular passengers (17%) and injuries to cyclists (13%). Errors, often multiple, occurred in 29 cases (45%). Errors most frequently involved airway control and ventilatory support (25%), volume replacement (19%) and delays in performing essential investigations (13%). Errors were most frequent at the referring hospitals (49% [17 of/35 referred cases], compared with 14% at the teaching hospital), and principally involved multiply injured victims of blunt trauma (81%, 13 of 16 patients). In only three cases (5%) would better management have salvaged the patient. This can be explained partly by the predominance of what were judged to be irretrievable intracranial injuries (90%) in patients suffering blunt injuries. In contrast, an analysis of the same patient group revealed that in 30-50% the fatality could have been prevented by the full application of well recognized safety strategies. While strategies such as triage and trauma teams should reduce the error rate, it is yet to be proven that optimal post-injury care will significantly reduce mortality.     

Nonoperative management of intra-abdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries

Nonoperative management of intra-abdominal bleeding (IAB) from blunt injuries in children has been advocated for many years. Nonoperatively managed patients, however, are at risk for missed associated intestinal injuries. To evaluate this question, we reviewed the charts of 120 children who had traumatic IAB; 106 were initially managed nonoperatively and observation failed in 2. Fourteen underwent emergency operation. Forty patients had isolated liver and/or splenic injuries while the others had injuries associated with several organs. During observation peritonitis developed in 3 patients and further radiologic examinations failed to confirm an intestinal injury. Diagnostic peritoneal lavage demonstrated contaminated blood and fecal particles from injured intestines in 3 patients; they underwent emergency operation at 10, and 26 h after admission. There was no mortality or morbidity associated with delayed treatment. These data suggest that the majority of patients with IAB may be successfully treated nonoperatively, but associated intestinal injuries should be suspected in all cases. Accepted: 16 May 1997     

Traumatic Emergencies Involving the Pediatric Airway

This article has outlined unique characteristics of the pediatric larynx that should be considered in the setting of neck trauma and has discussed how different types of external neck trauma (blunt vs penetrating) can result in a spectrum of injuries to the pediatric airway and important adjacent structures. For a child with an acutely injured, unstable airway, an orotracheal airway should, if possible, be established with either an endotracheal tube or rigid bronchoscope before any attempt to create a surgical airway. After airway stabilization, other priorities include consideration of cervical vascular and esophageal injuries. A predetermined, logical, stepwise approach by emergency department personnel toward the management of both the stable and unstable injured pediatric airway is recommended in an attempt to reduce morbidity and mortality from this uncommon, but potentially devastating, type of injury.     

Concurrent paediatric seat belt injuries of the abdomen and spine

Between 1981 and 1989, 541 children were admitted with abdominal injuries sustained as passengers in motor vehicle accidents. Twenty-nine of them had seat belt injuries of the abdomen. From 1981 to 1984, 1 child was admitted each year with such injuries and 21% of the abdominal injuries were due to seat belts. The number of cases had increased to 8 in 1989 and 78% of abdominal injuries were due to seat belts. These changes coincided with increased compliance with seat belt legislation in the State of Victoria. Restraint of children under 8 years of age in the front seat was legislated in 1976 and in the rear seat in 1981. In 1985, drivers were also held responsible for the restraint of children 8–17 years of age. Most of the children with seat belt injuries of the abdomen used lap belts or poorly fitting lap/sash belts. Twenty of the children had other non-abdominal injuries including 11 head, 7 thoracic, and 12 limb injuries. Eight children had spinal injuries including 7 Chance flexion-distraction fractures of the spine and 1 spinal cord injury without radiological abnormality. Chance fractures were only detected in one-half of the children on admission and in only 1 of the 9 children who had a laparotomy. Seventy-five per cent of children with spinal injuries had a laparotomy; 67% of those with abdominal injuries had spinal injuries, while only 7% of those not undergoing laparotomy had spinal injuries. These findings indicate that all children with seat belt injuries of the abdomen need careful clinical and radiographic assessment of the thoracolumbar spine. Prevention of seat belt injuries of the abdomen and spine requires legislation that ensures that all children use effective restraints that are appropriate for their age, size, and position within the vehicle. Correspondence to: W. G. Cole     

Nerve injuries due to obstetric trauma

The incidence of nerve injuries among 32637 deliveries over a period of ten years was 1.81/1000. Brachial plexus injury (1/1000) and facial nerve injury (0.74/1000) accounted for 98% of nerve injuries. Both the right and left side were involved equally. Bilateral nerve injury was not seen. Lack of antenatal care, macrosomia, abnormal presentations, and operative vaginal deliveries significantly increased the risk of nerve injuries. These babies had significantly higher incidence of meconium stained liquor and intrapartum asphyxia. Parity of the mother, gestational age and sex of the baby did not have significant role in the causation of nerve injuries. Injuries to brachial plexus and facial nerve were seen even in babies born by caesarean section, when it was performed for obstructed labour caused by cephalo-pelvic disproportion and abnormal presentations. Three babies with injuries expired and forty-three could be followed up for varying periods. None of the babies had residual defects. Detection of cephalopelvic disproportion and abnormal lie in the third trimester and their appropriate management would decrease the incidence of obstetric palsies to a significant extent.     

Current management of liver and splenic blunt trauma in children

Thirty-nine children with blunt liver and/or splenic injury were treated in our department from 1979 to 1987; 23 had a splenic injury, 10 a hepatic injury, and the remaining 6 had both. The diagnosis was suggested by the history and physical examination and was confirmed by CT and radioisotope scanning. Every hemodynamically stable patient was initially managed non-operatively. The children who failed to respond to conservative treatment and had unstable vital signs indicating intractable hemorrhage were eventually operated upon. Every effort was made to preserve the liver and spleen during the operation. Liver repair, splenorraphy alone or in combination with splenic artery ligation, and autotransplantation of splenic tissue were widely used procedures. Sixteen patients were successfully managed nonoperatively, but the remaining 23 required surgery. Only 5 children became completely asplenic and no liver lobe resection was performed. It is suggested that conservative management of children with liver and/or splenic injury is both safe and effective. When surgical intervention is inevitable great effort should be made to preserve liver and spleen.Presented at the XII International Congress of Greek Association of Paediatric Surgeons in Rhodes, 1987 Offprint requests to: G. Tryfonas     

Paediatric blunt abdominal trauma: challenges of management in a developing country.

BACKGROUND: In developed countries, the availability of advanced imaging techniques has reduced the necessity for laparotomy following blunt abdominal trauma in children. Laparotomy rates still remain high in developing countries where these advanced imaging techniques are lacking. A simple management protocol to identify patients who require laparotomy could reduce the laparotomy rate in children with blunt abdominal trauma in these countries. PATIENTS/METHODS: This is a review of children aged 15 years or below managed in our institution over a 5 1/2-year period for blunt abdominal trauma. The children were divided into two groups. Group A consisted of children managed from January 1999 - December 2000. During this period, there was no protocol. Group B consisted of children managed from January 2001 - June 2004. During this period, a simple management protocol was introduced. The laparotomy rates in the two groups were analysed using a simple chi-square. RESULTS: A total of 48 children, representing 63 % of children with abdominal trauma during the study period, were examined (Group A 17; Group B 31). Their ages ranged from 1.5 years - 15 years (median 9 years). Thirty-four were boys, 14 were girls (M:F = 2.4:1). Road traffic accidents accounted for 38 (79.1 %) and falls from heights for 9 cases (18.75 %), and one boy with a hydronephrotic kidney fell off the staircase at home. The diagnosis was clinical, supported by abdominal ultrasound scan (USS) and plain abdominal film. Twenty-eight (58.3 %) children had laparotomy (15 in Group A; 13 in Group B). There was a statistically significant difference in the laparotomy rates between Group A and B (p < 0.01). Nineteen children were managed nonoperatively (2 in Group A; 17 in Group B); one child died before an operation could be performed. There were 59 abdominal organ injuries in 45 children. In 2 children, ultrasound could not diagnose any organ injury. There were 33 splenic injuries; 15 children had splenic conservation, 7 underwent a splenectomy, while 10 were managed nonoperatively. One child with splenic injury died before operation. Of 7 liver injuries, 4 required suturing of lacerations, 1 subcapsular haematoma was left undisturbed at laparotomy, while 2 were managed nonoperatively. There were 4 pancreatic injuries. Three were managed nonoperatively, while 1 associated with duodenal injury had a laparotomy. All 6 gastrointestinal injuries had laparotomy. There were 5 renal injuries: 3 had laparotomy with suturing, while 2 were managed nonoperatively. There were 4 bladder injuries: 2 had laparotomy with suprapubic catheter insertion, while 2 were managed nonoperatively. There were 7 retroperitoneal haematomas in association with other organ injuries. Associated injuries included head injury in 2, long bone fracture in 2, spinal injury and chest trauma in 1 each. There were 4 deaths, 1 before surgery could be performed. CONCLUSION: Blunt abdominal trauma in children resulted mainly from road traffic accidents. The use of a simple protocol supported by ultrasound scan could reduce the laparotomy rate in countries with limited facilities.