|Year : 2023 | Volume
| Issue : 1 | Page : 48-53
Blunt abdominal trauma in children: A review of 105 cases
Salsabil Mohamed Sabounji, Doudou Gueye, Gabriel Ngom
Department of Paediatric Surgery, Albert Royer Children's Hospital, Dakar, Senegal
|Date of Submission||04-Aug-2021|
|Date of Decision||16-Jul-2022|
|Date of Acceptance||21-Aug-2022|
|Date of Web Publication||10-Jan-2023|
Salsabil Mohamed Sabounji
Department of Paediatric Surgery, Centre Hospitalier d'Enfants Albert Royer, Dakar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: The aim of the study is to identify the epidemiological, diagnostic, therapeutic, and evolutionary characteristics of patients admitted for blunt abdominal trauma (BAT) in a level 3 children's hospital.
Subjects and Methods: It was a retrospective and descriptive study on a series of 105 cases of BAT recorded over 8 years. The data were collected from patients' files. The analysis was done on Excel 2016. Several parameters were studied: frequency, age, sex, cause of trauma, circumstances, mechanism, mode of transportation, admission time, medical history, symptoms and signs, laboratory findings, radiological findings, injury assessment, associated injuries, type of treatment, and evolutionary modalities.
Results: The frequency was 13.1 cases/year. The mean age was 6.6 years. The sex ratio was 3.56. Road traffic accidents were the most frequent cause (54.3%). Abdominal tenderness (88.6%) was the most common physical sign. Associated lesions were found in 40% of cases. Abdominal sonography (85.7%) was the most common imaging tool followed by an abdominal computed tomography scan (34.4%). The liver was the most affected organ (24.7%) and contusion was the most frequent lesion (65.4%). The majority of patients had received nonoperative treatment (93.3%). The average length of hospitalization was 5.6 days. The outcome in all cases was favorable. No mortality was reported.
Conclusions: BAT in children is common in boys under the age of 10. They are caused by road accidents. Physical examination combined with abdominal ultrasound is very important in the therapeutic decision, which in most cases is a conservative one. Morbidity and mortality are almost nil.
Keywords: Blunt abdominal trauma, children, injury, nonoperative treatment, ultrasound
|How to cite this article:|
Sabounji SM, Gueye D, Ngom G. Blunt abdominal trauma in children: A review of 105 cases. J Indian Assoc Pediatr Surg 2023;28:48-53
|How to cite this URL:|
Sabounji SM, Gueye D, Ngom G. Blunt abdominal trauma in children: A review of 105 cases. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Feb 8];28:48-53. Available from: https://www.jiaps.com/text.asp?2023/28/1/48/367385
| Introduction|| |
Pediatric trauma accounts for approximately 14% of the overall trauma pathology. They are a major cause of death in children over 1 year of age., The abdomen is the third anatomical region affected in children, after the head and limbs, and accounts for approximately 25% of major trauma., Abdominal bruising (AB) or blunt abdominal trauma (BAT) represents approximately 80%–90% of abdominal trauma in children. Abdominal trauma is the most common cause of death due to undetected injuries. Nowadays, the progress made in resuscitation and imaging has allowed a revolution in their management with conservative nonoperative treatment in more than 95% of cases. Surgical treatment is restricted to well-defined situations of hemodynamic instability or rupture of a hollow organ or diaphragm. In the occident, abdominal contusions have been discussed in various publications in both adults and children. However, African literature remains quite limited on this subject, especially in children. Thus, the aim of this study is to identify the epidemiological, diagnostic, therapeutic, and evolutionary characteristics of patients admitted for BAT in a level 3 children's hospital in West Africa.
| Subjects and Methods|| |
It was a retrospective and descriptive study on a series of 105 patients admitted for BAT, recorded over 8 years from January 1, 2012, to December 31, 2019. Several parameters were studied: frequency, age, sex, cause of trauma, circumstances, mechanism, mode of transportation, admission time, medical history, symptoms and signs, laboratory findings, radiological findings, injury assessment, associated injuries, type of treatment, and evolutionary modalities. The data were collected from patients' files. The analysis was done on Excel 2016.
| Results|| |
In 8 years, 105 children were victims of BAT, representing a frequency of 13.1 cases/year and 2.99% of the admissions. Ages varied from 18 months to 15 years, with a mean of 6.6 years. Children between 5 and 10 years of age were the majority (46.6%). The sex ratio was 3.56. More than half of the patients were transferred (71.4%). Road traffic accidents (RTAs) were the most frequent cause (54.3%) [Figure 1]. The majority of patients did not benefit from emergency medical transportation (64.8%). Admission time was under 24 h in 78.1% of cases, with an average delay of 15.7 h. The majority of our patients did not have any significant history (91.4%). Abdominal pain was present in almost all cases (96.2%), only 27 patients presented vomiting (25.7%) and five patients had macroscopic hematuria (4.7%). On admission, altered consciousness was noted in one case, whereas the majority (98.1%) had a stable hemodynamic state. In eight patients, respiratory distress was noted (7.6%) in the context of an associated thoracic trauma and six patients presented a fever (5.7%).
Abdominal examination revealed: abdominal pain in 93 cases (88.6%), abdominal tenderness in 38 cases (36.2%), abdominal rigidity in six cases (5.7%), and distension in three cases (2.8%). Elsewhere, the examination revealed associated lesions (40%) [Table 1]. A biological assessment, namely, a blood count and a blood-Rhesus grouping, was performed on all our patients. Anemia was noted in 35 cases (33.3%), hyperleukocytosis in 32 cases (30.5%), and thrombocytopenia in five cases (4.8%). Elevated pancreatic enzymes were noted in three cases (2.8%).
A minimal radiological assessment was performed on all our patients. It consisted of an abdominal ultrasound in 90 cases (85.7%), an abdominal computed tomography (CT) scan in 36 cases (34.4%), and a full-body scan in nine cases (8.6%). Abdominal X-ray was performed in eight patients (7.6%). Ultrasound and/or CT scan allowed the following lesion assessment [Table 2].
Peritoneal effusions were found in 44.7% of cases. They were mostly of low abundance (49%) [Figure 2]. The liver was the most affected organ (n = 26/105) (24.7%) and contusion was the most frequent injury (n = 17/26) (65.4%) [Figure 3]. These injuries most often involved the right lobe (n = 21/26) (80.8%) and segment VII was the most represented (34.6%). The spleen came second (n = 14/105) (13.3%) with fracture as the most frequent lesion type (57.1%) [Figure 4]. The kidneys were affected in only six cases (5.7%) and finally the pancreas fracture in three cases (2.8%) [Figure 5] and [Figure 6]. In our study, 98 children (93.3%) benefited from nonoperative treatment with continuous clinical, radiological, and biological monitoring. Operative treatment was indicated in seven patients (6.7%) [Table 3]. The indication for surgery was decided either after the radiological assessment suggesting a visceral injury requiring surgery or was inconclusive, or in case of hemodynamic instability not responding to resuscitation measures. The postoperative follow-up in these patients was simple. The average length of hospitalization was 5.6 days with a range of 2 days and 26 days.
|Figure 4: Abdominal ultrasound showing a subcapsular hematoma of the spleen.|
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The outcome in all cases was favorable after a mean follow-up of 2.1 months.
One patient developed a pancreatic pseudocyst after 7 months. No mortality has been reported.
| Discussion|| |
AB or BAT accounts for about 80%–90% of abdominal trauma in children in the West. In Africa, no accurate epidemiological data have been identified and the exact frequency of BAT is not well documented. The average age varies between 7.1 and 9.5 years.,,, Most of these bruises occur in children with ages ranging from 5 to 9 years. The mean age of our series is below that of the literature but the most represented age range (between 5 and 10 years) is the same. Similar to the series reported in the literature, we noted a male prevalence., The restlessness and the great vivacity of boys could be the cause. In Africa as well as in the West, RTAs remain the first cause of intra-abdominal injuries in children.,, In developed countries, they are the leading cause of infant death. According to Naader, more than 50% of abdominal trauma (in adults and children) is due to RTAs. Spijkerman et al. found that RTAs were the first cause of injury in children over 12 years of age, followed by falls; the opposite was found in children under 12 years of age. In other studies, falls were the second most common cause of injury., The results of our series are consistent with those of the literature. Horse hoof strikes are not insignificant in our setting and remain absent in the international series that we have reviewed.
Physical examination is an important step in the evaluation of abdominal trauma. Abdominal tenderness is the first sign found in the literature with a prevalence that varies between 67% and 75%. It is followed by the defense (24%–39%) and contracture (16%–21%). Our results are similar to those in the literature., Physical examination and clinical judgment are of particular importance in cases of intestinal injury.,,
Although standard examinations still have a place in the emergency setting, it must be recognized that abdominal ultrasound and CT scans have considerably changed the facts of the problem: their availability in the emergency setting is now imperative in emergency centers. CT is the preferred imaging method in the evaluation of abdominal and pelvic injuries after blunt trauma in hemodynamically stable children.,, However, there are still concerns regarding radiation exposure and the risk of subsequent fatal malignancies. In addition, cost, need for contrast, and lack of portability are also considered limitations. Streck et al. retrospectively demonstrated that the use of a clinical prediction model based on six high-risk variables for intra-abdominal lesions for patients not limited to the abdominal examination can reduce the cost and radiation exposure of abdominal scans, potentially avoidable in children, without missing significant lesions. In our African setting, the limited access to this standard test, even in level 3 hospitals, is a real obstacle and contributes to a delay in management. Ultrasound remains the first-line diagnostic tool as it is less expensive, nonradiating, noninvasive, easier to perform, does not require any preparation or injection, and can be performed at the patient's bedside at the same time as first aid.,,,, It is also the key examination in the follow-up of patients with abdominal trauma. It allows assessment of the evolution of parenchymal contusions, approximate quantification and assessment of the evolution of a hemoperitoneum, and monitoring of the cystic evolution of a pancreatic fracture. Nowadays, focused assessment with sonography for trauma (FAST) is used more frequently in pediatric trauma management. Thus, it is performed in developed countries by both radiologists and nonradiologists and can be an alternative solution in our resource-limited countries, especially in regions without emergency CT. Indeed, institutional teaching of ultrasound is recommended by the American College of Emergency Physicians and the American College of Surgeons. These two colleges advocate initial ultrasound teaching as part of the curriculum for residents in both specialties.,, Smith et al., in a review of surgeon training for ultrasound in trauma patients, proposed that 10 examinations on healthy patients and 25 examinations on trauma patients were sufficient to qualify an operator in FAST., For this reason, we believe that it is essential to train physicians and surgeons to perform an emergency ultrasound for abdominal trauma. As in several recent literature series, we will discuss the most affected organs and their management. While in our study and that of Basaran and Ozkan, the liver is the most frequent location of visceral injuries, most studies find that the spleen is much more affected than the liver.,,, However, the liver and the spleen remain the two most affected organs.
The spleen is the most frequently affected organ in BAT. It is the most vascularized organ in the body. In fact, approximately 350 L of blood circulates through it every day; therefore, its injury is a potentially fatal situation, exposing the patient to massive hemoperitoneum. In the majority of cases, conservative treatment is sufficient. This is the case in our study. Splenectomy is necessary in case of continuous bleeding and if blood transfusion requirements exceed 40 ml/kg.
The lesions are often asymptomatic and in 70% of cases, they can be treated nonoperatively. Over the past decade, mortality associated with liver and spleen lesions has significantly decreased. Conservative treatment of these lesions has become a standard with more than 96% of isolated lesions managed without surgery.,,,
The third most affected organ, the kidney, is less frequently affected than the liver and spleen.,, Renal ultrasound and CT are useful modalities for assessing the degree of renal injury. However, CT is preferred for the evaluation of hematuria in a trauma patient, as it allows for simultaneous assessment of bladder injury and associated injury to intraperitoneal structures. The most specific sign is abundant hematuria, which is not always related to the severity of the trauma. A contusion is the most frequent injury. Renal parenchymal trauma can be safely treated conservatively., Failure of nonsurgical management occurs in only about 3% of cases, mainly high-grade injuries., Surgical treatment is necessary in hemodynamically unstable patients, or when there is either complete destruction of the pyeloureteral junction or renal artery or vein injury with devascularization of the kidney.,
Pancreatic trauma occurs in 3%–12% of AB injuries. The injury is rarely isolated, but in 60% of cases, it is usually associated with injuries of the liver, spleen, or duodenum. This means that in patients with pancreatic injury, morbidity, and mortality are increased.,,
Trauma is a significant cause of morbidity and mortality worldwide. Pediatric trauma in both Low and Middle Income Countries (LMICS) and High Income Countries (HICS) is shifting toward nonoperative management. As related to the literature, management should be done in the intensive care unit. This allows good monitoring which is essential to prevent possible complications.
Nonoperative management is optimal for children because their blood vessels are smaller than those of adults, and there is a major vasoconstrictive response so visceral bleeding tends to be self-limiting despite the severity of the trauma.,,
For years, conservative nonoperative treatment has become the standard for the management of abdominal visceral injuries. This is currently based on the patient's stable hemodynamic state and no longer on the grade of the visceral injury in question.,,, The majority of our patients were hemodynamically stable on admission and during monitoring, which justifies the high rate of conservative treatment in our series (93.3%).
| Conclusions|| |
BAT in children is common in boys under 10 years of age. They are caused by RTA. Physical examination combined with imaging, especially ultrasound, is important in the therapeutic choice, which is conservative in most cases. Morbidity and mortality are practically nil.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]