Blunt trauma to the abdomen can be sneaky and is not always obvious on exam. There are a number of mechanisms that draw a red flag: isolated high energy blows (like falling on a bicycle handle-bar), MVCs/seat belts injuries, and falls from >20 feet. ALWAYS CONSIDER CHILD ABUSE. Physical Exam: There are some exam findings that should draw immediate attention: Any signs of hemodynamic instability should be concerning. If there is no response to fluid, immediate laparotomy is indicated. Ecchymoses, significan abrasions, seat belt marks, abdominal distension, marked tenderness, rigidity, and/or masses; should catch your attention. Pain in the left shoulder, KEHR'S SIGN, results from blood causing irritation of the peritoneal cavity and is often associated with a ruptured spleen. Be careful about calling LUQ pain isolated "rib fracture." One study noted that lower rib fractures were associated with hepatic or splenic injury in 31% of hospitalized pediatric trauma patients.
Repeat exams, rah, rah, rah, repeat exams, re, re, re, repeat exams, R-R-R-Repeat exams....rrrrrrrreeeeepeeeeeeet exams; may be your best means of determining the severity of pediatric abdominal injury. Do them. Document them. (Unfortunately, however, one study noted that 40% of children with significant hemoperitoneum had no clinical signs.) Rosoff L, Cohen JL, Telfer N, Helpern M. Injuries of the spleen. Surg Clin North Am 1972;52:667– 85.
Lab: WBC, serum glucose, LFTs, UA, amylase, and lipase all have limited sensitivity and limited negative predictive value in assessing pediatric blunt abdominal trauma. In a study of the "trauma panel", No single test had acceptable sensitivity or negative predictive value to be helpful in screening such patients. Glucose and AST had the highest sensitivity (75 and 63 percent, respectively) and lipase had the highest positive predictive value (75 percent). The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Capraro AJ, Mooney D, Waltzman ML; Pediatr Emerg Care. 2006;22(7):480. Gross hematuria is certainly indicative of renal trauma, but interestingly, microscopichematuria was more indicative of splenic and hepatic injuries than renal injury. In summary, I wouldn't hang my hat on lab testing.
Imaging: Plain radiographs are nearly worthless for isolated abdominal injuries, unless you are concerned about child abuse and would like to perform a skeletal survey. Ultrasound, FAST exam, is very sensitive but not specific. A negative FAST does not alone have adequate sensitivity or specificity to exclude intraabdominal injury. CT scan is most sensitive and specific in diagnosing liver, spleen, and retroperitoneal injuries. Unfortunately, CT with IV contrast alone is less sensitive in detecting injuries of the pancreas, intestinal tract, bladder, and lumbar spine. In one series of 106 children and adults with gastrointestinal injuries, only 76 percent had findings on helical CT. Sadly, a negative abdominal CT cannot reliably exclude hollow viscus injury after blunt abdominal trauma and should be correlated with clinical and laboratory findings. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Holmes JF, Offerman SR, Chang CH, Randel BE, Hahn DD, Frankovsky MJ, Wisner DH; Ann Emerg Med. 2004;43(1):120.
Whenever you choose to CT a child, you should be ready to discuss the risks of radiation. A VERY RECENTLY PUBLISHED multicenter prospective observational study of 12,044 children with blunt torso trauma derived clinical features that predict a low risk of intraabdominal injury requiring intervention (laparotomy, embolization, blood transfusion.) The low risk features are as follows:
- Glasgow coma scale of >= 14
- No evidence of abdominal wall trauma or seat belt sign
- No abdominal tenderness
- No complaints of abdominal pain
- No thoracic wall trauma
- No decreased breath sounds
The absolute risk of intra-abdominal injury for the children who met all seven of these criteria was 0.1%. These criteria have not yet been validated, but could lead to far fewer abdominal CT scans in pediatric trauma patients. ROCK ON PECARN!!! Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison AM, Yen K, Atabaki S, Menaker J, Bonsu B, Quayle KS, Garcia M, Rogers A, Blumberg S, Lee L, Tunik M, Kooistra J, Kwok M, Cook LJ, Dean JM, Sokolove PE, Wisner DH, Ehrlich P, Cooper A, Dayan PS, Wootton-Gorges S, Kuppermann N, Pediatric Emergency Care Applied Research Network (PECARN); Ann Emerg Med. 2013.____________________________________________________________________________________
So this brings us to our Hockey Phenom. You hopefully identified KEHR's sign as an indicator of peritoneal irritation and commonly associated with splenic injury. I was also hinting at this with the history of "feeling lightheaded." I probably would have CT scanned this patient. He has a bruise on his abdomen, positve Kehr's sign, and there is was suggestion that he may be "hemodynamially altered" (episode of lightheadedness.) What was once an automatic splenectomy is now often managed with inhospital observation. My training would have led me to CT him...then likely admit to surgery, and depending on the grade of the splenic injury: surgery vs observation with serial abdominal exams. You would not be wrong to defer imaging, admit, and perform serial abdominal exams.
Regarding, younger patients with blunt trauma: you have to consider hollow viscous injuries, and these are not easy to diagnose. If you are concerned, if the history/mechanism is concerning; admit and give the abdomen some time to tell you whether or not something bad is going on.
The biggest THUG of all time (since no one else voted) is hands down Marty McSorely: http://bleacherreport.com/articles/897210-nhl-video-50-biggest-thugs-in-hockey-history
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