Buckle up: Abdominal trauma

Case presentation

A 4-year-old male arrives via air ambulance after being involved in an all-terrain vehicle (ATV) accident. The child was riding with his older sister (he was in the front, riding on his sister’s lap) when the ATV turned over at a high rate of speed, causing the vehicle to flip onto the child. The ATV was pushed over by his father and several other witnesses to the accident and emergency medical services were called. The child was complaining of severe abdominal pain and had a Glasgow Coma Scale score (GCS) of 12. The accident occurred 1 to 2 hours by car from the nearest pediatric trauma center, so the decision was made to transport the child by air.

On arrival, he is alert and crying but consoles and tells you he has “tummy pain.” His vital signs are significant for a heart rate of 114 beats per minute, respiratory rate of 22 breaths per minute, and blood pressure of 95/65 mm Hg. He has diffuse abdominal tenderness with guarding and there is mild bruising to the right upper quadrant. His liver function tests are elevated: AST (aspartate aminotransferase) of 1721 U/L and ALT (alanine transaminase) of 1083 U/L.

Imaging considerations

Imaging is routinely employed in the evaluation of blunt abdominal trauma and its use is fairly routine in adult trauma victims. The role of imaging during the evaluation of abdominal trauma in the pediatric population, however, is somewhat controversial. Indeed, not all pediatric patients who sustain abdominal trauma require imaging. Several clinical decision tools have been devised to assist the clinician in determining which patients might have an intraabdominal injury ^, and benefit from imaging and which patients can forego computed tomography (CT) imaging safely, employing historical, clinical examination, and laboratory findings to render an imaging decision. Such decision rules do appear to reduce imaging use (specifically CT), reduce cost of care, and potentially reduce the risk of future cancer cases. ^, An example of one such decision rule is given below, devised by Streck et al., which takes into account five variables in patients with blunt abdominal trauma:

• 1.

  AST >200 U/L.

• 2.

  Abdominal wall trauma, tenderness, or distention.

• 3.

  Abnormal chest x-ray.

• 4.

  Complaint of abdominal pain.

• 5.

  Abnormal pancreatic enzymes.

This study included almost 2200 children with a mean age of 8 years. Patients who were negative for all five variables had a 0.6% risk of intraabdominal injury and 0.0% risk of intraabdominal injury requiring intervention. Thus, this clinical prediction model had a negative predictive value of 99.4% for intraabdominal injury and 100.0% for intraabdominal injury requiring acute intervention in patients with none of the prediction rule variables present.