Major trauma to the liver is a serious cause of morbidity. Severe hemorrhage is more common in patients with liver injury than with other abdominal injuries because of its dual blood supply. Without significant vascular injury, hepatic injury presents and behaves clinically like a splenic injury. Nonoperative management is recommended but requires close clinical observation for signs of ongoing blood loss or hemodynamic instability. As with splenic injury, there is a grading system based on the pattern of injury.
The kidney is less frequently injured than the liver or spleen, and when injured is often associated with other injuries. A young child’s kidney is more vulnerable to trauma than an adult’s because of a more compliant rib cage and relatively immature abdominal muscle development. The diagnosis of renal injury is based on history and physical examination coupled with urinalysis showing blood and increased protein levels. An ultrasound or CT may also be useful. Low-grade renal injury is usually managed conservatively, with bed rest, catheter drainage, and monitoring for resolution of injury by ultrasound or CT. Surgery may be required for falling hemoglobin levels, refractory shock, or urinary obstruction caused by clots.
Injuries of the pancreas are less common in children than inadults but are seen in bicycle handlebar injuries, motor vehicle crashes, and nonaccidental trauma. The diagnosis is difficult unless there is obvious injury to overlying structures,such as the stomach or duodenum. Diffuse abdominal tenderness, pain, and vomiting may be accompanied by elevations of amylase and lipase but may not occur until severaldays after the injury. Hemodynamic instability secondaryto retroperitoneal hemorrhage may be the presenting sign.Nasogastric suction and parenteral nutrition are indicatedin the management of these patients. Nonoperative management is appropriate for contusions, but surgical interventionmay be required in patients with distal transection. Drainage of pseudocysts, in patients who develop them, may berequired if they are unresponsive to bowel rest and parenteralnutrition.
Injury to the intestine occurs less frequently than injury to solid intra-abdominal organs and varies with the amount of intestinal contents. A full bowel is likely to shear more easily than an empty bowel. Shearing occurs at points of fixation (the ligament of Treitz, the ileocecal valve, and the ascending and descending peritoneal reflections). Pneumoperitoneum should prompt surgical exploration. Serial physical examinations are useful when the clinical picture is uncertain.
Duodenal hematoma can occur in the absence of perforation. Duodenal hematomas result from blunt injury to the abdomen, and affected patients often present with persistent pain and bilious emesis. Most hematomas respond to nonoperative management with gastric decompression and parenteral nutrition.
Patients requiring hospitalization for multiple trauma are at risk for a variety of complications based on the type and severity of injury. Sepsis and multiple organ failure may occur in children with multiple trauma. Delays in enteral nutrition because of an ileus may further increase the risk of sepsis secondary to translocation of bacteria across the intestinal mucosa.
Renal failure secondary to myoglobinuria may be seen in children who sustain crushing or electrical injuries and burns. Deep venous thrombosis is less common in the pediatric population, but prophylaxis for children who will be immobilized because of injury is often provided.
Unintentional injury is the leading cause of death for children ages 1 to 18; however, many of these deaths occur in the field, immediately after the injury. Once admitted to the hospital, mortality rates are much lower. Morbidities are numerous and include hypoxic-ischemic brain injury, loss of limbs, and psychological dysfunction.
SEE CHAPTER 41.
Drowning, as defined by the World Congress on Drowning in 2002, is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning can further be categorized as fatal or nonfatal, but other terms such as near-drowning, secondary drowning, or dry drowning should be abandoned.