Pediatric emergency medicine trisk 801

population (see Chapter 87 Child Abuse/Assault ). Major blunt abdominal trauma
resulting from physical abuse is uncommon but highly fatal in children; mortality
rates are as high as 50%. This high fatality rate is the result of the unfortunate but
typical delay with which parents or caregivers who abuse children seek treatment.


FIGURE 103.10 Plain radiograph of the lumbar spine of a 15-year-old boy lap belt only–
restrained passenger in a motor vehicle crash over an embankment. There is a transverse
Chance fracture of the vertebral body and posterior elements of L2. The lap belt complex in this


patient also included a small bowel contusion, pancreatic head contusion, a focal area of aortic
disruption (dissection) just inferior to the renal arteries, and a retroperitoneal hematoma.

FIGURE 103.11 Intraoperative photograph of a segment of small bowel of a 15-year-old boy
who was a lap and shoulder belt–restrained back seat passenger in a motor vehicle collision.
Initial examination revealed ecchymosis below the umbilicus and significant tenderness upon
palpation of the lower abdomen. Findings at laparotomy included near transaction of the
terminal ileum with devitalized tissue at the edges of the injury.

Children who are seriously injured because of physical abuse commonly have
more than one site of trauma; some of the injuries can be occult, and others may
have been inflicted at different times. Abdominal injuries are usually inflicted by
fists, feet, or small handheld objects and are rarely penetrating. The diagnosis of
blunt abdominal injury caused by battering is difficult to make unless a high
index of suspicion for child abuse is maintained. An important clue is often an
implausible historical account for the seriousness of the injury. As with
abdominal trauma caused by other mechanisms, physical examination findings
may not be obvious. Laboratory analyses and abdominal CT may be necessary to
confirm the diagnosis.
Severe injuries may present with obtundation and shock, abdominal distention,

and tenderness. Intra-abdominal injuries most commonly involve the liver and the
spleen, as well as the pancreas–duodenum–jejunum region. In all such cases in
which child battering is suspected, a child protection consultant should be
involved early.


Suggested Readings and Key References
Initial Evaluation and Management of Abdominal Trauma
Adelgais KM, Kuppermann N, Kooistra J, et al. Accuracy of the abdominal
examination for identifying children with blunt intra-abdominal injuries. J
Pediatr 2014;165:1230–1235.e5.
Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of
clinically important blunt abdominal injuries. Ann Emerg Med 2013;62:107–
116.e2.
Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr Opin Pediatr
2012;24:314–318.
Subcommittee on Advanced Trauma Life Support of the American College of
Surgeons Trauma Committee. Advanced Trauma Life Support for Doctors. 9th
ed. Chicago, IL: American College of Surgeons; 2013.
Management of Blunt Abdominal Trauma
Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and
treatment. J Trauma 2009;67(2 Suppl):S135–S139.
Iqbal CQ, St. Peter SD, Tsao K, et al. Operative vs non-operative management for
blunt pancreatic transection in children: multi-institutional outcomes. J Am
Coll Surg 2014;218:157–162.
Leeper CM, Yazer MH, Cladis FP, et al. Use of uncrossmatched cold-stored
whole blood in injured children with hemorrhagic shock. JAMA Pediatr
2018;172:491–492.
Marwan A, Harmon CM, Georgeson KE, et al. Use of laparoscopy in the
management of pediatric abdominal trauma. J Trauma 2010;69:761–764.

Wood JH, Partrick DA, Bruny JL, et al. Operative vs nonoperative management
of blunt pancreatic trauma in children. J Pediatr Surg 2010;45:401–406.
Management of Penetrating Abdominal Trauma
Adesanya AA, da Rocha-Afodu JT, Ekanem EE, et al. Factors affecting mortality
and morbidity in patients with abdominal gunshot wounds. Injury
2000;31:397–404.
Berardoni NE, Kopelman TR, O’Neill PJ, et al. Use of computed tomography in
the initial evaluation of anterior abdominal stab wounds. Am J Surg
2011;202:690–695.
Boleken ME, Cevik M, Yagiz B, et al. The characteristics and outcomes of
penetrating thoracic and abdominal trauma among children. Pediatr Surg Int
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