Pediatric emergency medicine trisk 3203 3203

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.