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and emergency medical personnel. Penetrating trauma is usually evident on
careful inspection of both the anterior and posterior torsi. In contrast, blunt
abdominal trauma must be suspected from both historical information and careful
physical examination. Children with severe multiple trauma are obviously at risk
for intra-abdominal injuries, but sufficient energy to injure may also be present in
apparently minor falls, direct blows to the abdomen from balls, bats, bicycle
handlebars, toys, and during contact sports or assault.

Clinical Considerations
Clinical Recognition
Life-threatening abdominal injuries may be occult or manifest in several ways:
the presence of shock, abdominal tenderness, ecchymoses or distention, or
external hemorrhage (e.g., from a penetrating injury). Historical information or
physical examination findings are often subtle or lacking. Children have the
capacity to maintain a normal blood pressure level in the face of significant blood
loss and hence major intra-abdominal bleeding may not be obvious. Sustained
tachycardia is often the first sign of significant hemorrhage. The examining
physician must always keep in mind that the abdomen is a large potential
reservoir for blood loss.
Triage Considerations
The American College of Surgeons suggests that triage of the trauma patient
should be based on severity of the mechanism of injury and physiologic status of
the patient. Clearly the patient with a mechanism associated with high velocity or
with abnormal vital signs must be immediately resuscitated and evaluated for
injuries. That said, even those patients with a lesser mechanism of injury and
stable vital signs should be evaluated with great vigilance.
Clinical Assessment
Physical examination. A traumatized child is often difficult to examine; pain
associated with extra-abdominal injuries may obscure abdominal findings. In
addition, the results of physical examination may be subtle or unreliable in an
unconscious, developmentally delayed or autistic, intoxicated, agitated, or fearful

child. Vital signs, including blood pressure and pulse, may be normal for age,
especially in children with isolated injuries of the liver and spleen. Physical
examination findings, such as external signs of injury, abdominal tenderness, and
presence of long bone fractures are helpful in determining which children require
more extensive evaluation.