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Careful serial examinations are critically important in maintaining the index of
suspicion necessary to proceed with more sophisticated testing when appropriate.
Inspection should note abrasions, lacerations, ecchymoses, penetrating wounds
(including missile entry and exit sites), and telltale markings (e.g., seat belt and
handlebar marks, tire tracks). Attention should be paid to the anterior and
posterior abdomen and to both flanks, as well as to the lower thorax, when
considering abdominal injuries. Abdominal distention may be caused by
hemoperitoneum or peritonitis but most often results from gastric distention from
air swallowed by the crying child. Early gastric decompression may assist the
abdominal examination and prevent vomiting with aspiration of gastric contents.
The presence or absence of bowel sounds is generally not of much significance in
the initial evaluation, but prolonged ileus may be a sign of intra-abdominal
pathology. Tenderness upon palpation, percussion, or shaking may be caused by
abdominal wall contusion or may indicate intra-abdominal injuries. Pelvic
stability is evaluated by gently compressing and distracting the iliac wings.
Digital rectal examination should be performed; the presence of blood may
indicate perforation of the bowel. A boggy or high-riding prostate, blood at the
urethral meatus, or a distended bladder may be present with urethral disruption
and preclude bladder catheterization until a retrograde urethrogram has been
performed (see Chapter 108 Genitourinary Trauma ). Diminished or absent rectal
sphincter tone may indicate a spinal cord injury.
Laboratory assessment. Blood should be obtained and sent for immediate
baseline hemoglobin measurement and typing and crossmatching, not only in all
instances of multiple trauma but also if isolated intra-abdominal injury is
suspected.
Routine multipanel laboratory testing (the so-called “trauma panels”)
historically has been standard for patients with trauma, but more recent studies
have called into question this undifferentiated approach. Nonetheless, laboratory
studies that are commonly added include measurement of liver transaminases,
lipase, and urinalysis.
Many recent studies indicate that, in combination with the presence of physical

examination findings, abnormal laboratory findings contribute to the
identification of children with intra-abdominal injuries. Elevated serum liver
transaminase levels may be associated with intra-abdominal trauma, especially
hepatic injuries. Screening for intra-abdominal injuries by evaluating
transaminase levels is not universally accepted because sensitivity and specificity
vary widely in the literature, but some data suggest that elevated transaminase
levels (aspartate aminotransferase more than 200 U/L and alanine