Pediatric emergency medicine trisk 3180 3180

aminotransferase more than 125 U/L) correlate well with the presence of an intraabdominal injury. Using thresholds such as these may allow for more judicious
use of computerized tomographic (CT) scan of the abdomen for children with
blunt abdominal trauma.
Examination of the urine may also play a role in an increased suspicion for
intra-abdominal injury after blunt force trauma to the abdomen. Grossly bloody
urine indicates likely injury to the kidneys and has been shown to be associated
with nonrenal intra-abdominal injuries in pediatric patients with trauma. The
predictive capacity of microscopic hematuria is controversial. In one study,
microscopic examination of urine that revealed more than 50 red blood cells
(RBCs) per high-powered field (hpf) was 100% sensitive and 64% specific for the
presence of an intra-abdominal injury (see Chapter 108 Genitourinary Trauma ).
A more recent study suggests consideration of CT scan of the abdomen in the
context of a urinalysis demonstrating as few as five or more RBCs per hpf when
the history indicates a significant force has been applied to the abdomen. In
addition, clinicians must remember that major trauma may cause complete
disruption of a renal pedicle and the absence of hematuria.
Management
Basic principles of management. Airway management and cervical spine
stabilization are first priorities ( Fig. 103.1 ). Supplemental oxygen should be
administered to any child with significant injuries, regardless of whether obvious
signs of shock are present. Intravenous or intraosseous access should be obtained
while the primary survey is completed. Immediate life-threatening injuries should
be treated promptly. Hemorrhagic shock should be addressed with judicious
administration of isotonic crystalloid solution. A first intravenous administration
of a bolus of 20 mL/kg may be given rapidly, and, if the pulse and blood pressure
remain outside the physiologic range, administration of blood should be
considered. If the child has received more than a total of 40 cc/kg of crystalloid,
including fluids received prehospital, and remains hemodynamically unstable,
ongoing bleeding should be suspected and administration of blood strongly
considered. The initial blood product administered should be O-negative–packed
RBCs; there is no justification for waiting for type-specific blood products to treat

ongoing bleeding. The incidence of trauma-induced coagulopathy in severely
injured children is significant and associated with poor outcome. Data supports an
initial resuscitation strategy of 1:1:1 transfusion of red cells, plasma, and
platelets, followed by goal-directed resuscitation according to either real-time
viscoelastic testing (TEG or ROTEM) or traditional measure of coagulation