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presence of a hematoma, and the findings will dictate the next steps with regard
to evaluation of the abdomen. If hemodynamic instability or the need for
immediate craniotomy exists and does not allow for CT evaluation of the
abdomen ( Fig. 103.2 ), a focused abdominal sonography for trauma (FAST
examination) should be performed either in the ED or in the operating suite. In
the presence of a positive FAST examination, laparotomy or laparoscopy and
craniotomy proceed simultaneously. Finally, if neither thoracotomy nor
craniotomy is indicated, emergent laparotomy or laparoscopy is performed when
pneumoperitoneum is noted on a plain radiograph or when the patient remains
hemodynamically unstable in the face of historical or physical evidence of
abdominal trauma. With massive hemorrhage, fresh frozen plasma and platelets
should be administered along with packed RBCs.
Initial management of the stable patient. Commonly, the injured child can be
stabilized in the ED with proper airway and cervical spine management, and with
intravenous fluid therapy and blood transfusion. A careful secondary survey
should then be performed. On the basis of history and careful, serial abdominal
examinations, CT is indicated when intra-abdominal injuries are suspected (
Table 103.1 ). An abdominal CT scan may be merited based solely on severe
force inherent in a particular mechanism of injury, despite an unremarkable
physical examination or the absence of abnormal screening laboratory values.
FAST examination and laboratory studies may help guide the decision making
regarding abdominal CT scan.
Additional management. Children with abdominal trauma often need
decompression of the stomach; this procedure facilitates examination, may
provide information concerning gastric or diaphragmatic injury (bloody aspirate,
radiographic evidence of the nasogastric tube in the thoracic cavity), and relieves
the discomfort of an ileus. Major maxillofacial trauma precludes nasogastric tube
placement, but an orogastric tube suffices in these instances. Urinary bladder
catheterization may provide evidence of genitourinary system injury and is
helpful in monitoring urinary output. Bladder catheterization is contraindicated
when urethral disruption is suspected on the basis of the findings described

previously.