**3. Specific injuries**

#### **3.1 Liver**

It is usually associated with other abdominal or extra-abdominal injuries and is most commonly associated with spleen injuries. Since the posterior right lobe is fixed by the coronary ligaments, most injuries occur in this part.

Although liver injuries require aggressive resuscitation and close observation, they often require surgical intervention, which is done based on adult protocols. The greatest challenge in the management of liver injuries is their timely identification and the correct timing of aggressive resuscitation and laparotomy. Surgery should be considered in unstable patients, and it should be performed in experienced centers since liver injuries in the pediatric age group can be difficult to manage and have high morbidity and mortality.

Complications consisting of hemobilia, intrahepatic duct rupture and accompanying biliary fistula, bilemia, intrahepatic hematoma, vascular outflow obstruction, and gallstones can be seen in the early or late period. The prognosis is generally good if treated early.

The grading of liver injury performed by the American Association for the Surgery of Trauma (AAST) is given in **Table 1** [20].

Even if stability is ensured, the patient should be followed closely for late complications, especially bleeding that may occur in the late period, and CT imaging should be performed. Especially in patients with ongoing abdominal pain, care should be taken in terms of bleeding and long bed rest should be provided if necessary [8–11].

#### **3.2 Spleen**

Another organ frequently injured in blunt trauma is the spleen which is also seen quite frequently with other organ injuries. Because it is smaller than other organs, it may show varying degrees of fragmentation and may be associated with intraparenchymal or subcapsular hematoma. However, unlike hepatic injury, intraperitoneal bleeding may not always be seen. If there is no rupture in the splenic cilium, a retroperitoneal hematoma extending into the anterior pararenal space may be seen. Bed rest should be given to patients with splenic injury until the pain subsides. In clinically stable patients, it may not be necessary to repeat the ultrasound [9–11].

Bleeding seen in spleen injuries can often stop spontaneously without the need for surgery. Splapsule, the hemoperitoneum may not be seen. If there is an injury extending to the henic clefts can be confused with splenic tears and may be misdiagnosed after splenic injuries.


#### **Table 1.**

*Criteria for staging liver trauma based on the American Association for the Surgery of Trauma (AAST) liver injury scale.*


#### **Table 2.**

*Criteria for staging splenic trauma based on the AAST splenic injury scale.*

However, splenic clefts can be easily distinguished from tears by their smooth contours and the absence of hematoma or fluid around them [24].

The grading of spleen injury performed by the American Association for the Surgery of Trauma (AAST) is given in **Table 2** [20].

#### **3.3 Kidney**

Kidney injury, which is the third most common organ injury after blunt trauma in children, may be complicated by subcapsular or perinephric hematoma that can be distinguished by CT [32].

Renal parenchymal damage can be seen, as well as vascular and collecting system damage. The injured kidney appears larger than the other kidney on CT due to edema. Early diagnosis can be made easily by imaging with ultrasound, but patients may require contrast-enhanced CT. If there is ongoing bleeding despite resuscitation treatments, laparotomy may be required, which may result in nephrectomy [30–32].

Ongoing hematuria may be seen due to AV fistula. Patients with serious injuries should be followed up with repeat ultrasound and dimercaptosuccinic acid (DMSA) scanning [7–11].

#### **3.4 Pancreas**

While pancreatic injury alone is rare in children, it can usually be seen together with other organ injuries. If the pancreas is small and has little surrounding fat, it can mask signs of injury. Unexplained peripancreatic fluid seen on CT is the best indicator of pancreatic damage. Fluid collected in the anterior pararenal space may cause dissection between the pancreas and the splenic vein. At the same time, trauma can cause pancreatitis in children [20–25, 34].

It may cause peripancreatic fluid collection that transforms into a pancreatic pseudocyst or resolves spontaneously after pancreatic injury.

Initial serum amylase level does not correlate with the severity of the pancreatic injury.

There is no indication of emergency laparotomy in pancreatic injuries. Pain, nausea, and vomiting should be treated with a conservative approach, oral intake should be stopped until symptoms improve, and a CT scan should be performed in severe traumas [20–22].

#### **3.5 Intestine**

Intestinal injury, which is rare in children, is usually associated with mesenteric injury. It is mostly seen in cases where seat belts are not worn after traffic accidents [7–11].

Diagnosis is often difficult and delayed due to the late onset or absence of symptoms, and often a CT scan may be required. Free air on CT supports the diagnosis. If there is no significant free air in the radiographs, it may not be possible to diagnose perforation in blunt abdominal traumas. Initially, localized tenderness may worsen within 6–10 hours, and peritonitis or obstruction may develop during this time. In contrast to CT, it may be possible to diagnose enteric deterioration earlier with repeated physical examinations and serial examinations. If perforation is detected, laparotomy should be performed in the early period [20–22].

Chemical peritonitis due to perforations of the proximal gastrointestinal tract is painful and can be diagnosed early. However, since perforations occurring in the distal part of the intestine have a neutral pH and a lower bacterial load, they may be asymptomatic initially, while the onset of symptoms may be delayed, and the diagnosis due to abdominal peritonitis or sepsis may be delayed up to 24 hours, which causes a serious increase in mortality and morbidity [18–21].

Diagnosis of duodenum perforations is difficult as in other intestinal parts. The presence of extraluminal air and fluid and extravasation of oral contrast should lead to suspicion of perforation [19–22].

Intramural hematoma due to partial tear, most commonly seen in the duodenum; or rupture, most commonly located in the jejunum. Unexplained peritoneal fluid on CT is the most common finding after bowel rupture and may be the only finding [18–20].

In addition, thickening of the intestinal wall, mesentery damage, and chemical irritation may also occur. If there is intraperitoneal gas, an emergency laparotomy should be performed [20].

#### **3.6 Bowel**

Another organ that can be damaged in abdominal trauma is the intestines. In a possible trauma, all intestines should be evaluated from the esophagus to the rectum. Serious infections may occur due to contamination of the abdominal cavity in intestinal traumas. This is because large bowel traumas are detected later than small bowel injuries due to their retroperitoneal location. However, in pediatric patients, complete recovery can often be achieved with primary treatment without fecal contamination [26–30].

Perforations occurring in the rectosigmoid region may cause contamination of the abdominal cavity. Because of its retroperitoneal nature, colonic injuries often cannot be diagnosed early, resulting in fecal contamination. However, colonic injuries in pediatric patients can often be repaired with the primary repair without significant fecal contamination, except for diversions [28–30].

#### **3.7 Bladder**

Bladder injury, which is rare in children, can be intraperitoneal or extraperitoneal. It is accompanied by bruising in the suprapubic region. After a traffic accident, intraperitoneal injury is observed due to the compression of the seat belt on the full bladder, while extraperitoneal injury is observed due to pelvic fractures. Ultrasound can be helpful in diagnosis [18–20].

Although bladder rupture is very rare in the pediatric age group, it should be suspected in a patient with no urine output after blunt trauma, abdominal bloating, abdominal tenderness, and pain. As with other organ ruptures, a delayed diagnosis will increase morbidity and mortality. Extravasation of urine and blood into the peritoneal cavity due to bladder rupture may cause electrolyte imbalance, and uremia due to urine absorption [18–20].

Bladder injury can be diagnosed by demonstrating extravasation of IV contrast media on CT. At the same time, the location of the iv contrast agent on CT enables differentiation of intraperitoneal and extraperitoneal bladder rupture. Recognition of this is important in guiding treatment. Extraperitoneal injuries can be treated conservatively, whereas intraperitoneal injuries require immediate surgical repair [20–22, 25].

A suprapubic catheter may be required for bladder neck injuries [20].

#### **4. Trauma anesthesia in a pediatric patient**

Anesthetic management of a pediatric trauma patient has multiple issues to consider; management of the airway (may be traumatized or difficult), especially in the presence of a cervical spine injury, the possibility of full stomach (the stomach may be full of blood or secretions at least), the need for rapid sequence intubation, unstable or immediately decompensated hemodynamic status, particularly in the presence of traumatic brain injury (TBI), the possibility of significant hemorrhage and transfusion. Intraabdominal trauma occurs frequently (10%) and is the leading cause of initially unrecognized fatal injury and hemorrhage; the most injured organs, with the descending order, are the spleen, liver, renal, intestine then pancreas.

The mortality decreases with good prehospital care, appropriate triage, and effective resuscitation. Basic Advanced Trauma Life Support principles apply; initial stages of resuscitation, stabilization, and definitive management. Anesthetists should know

#### *Pediatric Abdominal Trauma DOI: http://dx.doi.org/10.5772/intechopen.108677*

the management of the trauma patient in the prehospital care and emergency department, to provide better intraoperative anesthetic management. A thorough yet quick history must be taken, regarding TBI, breathing, airway, intubation, manual in-line stabilization, and assessment of neurological and hemodynamic status. If the patient is not stabilized after two 20 ml/kg boluses of crystalloid, a transfusion of 10–20 ml/kg of packed red blood cells (PRBCs) should be prepared [8, 33]. After that, a secondary survey with diagnostic testing is completed. After all injuries are identified, definitive care and if necessary, surgical care should be decided.

The management of anesthetic induction should be performed regarding the child's injury, presence, or absence of TBI, hemodynamic stability, and the anesthetists' experience. Besides ASA standard monitorization, a functional intravenous line is essential. If not intubated before coming to the operating room, caution must be applied regarding difficult mask, airway, and full stomach (blood, mucus in the mouth, or previously aspirated or swallowed blood). If intubated, the location of the endotracheal tube should be verified.

If there is hemorrhage, damage control resuscitation will be planned and guided by both laboratory and clinical criteria, restrictive blood transfusion thresholds should be considered guiding allogenic blood transfusion. Damage control resuscitation is the strategy of treating massive hemorrhage with the transfusion of blood and blood components [35]. Crystalloid predominant resuscitation in the bleeding pediatric patient has negative influence on mortality and discouraged.

There is no consensus or universal protocols or definition of massive transfusion in pediatric patient. The dynamic definition of massive transfusion in children and neonates is suggested by Diab et al. [36] "transfusion of >50% of total body volume (TBV) in 3 hours, transfusion >100% TBV in 24 hours, or transfusion support to replace ongoing blood loss of >10% TBV per min". Other definitions, transfusion requirements of 40 ml/kg in 12 hours or 80 ml/kg within 24 hours [37].

Protocols involving early and liberal use of a fixed ratio of red blood cells:fresh frozen plasma (FFP):platelets have been used, with most suggesting 1:1:1, while occasionally 2:1:1 has also been described [35, 38]. Consideration must be given to the patient's volume, hemodynamic status, tissue oxygenation, hemorrhage control, coagulation abnormalities, large volume blood, and blood products administration problems like potassium, ionized calcium, acid–base balance changes, and hypothermia. Acidosis, hypothermia, and coagulopathy constitute the "deadly" triad.

Trauma-induced coagulopathy (TIC) can be managed by early identification, massive transfusion protocols (MTP), tranexamic acid, and recombinant factor VIIa usage, desmopressin, and prothrombin complex concentrate. If available, coagulation tests, including thromboelastogram (TEG), rotational thromboelastometry (RoTEM), and impedance aggregometry can be used to guide, evaluate, and inform TIC in children older than 1 year.

Pain management needs careful titration and judicious use of multimodal techniques to benefit from regional as well as pharmacological and non-pharmacological interventions.
