Selective Management of Blunt Abdominal Trauma in Children—The Triage Role of Peritoneal Lavage

Abstract

The evolution of selective laparotomy in children sustaining blunt abdominal trauma has been highly controversial. This report describes our experience and policy change during this transitional period. Emergency laparotomies performed in the pediatric age group ( Grade III spleen, one hepatic vein, one small bowel). The remaining ten patients (67.5%) had injuries which probably could have been managed nonoperatively (eight ≤ Grade II spleen, two ≤ Grade II liver). We additionally reviewed 46 peritoneal lavages done in children during 1984, and noted a 100% sensitivity but 86% specificity when considering essential laparotomies. Based on these data, we established a selective management protocol and initiated a prospective study in January 1985. The protocol consisted of: 1) routine peritoneal lavage (DPL) in children at high risk for abdominal injury, 2) immediate laparotomy for DPL positive for blood in conjunction with hemodynamic instability, 3) selective laparotomy for DPL positive for blood in a stable child, additionally evaluated by abdominal CT scan (major mechanism) or liver/spleen scan (minor mechanism), and 4) mandatory laparotomy for DPL effluent positive by criteria other than blood. This policy reduced unnecessary laparotomy, otherwise warranted by DPL, to 187% (2/11); both patients had Grade II splenic injuries. Five children sustaining low-energy trauma were managed nonoperatively following peritoneal aspiration of gross blood with L-S scan confirming minor solid visceral injury. Conversely, major pancreatic injury was identified by DPL amylase concentration but missed by CT scanning and ultrasonography in two boys. Our experience confirms the disparity in blunt abdominal injury pattern between children and adults, and supports a selective laparotomy policy based on DPL as the critical triage decision.