|Year : 2017 | Volume
| Issue : 1 | Page : 11-18
Blunt abdominal trauma in child: Epidemiological, diagnostic, and therapeutic analysis of 55 cases
Oumar Ndour, Souleymane Camara, Vianel Tendart, Aimee Lakh Faye Fall, Fatou Gassama, Pape Alassane Mbaye, Ndeye Aby Ndoye, Cheikh Diouf, Mbaye Fall, Gabriel Ngom
Department of Pediatric Surgery, Aristide Le Dantec Hospital, Dakar, Sénégal
|Date of Web Publication||2-Feb-2018|
Prof. Oumar Ndour
Department of Pediatric Surgery , Aristide Le Dantec Hospital, Dakar
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to report the epidemiological, diagnostic, therapeutic, and evolutionary aspects of blunt abdominal trauma in children.
Patients and Methods: We carried out a descriptive retrospective study which collected between 55 children of victims of abdominal bruises and the children's surgery department of the Aristide Le Dantec hospital in Dakar between January 1, 2009, and December 31, 2015. The parameters studied were as follows: age, sex, circumstances and mechanisms, hemodynamic status, abdominal table, imaging, associated lesions, and treatment.
Results: The mean age was 7.2 years. Boys were more affected with a sex ratio of 3.58. Road accidents were the most frequent cause of accidents with 50.9%. Thirty-six lesions of solid and hollow organs were recorded. The liver was the most affected organ (23.63% of patients), followed by spleen (9.1%) and kidney (7.3%). Multiple trauma was observed in 30.9% of patients with extra-abdominal lesions involving the thorax (64.7%), the skull (35.3%), and the pelvis (35.3%). Forty-seven patients (85.45%) received conservative treatment with a success rate of 93.62%; 11 patients (20%) underwent surgery. The overall morbidity rate was 14.54%, and mortality was 1.81%.
Conclusion: Abdominal bruising in children is more common than wounds in the abdomen. Road accidents are the main etiology. Conservative treatment is in vogue in the service and gives very good results.
Keywords: Abdomen, child, conservative treatment, contusion
|How to cite this article:|
Ndour O, Camara S, Tendart V, Fall AL, Gassama F, Mbaye PA, Ndoye NA, Diouf C, Fall M, Ngom G. Blunt abdominal trauma in child: Epidemiological, diagnostic, and therapeutic analysis of 55 cases. Afr J Trauma 2017;6:11-8
|How to cite this URL:|
Ndour O, Camara S, Tendart V, Fall AL, Gassama F, Mbaye PA, Ndoye NA, Diouf C, Fall M, Ngom G. Blunt abdominal trauma in child: Epidemiological, diagnostic, and therapeutic analysis of 55 cases. Afr J Trauma [serial online] 2017 [cited 2018 Jul 16];6:11-8. Available from: http://www.afrjtrauma.com/text.asp?2017/6/1/11/224637
| Introduction|| |
The blunt abdominal trauma is the result of an impact affecting the abdominal cavity, whatever its location, without any solution of continuity of the abdominal wall. It is a medical and surgical emergency in which vital and functional prognoses are involved. Their frequency is around 80% of abdominal trauma, and the circumstances are dominated by road accidents., They constitute a permanent concern for the surgeon because it is necessary to know whether it is a purely parietal contusion or if there are visceral lesions requiring an appropriate therapeutic attitude. Modalities of nonsurgical management of closed abdominal trauma have evolved over the past three decades, partly due to advances in imaging. The generalization of this nonoperative attitude has been largely confirmed in the American, European, and African scientific literature., Their prognosis depends on the speed of management, the choice of methods of investigation, and the appropriate therapeutic decisions. The very high mortality (25%–30%), justifies an early and specialized management. In Senegal, the main studies carried out on this subject were carried out on adults  which led us to do this work to report the epidemiological, diagnostic, therapeutic, and evolutionary aspects of abdomen contusions in children in the surgery department of the Aristide Le Dantec hospital from 2009 to 2015.
| Patients and Methods|| |
This was a retrospective study of a descriptive type which collected between 55 children of children in abdominal contusion in the pediatric surgery department of the CHU Aristide Le Dantec in Dakar between January 1, 2009, and December 31, 2015. The parameters studied were epidemiological (frequency, age, sex, geographical origin, circumstances, mechanisms, and time of admission), diagnostic (clinical and paraclinical), therapeutic (surgery, conservative), and evolutionary.
Conservative therapy was indicated in all patients with full organ disease with stable hemodynamic status or parietal lesion without any effect on intra-abdominal organs.
The protocol used was as follows:
- Total diet for 72 h
- Vascular filling – with crystalloids (40 ml/kg) or macrolides (10 ml/kg). Transfusion is indicated in cases of nontolerated anemia or hemoglobin <7 g/dl. The transfusion rate is 40 ml/kg/24 h on an average
- Analgesics – paracetamol was administered as an intravenous injection at a dose of 15 mg/kg body weight
- Setting up a gastric tube – decreases the abdominal hyper-pressure due and reflex ileus
- Antibiotic therapy – according to the infectious risk.
- Clinical monitoring:
- a monitoring sheet for hemodynamic parameters (PA, pulse rate, respiratory rate, temperature, diuresis, partial oxygen saturation, appendages). Surveillance should be done every 15 min for 3 h, every 30 min for 3 h, then to a more spaced outlet per day
- A multiple-day clinical examination is required.
- Paraclinic monitoring:
- Daily biological monitoring of the hemogram
- An abdomino-pelvic ultrasound performed once every 2 days 73 for 1 week, then once a week until complete hemoperitoneum resorption
- A scannographic control: once the 1st week, then after a month.
| Results|| |
During the study period, we counted 66 cases of the abdominal trauma of which 55 were abdominal bruises or 83.33%.
Age and sex
The mean age of the patients was 7.2 years with extremes of 1 year and 14 years. The most representative age group was children aged 5–9 years [Figure 1].
The study population consisted of 43 boys and 12 girls; a sex ratio of 3.58.
The majority of our patients came from the suburbs of Dakar (30 patients, 54.5%), followed by downtown Dakar (36%) and other regions (9.5%).
Deadline for consultation
The average consultation time was 40.54 h with extremes ranging from 1 h to 3 weeks. Most of the patients (40%) were admitted to the service within 3 h following the trauma and 75% within 24 h.
Circumstances and mechanisms
The most frequent occurrence was road traffic accidents with 28 cases, a rate of 50.9%. Other circumstances were domestic accidents (25.5%), recreational accidents (21.8%), and brawls (1.8%).
The most frequent mechanism in our series was the direct mechanism with 50 cases or 91%. Indirect injury trauma involved 5.45% of patients.
AVPs accounted for 78.57% of pedestrians and 21.43% of vehicle passengers.
The means of transport implicated were either private vehicles (17 cases) or public transport (9 cases), a scooter (one case) or a cart (one case).
Among the traumas due to a domestic accident were falls of one floor (four cases), falls on the stairs (two cases), landslides (two cases), falls in height (one case), horse hoof blows (3 cases), ram horn shots (one case), and an unspecified case.
Injuries resulting from recreational accidents were kicks in the abdomen during a game (4 cases), the reception of a balloon on the abdomen (three cases), falls from a tree (2 cases) or stairs (one case) during a game, playing with a horse (one case) or receiving a chair on the abdomen during a game (one case).
References and means of evacuation
In our series, 38 patients (69.1%) were referred to us; or a hospital in 31 cases (56.4%) or a district or health center in seven cases (12.7%).
In our series of 27 patients, 49.1% were transported to our structure by an ambulance (12 times by firefighters, 10 times by hospital ambulance and 5 times by SAMU) and 28 patients, 50.9% by a particular vehicle.
On admission, 48 patients were hemodynamically stable, 87.27% and 7 patients were unstable, 12.72%. The latter were all polytrauma patients.
All patients had a clear conscience at entry except 1 patient who was received in a coma table with Glasgow at 9.
Abdominal pain was found in all patients. It was most commonly diffuse (38%) or more localized in the right hypochondrium (30%).
The clinical examination found a peritoneal irritation syndrome in 38.2% of the patients and a localized abdominal sensation in 61.8% of the patients.
All patients had a minimum biological check-up of blood count, blood grouping, rhesus, TP, and TCA.
The study of the hemoglobin at entry showed that 14.54% of the patients had a rate lower than 8 g/dlThe study of the white blood cell rate showed that 51.9% of patients had leukocytosis at the entry with an average rate of 13.3.103.
It was required in 17 patients and was normal in 14 cases. She had recovered: one case of inter- hepatodiaphragmatic gas crescent associated with hydro aerial levels, one case of isolated inter-hepatodiaphragmatic gas crescent and one case of hydro aerial type hail.
Ultrasound was performed in 49 patients and returned normal in 14 cases.
It was found in 25 cases of hemoperitoneum (11 of small abundance, 11 of medium abundance and three of high abundance) and 22 cases of organic lesions (eight hepatic, four renal, four splenic [Figure 2], four parietal, and two small bowel) [Table 1].
|Figure 2: Ultrasound of a 14-year-old child showing an intra parenchymatous splenic hematoma measuring 4.56 cm × 4.05 cm (HALD pediatric surgery service)|
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|Table 1: Distribution of patients according to organ lesions found on ultrasound|
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It was requested in 21 patients in our study and found an organic lesion in all cases with a predominance of liver lesions [Figure 3] with 11 cases [Table 2]. A hemoperitoneum was found in 15 cases.
|Figure 3: Computed tomography scan of a 7-year-old patient with intra-parenchymal hepatic hematoma of segment VII with a capsular hematoma (HALD pediatric surgery service)|
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They were dominated by trauma to the thorax (64.7%), TCE (35.3%) and trauma to the pelvis (35.3%); these traumas were sometimes entangled [Table 3].
|Table 3: Distribution of the population according to trauma and associated lesions|
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In 17 patients (30.90%), these associated lesions were part of a polytrauma.
Therapeutic and evolutive aspects
In our series, 47 patients had received conservative treatment, 85.45% compared with 11 patients who had undergone surgical treatment, i.e., 20% (8 cases of surgery at the outset and three cases after failure of conservative treatment).
In our series, 47 patients received conservative treatment, 42 of which were exclusively treated in pediatric surgery and five cases where conservative treatment was performed in the intensive care unit and then in infant surgery (one comatose and two patients with signs of shock and two cases of respiratory distress).
Resuscitation was required in all patients. All patients had paracetamol analgesia at a dose of 60 mg/kg/day distributed in four doses, and in 4 cases, TAL II analgesics were used.
Forty-eight patients out of 55, or 87.3%, had received antibiotic therapy with the combination of clavulanic acid amoxicillin most often, once associated with metronidazole by infusion.
Seven patients were transfused due to poorly tolerated anemia and 11 patients received anti-tetanus serotherapy.
Two patients received oxygen therapy due to respiratory distress.
Surgical indications from the outset
These were one case of gastric perforation (suture + epiplooplasty), two intestinal lesions (suture, resection + anastomosis), two bladder lesions (suture), two cases of diaphragmatic rupture (suture) hematoma of the hypogastric part of the large compressive (drainage) right on the bladder and responsible for dysuria.
Secondary surgical indications
- a case of secondary rupture of the spleen after 7 days of hospitalization (splenectomy)
- a case of renal infarction associated with a rupture of the right ureter (nephrectomy) diagnosed by performing an 8-day computed tomography (CT) scan of a preservative treatment indicated in a patient whose ultrasound had recovered an intrahepatic hematoma and a right renal capsular capsular hematoma
- a case of right parietal hematoma in whom the indication for surgical drainage was secondarily postponed to 5 days of a conservative treatment, faced with the poor response to medical treatment (persistence of the infectious syndrome and elevation of the rate of white blood cell at 21,400 cells/mm3).
In our series, 45 patients, 81.8% had favorable sequences and ten patients, or 18.2% had complications.
During the study, the progression in patients who received conservative treatment was favorable in 93.62% and there were three complications, i.e., 6.38%. It is a secondary rupture of the spleen, a renal infarction and a superinfection of a parietal hematoma.
In patients operated, the progression was favorable in 6 patients, i.e., 54.54% and complications occurred in five patients, i.e., 45.45% of the cases [Table 4].
In our series, one case of death was noted. It was a 9-year-old male with no specific pathological history received at H4 from post-AL trauma (he fell following a climbing game and then one of his comrades Fallen on the trunk). At the entry, he had stable hemodynamic constants and diffuse abdominal sensitivity. The paraclinic intake was made of an ASP that was normal and an NFS that showed: hemoglobin at 13.3 g/dl, white blood cell at 15,100, and platelet count at 324,000.
On day 1, the patient presented with a stoppage of substances and gases, vomiting, a fever at 38 degrees Celsius, 110b/min tachycardia, a flat abdomen, a generalized defense of the abdomen and a cry from the umbilicus. The ultrasound showed hemoperitoneum of average abundance. With the appearance of the signs of acute generalized peritonitis surgical treatment was indicated, and not realized.
The death occurred on day 2 of hospitalization and postmortem diagnosis (at autopsy) was acute peritonitis generalized by ileal perforation complicated by septic shock.
The average hospital stay was 10.89 days with a minimum of 1 day and a maximum of 48 days. The duration of hospitalization was higher for patients operated with an average of 21.17 days versus 8.05 days for nonoperated patients.
Remote evolution was favorable in all patients with an average of three appointments at 15 days, 1 month, and 2 months.
| Discussion|| |
According to the literature, abdominal bruises are close to 80% of abdominal trauma in children, as noted in our study. This figure is much higher than that of adults., This can be explained in adults on the one hand by their anatomy which gives them greater resistance to shock and on the other hand by greater exposure to trauma by firearm, stabbing, attacks, and brawls.
The majority of our patients came from the Dakar suburbs. This area is often characterized by a certain amount of promiscuity, a high level of road traffic, and a lack of developed playgrounds, which are the most important factors in children's exposure to traffic accidents.
In the literature, a male predominance is reported by most authors , as we noted in our study. This can be explained by the fact that boys are more active, more turbulent and tend to engage in more dangerous activities.
According to the literature, mean age varies from 7.5 to 10 years in the pediatric population.,
In our study, the mean age was 7.2 years, which corroborates the data of the literature. The most affected age group is 5–9 years old, which corresponds to the beginning of schooling in primary school and the temptation to test an often unrecognized and hostile environment.
Road accidents are the first circumstance in our study. They remain the main etiology of abdominal bruising in both developing and developed countries., The development of roads and road transport, noncompliance with safety regulations and lack of discipline in traffic, explain this frequency of road accidents. It should be noted that fall trauma occupies a significant percentage of abdominal contusion in children in the literature, with rates ranging from 36.58% to 45.6%., In our series, trauma falls from a higher or lower height represent 20% of the mechanisms.
In our series, the admission time varies from 1 h to 3 weeks with an average of 39.54 h; About the same time in the BIKANDO series in Congo  and COTTE in France, which was from 2 h to 2 weeks. Our patients consulted in 75% of cases within 24 h. These data show that the consultation period is shorter for children than for adults. This can be explained by the fact that adults are better at bearing pain and often tend to self-medicate before going to the hospital.
The transport of our patients is ensured in 50.9% of the cases by private vehicles or the fire brigades in 18.18% of the cases. The latter in our regions provide nonmedical transport, which means that patients do not often benefit from prehospital care.
The diagnosis is primarily clinical before the notion of abdominal trauma and the absence of parietal invasion. The reasons for consultation are variable and depend on the lesion mechanism and the associated lesions. However, the digestive signs are in the foreground with as main symptom the abdominal pain. The frequency of this is 100% for almost all authors.,,,
In the literature, the frequency of unstable patients at entry is variable. Indeed, Bikando et al. and Elabbassi-Skalli et al. found a frequency of 19.5% and 2.86%, respectively. In our series, hemodynamic instability was noted in 12.72% of patients and all unstable patients had a hemoglobin level of <8 g/dl. Instability varies according to the mechanisms of injury, associated trauma and time to consultation, and is most often due to hypovolemic shock.
The peritoneal irritation table was present in 38.2% of the cases. The peritoneal irritation is due to the importance of the hemoperitoneum and/or to its superinfection.
Clinical examination is supplemented by radiological investigations, which are indispensable in the detection, characterization of organic lesions and decision-making in the therapeutic attitude. Progress in the area of ultrasound and CT has largely changed the management of trauma in the abdomen.,
Ultrasound is often urgently lacking in our context, but allows early diagnosis of lesions of solid organs and some doubtful pictures. It does not allow direct diagnosis of perforations of hollow organs but it can visualize the intraperitoneal effusion. It is better adapted in children than CT because it is more accessible, less expensive, less hampered by lack of cooperation, and does not require sedation. There is a growing tendency to perform an ultrasound systematically in the initial assessment before any polytrauma. In a collective review of 4,941 patients, Rozycki and Shackford  concluded that ultrasound has a sensitivity of 93.4%, a specificity of 98.7% and a diagnostic accuracy of 97.5% for the detection of hemoperitoneum and visceral lesion. In our series, it was requested 49 times and allowed to find 22 cases of organic lesions and 25 cases of peritoneal effusion.
CT is an imaging method of choice in trauma to the abdomen. It provides a more reliable diagnosis of most intra- and extra-abdominal traumatic lesions  including centers with few abdominal traumas. Most of the series around the world report a sensitivity and specificity rate higher than 90%., However, it is very little carried out in children due to its still high cost and the need for sedation and is not always available urgently. In our series, it was requested 21 times and found the organic lesion in all cases either a sensitivity of 100%.
ASP draws its interest in lesions of hollow organs. In the 5 patients in our series with a hollow organ lesion, four received a PSA and the examination allowed a diagnostic orientation in 3 cases or a sensitivity of 75% in the detection of lesions of hollow organs. Massengo  and Bikando et al. also obtained similar results.
In our series, 54.54% of patients had organic lesions. The diagnosis was radiological in 88.89% of the cases and perioperative in 11.11% of the cases. The following table compares our results with the literature data.
In the literature, most authors describe the spleen as the organ most affected by abdominal bruising., However, Velmahos found a higher frequency of liver damage. The renal lesions come in third place.,, In our study, the liver is the organ most affected which is in adequacy with certain authors [Table 5].
Therapeutic and evolutive aspects
Treatment should be instituted very early as patients are picked up by a medical system in order to avoid complications but, above all, to improve the management of severe patients., It depends first on the hemodynamic state of the child: in the event of instability and despite appropriate resuscitation measures, management of the operating room in an emergency is sometimes necessary to control an active hemorrhage. Other urgent surgical indications are suspicion or diagnostic certainty of perforation of hollow viscera, diaphragmatic rupture or sub-intimal rupture of the renal artery, whatever the hemodynamic state of the patient. In the case of a lesion of solid viscera in a hemodynamically stable child, the treatment is a priori nonoperative. Indeed, there is a growing trend toward conservative treatment of abdominal trauma. This attitude is partly made possible by advances in imaging, interventional radiology and endoscopy, which allow for accurate diagnosis and effective treatment. Nonsurgical treatment of abdominal trauma increased from 55% in 1988 to 79% in 1992 for liver damage, and from 34% to 46% in splenic lesions. In the multicenter work of the Western Trauma Association, the success rate of nonsurgical treatment of splenic trauma was 98% in children. The rate of failure of conservative treatment varies between 7.6% to 13% according to the authors.,
In our series, 47 of our patients received a conservative treatment of 85.45% with a failure rate of 6.38%. This rate is slightly lower than the range currently observed and can be explained by a more rigorous selection bias of patients candidates for conservative treatment and a good system of hourly monitoring.
The rate of surgical intervention in the different series varies according to age and years. It is 70% in the series of Bikando et al. in 1992. In our series, 20% of the patients have undergone surgery.
The rate of surgery obtained by Bikando et al. is higher than the rates observed recently because in 1992 the ultrasound was not very available and the technicians few; which explains the surgical attitude before any doubt diagnosis, with a relatively high white laparotomy rate 17.5%.
In our series, the indications of the surgery were respected, all the patients presenting a lesion of hollow organ or a diaphragmatic rupture were operated from the outset. Three patients had to undergo surgery following the failure of conservative treatment.
The duration of hospitalization depends on the severity of the lesion, the therapeutic option and the associated lesions. It is especially long in cases of polytrauma and in patients undergoing surgery.
In our series, the mean hospital stay is 10.89 days with extremes of 2–48 days.
The overall mortality rate is very variable in the literature. In the series of cotte  in France and Elabbassis  in Morocco, the mortality is zero. It is 4.87% in the Congo  and 7.1% in the Cassandra series in adults. In our series, the mortality is 1.81%. This variability can be explained by differences in the level of the technical plates.
| Conclusion|| |
Blunt abdominal trauma is more common than the wounds of the abdomen in children. Road accidents are the main circumstance. The current trend towards systematic ultrasound in the face of any abdominal trauma is not yet fashionable in our context. Our results of conservative treatment are satisfactory.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]