Abdominal Trauma with Dr. Richard Falcone

When a trauma patient comes in with a penetrating injury, like a gunshot wound, a stabbing, you know, we have an algorithm but then it can get easier to narrow down the diagnosis because it's a puncture right in front of you. But what about when a patient comes in with blunt abdominal injury? Well, then it can get a little bit more complicated. That's why today we're going to talk about blunt abdominal trauma, the workup, the management evaluation, and we've got an expert. So, good to talk about pediatric trauma, um, and, and specifically blunt abdominal trauma evaluation. That's Dr. Rich Falcone. He's the previous director of trauma services at Cincinnati Children's Hospital Medical Center. Stick around. This is the Stay Current Pediatric Surgery Podcast. Okay, so the leading cause of mortality in the pediatric patient over 1-year-old is trauma. And about 80% of those trauma injuries are blunt. Um, kind of makes sense. I mean, they come in with an injury, you can't really see it cause it's under their skin, right? So, why not just CT scan every blunt abdominal trauma patient that comes in? You know, then you don't miss any injuries, you'll catch injuries earlier. Well, Dr. Falcone says not so fast. CT scanning is necessary, right? We do a lot of it. It's still an important tool. So this is not at all to say, don't ever CT scan a kid. It's how do we limit CT scanning kids to those that really need it? Why do we see more blunt abdominal injuries in kids versus adults? Because of the smaller size of the abdomen, everything's closer together. So it's easier to kind of hurt or have force distributed from one spot to another. The flexible ribs don't protect the intra-abdominal organs as much as they do in adults, right? So, even though, you know, and your spleen and liver often can be a little lower and they're just, you know, the, the strong ribs that get broken in adults just kind of take some of that impact are flexible in kids so just, the force goes into the solid organs. So, as we treat more and more pediatric patients who suffer from blunt abdominal trauma, you might also be tempted to get more and more imaging studies. But Dr. Falcone says, don't rely on that. Because, you know, scans are not necessarily benign and it goes back to that battle of overexposure to radiation. What are the risks? There's definitely some risk, um, for kids, because, right where they're developing, they have that exposure that lasts the rest of their lifetime. Um, and we may not even be seeing the impacts to 50 years down the line from their, their cumulative radiation. They got their, you know, CAT scan for their appendicitis. They got their CAT scan for their trauma. They got their CAT scan because they were constipated once, who knows, right? And, and over a lifetime those all add up. So it's, it's a matter of selecting who needs it and when. In one study, 78% of 125 patients were scanned after blunt abdominal trauma. And guess what? Only 15% had an identifiable injury. Wait, did I read that right? 15%. Well, fortunately the study also identified six clinical factors that can help you predict those patients who might be more in need of a scan than others. All right, Dr. Falcone, let's hear it. What are the six factors? So, if they have a normal blood pressure for their age, a normal abdominal exam, they use labs, so they had a normal AST less than 200, which is the same cutoff that we use. Hematocrit greater than 30 and a normal chest x-ray. So, if all of those things were true, they had a 99% negative predictive value that you were going to, that there was going to be an injury. So, their argument was, if all those are true, you shouldn't be scanning. Well, if that doesn't get your attention, there's a larger multi-institutional study that Cincinnati Children's Hospital just happens to have participated in. And they looked at blunt abdominal trauma and the clinical evaluation. They looked at the patients who had no abdominal tenderness, no distension, normal X-ray, normal liver labs, normal pancreatic enzyme. So, what did they find? Well, turns out 34% of that population only had a 0.6% chance of an abdominal injury. And then of that 0% had an injury that required an intervention. So, it sounds like the perfect scenario, right? But keep in mind that we're talking about the pediatric patients. I mean, they, they get fussy. They cry. They can tell you in other ways. I mean, if you're an adult and you cry too, that's, that's okay. I mean, Pixar does that to me as well. But the point is that clinical judgment is key. Under certain circumstances, scanning should be considered in combination with your clinical evaluation. You got tenderness and you got bruising and you got abnormal chest X-ray. Um, you know, I would say in that situation, you wouldn't even get to the labs, you'd probably be, you know, choosing to scan. But then if you had abnormal labs on top of that, you're going to do it. Okay, so algorithms help guide us, especially if the children is asymptomatic on clinical evaluation. But you have to keep in mind that this is just a screening algorithm. If there is significant concern for an abdominal injury, or they just clinically are kind of off the scale here, you know, this algorithm might not apply to them. As soon as you have one reason on that any of those algorithms to scan the kid, you can stop going down the algorithm, you don't need labs. Um, we actually, probably now eight or so years ago took out kind of trauma labs or belly labs as part of our initial lab draw because they were just wasting a lot of money and a lot of losing IVs and, and sticking kids multiple times to get those labs, right? What we need is type and screen and a CBC or a gas is, you know, probably the only labs you really need acutely. Coags for brain injury kids, but, um, belly labs should not be part of your routine panel of labs. So, CT scanning is amazing. The level of detail you get in these images today, it's absolutely fascinating. But we should look more towards diagnostic tools that don't involve radiation. I mean, most of these kids and, and families, they want to get back to their lives. Some of these kids are even, you know, sports stars, they want to get up, they want to get active. So, what about ultrasound? How does that work? You know, some bubbles inject it, um, and then do the, do the ultrasound. So this is just a sample, right? So here's CT, obviously easy to see the, the laceration there. Here's doing a regular ultrasound, your fast, don't see anything there, and here's the contrast enhanced ultrasound where now you can see that laceration. So, moving on to organ injury, what about blunt splenic injury? Well, there's been longstanding guidelines with various grades of injury. A lot of that changed in 2015 when Atomic came out. Essentially, Atomic goes back to relying on your clinical assessment. The Atomic guidelines look at the splenic injury and bleeding that's ongoing, regardless of the grade. If the hemoglobin is greater than seven and the patient is able to get up and move around and tolerate a regular diet and they have a stable hemoglobin after two checks. Well, then that kid can go home. And that's pretty much how we do it at Cincinnati Children's Hospital. So, I, I know that these might seem radical and they'll be difficult to implement at your particular institution. I mean, even Dr. Falcone has gotten some pushback. I got in trouble from someone in the ICU a couple years ago because I made the decision to not admit a Grade Four spleen to the ICU and they next day said, this is not the protocol. I'm like, oh, I kind of know the protocol and it's okay, kids stable. Um, and did fine on the floor. But right, you got to use some clinical judgment as well as just the imaging and that's really what this what the atomic team found is this is reliable. This works. Wait a minute, what about like the good old fashioned trauma splenectomy? I mean, does this mean we're, we're not going to do splenectomies anymore? We're not going to angioembolize the spleen anymore? You got to do it based on vital signs and how they're responding to fluid resuscitation. Okay, wait, but what if you have like a blush on imaging? I mean, then you have to go to angiography, right? Or not? If they're stable and the radiologist calls and says you have a blush and the kid's like sitting there talking to you and it's a heart rate of 70, I'm not rushing that kid to angio. Um, I'm saying, okay, that's good to know. If something changes overnight, I now know that I'd probably go to angio first rather than the operating room to do a splenectomy maybe. Um, but I'm not going to do it just because I see a blush. And there's data out there obviously that supports that approach that you don't have to go get an angio and embolize these. Okay, so renal trauma is another common blunt abdominal injury that we see. Are, are those guidelines similar to the spleen or, or what are those like? Renal trauma really kind of the answers are, it's, it's the same. I mean, we don't non-operative trauma works for renal patients as well if they're hemodynamically stable and actually, you know, allows you to salvage renal tissue and and and things. Um, we do worry a little bit more about the higher grade, Grade three through five for the risk of, um, long-term hypertension and that's really, um, that and the risk of urinoma why we get urology involved in those higher grade, you know, renal injuries. Um, but, you know, Grade two kidney injury does not need urology. It does not need anything different than a Grade two, you know, spleen injury. It's, it's fairly straightforward, um, management. Okay, rounding out our talk about abdominal injuries, we, we have to talk about pancreatic injury. The American Association for the Surgery of Trauma, or the AAST has a well-known guideline with grades of pancreatic injury that has injuries and then recommended treatments for those injuries. And it's pretty straightforward. I mean, one and two, you do simple observation. On the other end, four and five are more severe injuries. So they have recommended therapies for that. But then what about right in the middle, grade three. I mean, do, do you observe or do you go ahead with a distal pancreatectomy? I mean, those are two totally different treatments. So, how do we decide? You know, our center in general has been a non-operative approach on these because the feeling was that sometimes the, the spleen parenchyma fractures, but the duct remains intact and it'll look like a complete transaction on this, this CT, but the duct itself is not transected. It, it stayed intact. So, non-operative management, you know, these kids get through or they get a little pseudocyst and that gets better. Um, and the feeling is, well, what's, what's better? That or an operation and potential complications and especially an operation on the kid who might have other injuries that this now leads, you know, to more complications. So maybe that spleen now, I mean, that spleen now needs to come out because you were in there and you're retracting on it and, you know, cause, cause injury when it, it might not have otherwise need to come out. A study of 20 different institutions, including Cincinnati Children's Hospital, looked at patients who had pancreatic injuries Grade three through five, analyzing pancreatic fluid collections, use of ERCP, serial enzymes, and compared that to a surgical intervention. And the results were kind of surprising. The non-operative patients actually did great. Hold on a second. What's the biggest challenge when evaluating a pancreatic injury? You got to make your decision early, right? So you got to know if that duct's completely disrupted and you're going to go operate or you're not. Because once you get more than three or four days out from the injury, you don't want to go in there at that point to try to operate and remove the duct. You're, you're now down your non-operative pathway. So if you're going to do it, do it early. Um, and then sorry, discharge based on symptoms and not, not labs again, right? When they're eating and their pain's under control, they can be discharged. Why is that so important? I mean, what if we wait a week to get the ERCP to evaluate the pancreas? A week to get that ERCP and find a duct disrupted. That's a pretty crummy time to make a decision about going into operatively manage that. Is there a stricture? Can you put a stent across a leaking, um, duct? I think if the answer is you can do any of those interventions, it helps, um, and if you have the skills like we do here, fortunately to get those studies, um, I think it could be helpful. I think where we have to balance is, well, how long do you try to get a wire across something and, and do you risk, you know, taking a partial disruption and making it a complete disruption as you're trying to fish a wire across or a stent across and, and is, is doing a sphincterotomy and, and getting out, um, the better part of valor in some of those cases. And that's a wrap on blunt abdominal trauma with Dr. Rich Falcone, specifically solid organ injury. If you liked this episode, I mean, be sure to follow us on social media. Subscribe to our YouTube page. Download the Stay Current and Pediatric Surgery app. It's in the Apple app Store, it's in the Google Play Store. But until next time, I'm Rod from Cincinnati Children's and remember, knowledge should be free.