Chapter 18

Ultrasound is an especially appealing imaging modality in children. Examinations can be performed at the bedside, at times with the child being held by a parent. This diagnostic test is noninvasive, involves no contrast or ionizing radiation, and is considered virtually risk-free.1 Also, pediatric patients generally have less body fat and thinner abdominal walls, which enhances the ultrasound examination.

Trauma remains the most common cause of morbidity and mortality in children. Traumatic injuries result in hospital admission for approximately 600,000 children each year.2 In the pediatric age group, blunt trauma is more prevalent than penetrating injuries. Twenty to 30% of pediatric trauma cases involve the abdomen.2 Timely, accurate, and cost-effective evaluation of children suffering from blunt abdominal trauma remains a challenge for physicians.

The history and physical examination form the foundation of patient evaluation; however, they may be difficult or impossible to obtain in children who have altered mental status, central nervous system trauma, or distracting injuries. In one study of children with blunt abdominal trauma, an initial physical examination was considered reliable in only 41% of cases.3 The physical examination has been reported to be misleading in up to 45% of injured children.4, 5 Although the physical examination is an important piece in the diagnostic puzzle, the clinician must resort to other modalities to adequately evaluate and treat the pediatric blunt abdominal trauma patient.

Clinical Considerations

In the 1960s, diagnostic peritoneal lavage became a popular procedure for detecting blood or bowel contents in the peritoneal cavity. It can be performed at the bedside and is relatively rapid and safe, with a complication rate of approximately 1%.6–8 Studies of diagnostic peritoneal lavage in children have demonstrated a high sensitivity in detecting injury (96%), but have noted the findings to be too nonspecific. Positive diagnostic peritoneal lavage studies do not provide information on which organ is injured or how severely, and have led to nontherapeutic laparotomy rates between 13% and 19%.9, 10 Since these studies were published, the trend toward nonoperative management of pediatric abdominal injuries has increased significantly.11–24 In the 1980s, the direction shifted away from the use of diagnostic peritoneal lavage and toward the use of abdominal computed tomography (CT).

CT is now the most commonly used modality in evaluating pediatric abdominal injuries.25–34 The primary advantage of CT is that it identifies and characterizes most abdominal injuries and provides important information to guide the management of the patient. CT is noninvasive and can evaluate intraperitoneal and retroperitoneal structures. The primary disadvantage of CT is that the test requires the transportation of the patient to the medical imaging department; consequently, its use is inadvisable in the hemodynamically unstable patient.6 In addition, CT often requires sedation of pediatric patients. CT involves the administration of intravenous (IV) and oral contrast. This results in filling the stomach in a patient already at ...

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