Ans: A (Spleen) Ref Emedicine Medscape online (Pediatric Abdominal Trauma Clinical Presentation), Shah SM, Shah KS, Joshi PK, Somani RB, Gohil VB, Dakhla SM. To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum managed by laparoscopy. J Minim Access Surg 2011 Jul;7(3):169-72. Sabiston, Bailey and Schwartz Explanation Both Spleen and Liver are the most common organs to be injured in blunt injury abdomen. "The spleen is the most commonly injured abdominal organ in the NTDB (National Trauma Database), with 3.2% of all injured patients and 50.7% of patients with blunt abdominal trauma demonstrating splenic injuries." Sabiston Pg 457 "Second only to the spleen, injury to the liver is extremely common after blunt abdominal trauma." Sabiston Pg 459. "The most commonly injured organs are the spleenr liver retroperiioneum, small bowel kidneys, bladder cobrectum, diaphragm, and pancreas." (Ref: Medscape emedicine) Liver followed by the spleen were the most common sites of injuries.(Ref: Shah et at.) Spleen is the most common damaged organ in blunt abdominal trauma. (Ref: Schwartz) * Liver injuries are fortunate!'/ uncommon because of the livers position under the diaphragm protected by the chest wall. (Ref: Baileyj Patterns of Abdominal Organ Injury fay Mechanism of injury in Children (Ref: Emedicine Medscape) Frequency of Organ Injury Blunt Trauma Penetrating Trauma Liver 15% 22% Spleen 27% 9% Pancreas 2% 6% Kidney 27% 9% Stomach 1% 10% Duodenum 3% 4% Small bowel 6% 18% Colon 2% 16% Other 17% 6% Blunt AbdominaI Trauma Pathophysiology Blunt force injuries to the abdomen can generally be explained by 3 mechanisms: Deceleration. Crushing External compression, Signs and Symptoms The initial clinical assessment of patients with blunt abdominal trauma is often difficult and notably inaccurate. The most reliable signs and symptoms in alert patients are as follows: Pain. Tenderness. Gastrointestinal hemorrhage. Hypovolemia. Evidence of peritoneal irritation. Bradycardia may indicate the presence of free intraperitoneal blood. On physical examination, the following injury patterns predict the potential for intra-abdominal trauma: Lap belt marks: Correlate with small intestine rupture. Steering wheel-shaped contusions. Ecchymosis involving the flanks [Grey Turner sign} or the umbilicus [Cullen sign): Indicates retroperitoneal hemorrhage. Abdominal distention. Auscultation of bowel sounds in the thorax -- Diaphragmatic injury. Abdominal bruit: Underlying vascular disease or traumatic arteriovenous fistula. Local or generalized tenderness, guarding, rigidity or rebound tenderness: Peritoneal injury. Fullness and doughy consistency on palpation: Intra-abdominal hemorrhage. Crepitation or instability of the tower thoracic cage: Indicates the potential for splenic or hepatic injuries. Diagnosis Assessment of hemodynamic stability. In the hemodynamically unstable patient, a rapid evaluation for hemoperitoneum can be accomplished by means of diagnostic peritoneal lavage [DPL) or the focused assessment with sonography for trauma (FAST). Radiographic studies of the abdomen are indicated in stable patients when the physical examination findings are inconclusive. FAST Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination that can be performed by emergency clinicians and trauma surgeons to detect hemoperitoneum. The current FAST examination protocol consists of 4 acoustic windows (pericardiac perihepatic, perisplenic, pelvic) with the patient supine. An examination is interpreted as: o Positive if free fluid is found in any of the 4 acoustic windows. o Negative if no fluid is seen. o Indeterminate if any of the windows cannot be adequately assessed. Diagnostic Peritoneal Lavage DPL is indicated for the following patients in the setting of blunt trauma: DPL is done when FAST is not available. Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure. Computed Tomography Computed tomography is the standard for detecting solid organ injuries. Provide excellent imaging of the pancreas, duodenum and genitourinary system. Also can determine the source of hemorrhage. Management Treatment of blunt abdominal trauma begins at the scene of the injury and is continued upon the patient's arrival at hospital. Management may involve nonoperative measures or surgical treatment as appropriate. Indications for Laparotomy Signs of peritonitis. Uncontrolled shock or hemorrhage. Clinical deterioration during observation. Hemoperitoneum findings on FAST or DPL in a hemodynamically unstable patient. Nonoperative Management in blunt abdominal trauma, including severe solid organ injuries, selective nonoperative management has become the standard of care. Nonoperative management strategies are based on CT scan diagnosis and the hemodynamic stability of the patient, as follows: o Pediatric patients can be resuscitated and treated nonoperatively. o Hemodynamically stable adults with solid organ injuries (liver and spleen). o Splenic artery embolotherapy, may be used for adult blunt splenic injury.