MANEJO INICIAL EN TRAUMA (CUADRO SUPER RESUMIDO)

pCO2: partial pressure of carbon dioxide; O2: oxygen; GCS: Glasgow coma scale; FAST: focused abdominal sonography for trauma.
* Clinicians should always perform actions in RED.
Administer 20 mL/kg of warmed normal saline or Ringer's lactate over 10 to 20 minutes.
Signs of herniation include coma, unilateral pupillary dilation with outward eye deviation followed by hemiplegia, hyperventilation, Cheyne-Stokes
respirations, and/or decerebrate or decorticate posturing.

Glasgow Coma
Sign Pediatric Glasgow Coma Scale[2] Score
Scale[1]
Eye opening Spontaneous Spontaneous 4

To command To sound 3

To pain To pain 2

None None 1

Verbal Oriented Age-appropriate vocalization, smile, or orientation to sound, interacts (coos, babbles), 5
response follows objects

Confused, disoriented Cries, irritable 4

Inappropriate words Cries to pain 3

Incomprehensible sounds Moans to pain 2

None None 1

Motor Obeys commands Spontaneous movements (obeys verbal command) 6

response
Localizes pain Withdraws to touch (localizes pain) 5

Withdraws Withdraws to pain 4

Abnormal flexion to pain Abnormal flexion to pain (decorticate posture) 3

Abnormal extension to Abnormal extension to pain (decerebrate posture) 2

pain

None None 1

Best total score 15

The Glasgow coma scale (GCS) is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters:
best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded
individually; for example, E2V3M4 results in a GCS of 9. A score of 13 or higher correlates with mild brain injury; a score of 9 to 12
correlates with moderate injury; and a score of 8 or less represents severe brain injury. The pediatric Glasgow coma scale (PGCS) was
validated in children 2 years of age or younger.

TRAUMA DE TRAX
Traumatismo raro, 4-25%, mortalidad() de 2.6%,
(Primera causa de muerte: TCE, segunda: Trauma de trax por si les tena con el pendiente la segunda causa de de mortalidad por
trauma jajaja)

Cuando se combinan trax y crneo/abdomen: 25%. En total ocurre 2-3 veces ms en varones ()

75% de estas lesiones ocurren en accidentes motorizados en las que el paciente es pasajero o peatn
50% contusiones pulmonares, 20% lesiones neurolgicas, 10% hemotrax.
75% trauma cerrado, 10% trauma penetrante (nios mayores y mayor )
Ashcraft: Contusin o laceracin del parnquima pulmonar es la lesin ms comn y se puede asociar a fracturas costales y
neumotrax o hemotrax.

Las lesiones a otros rganos como el rbol traqueo bronquial<1%, esfago<1%, aorta <1%, diafragma 4%, corazn 6% (poco
frecuentes pero de harta mortalidad XD)

ANATOMIA Y FISIOLOGIA

Cabeza > grande predisposicin a la flexin del cuello con oclusin de la va area en posicin supina.
Lengua y paladar > grande, glotis ms anterior dificultad para observar va area.
Trquea ms corta, ms angosta y ms compresible que la del adulto ms susceptible a la oclusin con moco y
obliteracin por edema de la va area.
Respiracin: trax con elasticidad y masa muscular mayor transmisin de impacto y dao a rganos internos
Mayor consume de oxgeno mayor riesgo de hipoxia
La hipovolemia se compensa FC y pueden perder hasta 25% del volumen antes del choque hipovolmico.
Mayor superficie corporal en relacin a su peso mayor riesgo de hipotermia.

LESIONES ESPECFICAS
Por localizacin:
I Pared torcica
a)Trax inestable
b)Neumotrax abierto
c)Fx de Costilla
d)Asfixia traumtica
II Pleura / Parnquima pulmonar
a)Neumotrax a tensin
b)Hemotrax
c)Neumotrax simple
d)Contusin pulmonar/laceracin
e)Lesin diafragmtica
III Mediastino
a)Tamponade
b)Lesin a grandes vasos
c)Lesin traqueo bronquial
d)Contusin cardiaca
e)Lesin esofgica

FRACTURAS COSTALES
Generalidades: Los nios tienen un Trax elstico hasta los 8-10 aos, por lo tanto las fx de costilla = trauma de alto impacto
Sospechar en abuso infantil especialmente en < 3 aos.

Dx gabinete: rastreo seo (medicina nuclear) y serie sea (radiografas simples)

Complicaciones asociadas: Neumotrax y hemotrax (las ms frecuentes), Fx de clavcula, dao a SNC, fx faciales, pelvis, lesiones
en extremidades y trauma vascular.
Mortalidad en mltiples fx de costillas hasta 42%.

Tratamiento: de soporte, AINES (el tratamiento del dolor previene atelectasias y neumona secundaria), drenaje en caso de
neumotrax o hemotrax.

TORAX INESTABLE
Fracturas mltiples continuas costales (>2). Se asocia a movimiento paradjico del segmento inestable = falla respiratoria y dao
pulmonar subyacente.
A) Flail chest occurs when multiple rib fractures result in a loss of stability of the chest wall. The loss of continuity with the remainder of the rib cage causes the flail
segment to move paradoxically. B) Pressure within the chest is negative during inspiration, causing the flail segment to retract. C) With expiration, intrathoracic
pressure becomes positive and the flail segment bulges.

Tratamiento: De soporte (AINES), tratamiento de la dificultad respiratoria con ventilacin mecnica de presin positiva y en casos
seleccionados estabilizar las fx.

(Parntesis para sello de agua)

1. First chamber (ie, collection chamber depicted with three sub-sections) accepts air and fluid from the patient via the chest
tube; the fluid accumulates in this chamber.

2. Second chamber (ie, water seal chamber) which contains water at the bottom. Air from the patient enters this chamber
below the water level bubbling through the water seal preventing return of air to the patient.
 3. The air enters the third chamber (ie, suction chamber) connected to wall suction, and is discharged through the hospital
collection system.

The height of water in the suction chamber indicates the amount of suction applied. Suction pressures are typically between -10 and -
40 mmHg. An atmospheric vent prevents the application of excessive suction; manual venting through a pressure relief valve rapidly
equilibrates the collection chamber with atmospheric pressure.

NEUMOTORAX ABIERTO (herida succionante)

La presin negativa en la cavidad pleural (3 a 5 mmHg) succiona aire dentro del tdax, esto ocasiona colapso y desplazamiento del
mediastino contralateral

Tratamiento: ocluir la herida y colocar sello pleural, drenaje de hemo/neumotrax.

NEUMOTRAX SIMPLE

Ocurre generalmente por una fuga de aire (cerrado) dentro de la pleura por una laceracin por costal o ruptura del
parnquima pulmonar.
Estudio inicial (usualmente el nico): Radiografa simple de trax
Otros: TAC y USG (ms sensibles pero poco usados como estudio inicial)
Tratamiento: Indicaciones de drenaje: 20% del espacio pleural.
Oxgeno: en mascarilla o puntas nasales (cursan con hipoxia), generalmente se necesita las primeras 24-48hr.
Neumotrax a tensin primer procedimiento : descompresin con aguja (an sin radiografa ni otros estudios nicamente
clnica) Todos los pacientes requerirn toracostoma posterior.
Si no se logra la descompresin colocar catter pigtail cola de cerdo o toracostoma como manejo incial.
Complicaciones: edema de re-expansin pulmonar (ms frecuente) sobre todo en neumotrax a tensin, otras TEP,
fstulas venosas,

HEMOTRAX

puede ser por trauma contuso o penetrante, ruptura de los vasos de la pared torcica, pleura o parnquima pulmonar, se asocia
a fx de costilla y laceraciones . Cada hemitrax puede contener el 40% del volumen sanguneo del nio y no presenta clnica
evidente con volmenes pequeos.
Tratamiento: toracostoma y drenaje con sello, para reexpandir el pulmn y cuantificar prdidas
Exploracin quirrgica: >15ml/kg o prdida continua de 2-3ml/kg/hr por > 3horas.
Complicaciones: si no se drena = Fibrosis por organizacin de la sangre y restriccin pulmonar. Fibrinolticos?

QUILOTRAX

Acumulacin de quilo por lesin de linfticos o conducto torcico. Poco frecuente secundario a trauma. Se diagostica casi
siempre 3-7 das despus del traumatismo. El diagnstico es con drenaje y anlisis del lquido.
 Conteo celular: predominio de linfocitos, >80%. Linfocitos T policlonales
Lpidos. (caracterstica clave): Triglicridos en concentracin >110 mg/dL (muy sugestivo), niveles menores deben ser
evaluados con electroforesis si an se sospecha en quilotrax para detectar quilomicrones (diagnstico definitivo).
Colesterol menos de 200mg/dl.
Tincin de sudn: para ver quilomicrones.
Puede encontrarse con caractersticas de exudado por criterios de light pero las caractersticas macroscpicas y la clnica
orientan al diagnstico diferencial con otras causas de derrame pleural.
pH 7.4-7.8
Diagnstico diferencial con ascitis quilosa que ha atravesado el diafragma: las caractersticas qumicas, deben ser similares a
los hallazgos en la ascitis.
Diferenciar de lquido de NPT en pleura: Glucosa liquido/suero = <1 vs (pleura) >1 (NPT)
Tratamiento: drenaje y sello de agua y soporte diettico

ESTOS DATOS SON DE UPTODATE:

For the majority of patients with traumatic chylothorax (eg, nonsurgical or postoperative), we suggest initial conservative
management rather than surgical intervention (Grade 2C). Conservative management includes chest tube drainage and either
bowel rest with total parenteral nutrition or a high protein-reduced fat diet with MCT supplementation. Close attention to fluid
and electrolyte management, nutrition, and the daily volume of pleural drainage is needed.

For patients with a chylothorax in a postpneumonectomy space and mediastinal shift to the side of the pneumonectomy, we
suggest dietary control measures without chest tube drainage (Grade 2C).
 Shift of the mediastinum back to the midline suggests development of tension chylothorax, which requires urgent placement of a
chest tube, followed by surgery to gain control of the lymphatic leak.

For patients with a traumatic chylothorax (eg, nonsurgical or postoperative) chylothorax and large volume drainage of
chylous fluid (>1L per day) through the chest tube who can tolerate surgery, we recommend early thoracic duct ligation (eg,
within 5 to 7 days) (Grade 1B). Pleurodesis may be performed at the time of thoracic duct ligation via mechanical abrasion
or insufflation of talc.
For patients with a traumatic chylothorax (eg, nonsurgical or postoperative) and continued pleural drainage after 14 days of
conservative therapy, we recommend thoracic duct ligation (Grade 1B). A longer duration of conservative therapy is
associated with nutritional depletion and high mortality rates. Pleurodesis may be performed at the time of thoracic duct
ligation via mechanical abrasion or insufflation of talc. Alternatively, for patients who are not good surgical candidates,
chemical pleurodesis via the chest tube is an option.

UPTODATE:
SUMMARY AND RECOMMENDATIONS (TRAUMA DE PARED TORACICA)

Chest wall injuries in children are significant primarily because they often occur following forceful mechanisms that also cause
serious associated injuries. Included in chest wall injuries are rib fractures, flail chest, and sternal and scapular fractures.

Chest wall injuries in children occur primarily as the result of blunt thoracic trauma, often involving a motor vehicle.
Mortality is usually the result of associated injuries, particularly head injury.
The thoracic cage of a child is more compliant than that of an adult. Consequently, chest wall injuries usually occur as the
result of considerable force and are more likely to be associated with intrathoracic injury.
The most common chest wall injury is rib fracture. Flail chest, sternal fractures, and scapular fractures occur infrequently.
The initial management of chest wall injuries must focus on identifying and stabilizing life-threatening associated injuries.
Plain chest radiography is sufficient to identify rib fractures, although the addition of oblique views may be helpful when an
inflicted injury is suspected. Children with first rib fractures, sternal fractures, and posterior sternoclavicular fracture
dislocations should generally receive computed tomography of the chest to exclude associated intrathoracic vascular injuries.
Children with sternal fractures should receive electrocardiograms to identify myocardial injury.
Children with flail chests who are in respiratory distress should receive assisted ventilation.
Children with multiple rib fractures should be admitted to the hospital. They should receive intravenous analgesia for pain
control. We suggest epidural analgesia for children with any respiratory compromise or for whom intravenous analgesia is
inadequate (Grade 2C).

SUMMARY AND RECOMMENDATIONS (EVALUACIN DE TRAUMA DE TORAX EN NIOS)

Thoracic injury in children typically occurs as the result of forceful mechanisms such as motor vehicle crashes. For blunt
mechanisms, death usually occurs as the result of associated injuries.
Anatomic and physiologic characteristics of children influence injury patterns caused by thoracic trauma.

Pulmonary contusion, pneumothorax, and rib fracture occur most frequently

Immediately life-threatening (usually suspected on initial assessment)

Airway obstruction
Open pneumothorax
Flail chest
Tension pneumothorax
Massive hemothorax
Cardiac tamponade
Potentially life-threatening (usually noted on secondary survey, chest radiograph, ECG, or reevaluation)
Tracheobronchial tear
Pulmonary contusion
Myocardial contusion
Ruptured diaphragm
Esophageal rupture
Aortic transection
Generally not life-threatening
Simple pneumothorax
Small hemothorax
Rib fracture
Chest wall laceration/contusion

Head injury is the associated injury seen most commonly in children with thoracic trauma.
Immediately life-threatening injuries (such as tension pneumothorax, cardiac tamponade, or injury to the great vessels) must
be identified and treated during the initial rapid assessment. Interventions may include assisted ventilation, needle or tube
thoracostomy, or (rarely) emergency thoracotomy.
Emergency department thoracotomy may be performed for patients in extremis (cardiac arrest or decompensated shock) to
release pericardial tamponade, control hemorrhage, control massive air embolism, or perform open cardiac massage. Specific
indications are discussed in detail in the text but include an experienced clinician performing the procedure and timely
availability of a thoracic or trauma surgeon.

1. Indications for urgent surgical intervention include the following:

a. Massive hemorrhage identified at thoracostomy placement (20 to 30 percent of blood volume for a child or 1000 to 1500
cc for an adolescent)
b. Persistent hemorrhage (2 to 3 cc/kg per hour over four hours)
c. Tracheobronchial rupture
d. Esophageal disruption
e. Diaphragmatic rupture
f. Cardiac tamponade
g. Great vessel injury

Ashcraft:

Diagnostic studies that may be useful for the evaluation of children with thoracic trauma include plain chest radiography
(inicial), computed tomography, and electrocardiography.
Most children with thoracic trauma should receive oxygen and surgical consultation. Cervical spine immobilization should be
considered for those with multiple injuries, particularly head injuries. Some patients require specific interventions such as
assisted ventilation, fluid resuscitation, or tube thoracostomy.
Rarely, thoracic injuries require urgent surgical intervention. Hospitalization for medical treatment or observation is indicated
for most children. Some children with mild thoracic injuries can be safely discharged from the emergency department.

Ms sobre trauma de trax:

 Thoracic trauma is a marker for severe injury because thoracic injury typically occurs as the result of forceful mechanisms
that also cause serious associated injuries. The following injuries occur uncommonly as the result of blunt or penetrating
thoracic injury in children.Pulmonary laceration can cause exsanguinating hemorrhage, requiring transfusion, particularly
after placement of tube thoracostomy.
Traumatic asphyxia is a rare consequence of thoracic trauma that occurs in children because of the greater flexibility of their
thoracic cages. Dramatic physical findings include conjunctival hemorrhages, facial edema, and cyanosis.
Children with blunt cardiac injuries (BCI) may have arrhythmias, new murmurs, heart failure, or hypotension. We suggest
that evaluation of children with suspected BCI include CXR, EKG, and measurement of troponin levels.
Clinical manifestations of traumatic aortic injury include hypotension, diminished blood pressure and/or pulses in lower
extremities (as compared with upper extremities), or paraplegia. CXR is often abnormal. CT, transesophageal
echocardiography, and aortography can be used to confirm the diagnosis.
We suggest that stable children with traumatic aortic injury receive beta blockers (Grade 2C). Experience with this therapy
for children is limited. Patients should be managed by a surgeon with pediatric experience.
Esophageal injuries may be overlooked during the initial evaluation. Patients typically have pain and develop subcutaneous
emphysema. Injuries must be repaired.
Children with a persistent air leak after tube thoracostomy may have tracheobronchial injury. Patients with suspected
tracheobronchial injury should be intubated in a controlled situation with bronchoscopic guidance, whenever possible.

DIAPHRAGMATIC INJURY Diaphragmatic injury may occur as the result of thoracic or abdominal trauma (4%) Penetrating
mechanisms are frequently involved. Associated injuries in 75% : pulmonary contusion and hepatic or splenic lacerations.

At initial presentation, the patient may have chest pain radiating to the shoulder, shortness of breath, or abdominal pain. Children may
have greater respiratory distress than adults because they have a tendency to swallow air when they are stressed, resulting in dilation
of the herniated stomach.

Physical findings associated with diaphragmatic rupture include auscultation of bowel sounds in the chest, diminished breath sounds
on the side of the injury, and scaphoid abdomen. Children with diaphragmatic injuries may have no external signs of injury [31].

Chest radiographs may demonstrate bowel gas or loops of intestine above the diaphragm, the presence of the tip of the nasogastric
tube above the diaphragm, or elevated or obscured hemidiaphragm. Additional nonspecific findings include small mediastinal shifts,
lower lobe atelectasis, unilateral pleural effusion, air-fluid levels in the basal lung fields, lower thoracic rib fractures, and
pneumothorax or hemothorax. Computed tomography with contrast and upper and lower gastrointestinal series may be useful for
confirming the diagnosis.

The following characteristics of diaphragmatic injuries have been noted:

Diaphragmatic injury classically occurs with a left-sided predominance because of the protective effect of the liver. The
distribution is more equal among patients with severe trauma.
The diaphragmatic tears that follow blunt trauma to the chest typically are larger than those that occur with penetrating
trauma.
Penetrating injuries to the diaphragm have been described as high as the third intercostal space and as low as the twelfth rib,
depending on the phase of respiration at the time of injury.

The initial management for patients with diaphragmatic injuries includes resuscitation and stabilization of associated injuries.
Herniated abdominal organs can be damaged when a tube thoracostomy is performed in the hemithorax of an undiagnosed
diaphragmatic injury. Consequently, a finger should be inserted through the chest wall incision and the diaphragm palpated before the
tube is placed, whenever diaphragmatic injury is suspected.

Most diaphragmatic defects require operative repair. However, this procedure may be deferred in children with multiple injuries
until more urgent diagnostic and therapeutic measures are performed.
TRAUMA CONTUSO DE ABDOMEN

SUMMARY AND RECOMMENDATIONS

Mechanisms of injury that are associated with intraabdominal trauma include isolated high energy blows to the abdomen (eg,
fall from a bicycle on to the handlebar), motor vehicle collisions, seat belt usage, and falls from a height greater than 20 feet
(6.6 metros aprox)
Variably present signs of abdominal injury include ecchymoses (particularly of the umbilical or flank regions); abrasions;
tire-tracks; seat-belt marks; abdominal distension, tenderness, rigidity, or masses; pain in the left shoulder induced by
palpation of the left upper quadrant (Kehr's sign); or prolonged ileus (greater than four hours).
Signs of abdominal injury are variable and may evolve over time necessitating repeated serial examinations.
The laboratory evaluation of children with blunt abdominal trauma varies depending upon the severity of trauma. The most
useful tests include a hematocrit, urinalysis, and serum liver transaminases (AST and ALT).
In hemodynamically unstable children, hemoglobin and hematocrit should be followed serially since the initial hemoglobin
and hematocrit in a patient with acute blood loss can be normal if equilibration of intravascular volume has not yet occurred.
We recommend that clinicians obtain transaminases in patients who have sustained potentially significant abdominal trauma,
are hemodynamically stable and have a low clinical likelihood of intraabdominal injury that will require surgical
intervention. We recommend that patients with elevated liver enzyme studies (AST >200 IU/L or ALT >125 IU/L) undergo
computed tomography (CT) of the abdomen and pelvis. Gross hematuria is also an indication for CT.
Ultrasonography is useful, when available, for the rapid, early evaluation of hemodynamically unstable children with
potential blunt abdominal trauma. Because ultrasonography lacks adequate sensitivity, Abdominal and pelvic CT scan with
intravenous contrast is usually performed in all hemodynamically stable patients with clinical findings suggestive of
intraabdominal injury regardless of ultrasound results.
Indications for abdominal and pelvic CT in children with serious blunt abdominal trauma are provided.

Potential indications for abdominal CT scan (only for use in the hemodynamically stable patient) include the following

Abdominal tenderness not caused by minor, superficial injury (eg, bruise, abrasion)
Seat belt syndrome (combination of a transverse bruise on the abdomen, anterior compression fracture or subluxation of
the lumbar spine from hyperflexion, visceral trauma, and, rarely, abdominal aortic injury. The rate of intraabdominal
injury in patients with transverse lap belt-induced bruises ranges from 15 to 50 percent)
History or mechanism of injury suggestive of intraabdominal injury in a patient with distracting injuries
Initial serum aspartate aminotransferase (AST) >200 IU/L or alanine aminotransferase (ALT) >125 IU/L
Gross or microscopic hematuria (50 red blood cells per high powered field) in otherwise asymptomatic patients
Declining or unexplained hematocrit or hematocrit <30 percent
Unaccountable fluid or blood requirements
Inability to perform adequate abdominal examination or serial abdominal examinations (eg, children younger than two to
three years or those with substance use, head injury, altered sensorium, or planned general anesthesia) in a patient with
history or mechanism suggestive of intraabdominal injury
Positive focused assessment with sonography for trauma (FAST) exam in a stable patient

The general approach to the child with blunt abdominal trauma is the same as for any seriously injured child.
and Hemodynamically stable children with blunt abdominal trauma are usually managed nonoperatively.

Peritoneal lavage Diagnostic peritoneal lavage (DPL) may be useful in the evaluation of a hemodynamically unstable child,
particularly if he or she requires emergent surgery (eg, craniotomy), and time does not permit abdominal CT scan Some surgeons
prefer performance of emergent laparotomy to DPL. DPL is considered positive if

More than 5 mL of gross blood are obtained

 Obvious enteric contents (eg, bile, stool) are obtained
Extravasation of peritoneal lavage fluid from a chest tube or urinary bladder catheter occurs
Lavage fluid contains >100,000 red blood cells or >500 white blood cells per mm3
The amylase concentration of peritoneal lavage effluent is elevated (>175 IU/L) [2.92 nkat/L]

Hemodynamically unstable children not responsive to intravenous crystalloid and blood transfusions warrant emergent
laparotomy.

Laparotomy Indications for immediate laparotomy include supporting evidence of significant intraabdominal injury (based upon
history, physical examination, computed tomography, DPL, or ultrasound) and:

Perforation from a hollow viscus injury demonstrated as pneumoperitoneum

Intraabdominal bleeding of more than the patients blood volume demonstrated as persistent or recurring
hemodynamic instability, despite crystalloid infusion and blood transfusion, especially when accompanied by
abdominal distension. Of note, hemodynamic instability caused by a pelvic fracture frequently warrants treatment other
than laparotomy.
Relative indications for laparotomy include
Increasing abdominal tenderness or peritoneal irritation
Transfusion requirement of greater than 20 mL/kg of packed red blood cells for intraabdominal bleeding

Other indications for laparotomy vary according to the specific injury:

Diagnosis of hollow visceral injury

Solid organ injury with evidence of continued bleeding
Pancreatic injury with major parenchymal or ductal disruption
Management strategies also vary depending on the type of organ injury. (ver ms adelante)

TRAUMATISMO DE VISCERA HUECA.

SUMMARY AND RECOMMENDATIONS

1. Hollow viscus injuries (ie, mesenteric injury; duodenal hematoma; and perforation of the stomach, small intestine, and colon)
result from discrete point of energy transfers, such as those related to inappropriately applied seat belts during motor vehicle
crashes, bicycle handlebars and direct blows. Hollow viscus injury is also frequently observed in abused children.
(See 'Epidemiology' above.)
2. Initial evaluation of pediatric trauma patients should follow the standard Advanced Trauma Life Support (ATLS) protocol,
with life threatening injuries that compromise airway, breathing, and circulation addressed first. Assessment for abdominal
injury should take place as part of the secondary survey.
3. Children who present with hemodynamic instability after blunt abdominal trauma that does not respond to crystalloid
infusion and blood transfusion should undergo exploratory laparotomy without delay. Focused assessment with sonography
for trauma (FAST) may provide diagnostic assistance in these patients.
4. FAST (Focused Assessment with Sonography for Trauma) FAST is a rapid ultrasound examination of four abdominal
locations: right upper quadrant, left upper quadrant, subxiphoid region, and pelvis. The primary utility of this examination for
the unstable trauma patient is the detection of hemopericardium and/or intraperitoneal fluid secondary to intraabdominal
injury (IAI).
5. The presentation of blunt hollow viscus injury is often subtle, and recognition may require a high index of suspicion as well
as hospital observation over time for asymptomatic or minimally symptomatic patients deemed to be at high risk.
 6. For children with stable hemodynamic status, injury mechanism, physical examination, and selected diagnostic studies may
identify or at least raise the clinical suspicion for blunt hollow viscus injury. However, history, physical examination, and
laboratory studies have limited sensitivity and negative predictive value for hollow viscus injury.
7. Abdominal CT is the best imaging test in children with suspected intraabdominal injury.
8. A CT scan in the stable child with a blunt abdominal injury may establish the diagnosis of hollow viscus injury when free air
or extravasated contrast is seen. However, a negative study does not exclude the diagnosis, especially in patients with
concerning physical findings (eg, abdominal tenderness or distension, decreased bowel sounds, or vomiting). Repeated
physical examinations may be the most sensitive tool for identifying hollow viscus injuries in such patients.
9. After the patient has been assessed, resuscitated, and stabilized the child should receive ongoing care directed by a trauma
surgeon with pediatric expertise, when available. Because optimal care and outcomes occur when the critically injured child
is initially resuscitated and subsequently managed in a pediatric trauma center (PTC), it is preferable to provide initial care in
such facilities from the outset, whenever possible, or to arrange transfer to a PTC for ongoing management.
10. Definitive management of children with blunt abdominal trauma who are evaluated for hollow viscus injury depends upon
clinical findings, including hemodynamic status and underlying injury. Appropriate analgesia
(eg morphine 0.1 mg/kg, maximum dose: 10 mg) should be provided both before and after operative care.
11. Diagnosis of a hollow viscus abdominal injury in a child with a questionable mechanism of injury should prompt
involvement of an experienced child protection team (eg, social worker, nurse, subspecialist physician), if available. In many
parts of the world (including the US, UK, and Australia), a mandatory report to appropriate governmental authorities is also
required for suspected child abuse.

SUMMARY AND RECOMMENDATIONS

Liver > spleen injuries are the most common, potentially life-threatening intraabdominal injuries in children who
sustain blunt trauma. Pancreatic injury, which is less common, may result in peritonitis or a pseudocyst if a large
duct is transected.

Clinical findings

Children with liver, spleen, or pancreas injury usually have a history of a direct blow to the trunk over the upper
abdomen (bicycle handlebar, hockey stick jammed between the boards and abdomen, helmet "spearing" in
football) or a high-energy mechanism, such as a high-speed motor vehicle crash or a fall from a great height.
Clinical findings include local pain and tenderness over the upper abdomen, shoulder pain, or signs of shock from
blood loss. Altered mental status or multiple traumatic injuries may mask significant injury to the liver, spleen, or
pancreas.
An initial hematocrit and blood for type and cross are the most essential laboratory studies, especially in children
with signs of hypovolemic shock.
Abdominal CT with intravenous contrast is the single most useful diagnostic test for liver, spleen, and pancreas
injuries. (VER INDICACIONES PARA TAC EN TRAUMA DE ABDOMEN MAS ARRIBA)
When a major pancreatic injury is suspected based upon computed tomography findings, endoscopic retrograde
cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) may be used to
determine whether one of the major pancreatic ducts has been disrupted.

Treatment

The most common error in the management of liver and spleen injuries is failure to recognize life-threatening bleeding at
an early stage. The critical period for bleeding is the first 12 hours after injury. Delayed hemorrhage is a rare event.

We suggest that clinically stable children with isolated liver and spleen injuries, grades I through IV, receive
nonoperative management according to the clinical practice guidelines established by the American Pediatric
Surgical Association
In most children with liver and spleen injuries and in the majority of children with pancreas injuries, complete
healing will occur without any direct intervention. Thus, definitive management consists of hospital admission with
careful and frequent monitoring of vital signs, urine output, and hematocrit.
 The main indication for surgery is massive or continuing blood loss in patients with liver or spleen injury that is
unresponsive to administration of intravenous fluids and blood, or evidence of major parenchymal or ductal
disruption in patients with pancreas injury.

Spleen injury scale (1994 revision)

Grade* Injury type Injury description
I Hematoma Subcapsular, <10 percent surface area

Laceration Capsular tear, <1 cm parenchymal depth

II Hematoma Subcapsular, 10-50 percent surface area; intraparenchymal, <5 cm in diameter

Laceration 1-3 cm parenchymal depth which does not involve a trabecular vessel

III Hematoma Subcapsular, >50 percent surface area or expanding; ruptured subcapsular or parenchymal
hematoma

Intraparenchymal hematoma >5 cm or expanding

Laceration >3 cm parenchymal depth or involving trabecular vessels

IV Laceration Laceration involving segmental or hilar vessels producing major devascularization (>25 percent
of spleen)

V Laceration Completely shattered spleen

Vascular Hilar vascular injury which devascularizes spleen

* Advance one grade for multiple injuries, up to grade III.

Adapted from: Moore, EE, Cogbill, TH, Jurkovich, GJ, et al. Organ injury scaling: spleen and liver (1994 revision). J
Trauma 1995; 38:323.

Liver injury scale (1994 revision)

Grade* Injury type Injury description
I Hematoma Subcapsular, <10 percent surface area

Laceration Capsular tear, <1 cm parenchymal depth

II Hematoma Subcapsular, 10-50 percent surface area

Intraparenchymal, <10 cm in diameter

Laceration 1-3 cm parenchymal depth, <10 cm in length

III Hematoma Subcapsular, >50 percent surface area or expanding; ruptured subcapsular or parenchymal
hematoma

Laceration Intraparenchymal hematoma >10 cm or expanding

>3 cm parenchymal depth

IV Laceration Parenchymal disruption involving 25-75 percent of hepatic lobe or 1-3 Couinaud's segments within
a single lobe
 V Laceration Parenchymal disruption involving >75 percent of hepatic lobe or >3 Couinaud's segments within a
single lobe

Vascular Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major hepatic veins

VI Vascular Hepatic avulsion

* Advance one grade for multiple injuries, up to grade III.

Adapted from: Moore, EE, Cogbill, TH, Jurkovich, GJ, et al. Organ injury scaling: spleen and liver (1994 revision). J
Trauma 1995; 38:323.

Pancreatic organ injury scale

Grade* Injury type Injury description
I Hematoma Minor contusion without duct injury

Laceration Superficial laceration without duct injury

II Hematoma Major contusion without duct injury or tissue loss

Laceration Major laceration without duct injury or tissue loss

III Laceration Distal transection or parenchymal injury with duct injury

IV Laceration Proximal transection or parenchymal injury involving ampulla

V Laceration Massive disruption of pancreatic head

* Advance one grade for multiple injuries to the same organ.

Based on most accurate assessment at autopsy, laparotomy, or radiologic study.
Proximal pancreas is to the patients' right of the superior mesenteric vein.
Reproduced with permission from: Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scalin, II: Pancreas, duodenum,
small bowel, colon, and rectum. J Trauma 1990; 30: 1427. Copyright 1990 Lippincott Williams & Wilkins.

TRAUMA EN NIOS MALTRATADOS (OPCIONAL) LO REVIS AHORA PORQUE NO PIENSO LEERLO DESPUS
XD

SUMMARY

Thoracic, cardiac, abdominal, and retroperitoneal injuries typically occur in the setting of high-impact trauma (ie, a fall from
significant height or a motor vehicle accident [MVA]). When these injuries occur in the absence of such history, inflicted
injury must be suspected.
Inflicted esophageal perforation can result from forced foreign body ingestion, forced caustic ingestion, blunt external
trauma, and penetrating external trauma and may result in esophageal perforation.
Inflicted blunt chest trauma may cause pulmonary laceration, pulmonary contusion, chylothorax, or diffuse alveolar damage.
Child abuse-related cardiac injuries include trauma-induced dysrhythmias and direct cardiac trauma.
Duodenal hematoma, intestinal perforation, and liver or splenic laceration comprise common inflicted abdominal injuries.
The pediatric kidney is particularly vulnerable to abusive blunt trauma because it is relatively larger, located lower in the
abdomen, and has less protective perirenal fat than the adult kidney. The severity of injury ranges from contusion or
subcapsular hematoma to shattered kidney or vascular pedicle avulsion. Besides incurring direct trauma, children with
inflicted injuries may develop acute renal failure resulting from rhabdomyolysis and myoglobinuria secondary to muscle
injury or hypoperfusion.
Diagnosis of a severe esophageal, pulmonary, cardiac, or abdominal injury in a child with a questionable mechanism of
injury should prompt involvement of an experienced child protection team (eg, social worker, nurse, physician with more
 extensive experience in the management of child abuse), if available. In many parts of the world (including the US, UK, and
Australia), a mandatory report to appropriate governmental authorities is also required for cases of suspected child abuse.

TRAUMA ESCROTAL

SUMMARY AND RECOMMENDATIONS

Serious scrotal trauma is rare in children and adolescents. Blunt scrotal trauma is most common in school-age boys and is
typically unilateral. The mechanism of injury often involves compression of the scrotal contents against the pubic bone as a
result of a sports injury or fall. Penetrating scrotal injuries are uncommon in children but can occur from bicycle handlebars,
falls with impalement, and animal bites. In adolescents and young adults, gunshot wounds account for most penetrating
injuries.
Clinical findings that suggest significant scrotal trauma include marked testicular pain, scrotal swelling, laceration into or
through the dartos layer, or a large scrotal hematoma. Blood at the meatus or ecchymosis of the penis, perineum or scrotum
suggest urethral injury.
Boys with significant pain and swelling after scrotal trauma should receive a urinalysis and undergo color Doppler ultrasound
of the scrotum. Retrograde urethrography is indicated for children with suspected urethral injury based on findings such as
blood at the tip of the urethral meatus. Other laboratory studies and imaging should be obtained in children with multiple
trauma according to mechanism of injury and physical findings.
Life-threatening injuries that compromise airway, breathing, or circulation in children with scrotal trauma should be treating
first according to the principles of Advanced Trauma Life Support
Initial management of scrotal includes analgesia and, in patients with penetrating scrotal trauma including human or animal
bites to the scrotum, tetanus prophylaxis, and if indicated, rabies and other viral prophylaxis.
Definitive management of blunt scrotal trauma is based upon the type and extent of injury. For the majority of children, pain
or scrotal swelling is minimal and the testes are normal. For these patients, treatment consists of bed rest, ice packs as
tolerated, supportive underwear (briefs instead of boxers), and nonsteroidal antiinflammatory medications (eg, ibuprofen).
Children with significant testicular pain and scrotal swelling after blunt scrotal trauma warrant prompt scrotal ultrasound and
evaluation by an appropriate surgeon as do patients with the following injuries:

Testicular rupture, fracture, or hematoma

Testicular torsion or dislocation
Hematocele (blood in the tunica vaginalis)
Large scrotal hematoma
Scrotal avulsion

Definitive management of penetrating scrotal trauma depends upon wound depth. Superficial scrotal wounds that only
involve the skin should undergo local wound care and closure with absorbable sutures. Penetrating scrotal trauma into or
through the dartos layer requires surgical exploration.

The scrotal layers from external to internal include the skin, dartos, intercrural fascia, cremaster muscle, infundibulum,
parietal tunica vaginalis, and visceral tunica vaginalis. Superficial lacerations of the scrotum (figure A) should undergo local
wound care and closure with absorbable sutures. Penetrating scrotal trauma to or through the dartos layer (figure B) has a
high rate of associated testicular injury and warrants prompt referral to a urologist for surgical exploration in the operating
room.
We suggest that children with penetrating scrotal injuries receive empiric treatment with parenteral antibiotics (Grade 2C).
Potential regimens for wounds other than bite wounds include ampicillin-sulbactam alone in regions where methicillin-
resistant Staphylococcus aureus (MRSA) is not prevalent or gentamicin combined with clindamycin if coverage for MRSA is
desired or if the patient is allergic to penicillin. Children with human, dog, or cat bites to the scrotum should receive
prophylactic antibiotics tailored to the typical pathogenic organisms isolated from bite wounds
Potential indications for surgical exploration of the scrotum include scrotal wounds into or through the dartos layer; testicular
rupture, fracture, torsion, or dislocation; acute hematocele (blood in the tunica vaginalis); or large scrotal hematomas with
testicular compression.

Genitourinary injury

SUMMARY AND RECOMMENDATIONS

Specific mechanisms lead to injury in different parts of the genitourinary (GU) system. Timely identification and
management of such injuries minimizes associated morbidity, which may include renal insufficiency and
impairment of urinary and sexual function. Significant force is required to injure the kidney and associated
intraabdominal injuries are common. The GU tract is rarely injured in isolation.
Injury identification depends upon a systematic evaluation with consideration of the mechanism of injury, pertinent
physical examination findings, analysis of the urine, and appropriate diagnostic imaging performed in the correct
sequence. Perform a complete physical examination to avoid missing occult injuries.
Investigate for GU injury in a retrograde fashion beginning with evaluation of the external genitalia and urethra
prior to that of the bladder. When urethral injury is suspected and a Foley (ie, bladder or urinary) catheter cannot
be easily placed after a single gentle attempt, perform a retrograde urethrogram. In cases of gross
hematuria or high-risk pelvic fracture, obtain a retrograde cystogram or retrograde CT cystogram to evaluate for
bladder injury. Defer such studies when pelvic angiography is indicated for the diagnosis or management of pelvic
hemorrhage.
Evaluate the ureters and kidneys (ie, upper tract) after lower tract injury is excluded, or after initiation of
appropriate emergency management for an identified lower tract injury. Suspect upper tract injury and obtain an
 IV contrast enhanced CT scan in patients with gross hematuria, microscopic hematuria (3 to 5 RBCs/HPF)
associated with shock, or injuries sustained from rapid deceleration. Obtain additional, delayed CT images (10
minutes after contrast injection) when the initial images are nondiagnostic in cases of suspected collecting system
involvement.
Most patients with significant GU injuries require urgent or emergent urologic consultation. Many patients will
have associated nonurologic injuries that mandate surgical consultation. In the event that appropriate specialists
are unavailable, expeditious transfer to a referral center is indicated after the initial assessment and stabilization.
Do not delay transfer to obtain imaging studies in a patient who is hemodynamically unstable or at risk of
decompensation.

SUMMARY AND RECOMMENDATIONS

Minor head trauma occurs commonly in children. Although associated intracranial injury occurs in a small
percentage of those children who have a normal neurologic examination at presentation, it must be recognized in
order to prevent deterioration and subsequent morbidity or mortality. In addition, inflicted injury must also be
identified because it often results in serious intracranial injury and carries a significant risk of recurrence.
(See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children".)