21/1/2024

[drsamreen]

D
persistent tachy calls for exploration after optimization

[Muhammad uzair]

B

[[email protected]]

D

[Dr Lu]

D

[Admin]

correct answer
D Exploratory laparotomy/laparoscopy.

Blunt abdominal trauma is a relatively common source of traumatic injury in the pediatric patient. Most commonly, one sees injuries to the solid organs including the spleen, liver and kidney that may be treated nonoperatively based upon the grade of injury and clinical status of the patient. Injuries to the small intestine and mesentery are less commonly encountered but are treated operatively. These injuries may be missed on clinical exam due to the confounding findings of a seatbelt sign or other abdominal wall contusions. Additionally, patients may not present with peritonitis. CT scan has been shown to be effective in evaluating evidence of intestinal or mesenteric injuries with Graham and Wong commenting that it is a sensitive tool for the evaluation of intra-abdominal injury in children. Pneumoperitoneum, extraluminal oral contrast and evidence of mesenteric ischemia are clear signs of bowel or mesenteric injury. However, other findings may be more subtle and need to be recognized by the clinician on imaging. These findings include bowel wall thickening, mesenteric stranding, fluid at the mesenteric root, focal hematoma, and mesenteric pseudoaneurysm. Additionally, free fluid may be found in many trauma patients. A report in 2014 recommended that adult patients with blunt trauma who have moderate to large amounts of free fluid without solid organ injury on CT but have abdominal tenderness should undergo immediate operative exploration. They noted patients with neither of these findings may be observed.

Hounsfield units (HU) are a relative measure of radiodensity and can aid in the distinction of materials on CT, from soft tissue to blood to various fluids. For fluids, the density is largely dependent on the iron content of blood; therefore, plasma (iron-poor) will be hypodense and be associated with a much lower Hounsfield Unit than active bleeding. Uncoagulated blood typically measures 30 to 45 HU. Clotted (or concentrated) blood measures higher at 60 to 100 HU. Separated serum plasma is closer to water at 0 to 20 HU. Finally, ascites also has a Hounsfield measurement of around 0 to 20 HU. Recently, Perea et al. noted that pediatric patients with blunt trauma with isolated intraperitoneal free fluid with HU Units of 25 or less seen on CT and a non-peritonitic physical exam did not require operative exploration or further workup for intra-abdominal injury. Thus for patients with simple fluid as measured by Hounsfield units, observation with serial abdominal exams may be an appropriate option. The patient described has evidence of intra-abdominal bleeding with no obvious source and should undergo exploration for a possible bowel or mesenteric injury. This can be accomplished through laparoscopy or laparotomy.