Specific considerations

Specific considerations

Spleen There is a risk of splenic pseudoaneurysm after splenic trauma, which is unrelated to the severity of the injury ( Table 19.1 Therefore, a follow-up ultrasound is recommended. Claude Couinaud , 1922–2008, French surgeon and anatomist, described the segmental anatomy of the liver. - - , - - Liver The grades of liver trauma are given in Table 19.2 . Bile leaks ). are rare and often resolve after drainage rather than repair but should be discussed with a paediatric liver surgeon.

Grade Injury type Description of injury I Haematoma Subcapsular,<10% surface area II Laceration Capsular tear,<1 /uni00A0 cm parenchymal depth Haematoma Subcapsular, 10–50% surface area, intraparenchymal,<5 /uni00A0 cm in diameter III Laceration Capsular tear, 1–3 /uni00A0 cm parenchymal depth not involving a trabecular vessel Haematoma Subcapsular,>50% surface area or expanding; ruptured subcapsular or parenchymal haematoma, intraparenchymal haematoma ≥ 5 /uni00A0 cm or expanding IV Laceration >3 /uni00A0 cm parenchymal depth or involving a trabecular vessel Laceration Laceration involving segmental or hilar vessels producing major devascularisation (>25%) V Laceration Completely shattered spleen Vascular Devascularised by a hilar injury TABLE 19.2 Liver injury scale. Grade Injury type Description of injury I Haematoma Subcapsular,<10% surface area Laceration Capsular tear,<1 /uni00A0 cm parenchymal depth II Haematoma Subcapsular, 10–50% surface area, intraparenchymal,<10 /uni00A0 cm in diameter III Haematoma Subcapsular,>50% surface area or expanding; ruptured subcapsular or parenchymal haematoma; intraparenchymal haematoma ≥ 10 /uni00A0 cm or expanding Laceration >3 /uni00A0 cm parenchymal depth or involving a trabecular vessel IV Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Couinaud segments in a single lobe V Laceration Parenchymal disruption involving >75% of hepatic lobe or>3 Couinaud segments within a single lobe Vascular Juxtahepatic venous injuries VI Vascular Hepatic avulsion

Pancreatic trauma may lead to a pancreatic pseudocyst, which requires endoscopic drainage into the stomach. For distal lacerations in the pancreatic tail, some surgeons prefer an early distal pancreatectomy rather than non-operative management. Proximal pancreatic duct injuries in older children can be stented. Renal After severe renal injuries, hypertension can develop, which may need treatment. A dimercaptosuccinic acid (DMSA) scan is used to assess function in those with hypertension or following grade IV or V injuries ( Table 19.3 ). Duodenum A duodenal haematoma has a risk of late perforation, which may be retroperitoneal. Therefore, a second abdominal CT scan or a contrast study should be considered if there is dete rioration or recovery is particularly slow . Bowel There are three mechanisms: the bowel wall may fail instantly if pressure rises rapidly in a trapped loop, it may fail up to 72 /uni00A0 hours after a direct crush injury or it may become ischaemic following a mesenteric injury damaging its blood supply . In straddle injuries and pelvic fractures there may be blood at the urethral meatus. Urethral catheterisation can aggravate a urethral injury , and so a suprapubic catheter should be placed.

TABLE 19.3 Renal injury scale. Grade Injury type Description of injury I Contusion Microscopic or gross haematuria. Normal imaging Haematoma Subcapsular, not expanding and without parenchymal laceration II Haematoma Non-expanding peri-renal haematoma con /f_i ned to the retroperitoneum Laceration <1.0 cm parenchymal depth without extravasation of urine III Laceration

1.0 cm parenchymal depth without collecting system rupture or extravasation of urine IV Laceration Parenchymal laceration extends through the cortex, medulla and collecting system Vascular Main renal artery or vein injury with contained haemorrhage V Laceration Shattered kidney Vascular Avulsion of the renal hilum devascularising the kidney

Specific considerations

Spleen There is a risk of splenic pseudoaneurysm after splenic trauma, which is unrelated to the severity of the injury ( Table 19.1 Therefore, a follow-up ultrasound is recommended. Claude Couinaud , 1922–2008, French surgeon and anatomist, described the segmental anatomy of the liver. - - , - - Liver The grades of liver trauma are given in Table 19.2 . Bile leaks ). are rare and often resolve after drainage rather than repair but should be discussed with a paediatric liver surgeon.

Grade Injury type Description of injury I Haematoma Subcapsular,<10% surface area II Laceration Capsular tear,<1 /uni00A0 cm parenchymal depth Haematoma Subcapsular, 10–50% surface area, intraparenchymal,<5 /uni00A0 cm in diameter III Laceration Capsular tear, 1–3 /uni00A0 cm parenchymal depth not involving a trabecular vessel Haematoma Subcapsular,>50% surface area or expanding; ruptured subcapsular or parenchymal haematoma, intraparenchymal haematoma ≥ 5 /uni00A0 cm or expanding IV Laceration >3 /uni00A0 cm parenchymal depth or involving a trabecular vessel Laceration Laceration involving segmental or hilar vessels producing major devascularisation (>25%) V Laceration Completely shattered spleen Vascular Devascularised by a hilar injury TABLE 19.2 Liver injury scale. Grade Injury type Description of injury I Haematoma Subcapsular,<10% surface area Laceration Capsular tear,<1 /uni00A0 cm parenchymal depth II Haematoma Subcapsular, 10–50% surface area, intraparenchymal,<10 /uni00A0 cm in diameter III Haematoma Subcapsular,>50% surface area or expanding; ruptured subcapsular or parenchymal haematoma; intraparenchymal haematoma ≥ 10 /uni00A0 cm or expanding Laceration >3 /uni00A0 cm parenchymal depth or involving a trabecular vessel IV Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Couinaud segments in a single lobe V Laceration Parenchymal disruption involving >75% of hepatic lobe or>3 Couinaud segments within a single lobe Vascular Juxtahepatic venous injuries VI Vascular Hepatic avulsion

Pancreatic trauma may lead to a pancreatic pseudocyst, which requires endoscopic drainage into the stomach. For distal lacerations in the pancreatic tail, some surgeons prefer an early distal pancreatectomy rather than non-operative management. Proximal pancreatic duct injuries in older children can be stented. Renal After severe renal injuries, hypertension can develop, which may need treatment. A dimercaptosuccinic acid (DMSA) scan is used to assess function in those with hypertension or following grade IV or V injuries ( Table 19.3 ). Duodenum A duodenal haematoma has a risk of late perforation, which may be retroperitoneal. Therefore, a second abdominal CT scan or a contrast study should be considered if there is dete rioration or recovery is particularly slow . Bowel There are three mechanisms: the bowel wall may fail instantly if pressure rises rapidly in a trapped loop, it may fail up to 72 /uni00A0 hours after a direct crush injury or it may become ischaemic following a mesenteric injury damaging its blood supply . In straddle injuries and pelvic fractures there may be blood at the urethral meatus. Urethral catheterisation can aggravate a urethral injury , and so a suprapubic catheter should be placed.

TABLE 19.3 Renal injury scale. Grade Injury type Description of injury I Contusion Microscopic or gross haematuria. Normal imaging Haematoma Subcapsular, not expanding and without parenchymal laceration II Haematoma Non-expanding peri-renal haematoma con /f_i ned to the retroperitoneum Laceration <1.0 cm parenchymal depth without extravasation of urine III Laceration

1.0 cm parenchymal depth without collecting system rupture or extravasation of urine IV Laceration Parenchymal laceration extends through the cortex, medulla and collecting system Vascular Main renal artery or vein injury with contained haemorrhage V Laceration Shattered kidney Vascular Avulsion of the renal hilum devascularising the kidney

Specific considerations

Spleen There is a risk of splenic pseudoaneurysm after splenic trauma, which is unrelated to the severity of the injury ( Table 19.1 Therefore, a follow-up ultrasound is recommended. Claude Couinaud , 1922–2008, French surgeon and anatomist, described the segmental anatomy of the liver. - - , - - Liver The grades of liver trauma are given in Table 19.2 . Bile leaks ). are rare and often resolve after drainage rather than repair but should be discussed with a paediatric liver surgeon.

Grade Injury type Description of injury I Haematoma Subcapsular,<10% surface area II Laceration Capsular tear,<1 /uni00A0 cm parenchymal depth Haematoma Subcapsular, 10–50% surface area, intraparenchymal,<5 /uni00A0 cm in diameter III Laceration Capsular tear, 1–3 /uni00A0 cm parenchymal depth not involving a trabecular vessel Haematoma Subcapsular,>50% surface area or expanding; ruptured subcapsular or parenchymal haematoma, intraparenchymal haematoma ≥ 5 /uni00A0 cm or expanding IV Laceration >3 /uni00A0 cm parenchymal depth or involving a trabecular vessel Laceration Laceration involving segmental or hilar vessels producing major devascularisation (>25%) V Laceration Completely shattered spleen Vascular Devascularised by a hilar injury TABLE 19.2 Liver injury scale. Grade Injury type Description of injury I Haematoma Subcapsular,<10% surface area Laceration Capsular tear,<1 /uni00A0 cm parenchymal depth II Haematoma Subcapsular, 10–50% surface area, intraparenchymal,<10 /uni00A0 cm in diameter III Haematoma Subcapsular,>50% surface area or expanding; ruptured subcapsular or parenchymal haematoma; intraparenchymal haematoma ≥ 10 /uni00A0 cm or expanding Laceration >3 /uni00A0 cm parenchymal depth or involving a trabecular vessel IV Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Couinaud segments in a single lobe V Laceration Parenchymal disruption involving >75% of hepatic lobe or>3 Couinaud segments within a single lobe Vascular Juxtahepatic venous injuries VI Vascular Hepatic avulsion

Pancreatic trauma may lead to a pancreatic pseudocyst, which requires endoscopic drainage into the stomach. For distal lacerations in the pancreatic tail, some surgeons prefer an early distal pancreatectomy rather than non-operative management. Proximal pancreatic duct injuries in older children can be stented. Renal After severe renal injuries, hypertension can develop, which may need treatment. A dimercaptosuccinic acid (DMSA) scan is used to assess function in those with hypertension or following grade IV or V injuries ( Table 19.3 ). Duodenum A duodenal haematoma has a risk of late perforation, which may be retroperitoneal. Therefore, a second abdominal CT scan or a contrast study should be considered if there is dete rioration or recovery is particularly slow . Bowel There are three mechanisms: the bowel wall may fail instantly if pressure rises rapidly in a trapped loop, it may fail up to 72 /uni00A0 hours after a direct crush injury or it may become ischaemic following a mesenteric injury damaging its blood supply . In straddle injuries and pelvic fractures there may be blood at the urethral meatus. Urethral catheterisation can aggravate a urethral injury , and so a suprapubic catheter should be placed.

TABLE 19.3 Renal injury scale. Grade Injury type Description of injury I Contusion Microscopic or gross haematuria. Normal imaging Haematoma Subcapsular, not expanding and without parenchymal laceration II Haematoma Non-expanding peri-renal haematoma con /f_i ned to the retroperitoneum Laceration <1.0 cm parenchymal depth without extravasation of urine III Laceration

1.0 cm parenchymal depth without collecting system rupture or extravasation of urine IV Laceration Parenchymal laceration extends through the cortex, medulla and collecting system Vascular Main renal artery or vein injury with contained haemorrhage V Laceration Shattered kidney Vascular Avulsion of the renal hilum devascularising the kidney