Canty T G, Canty T G, Brown C
Division of Trauma, Children's Hospital, San Diego, California, USA.
J Trauma. 1999 Feb;46(2):234-40. doi: 10.1097/00005373-199902000-00005.
Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome.
We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome.
The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function.
Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.
儿童钝性创伤所致实体器官损伤的非手术治疗引发了人们对中空脏器损伤诊断可能延迟的关注，这会导致发病率、死亡率上升以及成本增加。这项针对大型儿科创伤数据库的研究将审视与确定性治疗及预后具体相关的诊断困难和/或延迟问题。
我们调查了1985年至1997年期间连续入住某指定儿科创伤中心的11592例患者，以确定有钝性创伤所致胃肠道（GI）损伤记录的儿童。对这些记录进行了广泛分析，特别涉及损伤机制、损伤类型和部位、诊断时间、手术治疗、并发症及最终结局。
共识别出79名儿童，年龄在4个月至17岁之间，其中女性27名，男性52名。损伤机制包括15名系安全带和7名未系安全带的乘客、15名行人、15名受虐儿童、10例自行车车把插入伤、8例腹部离散打击伤、4例自行车与汽车碰撞伤、3例跌倒伤和2例挤压伤。有51处穿孔、6处撕脱伤以及22处较轻损伤，包括挫伤。小肠损伤最为常见，共44例，其次是十二指肠，18例，结肠，17例，胃，6例。45名儿童通过明显的临床体征、平片和/或初始计算机断层扫描结果的组合迅速确诊，这些结果要求进行紧急手术干预。34名儿童的诊断延迟超过4小时，17名儿童延迟超过24小时，诊断是基于持续的临床怀疑，并借助肠壁水肿或不明原因液体的延迟计算机断层扫描结果做出的。6例死亡由严重头部损伤导致。并发症包括2例延迟性脓肿和2例肠梗阻。所有73名幸存者出院时肠道功能均正常。
儿童钝性创伤所致胃肠道损伤并不常见（<1%）。大多数胃肠道损伤（60%）是由离散的能量传递点引起的，如安全带（19%）、车把（13%）、虐待所致打击（19%）或其他打击，这在该人群中是独特的。尽管诊断可能困难且常常延迟，但这并未导致过高的发病率或死亡率。胃肠道损伤的安全有效治疗与儿童钝性腹部创伤相关的大多数其他损伤的非手术治疗兼容，同时降低了非治疗性剖腹手术的风险。
