Early Recognition and Operative Intervention Can Increase

Survival for Pediatric Trauma Patients

Debbi Thomson MSN, CPNP
Department of General Surgery, Brenner Childrens Hospital, Winston-Salem, NC

Case Study

Abdominal Compartment Syndrome

A 6 year old girl was an unrestrained passenger in a MVC.

She was found 15 minutes after the crash, unresponsive on
the floorboard of the back seat of the car. She was brought
to the hospital by EMS as a Level I trauma code.

Injured children receive fluid resuscitation and are susceptible to capillary leak and thirdspacing in the abdomen. Edema in the abdominal cavity (including the intestines,
retroperitoneum, and other organs) increased intra-abdominal pressure (IAP) Increased
IAP compresses the inferior vena cava. Blood flow into the heart is decreased to renal
and mesenteric ischemia, followed by poor tissue perfusion and multiple organ failure.

Multiple traumatic injuries included:

Right parietal skull fracture with small extra-axial
hemorrhage
Bilateral pulmonary contusions, right hemothorax
Multiple thoracic spine fractures, T6-8 vertebral body
fractures with epidural hematoma, perched facet T10-T11
Liver laceration, grade 2, retroperitoneal hematoma,
possible duodenal or pancreatic contusions on CT scan
Right proximal femur fracture
Difficult Intubation
Admitted to PICU, intubated and mechanically ventilated
with bilateral chest tubes, NG tube, foley catheter

Abdominal Compartment Syndrome (ACS ) in children is a sustained

elevation in IAP of greater than 10mm Hg associated with new or
worsening organ dysfunction (World Society of Abdominal
Compartment Syndrome). It is infrequently reported, rapidly progressive
and underappreciated in the pediatric population . It is associated with
90 to 100% mortality if not recognized and treated promptly.

Decompressive Laparotomy
Surgical decompressive laparotomy (DL) with open abdomen management for ACS is the
definitive treatment of choice when medical and less invasive therapies have failed. Its use
has shown improvement in organ function and mortality. DL improves respiratory mechanics,
restores abdominal organ perfusion, and venous return to the heart.

Assessment
After several hours in PICU:
Vital Signs: 97.1 F P 161 RR 21
BP: 75/34 SPO2: 87% FiO2: 100%
On oscillator Lactic acid 2.9
Difficult to oxygenate & ventilate
Abdomen distended
Bladder pressure = 20 mm Hg
Urine output: 0.3ml/kg/hr

Measuring Abdominal Pressure

Bladder Pressure Monitoring via a Urinary
Catheter
Used to measure intra-abdominal hypertension
(IAH)
Connect valve to urinary catheter
Level the pressure transducer at the iliac crest
at the mid-axillary line
Infuse normal saline into the system as
recommended
The transducer will pick up the waveform and
measure the intra-abdominal pressure.
Abviser by Convatec

Surgery in the PICU

Surgery at the bedside in the PICU was performed by Kristen Zeller, M.D. After induction of
anesthesia, a midline laparotomy incision was made from the xiphoid to the pubis.
Approximately 600 ml of thin serosanguinous fluid was evacuated from the abdomen. The
bowel was edematous but viable. No bowel injury was identified. There was no evidence of
hemorrhage. There was oozing from the inferior edge of the right lobe of the liver, which
was controlled with packing. The fluid warmer drape was cut and perforated to act as a
bowel bag over the abdominal viscera. A green towel was placed over the bowel bag. The
dressing was secured with an Ioban drape and placed to suction using a track pad and
negative pressure wound therapy. A good seal was obtained . The patients oxygen
saturations and blood pressure had dramatically improved after opening her abdomen. She
remained in the ICU in critical condition.

Hospital Course

References

The abdominal negative pressure wound dressing was changed at the bedside in the
PICU 2 days following surgery.
4 days later the abdomen was closed in the operating room & an open reduction &
internal fixation (ORIF) of the right femur was done by Orthopedic Surgery
On hospital day 8 she was extubated
Transferred to intermediate care, then to general pediatric unit.
Worked with physical and occupational therapy and nutrition (enteral feeding tube for 2
weeks)
Discharged to home on hospital day 17 with cervical collar, thoraco-lumbar-sacral brace
s/p surgical repair to right leg and cast to left arm

1. Carr, JA. Abdominal compartment syndrome: a decade

of progress. Journal of the American College of Surgeons
(2013) Elsevier.
2. DeCou et al. Abdominal compartment syndrome in children: experience with three cases. Journal of
Pediatric Surgery (2000) 36 (6) 840-842.
3. Ejike, JC & Mathur, M. Abdominal decompression in children. Critical Care Research and Practice
(2012)
4. Gutierrez, IM & Collin G. Negative pressure wound therapy for children with an open abdomen.
Langenbecks Archives of Surgery (2012) 397: 1353-1357.
5. Kirkpatrick, AW et al. Intra-abdominal hypertension and the abdominal compartment syndrome:
updated consensus definitions and clinical practice guidelines from the World Society of the
Abdominal Compartment Syndrome. Intensive Care Medicine (2013) 39 (7) 1190-1206.
6. Neville HL, Lally KP, Cox CSJ. Emergent abdominal decompression with patch abdominoplasty in
the pediatric patient. Journal of Pediatric Surgery (2000) 35: 705-8.
7. Newcombe, J, Mather, M & Ejike, C. Abdominal compartment syndrome in children Critical Care
Nursing (2012) 32(6) 51-61.
8. Pearson, EG et al. Decompressive laparotomy for abdominal compartment syndrome in children:
before it is too late. Journal of Pediatric Surgery (2010) 45, 1324-29.
9. Spencer, P, Kinsman, L & Fuzzard, K. A critical care nurses guide to intra-abdominal hypertension
and abdominal compartment syndrome. Austrian Critical Care (2008) 21, 18-28.

Conclusions
ACS is a potentially lethal condition in pediatric trauma patients who are severely injured
or receive large volume fluid resuscitation
ACS must be recognized early
IAP should be closely followed and measured accurately
RNs can be the first to recognize IAH and the progression of patients to ACS
Consider surgical decompressive laparotomy in any child with lactate> 3 mg/dL,
persistent oliguria, elevated ventilatory pressures, and a rising bladder pressure
Abdominal decompression appears to have a positive effect on patient survival

Photos used with written consent from parent on file