Pediatric Blunt Abdominal Aortic Trauma

Abstract

A ortic injury is a rare finding after blunt traumatic injury in children. Ninety-five percent of aortic injuries in blunt trauma occur in the thorax just distal to the left subclavian artery, at the junction of the tethered and mobile segments of the aorta. 1 Feczko, in an autopsy case review of 142 blunt injuries of the aorta, noted that only 6% were found in the abdominal segment. 2 Only 10 cases of blunt injuries to the abdominal aorta in the pediatric age group were identified in a review of the English language literature since 1960. We report a case with discussion on the clinical and radiologic findings, and the available treatment options. CASE REPORTA 9-year-old boy was brought to our Level I pediatric trauma resource center after a bicycle versus motor vehicle crash. The child had hit the front end of the vehicle and sustained injury to his abdomen. His primary survey revealed no cardiorespiratory instability (pulse of 90 bpm, a blood pressure of 90/60 mm Hg, and respirations of 22 breaths/min) and a Glasgow Coma Score (GCS) of 15. On secondary survey, his abdominal examination revealed a large bruise across the midportion of the abdomen. There was no distension, tenderness (except over the bruise) or guarding. His pelvis was stable, and he had palpable peripheral pulses, with ankle brachial indices (ABIs) of 1.0 bilaterally and no distal neurologic deficit. His hemoglobin at admission was 12.2 g/dL with a hematocrit of 36%. His medical history was significant for attention deficit disorder and an inpatient admission 6 months earlier for blunt abdominal trauma, caused by a handlebar injury, where he had contused his pancreatic parenchyma. A computed tomography (CT) scan (Fig 1) of the abdomen was obtained. It showed a localized dissection of the infrarenal aorta with an intimal flap. In addition it showed a large abdominal wall bruise and a Grade I laceration of the liver. In addition, there was a localized dissection of the infrarenal aorta with an intimal flap. The distal aorta demonstrated normal caliber and contrast opacification. Review of the CT done 6 months earlier revealed a pancreatic injury, and showed an intimal flap that had been missed. A magnetic resonance (MR) angiogram demonstrated a nearly 50% narrowing of the aorta at the site of injury with preserved flow distally (Fig 2). Considering the stable nature of the lesion during a period of 6 months, we elected a conservative strategy of observation in the intensive care unit, with serial hematocrits, ABIs, and clinical examination. The patient remained stable for 72 hours and was commenced on a regular diet before discharge. A vascular ultrasound examination performed before discharge demonstrated the intimal flap. A follow-up vascular ultrasound examination performed at 18 months showed a stable intimal flap and no pseudoaneurysm formation (Fig 3).

Aortic bifurcation rupture after blunt abdominal trauma in a child: a case report

“…Intraabdominal injury was present in about two thirds of patients with abdominal aortic injury with the bowel being affected in nearly 50% [1,4]. Vertebral body fractures (Chance fractures) were present in 4 patients and nerve damage in 7 of the 18 previously reported cases.…”

“…Since 1966, only 18 cases of blunt abdominal aortic injury have been reported in children [1][2][3][4][5][6]. Most of these injuries occurred in children between the ages of 2 and 13 years with only 2 cases of blunt aortic trauma in children younger than 2 years [5,6].…”

“…Traumatic pseudoaneurysm, the most commonly reported injury, often presents late and may remain asymptomatic for weeks or even months [10]. Significant lesions such as flow-limiting intimal flaps with secondary aortic thrombosis, aortic transection, or free aortic rupture usually present immediately after the injury with signs of significant vascular insufficiency and lower extremity paralysis [1]. Reflecting the range of actual lesions after blunt aortic trauma, only 40% of children have decreased or absent pulses in the lower extremities after blunt abdominal aortic injury [11].…”

A case study involving a blunt abdominal trauma leading to disruption of the aortic bifurcation in an infant

“…12 Unlike the rigid atherosclerotic aorta observed in adults, in children and infants the aorta is elastic, and therefore resistant to greater shear forces. 5 The different responses of the abdominal aorta and the iliac arteries to extrinsic compression cause disruption at the point of greatest stress, the bifurcation. Therefore, rupture of the aortic bifurcation in a 5-year-old child must involve great pressure exerted against the lumbar and sacral vertebrae.…”

“…1 Descriptions of a total of 21 cases of abdominal aortic trauma in children were published from 1966 to 2012 and most of these cases involved motor vehicle collisions. [2][3][4][5][6][7][8] Clinical presentations ranged from stable and asymptomatic patients to cases with rupture and hypovolemic shock.…”