Notes:
(1) The algorithm relies on the presence or absence of abdominal tenderness in the alert child. The presence of signs suggestive of major intestinal injury are present in children at the time of initial physical examination or shortly thereafter.
(2) An abdominal CT scan does not exclude hollow organ injury.
Steps in Algorithm (Figure 3, page 583)
(1) Is the child:
(1a) stable but obtunded?
(1b) stable and awake/alert?
(1c) hemodynamically unstable?
(2) If the child is stable and obtunded, perform a CT scan.
(2a) If free air is seen on CT scan, perform an exploratory laparotomy.
(2b) If solid organ injury is seen on CT scan, then evaluate (observation, serial examinations, laboratory tests). If a hollow viscus injury is suspected, then perform a diagnostic peritoneal lavage.
(2c) If no solid organ injury is seen on CT scan but free fluid is seen, then evaluate (observation, serial examinations, laboratory tests). If a hollow viscus injury is suspected, then perform a diagnostic peritoneal lavage.
(2d) If no solid organ injury and no free fluid is seen on CT scan, then repeat the abdominal examination and perform an exploratory laparotomy if there are progressive signs and symptoms.
(3) If the child is stable and awake/alert, perform an abdominal examination.
(3a) If the abdomen is non-tender, then repeat the abdominal examination and perform an exploratory laparotomy if there are progressive signs and symptoms.
(3b) If the abdomen is diffusely tender, then perform an exploratory laparotomy.
(3c) If the abdomen is tender in the lower quadrants, then repeat the abdominal examination and perform an exploratory laparotomy if there are progressive signs and symptoms.
(3d) If the abdomen is tender in the upper quadrants, then perform an abdominal CT scan to rule out solid organ injury.
(4) If the person is hemodynamically unstable, perform an exploratory laparotomy.
