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The Management of Blunt Trauma to the Abdomen in Infancy and Childhood
The Management of Blunt Trauma to the Abdomen in Infancy and Childhood FREDERICK LEIX, M.D., F.A.C.S.* E. M. GREANEY, JR., M.D., F.A.C.S. ** SHERMAN W. HARTMAN, M.D., F.A.C.S.*** PAUL W. JOHNSTON, M.D., F.A.C.S.** PAUL C. DOEHRING, M.D., F.A.C.S.**
The purpose of this discussion is to review the management of blunt abdominal trauma in infancy and childhood with comments on current practice. For obvious reasons, blunt trauma occurs more frequently than penetrating injuries, such as bullet or stab wounds, in the younger age group. During the years, 1964 to 1967, 47 such patients between the ages of two months and 14 years have been treated on the Pediatric Surgical Service of the Los Angeles County-University of Southern California Medical Center, with four deaths. The incidence of severe nonpenetrating trauma to the abdomen increases with the age of the child. Birth trauma resulting in hemorrhage from the liver or spleen is rare; however, hepatic hemorrhage in stillbirths and neonatal deaths comprises from 1.2 to 5.3 per cent in large series. 13 A history of difficult delivery and a pallid, flaccid neonate with a reduction in hemoglobin from the normal of 18 gm./100 ml. to half that value should alert the physician to the possibility of major
From (1) the Department of Surgery, University of Southern California School of Medicine, and (2) the Pediatric Surgical Service, Los Angeles County-University of Southern California Medical Center, Los Angeles, California *Clinical Professor of Surgery (1); Senior Attending Physician, General Surgery (2) **Assistant Clinical Professor of Surgery (1); Attending Physician, General Surgery (2) ***Instructor in Surgery (1); Attending Physician, General Surgery (2)
Surgical Clinics of North America- Vol. 48, No.6, December, 1968
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LEIX, GREANEY ]R., HARTMAN, jOHNSTON, DOEHRING
organ fracture. Subcapsular hematoma may result in a palpable mass, or abdominal roentgenograms may suggest the presence of free fluid. The causes of hemorrhage such as fetal, placental, and umbilical cord, or bleeding into the maternal circulation and bleeding into the circulation of a twin are considered with hemolytic disease in differential diagnosis. There are few differences in principle or practice in dealing with the problem of blunt abdominal trauma in children or adults. The major differences from a practical standpoint are: (1) Smaller blood volume increases the chance of undertransfusing or overtransfusing; in either case, circulatory failure might result. (2) The size of the structures to be repaired is at times so small that reconstruction is difficult or impossible. Obviously a two-year-old child with fracture of the femur and hemoperitoneum of 300 to 400 cc. due to ruptured spleen presents a problem in urgent diagnosis and treatment more pressing than the similar situation in an adult.
A PLAN OF ACTION As an example that may be used to document the plan of action necessary for optimal management of a critically injured child, this picture is presented: A young mother frantically enters an emergency room carrying her 40 pound 21f2-year-old child. A tire mark is evident over his right lower chest and left upper abdomen. The child is pale and tachypneic with grunting respirations. 1. The presence of a clear airway and the absence of a tension pneumothorax must be established. A life-threatening pneumothorax is detected by tympany and absent breath sounds on the affected side with shift of the heart to the opposite side of the chest. Appropriate decompression is instituted through the second anterior intercostal space using a Foley catheter, a plastic tube (Intracath), or a needle attached to intravenous tubing and placed under water as a seal. 2. A reliable conduit for intravenous fluid administration is established in the great saphenous vein at the ankle. In some instances we prefer two channels (a) to provide safety in the event that one becomes obstructed by thrombus, kinking or penetration of the vein wall, and (b) to maintain repletion should temporary obstruction of the inferior vena cava be necessary during operation. The second catheter is placed in the superior vena cava through a cutdown exposing a median vein above the antecubital fossa. Percutaneous puncture of the subclavian vein is a more hazardous method of placing a catheter in the superior vena cava. In either instance, the central venous pressure is recorded and monitored. High levels, above 12 to 16 em., may indicate heart failure or hypervolemia requiring urgent treatment. Lower levels are considered normal. 3. Five per cent dextrose in normal saline or Ringer's lactate to which a broad-spectrum antibiotic such as Kanamycin has been added,
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is infused. Alternate solutions are dextran or plasma substitutes (Albumisol, Plasmanate or 5 per cent albumin) as volume expanders. In some circumstances "0" negative blood must be used while results of typing and crossmatching are awaited. 4. Blood is drawn for typing, crossmatching, and complete blood cell count. Blood amylase level and baseline electrolyte values are requested. 5. Vital signs are recorded and physical examination of the abdomen continues. Tenderness and peristaltic activity are recorded. Evidence of multiple injuries is explored; these occur commonly. 6. A Foley catheter is inserted in the bladder. This serves three purposes: (a) urine output is an index of hypovolemia, (b) a specimen is obtained for urinalysis, and (c) a means for doing a cystogram is accomplished. 7. A nasogastric tube is passed to treat gastric dilatation and prevent aspiration, reveal blood in the stomach contents, and provide the means for doing gastroduodenography using an aqueous contrast material. 8. Tetanus toxoid is administered. If there has been no previous active immunization, human antitoxin is given. 9. Continuing hemorrhage requires immediate operation without further diagnostic procedures. If shock responds to treatment and the patient's vital signs become stable, further diagnostic modalities may be utilized. The most important of these is roentgenography. Prior to moving the child to the x-ray unit, Hypaque is given intravenously so that the initial scout film of the abdomen will be a screening pyelogram, as concomitant genitourinary tract injury is not unusual. An abdominal series of films including an upright of the chest and abdomen and a flat film of the abdomen is obtained. Lateral decubitus films may be impractical because of lack of cooperation of the patient. Both free and extraperitoneal gas is searched for in the films; the latter often occurs in retroperitoneal duodenal injury. 10. One surgeon must assume responsibility for the patient. Continuous close observation by the same responsible surgeon and careful recording of pulse rate, respiratory rate, blood pressure, abdominal findings and hematocrit are the most valuable diagnostic aids in formation of a decision to explore the abdomen. Another method used in diagnosis is the four-quadrant peritoneal tap. We use the tap in unconscious patients when intraperitoneal injury is suspected and occasionally employ it in borderline patients when additional evidence for or against the need for abdominal exploration is required. Another method utilizing a polyethylene catheter and instilling fluid with subsequent aspiration and microscopic examination has not been utilized at this hospital. 11. Angiography for delineation of major organ disruption has not been used extensively in our hospital. Freeark4 and others have reported good results. After all diagnostic methods have been utilized, a decision must be made by the responsible clinician. If surgery is performed, approximately 15 per cent of laparotomies will not disclose a ruptured viscus. 18 In these instances, the findings may have been caused by abdominal wall contusion or minimal extraperitoneal hematoma.
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LEIX, GREANEY
]R., HARTMAN, jOHNSTON, DOEHRING
12. With blood volume reconstituted and blood available, the patient is transferred to the operating room, placed on a cassete, and x-ray personnel are alerted for cholangiographic studies. These are done to determine the integrity of the biliary system and to pinpoint injuries. If these preparations are not made, valuable time will be lost.
INTRAOPERATIVE MANAGEMENT ANESTHESIA. We use endotracheal anesthesia in all instances. When necessary, intubation may be done awake in infants and in patients with full stomachs. INCISION. Either a transverse supraumbilical or midline vertical incision may be used effectively. The incision, however, must be adequate for rapid, thorough examination of the abdominal contents. GASTROINTESTINAL INJURIES. Stomach rupture is treated by simple closure. Duodenal intramural hematoma is evacuated by serosal incision and the area is drained. Duodenal perforation, if not extensive, is closed primarily. If there is a leak postoperatively, immediate reoperation is required. With extensive duodenal injury or leak, primary gastrojejunostomy, tube duodenostomy, and drainage of the perforation repair, as for reperforation, may be necessary. Small bowel and mesenteric injuries are debrided and repaired. If they are extensive, resection and anastomosis should be performed. Large bowel injuries are exteriorized, if possible. If a wound is closed, proximal colostomy is carried out. RETROPERITONEAL INJURIES. Expanding hematoma in the region of the kidney should be explored. Hematoma in the kidney region should not be explored unless the intravenous pyelogram shows transection of the ureter or complete absence of function; the latter may indicate renal artery transection. Ureteral injuries are repaired over a catheter splint. Bladder injuries are sutured and an indwelling catheter is left in place for 10 to 12 days. Hematoma in the region of the aorta and vena cava should be explored. Injuries to the great vessels should be repaired using vascular techniques. HEPATOBILIARY INJURIES. Most liver injuries are best treated by debridement and suture with drainage. Drainage of the biliary tract should also be done. In this age group, cholecystostomy is usually performed because of the small caliber of the common duct. Massive liver injuries are treated by lobectomy using techniques referred to elsewhere in this issue, through thoraco-abdominal incisions. Injury to the hepatic veins requires special techniques to control hemorrhage while lobectomy and repair of the vena cava are accomplished. A shunt technique through the right auricle has recently been described by Schrock, Blaisdell, and Mathewson. 15 Although we have had no experience with this method, we feel that this general approach is necessary to prevent exsanguination. Injuries to the biliary tract must be anticipated and searched for. A cholangiogram is obtained to detect and delineate injuries to the ductal system. Perforation of the gallbladder is treated by cholecystectomy.
BLUNT TRAUMA TO THE ABDOMEN IN INFANCY AND CHILDHOOD
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Duct'injuries are repaired over aT-tube. If the lumen is too small and there is continuity of the wall but not of the lumen, a splint of polyethylene may be used. This is passed through the ampulla of Vater and brought out through the duodenum and the abdominal wall. SPLEEN AND PANCREAS. Splenectomy should always be performed for hemorrhage from the spleen. On occasion the use of a noncrushing clamp across the splenic pedicle to control hemorrhage will facilitate rapid mobilization and removal of the spleen. Pancreatic injuries are treated by resection of the traumatized portion, when distal. Penrose drains are placed near the sutured pancreas. DIAPHRAGM. Traumatic rupture of the diaphragm is approached through the abdomen. This facilitates adequate exploration of the abdomen and allows for good repair of the injury.
SUMMARY AND CONCLUSIONS The management of a child with severe blunt trauma injury to the abdomen is presented. Continued observation and assumption of responsibility for treatment of the injured child should, ideally, be undertaken by a surgeon experienced in trauma, with consultants as necessary. Continuing clinical observation by the same responsible surgeon is the most valuable diagnostic tool. Preparation for massive blood volume replacement, if needed, is the key to successful management. The awareness of the surgeon of the lesions most commonly overlooked will prevent tragic errors. A bold, accurate surgical attack on specific lesions will save lives. The dictum, "if in doubt-operate," should be followed, particularly in infants and children because the margin of permissible error is small.
REFERENCES 1. Arcari, F. A.: Blunt abdominal trauma in infants and children. J. Mich. Med. Soc., 61:335, 1962. 2. D'Ambrosio, G., Guglielmi, M., and Vecchioni, R.: Infarction of the ascending colon due to closed trauma of the abdomen. Riv. Anat. Pat., 22:939, 1962. 3. Dargan, E. L., Steichen, F. M., Pearlman, D. M., and Wei!, P. H.: Newer concepts in the management of penetrating abdominal trauma. J. Nat. Med. Assoc., 59:198, 1967. 4. Freeark, R. J., Shoemaker, W. C., and Baker, R. J.: Aortography in blunt abdominal trauma. Arch. Surg., 96:705, 1968. 5. Giugiaro, A., and Grassi, E.: Intestinal occlusion due to post-traumatic intramural hematoma. Minerva Pediat., 19:1505, 1967. 6. Gumbert, J. L., Froderman, S. E., and Mercho, J.P.: Diagnostic peritoneal lavage in blunt abdominal trauma. Ann. Surg., 165:71, 1967. 7. Hartman, S. W., and Greaney, E. M., Jr.: Traumatic injuries to the biliary system in children. Amer. J. Surg., 108:150, 1964. 8. Miller, R. E., and Rhamy, R. K.: Acute perforation in infants. Surg., Gynec. Obstet., 117: 61, 1963. 9. Nelson, J. F.: The roentgenologic evaluation of abdominal trauma. Radio!. Clin. N. Amer., 4:415, 1966. 10. Nicholson, R., and Golden, G.: Blunt abdominal trauma in head injuries. The Lancet, 793, 1966. 11. Nick, W. V., Zollinger, R. W., and Pace, W. G.: Retroperitoneal hemorrhage after blunt abdominal trauma. J. Trauma, 7:652, 1967. 12. Pfahler, R.: Blunt trauma of the abdomen in childhood. Zbl. Chir., 84:1767, 1959. 13. Schaffer, A. J.: Diseases of the Newborn. Philadelphia, W. B. Saunders Co., 1960, p. 515. 14. Scharli, A.: Blunt abdominal trauma in childhood. Chir. Praxis, 11 :461, 1967.
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LEIX, GREANEY JR., HARTMAN, jOHNSTON, DOEHRING
15. Schrock, T., Blaisdell, F. W., and Mathewsen, C., Jr.: Management of blunt trauma to the liver and hepatic veins. Arch. Surg., 96:698, 1968. 16. Shaw, A., and Cinque, S.: Traumatic intramural hematoma. Amer. J, Dis. Child., 108: 667, 1964. 17. Weitzman, J. J., and Swenson, 0.: Traumatic rupture of the pancreas in a toddler. Surgery, 57:309, 1965. 18. Williams, R. D., and Zollinger, R. W.: Diagnostic and prognostic factors in abdominal trauma. Amer. J. Surg., 97:575, 1959. 3751 Stocker Street Los Angeles, Califomia 90008 (Dr. Leix)
The purpose of this discussion is to review the management of blunt abdominal trauma in infancy and childhood with comments on current practice. For obvious reasons, blunt trauma occurs more frequently than penetrating injuries, such as bullet or stab wounds, in the younger age group. During the years, 1964 to 1967, 47 such patients between the ages of two months and 14 years have been treated on the Pediatric Surgical Service of the Los Angeles County-University of Southern California Medical Center, with four deaths. The incidence of severe nonpenetrating trauma to the abdomen increases with the age of the child. Birth trauma resulting in hemorrhage from the liver or spleen is rare; however, hepatic hemorrhage in stillbirths and neonatal deaths comprises from 1.2 to 5.3 per cent in large series. 13 A history of difficult delivery and a pallid, flaccid neonate with a reduction in hemoglobin from the normal of 18 gm./100 ml. to half that value should alert the physician to the possibility of major
From (1) the Department of Surgery, University of Southern California School of Medicine, and (2) the Pediatric Surgical Service, Los Angeles County-University of Southern California Medical Center, Los Angeles, California *Clinical Professor of Surgery (1); Senior Attending Physician, General Surgery (2) **Assistant Clinical Professor of Surgery (1); Attending Physician, General Surgery (2) ***Instructor in Surgery (1); Attending Physician, General Surgery (2)
Surgical Clinics of North America- Vol. 48, No.6, December, 1968
1265
1266
LEIX, GREANEY ]R., HARTMAN, jOHNSTON, DOEHRING
organ fracture. Subcapsular hematoma may result in a palpable mass, or abdominal roentgenograms may suggest the presence of free fluid. The causes of hemorrhage such as fetal, placental, and umbilical cord, or bleeding into the maternal circulation and bleeding into the circulation of a twin are considered with hemolytic disease in differential diagnosis. There are few differences in principle or practice in dealing with the problem of blunt abdominal trauma in children or adults. The major differences from a practical standpoint are: (1) Smaller blood volume increases the chance of undertransfusing or overtransfusing; in either case, circulatory failure might result. (2) The size of the structures to be repaired is at times so small that reconstruction is difficult or impossible. Obviously a two-year-old child with fracture of the femur and hemoperitoneum of 300 to 400 cc. due to ruptured spleen presents a problem in urgent diagnosis and treatment more pressing than the similar situation in an adult.
A PLAN OF ACTION As an example that may be used to document the plan of action necessary for optimal management of a critically injured child, this picture is presented: A young mother frantically enters an emergency room carrying her 40 pound 21f2-year-old child. A tire mark is evident over his right lower chest and left upper abdomen. The child is pale and tachypneic with grunting respirations. 1. The presence of a clear airway and the absence of a tension pneumothorax must be established. A life-threatening pneumothorax is detected by tympany and absent breath sounds on the affected side with shift of the heart to the opposite side of the chest. Appropriate decompression is instituted through the second anterior intercostal space using a Foley catheter, a plastic tube (Intracath), or a needle attached to intravenous tubing and placed under water as a seal. 2. A reliable conduit for intravenous fluid administration is established in the great saphenous vein at the ankle. In some instances we prefer two channels (a) to provide safety in the event that one becomes obstructed by thrombus, kinking or penetration of the vein wall, and (b) to maintain repletion should temporary obstruction of the inferior vena cava be necessary during operation. The second catheter is placed in the superior vena cava through a cutdown exposing a median vein above the antecubital fossa. Percutaneous puncture of the subclavian vein is a more hazardous method of placing a catheter in the superior vena cava. In either instance, the central venous pressure is recorded and monitored. High levels, above 12 to 16 em., may indicate heart failure or hypervolemia requiring urgent treatment. Lower levels are considered normal. 3. Five per cent dextrose in normal saline or Ringer's lactate to which a broad-spectrum antibiotic such as Kanamycin has been added,
BLUNT TRAUMA TO THE ABDOMEN IN INFANCY AND CHILDHOOD
1267
is infused. Alternate solutions are dextran or plasma substitutes (Albumisol, Plasmanate or 5 per cent albumin) as volume expanders. In some circumstances "0" negative blood must be used while results of typing and crossmatching are awaited. 4. Blood is drawn for typing, crossmatching, and complete blood cell count. Blood amylase level and baseline electrolyte values are requested. 5. Vital signs are recorded and physical examination of the abdomen continues. Tenderness and peristaltic activity are recorded. Evidence of multiple injuries is explored; these occur commonly. 6. A Foley catheter is inserted in the bladder. This serves three purposes: (a) urine output is an index of hypovolemia, (b) a specimen is obtained for urinalysis, and (c) a means for doing a cystogram is accomplished. 7. A nasogastric tube is passed to treat gastric dilatation and prevent aspiration, reveal blood in the stomach contents, and provide the means for doing gastroduodenography using an aqueous contrast material. 8. Tetanus toxoid is administered. If there has been no previous active immunization, human antitoxin is given. 9. Continuing hemorrhage requires immediate operation without further diagnostic procedures. If shock responds to treatment and the patient's vital signs become stable, further diagnostic modalities may be utilized. The most important of these is roentgenography. Prior to moving the child to the x-ray unit, Hypaque is given intravenously so that the initial scout film of the abdomen will be a screening pyelogram, as concomitant genitourinary tract injury is not unusual. An abdominal series of films including an upright of the chest and abdomen and a flat film of the abdomen is obtained. Lateral decubitus films may be impractical because of lack of cooperation of the patient. Both free and extraperitoneal gas is searched for in the films; the latter often occurs in retroperitoneal duodenal injury. 10. One surgeon must assume responsibility for the patient. Continuous close observation by the same responsible surgeon and careful recording of pulse rate, respiratory rate, blood pressure, abdominal findings and hematocrit are the most valuable diagnostic aids in formation of a decision to explore the abdomen. Another method used in diagnosis is the four-quadrant peritoneal tap. We use the tap in unconscious patients when intraperitoneal injury is suspected and occasionally employ it in borderline patients when additional evidence for or against the need for abdominal exploration is required. Another method utilizing a polyethylene catheter and instilling fluid with subsequent aspiration and microscopic examination has not been utilized at this hospital. 11. Angiography for delineation of major organ disruption has not been used extensively in our hospital. Freeark4 and others have reported good results. After all diagnostic methods have been utilized, a decision must be made by the responsible clinician. If surgery is performed, approximately 15 per cent of laparotomies will not disclose a ruptured viscus. 18 In these instances, the findings may have been caused by abdominal wall contusion or minimal extraperitoneal hematoma.
1268
LEIX, GREANEY
]R., HARTMAN, jOHNSTON, DOEHRING
12. With blood volume reconstituted and blood available, the patient is transferred to the operating room, placed on a cassete, and x-ray personnel are alerted for cholangiographic studies. These are done to determine the integrity of the biliary system and to pinpoint injuries. If these preparations are not made, valuable time will be lost.
INTRAOPERATIVE MANAGEMENT ANESTHESIA. We use endotracheal anesthesia in all instances. When necessary, intubation may be done awake in infants and in patients with full stomachs. INCISION. Either a transverse supraumbilical or midline vertical incision may be used effectively. The incision, however, must be adequate for rapid, thorough examination of the abdominal contents. GASTROINTESTINAL INJURIES. Stomach rupture is treated by simple closure. Duodenal intramural hematoma is evacuated by serosal incision and the area is drained. Duodenal perforation, if not extensive, is closed primarily. If there is a leak postoperatively, immediate reoperation is required. With extensive duodenal injury or leak, primary gastrojejunostomy, tube duodenostomy, and drainage of the perforation repair, as for reperforation, may be necessary. Small bowel and mesenteric injuries are debrided and repaired. If they are extensive, resection and anastomosis should be performed. Large bowel injuries are exteriorized, if possible. If a wound is closed, proximal colostomy is carried out. RETROPERITONEAL INJURIES. Expanding hematoma in the region of the kidney should be explored. Hematoma in the kidney region should not be explored unless the intravenous pyelogram shows transection of the ureter or complete absence of function; the latter may indicate renal artery transection. Ureteral injuries are repaired over a catheter splint. Bladder injuries are sutured and an indwelling catheter is left in place for 10 to 12 days. Hematoma in the region of the aorta and vena cava should be explored. Injuries to the great vessels should be repaired using vascular techniques. HEPATOBILIARY INJURIES. Most liver injuries are best treated by debridement and suture with drainage. Drainage of the biliary tract should also be done. In this age group, cholecystostomy is usually performed because of the small caliber of the common duct. Massive liver injuries are treated by lobectomy using techniques referred to elsewhere in this issue, through thoraco-abdominal incisions. Injury to the hepatic veins requires special techniques to control hemorrhage while lobectomy and repair of the vena cava are accomplished. A shunt technique through the right auricle has recently been described by Schrock, Blaisdell, and Mathewson. 15 Although we have had no experience with this method, we feel that this general approach is necessary to prevent exsanguination. Injuries to the biliary tract must be anticipated and searched for. A cholangiogram is obtained to detect and delineate injuries to the ductal system. Perforation of the gallbladder is treated by cholecystectomy.
BLUNT TRAUMA TO THE ABDOMEN IN INFANCY AND CHILDHOOD
1269
Duct'injuries are repaired over aT-tube. If the lumen is too small and there is continuity of the wall but not of the lumen, a splint of polyethylene may be used. This is passed through the ampulla of Vater and brought out through the duodenum and the abdominal wall. SPLEEN AND PANCREAS. Splenectomy should always be performed for hemorrhage from the spleen. On occasion the use of a noncrushing clamp across the splenic pedicle to control hemorrhage will facilitate rapid mobilization and removal of the spleen. Pancreatic injuries are treated by resection of the traumatized portion, when distal. Penrose drains are placed near the sutured pancreas. DIAPHRAGM. Traumatic rupture of the diaphragm is approached through the abdomen. This facilitates adequate exploration of the abdomen and allows for good repair of the injury.
SUMMARY AND CONCLUSIONS The management of a child with severe blunt trauma injury to the abdomen is presented. Continued observation and assumption of responsibility for treatment of the injured child should, ideally, be undertaken by a surgeon experienced in trauma, with consultants as necessary. Continuing clinical observation by the same responsible surgeon is the most valuable diagnostic tool. Preparation for massive blood volume replacement, if needed, is the key to successful management. The awareness of the surgeon of the lesions most commonly overlooked will prevent tragic errors. A bold, accurate surgical attack on specific lesions will save lives. The dictum, "if in doubt-operate," should be followed, particularly in infants and children because the margin of permissible error is small.
REFERENCES 1. Arcari, F. A.: Blunt abdominal trauma in infants and children. J. Mich. Med. Soc., 61:335, 1962. 2. D'Ambrosio, G., Guglielmi, M., and Vecchioni, R.: Infarction of the ascending colon due to closed trauma of the abdomen. Riv. Anat. Pat., 22:939, 1962. 3. Dargan, E. L., Steichen, F. M., Pearlman, D. M., and Wei!, P. H.: Newer concepts in the management of penetrating abdominal trauma. J. Nat. Med. Assoc., 59:198, 1967. 4. Freeark, R. J., Shoemaker, W. C., and Baker, R. J.: Aortography in blunt abdominal trauma. Arch. Surg., 96:705, 1968. 5. Giugiaro, A., and Grassi, E.: Intestinal occlusion due to post-traumatic intramural hematoma. Minerva Pediat., 19:1505, 1967. 6. Gumbert, J. L., Froderman, S. E., and Mercho, J.P.: Diagnostic peritoneal lavage in blunt abdominal trauma. Ann. Surg., 165:71, 1967. 7. Hartman, S. W., and Greaney, E. M., Jr.: Traumatic injuries to the biliary system in children. Amer. J. Surg., 108:150, 1964. 8. Miller, R. E., and Rhamy, R. K.: Acute perforation in infants. Surg., Gynec. Obstet., 117: 61, 1963. 9. Nelson, J. F.: The roentgenologic evaluation of abdominal trauma. Radio!. Clin. N. Amer., 4:415, 1966. 10. Nicholson, R., and Golden, G.: Blunt abdominal trauma in head injuries. The Lancet, 793, 1966. 11. Nick, W. V., Zollinger, R. W., and Pace, W. G.: Retroperitoneal hemorrhage after blunt abdominal trauma. J. Trauma, 7:652, 1967. 12. Pfahler, R.: Blunt trauma of the abdomen in childhood. Zbl. Chir., 84:1767, 1959. 13. Schaffer, A. J.: Diseases of the Newborn. Philadelphia, W. B. Saunders Co., 1960, p. 515. 14. Scharli, A.: Blunt abdominal trauma in childhood. Chir. Praxis, 11 :461, 1967.
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LEIX, GREANEY JR., HARTMAN, jOHNSTON, DOEHRING
15. Schrock, T., Blaisdell, F. W., and Mathewsen, C., Jr.: Management of blunt trauma to the liver and hepatic veins. Arch. Surg., 96:698, 1968. 16. Shaw, A., and Cinque, S.: Traumatic intramural hematoma. Amer. J, Dis. Child., 108: 667, 1964. 17. Weitzman, J. J., and Swenson, 0.: Traumatic rupture of the pancreas in a toddler. Surgery, 57:309, 1965. 18. Williams, R. D., and Zollinger, R. W.: Diagnostic and prognostic factors in abdominal trauma. Amer. J. Surg., 97:575, 1959. 3751 Stocker Street Los Angeles, Califomia 90008 (Dr. Leix)