This post is adapted from teaching sessions and educational materials developed by Dr. Hannah Barber Doucet for pediatric and emergency medicine learners. The content has been edited for clarity and expanded into a written format for HipPEMcrates, with the goal of translating bedside teaching into a practical, on-shift reference for pediatric emergency clinicians. Stay tuned for future topics!
The 3 Things You Should Know
1️⃣ Kids can look well and still be seriously injured – so do a thorough secondary trauma survey!
Children can compensate remarkably well after trauma. Normal vital signs and a reassuring initial appearance do not exclude clinically significant intra-abdominal injury. Bruising patterns (especially abdominal wall ecchymosis) or persistent abdominal pain should raise concern even when the child appears stable.
2️⃣ EFAST is helpful – but it doesn’t independently clear the abdomen
EFAST can rapidly identify free fluid or pericardial effusion and is a useful adjunct in pediatric trauma. However, many children with intra-abdominal injuries have a negative EFAST. In pediatrics, free fluid is more commonly seen first in the pelvis, not the RUQ like in adolescents/adults. A positive exam increases concern; a negative exam does not rule out injury.
3️⃣ CT should be guided by risk, not reflex
CT abdomen/pelvis is an important diagnostic tool – but it shouldn’t be automatic. Imaging decisions should be driven by exam findings, symptoms, labs, and the ability to reliably examine the child, balancing radiation exposure against the risk of missed injury. Mechanism alone is not an indication to obtain a CT abdomen/pelvis for pediatric patients.
🚲 The Case
A 13-year-old boy presents after a bicycle accident. He struck a curb while traveling approximately 5–10 mph and flipped over the handlebars. He was wearing a helmet and denies head strike or loss of consciousness. He reports abdominal pain and has abrasions on his extremities. He has been ambulatory and has not vomited.
Vital signs:
HR 100 | BP 110/60 | RR 20 | SpO₂ 98%
Primary survey:
- A: Responds appropriately
- B: Equal breath sounds bilaterally
- C: 2+ femoral pulses bilaterally
- D: GCS 15
- E: Exposure reveals abdominal bruising
Positive findings on secondary survey:
- Abdomen: circular bruise with tenderness to palpation
- Extremities: abrasions
At this point, the child is hemodynamically stable—but clearly not low risk for a clinically significant intra-abdominal injury.
🔍 The Deeper Dive
Primary and Secondary Survey: Don’t Skip the Basics
Pediatric trauma evaluation should always start with a structured ABCDE primary survey, followed by a deliberate head-to-toe secondary survey. It’s easy to anchor on mechanism or vitals, but subtle abdominal findings are often the clue to occult injury.
A thorough secondary survey is essential in children, who may not localize pain reliably. This can be challenging in a young or scared pediatric patient. Use your resources to help calm the patient and gain their trust so that you can get the best possible exam – this could include removing crowds from the room, engaging a Child Life Specialist, or asking a family member for help. Don’t forget to give pain medications as appropriate – a child may be crying because they are in pain.
BONUS MATERIAL: Check out Don’t Forget The Bubbles’ Post on the Secondary Survey
EFAST: Pediatric-Specific Pearls
An EFAST exam should include:
- Lung sliding
- Pericardial assessment
- RUQ, LUQ, and pelvic views
In pediatric patients, free fluid is often identified first in the pelvis, rather than Morison’s pouch. While EFAST can help identify intra-abdominal free fluid and higher-risk patients, a normal study should never be used alone to exclude intra-abdominal injury.
BONUS MATERIAL: Check out NEJM’s video on how to do an EFAST
MORE BONUS MATERIAL: Check out ALiEM’s PEM POCUS Series on the FAST exam
Who Needs a CT?
Common indications used in pediatric blunt abdominal trauma pathways include:
- Abdominal pain or tenderness
- Abnormal abdominal exam or bruising
- GCS <13 or inability to reliably examine the patient
- Abnormal chest X-ray
- AST >200
- Elevated pancreatic enzymes
- Gross hematuria
In this case, abdominal pain and bruising make CT abdomen/pelvis with contrast a reasonable and evidence-supported next step. The appropriately alert pediatric patient who had blunt abdominal trauma but has a normal abdominal exam, without pain or vomiting, can likely forgo the radiation of a CT scan.
Dr. Lauren Ameden is a third year Pediatric Emergency Medicine fellow at Boston Medical Center.
Dr. Hannah Barber Doucet is a Pediatric Emergency Medicine physician and the Associate Program Director for the Pediatric Emergency Medicine Fellowship at Boston Medical Center. She can be reached at Hannah.BarberDoucet@bmc.org.
