The Stable-Looking Child After a Fall
A 5-year-old, 20 kg, falls approximately 8 feet from a play structure onto packed dirt. He cries immediately, is alert and oriented, and walks to the ambulance. In the ED: HR 118, BP 96/58, RR 22, SpO2 99% on room air, GCS 15. He complains of abdominal pain and has a seat-belt-sign-like abrasion across the upper abdomen. The abdomen is mildly tender in the epigastrium without distension or peritoneal signs. He has a small scalp hematoma but no loss of consciousness, no vomiting, and no focal neurologic deficit. FAST is performed by the emergency physician and is negative. The parents are anxious and ask for 'the scan that shows everything.' A surgical consultant is in the OR and will be unavailable for at least 45 minutes.
1. A negative FAST has been obtained. How should you weigh CT imaging of the abdomen versus observation, and what does the evidence say about FAST in this setting?
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A negative FAST does not exclude intra-abdominal injury in blunt pediatric trauma. FAST is most sensitive for free fluid (hemoperitoneum) and poorly sensitive for solid-organ injury without hemoperitoneum and for hollow-viscus/pancreatic injury. In a hemodynamically stable child, a negative FAST cannot be used to 'rule out' injury.
Given the mechanism (8-ft fall), the upper-abdominal abrasion suggesting a concentrated impact (possible duodenal/pancreatic or liver/spleen injury), and persistent pain, the child is at meaningful risk. In a stable child, CT abdomen/pelvis with IV contrast is the reference standard and is reasonable here; the alternative is serial abdominal exams with observation and lab monitoring (CBC, lipase, LFTs, urinalysis) in a monitored setting.
Judgment point: the exam is testing that you do not let a negative FAST produce false reassurance, and that stability - not the FAST result - governs the choice between CT and observation. Because the child is stable, there is time to discuss the small but real radiation and sedation-free considerations with the family rather than reflexively scanning or reflexively discharging.
2. The parents demand 'the scan that shows everything,' and surgery is 45 minutes away. How do you communicate and structure the plan?
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Communication:
- Acknowledge the fear and validate it: 'It's completely reasonable to want certainty after a fall like this.'
- Explain in plain language what CT can and cannot do: it is excellent for bleeding and organ injury but involves radiation and is not a 'show everything' test.
- Explain the reasoning: the exam and mechanism drive the decision, and because he is stable, we have time to choose wisely.
- Use shared decision-making with a clear safety net: what symptoms would prompt escalation.
Structure of plan:
- Monitored observation with serial abdominal exams, vital signs, and repeat hemoglobin.
- Labs: CBC, lipase, hepatic panel, urinalysis.
- Clear escalation triggers: worsening pain, peritoneal signs, falling hemoglobin, hemodynamic change, or vomiting → immediate CT and surgical activation.
- If the family still prefers imaging after informed discussion, document the conversation and proceed - the child is stable and CT is defensible; the key is an informed, documented choice, not a reflexive one.
- Notify surgery of the pending observation so a handoff exists even though they are in the OR.
Judgment point: balancing shared decision-making and family anxiety against resource stewardship and radiation stewardship, with a documented safety net.