Is there benefit to routine hospital admission in children with blunt abdominal trauma who have a negative abdominal CT? Do we really have to worry about children with a “seat belt” sign? Are there physical examination findings that can help identify children at risk for intra-abdominal injury?
Educational Objectives:
After evaluating this article, participants will be able to:
1. Incorporate strategies into practice to better identify children at risk for intraabdominal injuries.
2. Use the current data to better utilize CT in the clinical evaluation of blunt abdominal trauma.
3. Incorporate appropriate decision rules into clinical practice, regarding children with abdominal injuries.
Is there benefit to routine hospital admission in children with blunt abdominal trauma who have a negative abdominal CT? Do we really have to worry about children with a “seat belt” sign? Are there physical examination findings that can help identify children at risk for intra-abdominal injury? This article reviews the available literature on pediatric blunt abdominal trauma to try to give us some guidelines that will help us with patients that can be difficult to evaluate at times.
Q. What is the prevalence of intra-abdominal injuries (IAI) and the negative predictive value (NPV) of an abdominal computed tomography (CT) in children who present with blunt abdominal trauma?
A.The rate of IAI after blunt abdominal trauma with negative CT in children is low. Abdominal CT has a high NPV. The review shows that it might be safe to discharge a stable child home after a negative abdominal CT
Citation:
Citation #1 : Hom J. The Risk of Intra-abdominal Injuries in Pediatric Patients with Stable Blunt Abdominal Trauma and Negative Abdominal Computed Tomography Academic Emergency Medicine 2010; 17: 469-475.
Methodology: MEDLINE, EMBASE, and Cochrane Library databases were searched. Studies were selected if they enrolled children with blunt abdominal trauma from the emergency department (ED) with significant mechanism of injury requiring an abdominal CT. Studies were excluded if they included hemodynamically unstable patients, patients with penetrating injuries, or had a retrospective design.The primary outcome measure was the rate of IAI in patients with negative initial abdominal CT. The secondary outcome measure was the number of laparotomies, angiographic embolizations, or repeat abdominal CTs in those with negative initial abdominal CTs.
Findings: Three studies met the inclusion criteria, comprising a total of 2,596 patients. There were a total of 2,596 patients in the three studies used for the review. The mean ages of patients in the 3 studies were 7 years, 7.4 years, and 9.6 years.. The rate of intra-abdominal injuries detected following a negative abdominal CT was 0.09% (95% confidence interval = 0.02% – 0.51%) in one study, 0.48% (95% confidence interval = 0.15% – 1.73%) in the second, and 0.27% (95% confidence interval = 0.08% – 0.98%) in the third. The rate of intra-abdominal injury for the combined studies was 0.19% (95% confidence interval = 0.08% – 0.44%). The overall rate of IAI after a negative abdominal CT was 0.19% (95% confidence interval [CI] = 0.08% to 0.44%). The overall NPV of abdominal CT was 99.8% (95% CI = 99.6% to 99.9%). There were five patients (0.19%, 95% CI = 0.08% to 0.45%) who required additional intervention despite their initial negative CTs: one therapeutic laparotomy for bowel rupture, one diagnostic laparotomy for mesenteric hematoma and serosal tear, and three repeat abdominal CTs (one splenic and two renal injuries). None of the patients in the latter group required surgery or blood transfusion.
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Q. What are the objective clinical and radiologic predictors for the need of an abdominal exploration in children with abdominal wall bruising (AWB)? AWB is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC)
A. Intra-abdominal injuries in children with AWB after MVC are frequent. Associated lumbar fracture, the presence of free intra-abdominal fluid, and pulse rate higher than 120 are significant predictors of intestinal injuries. An abdominal exploration should be considered in these patients.
Citation:
Paris C, Brindamour M, Ouimet A etal.Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collisionJournal of Pediatric Surgery 2010;45:921–924.
Summary: AWB, a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC), is highly suspicious but not indicative of intestinal injury. The aim of this study was to find objective clinical and radiologic predictors for the need of an abdominal exploration in these children.
Methodology: A retrospective chart review of children admitted from 1998 and 2008 with AWB after MVC was conducted. Demographics, vital signs, physical examinations, radiologic investigations, associated injuries, management, and outcome were extracted. Univariate and multivariate statistical analyses were done.
Findings: Fifty-three children with a median age of 9 years (range, 3-16 years) were included. Forty-four patients (83%) had abdominal pain on arrival, and 25 (47%) had free intra-abdominal fluid on ultrasound/scan. Intraabdominal injuries were noted in 29 patients (55%), and the most common were mesenteric or bowel injuries (25%), splenic injuries (13%), and hepatic injuries (8%). Ten patients (19%) needed therapeutic laparotomy, and all were victims from collision involving 2 moving vehicles, had abdominal pain, free intra-abdominal fluid, and tachycardia. Five patients (50%) operated on had lumbar fracture compared to only 4 patients (9%) in the nonoperative group. Pulse rate higher than 120 (P = .048), lumbar fracture (P = .008), and free intra-abdominal fluid (P
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Q. What is the accuracy of a previously derived clinical prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma?
A. A clinical prediction rule consisting of 6 variables, easily available to clinicians in the ED, identifies most but not all children with intra-abdominal injury. Application of the prediction rule to this sample would have reduced the number of unnecessary abdominal CT scans performed but would have failed to identify 1 child undergoing (a nontherapeutic) laparotomy. Thus, further refinement of this prediction rule in a large, multicenter cohort is necessary before widespread implementation
Citation:
Holmes JF, Mao A, Awasthi S etal. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.Ann Emerg Med. 2009 Oct;54(4):528-33.
Methodology: A prospective observational study was performed of children with blunt torso trauma who were evaluated for intra-abdominal injury with abdominal computed tomography (CT), diagnostic laparoscopy, or laparotomy at a Level I trauma center during a 3-year period to validate a previously derived prediction rule. The emergency physician providing care documented history and physical examination findings on a standardized data collection form before knowledge of the results of diagnostic imaging. The clinical prediction rule being evaluated included 6 “high-risk” variables, the presence of any of which indicated that the child was not at low risk for intra-abdominal injury: low age-adjusted systolic blood pressure, abdominal tenderness, femur fracture, increased liver enzyme levels (serum aspartate aminotransferase concentrat
ion >200 U/L or serum alanine aminotransferase concentration >125 U/L), microscopic hematuria (urinalysis >5 RBCs/high powered field), or an initial hematocrit level less than 30%.
Findings: One thousand three hundred twenty-four children with blunt torso trauma were enrolled, and 1,119 (85%) patients had the variables in the decision rule documented by the emergency physician and therefore made up the study sample. The prediction rule had the following test characteristics: sensitivity=149 of 157, 94.9% (95% confidence interval [CI] 90.2% to 97.7%) and specificity=357 of 962, 37.1% (95% CI 34.0 to 40.3%). Three hundred sixty-five patients tested negative for the rule; thus, strict application would have resulted in a 33% reduction in abdominal CT scanning. Of the 8 patients with intra-abdominal injury not identified by the prediction rule, 1 underwent a laparotomy. This patient had a serosal tear and a mesenteric hematoma at laparotomy, neither of which required specific surgical intervention.