In reply

Abstract

We thank Drs. Lindberg, Berger, and Lane for their comments about our article titled “Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries.” They express concerns in implementing a clinical prediction rule for the evaluation of children with blunt torso trauma when the mechanism of injury is abuse. However, there are 2 main limitations to the comments from this group. First, they are misinterpreting the outcome variable of our study and are attempting to apply the clinical prediction rule to a different outcome variable. Patients with none of the variables in the prediction rule are at very low risk for intra-abdominal injury undergoing acute intervention and therefore “abdominal CT [computed tomography] is generally unwarranted.” The rule is not generated to predict an outcome of any intra-abdominal injury, rather only those undergoing acute intervention. If one needs to identify an injury that does not require a therapeutic intervention (as in physical abuse), then it is not appropriate to use the rule. According to their previous work,1Lindberg D.M. Shapiro R.A. Blood E.A. et al.Utility of hepatic transaminases in children with concern for abuse.Pediatrics. 2013; 131: 268-275Crossref PubMed Scopus (35) Google Scholar Lindberg et al suggest screening with hepatic transaminases (levels >80 IU/L) in all children being evaluated for abuse and suggest that it will maintain “CT rates lower than those reported in the current study.” Although we commend investigations into the appropriate evaluation of children who are at risk of physical abuse (ie, inflicted abdominal trauma), comparing the results from their study to those in the Pediatric Emergency Care Applied Research Network (PECARN) study is challenging and inappropriate. The referenced study retrospectively evaluated children selected to undergo specialty evaluation by a child abuse team.1Lindberg D.M. Shapiro R.A. Blood E.A. et al.Utility of hepatic transaminases in children with concern for abuse.Pediatrics. 2013; 131: 268-275Crossref PubMed Scopus (35) Google Scholar Such specialty evaluations generally occur outside of the emergency department (ED) setting and typically more than 24 hours after the injury occurs, which leads to the second limitation in their commentary. In the PECARN study, we included only patients who were injured within 24 hours of ED presentation. Childhood victims of physical abuse typically present with vague and conflicting histories, and the injuries are often inflicted more than 24 hours before presentation, outside of the inclusion timeframe for the PECARN study. The evaluation of an injured child must focus initially on identifying those whose injuries require acute therapeutic intervention. However, when physical abuse is suspected and identifying any injury, regardless of the need for therapy, is important, additional diagnostic screening tests are necessary. In those who are at high risk for intra-abdominal injury, abdominal CT is the definitive diagnostic test. However, if the concern is lower, such that the need for immediate abdominal CT is initially unclear, the following screening tests increase the risk of intra-abdominal injury in ED patients: low hematocrit level, elevated hepatic transaminase levels, microscopic hematuria, and abdominal ultrasonography with evidence of intraperitoneal fluid.2Holmes J.F. Sokolove P.E. Brant W.E. et al.Identification of children with intra-abdominal injuries after blunt trauma.Ann Emerg Med. 2002; 39: 500-509Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 3Holmes J.F. Gladman A. Chang C.H. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis.J Pediatr Surg. 2007; 42: 1588-1594Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 4Cotton B.A. Beckert B.W. Smith M.K. et al.The utility of clinical and laboratory data for predicting intraabdominal injury among children.J Trauma. 2004; 56 (discussion 1074–1075): 1068-1074Crossref PubMed Google Scholar, 5Isaacman D.J. Scarfone R.J. Kost S.I. et al.Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient.Pediatrics. 1993; 92: 691-694PubMed Google Scholar Children with abnormalities in these screening tests may then be selected for abdominal CT scanning. We provided such guidance in previous publications, but the threshold values of these screening tests depend on the time of patient presentation, which is highly variable in childhood victims of abuse. PECARN Abdominal Injury Rule Should Exclude Potentially Abused ChildrenAnnals of Emergency MedicineVol. 62Issue 3PreviewWe congratulate the Pediatric Emergency Care Applied Research Network (PECARN) investigators for another important study, which, when validated, could be a powerful tool to decrease unnecessary radiation exposure in children. However, we caution that there is potential for harm if this rule, even when validated, is applied to children with concern for physical abuse. Full-Text PDF