Intra-abdominal Injury In Children Research Articles

The Blunt Abdominal Trauma in Children Scores for early detection of intraabdominal injuries in children

The Blunt Abdominal Trauma in Children Scores for early detection of intraabdominal injuries in children

Presence of Microscopic Hematuria Does Not Predict Clinically Important Intra-Abdominal Injury in Children.

Screening for blunt intra-abdominal injury in children often includes directed laboratory evaluation that guides need for computed tomography. We sought to evaluate the use of urinalysis in identifying patients with clinically important intraabdominal injury ( ci -IAI). A retrospective chart review was performed for all patients less than 18 years who presented with blunt mechanisms at a level I trauma center between 2016 and 2019. Exclusion criteria included transfer from an outside facility, physical abuse, and death within thirty minutes of arrival. Demographics, physical exam findings, serum chemistries, urinalysis, and imaging were reviewed. Clinically important intraabdominal injury was defined as injury requiring ≥2 nights admission, blood transfusion, angiography with embolization, or therapeutic surgery. Two hundred forty patients were identified. One hundred sixty-five had a completed urinalysis. For all patients an abnormal chemistry panel and abnormal physical exam had a sensitivity of 88.9% and a negative predictive value of 99.3%. Nine patients had a ci -IAI. Patients with a ci -IAI were more likely to have abdominal pain, tenderness on exam, and elevated hepatic enzymes. When patients were stratified by the presence of an abnormal chemistry or physical exam with or without microscopic hematuria, urinalysis did not improve the ability to identify patients with a ci -IAI. In fact, presence of microscopic hematuria increased the rate of false positives by 12%. Microscopic hematuria was not a useful marker for ci -IAI and may lead to falsely assuming a more serious injury.

Paediatric Emergency Care; Applied Research Network Prediction Rule for Early Detection of Intra-Abdominal Injuries in Children

Paediatric Emergency Care; Applied Research Network Prediction Rule for Early Detection of Intra-Abdominal Injuries in Children

Thoracolumbar Injury Classification and Severity Scale Can Help Identify Intra-Abdominal Injury in Children Injured in an MVC

Background: Motor vehicle crashes (MVC) cause variable injury to the thoracolumbar (TL) region of children secondary to rapid deceleration from seatbelts. This mechanism can also predispose a child to intraabdominal injury (IAI), which necessitates early diagnosis to limit morbidity and mortality. While the maximum extent of TL spine injury can be appreciated shortly after presentation, the severity of IAI may not be appreciated until days later. It is hypothesized that a measure of TL-injury severity will identify patients at risk of concomitant IAI.Methods: Retrospective chart review identified 72 children with MVC-related TL spine injuries from 2007-2020. Patients were grouped based on the presence of IAI and TL spine injury (N=33) compared to isolated TL spine injury (no IAI, N=39). TL spine injury severity was classified according to the Thoracolumbar Injury Classification and Severity Scale (TLICS).Results: Demographics were similar in both groups. Children with concomitant IAI had primarily lumbar spine injuries, while injuries without associated IAI were more broadly distributed throughout the thoracolumbar spine. Children without concomitant IAI were more likely to sustain compression fractures (n=31, 79%), while children with IAI had more distraction injuries (n=24, 73%). TL injuries associated with IAI were significantly more severe than isolated TL injuries (median TLICS=7 [range: 1-9] vs. 1 [range: 1-10], p<0.001). As hypothesized, increasing TLICS is associated with an increased risk of concomitant IAI, such that for every point increase in TLICS, the risk of IAI increases 49% (OR: 1.492, [95% CI 1.254-1.817], AROC 0.795).Conclusions: Given the association between severe spine injury and IAI, this study examines the utility of TLICS score at presentation to establish an index of suspicion for concomitant IAI. While other clinical signs may be suggestive of the presence of IAI, our study may provide clinicians with another data point suggestive of spine injury severity in their diagnostic toolbox to optimally manage pediatric patients after MVC.Level of Evidence: III, Retrospective Cohort StudyKey Concepts•Pediatric patients are at risk for sustaining seatbelt syndrome (intraabdominal injury (IAI) associated with spinal column injury) after motor vehicle collisions when restraints are used improperly.•Occult IAIs may not be readily diagnosed with initial trauma workup and require a high index of suspicion to avoid delay in diagnosis and potential morbidity and mortality.•IAI is more frequently associated with spine fractures located in the lumbar spine.•IAI is associated with more severe spine injury (represented by Thoracolumbar Injury Classification and Severity Scale [TLICS] score >5).

Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department.

The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.

Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma.

In children with blunt abdominal trauma (BAT), focused assessment of sonography in trauma (FAST) has been reported with low sensitivity, on the whole, in the detection of intra-abdominal injuries (IAI). The aim of the present study was to assess test characteristics of FAST using different strategies including repeated FAST (reFAST), and physical exam findings. This retrospective study evaluated BAT pediatric patients with stable hemodynamics who underwent computed tomography (CT). Demographic data, initial physical examination, and results of FAST, reFAST (if done), and CT imaging were recorded. Different strategies of FAST were cross-tabulated with CT as the gold standard and test characteristics including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were interpreted. 129 patients with a mean age of 8.6 ± 4.7 were studied and 74% were male. Comparing CT-positive and -negative groups, from the demographic and clinical findings, only positive physical exam (tenderness or ecchymosis) was significantly higher in the CT-positive group (59% vs. 17%; p < 0.01). In a multivariate analysis, positive FAST modality and clinical exam remained independent predictors for a positive CT result (likelihood ratios of 34.6 and 6.4, respectively). Out of the different diagnostic strategies for the prediction of IAI, the best overall performance resulted from the FAST-reFAST-tenderness protocol with sensitivity, specificity, PPV, NPV, and accuracy of 87%, 77%, 70%, 91%, and 81%. For children with blunt abdominal trauma, physical examination plus FAST and reFAST as needed, seems to have reasonable sensitivity, specificity, and accuracy in detecting intra-abdominal injuries and may reduce the need for CT scans.

The Utility of Focused Assessment With Sonography for Trauma Enhanced Physical Examination in Children With Blunt Torso Trauma.

Computed tomography (CT), the reference standard for diagnosis of intraabdominal injury (IAI), carries risk including ionizing radiation. CT-sparing clinical decision rules for children have relied heavily on physical examination, but they did not include focused assessment with sonography for trauma (FAST), which has emerged into widespread use during the past decade. We sought to determine the independent associations of physical examination, laboratory studies, and FAST with identification of IAI in children and to compare the test characteristics of these diagnostic variables. We hypothesized that FAST may add incremental utility to a physical examination alone to more accurately identify children who could forgo CT scan. We reviewed a large trauma database of all children with blunt torso trauma presenting to a freestanding pediatric emergency department during a 20-month period. We used logistic regression to evaluate the association of FAST, physical examination, and selected laboratory data with IAI in children, and we compared the test characteristics of these variables. Among 354 children, 50 (14%) had IAI. Positive FAST (odds ratio [OR]= 14.8, 95% confidence interval [CI]= 7.5 to 30.8) and positive physical examination (OR= 15.2, 95% CI= 7.7 to 31.7) were identified as independent predictors for IAI. Physical examination and FAST each had sensitivities of 74% (95% CI= 60% to 85%). Combining FAST and physical examination as FAST-enhanced physical examination (exFAST) improved sensitivity and negative predictive value (NPV) over either test alone (sensitivity= 88%, 95% CI= 76% to 96%) and NPV of 97.3% (95% CI= 94.5% to 98.7%). In children, FAST and physical examinations each predicted the identification of IAI. However, the combination of the two (exFAST) had greater sensitivity and NPV than either physical examination or FAST alone. This supports the use of exFAST in refining clinical predication rules in children with blunt torso trauma.

Obesity is associated with a reduced odds for blunt intra-abdominal injuries in children

ObjectivesChildren with obesity may possess unique injury characteristics that may affect their emergency care. To better understand this relationship, we investigated the association of obesity in pediatric trauma patients and intra-abdominal injuries (IAIs) and routinely utilized emergency department (ED) diagnostic procedures (computed tomography (CT) scans and ultrasound (US) examinations). MethodsThis secondary data analysis utilized Pediatric Emergency Care Applied Research Network (PECARN) data from 2007 to 2010. Since height data were not available, children (2–17 years) with obesity were defined using weight-for-age percentiles. Non-parametric testing determined potential confounders. Adjusted odds ratios (aOR) were calculated using binary logistic regression for weight status and IAIs and diagnostic procedures. ResultsThere were 3846 patients with actual weight recorded: 3301 (85.8%) children without obesity and 545 (14.2%) with obesity. Children with obesity had decreased odds for IAI after adjusting for race, mechanical force injury (MFI) type, vomiting, and abdominal wall trauma (adjusted odds ratio (aOR)=0.58 (95% CI 0.35–0.97); p-value=0.04). Patients with obesity had reduced odds for a CT examination. No association was found between obesity status and US utilization. African-American patients had decreased odds for IAIs, CT scans and US examinations after adjustment which could be related to MFI type. ConclusionsObesity appears to reduce the odds for pediatric IAIs and CT scans, but not for US examinations. Selection bias is possible due to injury severity and missing or excluded weight data. Further research is needed in other pediatric populations with obesity and blunt injuries.

External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma

BackgroundComputed tomography (CT) is frequently used to identify intra-abdominal injuries in children with blunt abdominal trauma (BAT). The Pediatric Emergency Care Applied Research Network (PECARN) proposed a prediction rule to identify children with BAT who are at very low risk for clinically-important intra-abdominal injuries (CIIAI) in whom CT can be avoided. ObjectiveTo determine the sensitivity of this prediction rule in identifying patients at very low risk for CIIAI in our pediatric trauma registry. MethodsRetrospective review of our institutional trauma registry to identify patients with CIIAI. CIIAI included cases resulting in death, therapeutic intervention at laparotomy, angiographic embolization of intra-abdominal arterial bleeding, blood transfusion for intra-abdominal hemorrhage, and administration of intravenous fluids for two or more nights for pancreatic or gastrointestinal injuries. Patients were identified using ICD diagnosis and procedure codes. Kappa was calculated to evaluate inter-reviewer agreement. ResultsOf 5743 patients, 133 (2.3%) had CIIAI. 60% were male and the mean age was 8 (SD 4.4) years. One patient with CIIAI met the proposed very low risk criteria, resulting in a prediction rule sensitivity of 99%, 95% CI [96–100%]. This patient also had extra-abdominal arterial bleeding requiring revascularization, offering an alternative reason for transfusion. Kappa was 0.85, 95% CI [0.82, 0.89], indicating strong inter-rater agreement. ConclusionsOne out of 133 patients with CIIAI met very low risk criteria based on the PECARN prediction rule. This study supports the PECARN clinical prediction rule in decreasing CT use in pediatric patients at very low risk for CIIAI.

Costal Margin Tenderness and the Risk for Intraabdominal Injuries in Children With Blunt Abdominal Trauma.

The risk of radiation exposure from computed tomography (CT) imaging in children is well recognized. Patient history and physical examination findings, including costal margin tenderness (CMT), influence a physician's decision to image a child with blunt torso trauma. The objective of this study was to determine the importance of CMT for identifying children with intraabdominal injuries (IAI) found on CT and IAI undergoing acute intervention. We conducted an analysis of the Pediatric Emergency Care Applied Research Network (PECARN) IAI public use data set, representing a large prospective multicenter cohort study from May 2007 to January 2010. Isolated CMT was defined as CMT without other identified PECARN risk factors for IAI (i.e., abdominal or thoracic wall trauma, abdominal tenderness or pain, decreased breath sounds, or vomiting). Logistic regression was used to calculate adjusted odds of IAI in children presenting with isolated and nonisolated CMT. Risk differences were calculated to estimate the risk of IAI independently attributable to CMT in the setting of isolated PECARN risk factors. Finally, CT use among exposure groups was estimated to quantify potentially avoidable imaging. Among 9,174 children with Glasgow Coma Scale scores of 14 or 15 who sustained blunt torso trauma, 1,267 (13.8%) had CMT. Among those with CMT, 177 (14.0%) had isolated CMT and 1,090 (86.0%) had nonisolated CMT. No children (0/177; 0%, 95% confidence interval [CI]= 0.0%-2.1%) with isolated CMT had IAI, compared to 17.2% (187/1,090; 95% CI= 15.0%-19.5%) of those with nonisolated CMT. The risk differences were not statistically significant. 36/177 (20.3%; 95% CI= 14.7%-27.0%) children with isolated CMT underwent abdominal CT scans. The risk of IAI associated with isolated CMT is minimal. For children with blunt abdominal trauma and isolated CMT, abdominal CT scan is of low yield.

Factors associated with interventions for intra-abdominal injuries in children after motor vehicle crashes

Purpose: Motor vehicle crashes (MVCs) are a leading cause of abdominal injury in children, accounting for 32% of all intraabdominal injuries (IAIs) and 45% of IAIs undergoing medical or surgical intervention. A need exists to determine what factors identify children with MVC-related IAIs, particularly those undergoing acute intervention. The purpose of our study was to determine MVC characteristics, clinical findings, and laboratory results that are associated with IAIs undergoing intervention among children involved in MVCs. Methods: This is a secondary analysis of the Abdominal Trauma Public Use Database, a large, prospective observational …

Factors associated with interventions for intra-abdominal injuries in children after motor vehicle crashes

Factors associated with interventions for intra-abdominal injuries in children after motor vehicle crashes

The Value of Urinalysis in Detection of Abdominal Organ Injuries in Children with Hematuria Following Blunt Abdominal Trauma; A Diagnostic Study

Background Currently, almost all patients with probable abdominal injury undergo urinalysis in emergency department (ED). The present survey was conducted with the aim of assessing the diagnostic values of urinalysis compare with abdominal computed tomography (CT) scan with contrast for predicting possible intra-abdominal injuries in children affected by blunt trauma. Materials and Methods: The present diagnostic accuracy study was accomplished on patients' < 16-year-old with blunt abdominal trauma who were admitted to emergency department (ED) and underwent both urinalysis and abdominal CT scan. Demographic and baseline characteristics data, and the results of urinalysis and abdominal CT scan were recorded. Thereafter, screening performance characteristics were calculated. Results Seventy eligible patients with the mean age of 7.1 ± 4.86 years were enrolled (68.6% male). Screening performance characteristics including sensitivity, specificity and positive and negative predictive values of hematuria were 26.7%, 92.7%, 50.0% and 82.3%, respectively. Positive and negative likelihood ratios were calculated as 3.67 and 0.79, respectively. Conclusion It is likely that, presence of hematuria has acceptable specificity, but very low sensitivity in comparison with CT scan for prediction of abdominal organ injuries in children with blunt abdominal trauma. Therefore, urinalysis is not useful for screening the presence of organ injuries in this population.

MODERN TREATMENT OF BLUNT PANCREATIC INJURIES IN CHILDREN

Blunt abdominal traumas constitute the largest portion of intra-abdominal injuries in children. According to their frequency, pancreatic injuries are in the fourth place behind the rupture of the spleen, liver and kidneys. Surgical treatment of minor pancreatic injury is well accepted in clinical practice. Treatment of severe injury with capsular, ductal and parenchymal disruption of the pancreas is controversial and delicate because it requires surgical treatment in strictly selected cases. Posttraumatic pancreatic pseudocysts are the most common complications of traumatic lesions of the pancreas. Proper consideration with correct therapeutic approach in the choice of nonoperative surgical methods of treatment in blunt pancreatic injuries is crucial for the reduction of morbidity and mortality in the pediatric population. Acta Medica Medianae 2015; 54(2):48-51.

Does Severity of Pelvic Fractures Correlate with the Incidence of Associated Intra-Abdominal Injuries in Children?

Background Pelvic fractures are considered a marker of injury severity, especially in the pediatric population. However, the correlation between the severity of pelvic fractures and incidence of associated abdominal injuries is not clear. Methods A retrospective cohort study involving blunt trauma patients up to the age of 14 years, who suffered from pelvic fractures, with or without associated intra-abdominal injuries. Results A total of 812 trauma patients were included in this study. Overall, 671 of them suffered from pelvic fractures with abbreviated injury scale (AIS) of 2, 103 with AIS of 3, and 38 with AIS of 4 to 5. Overall mortality was found to be 5.2%, strongly correlating with the severity of the pelvic fractures (p value < 0.0001). There was no correlation between the incidence of most extrapelvic abdominal organ injuries (liver, spleen, small bowel, and pancreas) and the severity of pelvic fractures. A significant correlation was found with intrapelvic organ injuries (p value < 0.0001) and kidney injuries (p = 0.03). Conclusions Mortality of pediatric trauma patients with pelvic fractures is correlated with the severity of the fractures. An increase in the severity of pelvic fractures in this population is associated with an increased incidence of pelvic organ injury, but is not associated with the presence of extrapelvic abdominal injuries, except for kidney injuries.

Interobserver Agreement in the Clinical Assessment of Children With Blunt Abdominal Trauma

The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement. A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.

A Multicenter Study of the Risk of Intra-Abdominal Injury in Children After Normal Abdominal Computed Tomography Scan Results in the Emergency Department

We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma. This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention. Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%). In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.

Defining the percentage of intra-abdominal hemorrhage in abdominal computerized tomography using stereology in patients with blunt liver injury and determining its relationship with outcomes

The aim of this study is to determine the percentage of intra-abdominal hemorrhage (PIAH) on computerized tomographic (CT) scan via the Cavalieri method and to define whether this is correlated with the outcome. Fifty-one patients (24 children and 27 adults) with blunt hepatic injury were studied in this Level III prognostic clinical cohort study. The stereologic method of point counting based on the Cavalieri approach was adapted to CT data so as to assess IAH and abdominal volume. PIAH was calculated as intra-abdominal fluid volume/whole abdominal volume × 100. Mean PIAHs in children and adults were 4.20% ± 2.85% and 6.28% ± 5.21%, respectively. Coexisting intra-abdominal injuries in children and in adults were as follows: splenic injury (29.2, 11.1%; p = 0.012), kidney (25, 11.1%), bladder (4.2, 14.8%), and pelvic fracture (12.5, 11.1%). PIAH was moderately negatively associated with hemoglobin levels (r = -0.301; p = 0.032), hematocrit levels (r = -0.322; p = 0.021), and GCS (Glasgow Coma Scale) score (r = -0.276; p = 0.05). Neither receiver operating characteristic curve analyses for PIAH nor outcomes were statistically significant in children. In adults, sensitivity and specificity of PIAH in predicting the prognoses when the cutoff levels were taken as 5.39%, 9.9%, and 12.4%, respectively, were as follows: operation (71, 84%), mortality (36, 93%), and intensive care unit admission (25, 94%). In patients with blunt hepatic injury, the Cavalieri principle of stereology can easily be added to the CT slices to calculate PIAH. This method is repeatable in other institutions and can be used as a guide to predict outcomes. It is suitable for a universal parameter to measure intra-abdominal fluid in blunt injury. PIAH has low sensitivity but high specificity to predict intensive care unit admission and mortality in cases of blunt hepatic injury in adults. Its specificity in predicting the need for operation is better than that of the anatomic liver injury grading systems in computerized tomography. Prognostic study, level III.

Evaluation for intra-abdominal injury in children after blunt torso trauma

Blunt trauma is a leading cause of morbidity and mortality in children. Despite the potential for malignancy, increased cost, limited small bowel injury detection sensitivity, and the low incidence of injury requiring operative intervention, the use of computed tomographic (CT) scan in pediatric blunt trauma evaluation remains common. Previous studies suggest that a clinical model using examination and laboratory data may help predict intra-abdominal injuries (IAIs) and potentially limit unnecessary CT scans in children. A retrospective chart review of all blunt "trauma alerts" for patients younger than 16 years during an 18-month period was performed at a Level I trauma center. Clinical factors, which might predict blunt IAI (hemodynamics, abdominal examination, serology, and plain radiographs), and potential limitations to performing a reliable abdominal examination (altered mental status, young age) were reviewed. A previously defined clinical prediction model based on six high-risk clinical variables for blunt IAI (hypotension, abnormal abdominal examination, elevated aspartate aminotransferase, elevated amylase, low hematocrit, and heme-positive urinalysis) was applied to each patient. Of the 125 "trauma alert" patients who sustained blunt trauma during the study period, 97 underwent abdominal CT scan, with only 15 identified as IAI. Our prediction rule would have identified 16 of 17 patients with IAI (SE, 94%) as high-risk and missed only 1 patient (grade I spleen laceration, which did not require operation) (negative predictive value, 99%). Of the 83 patients with no risk factors for IAI based on the prediction rule, 54 underwent a negative abdominal CT scan. Of these 54 patients, only 22 had a potential limitation to a reliable abdominal examination. Application of our prediction rule could have prevented unnecessary CT scan in at least 32 patients (33%) during an 18-month period. Use of a prediction model based on high-risk variables for IAI may decrease cost and radiation exposure by reducing the number of abdominal CT scans in children being evaluated for blunt abdominal trauma.

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

Purpose Abdominal wall bruising (AWB) is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC) and 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. Materials and Methods 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. Results 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 intraabdominal 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 intraabdominal 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 intraabdominal fluid ( P ≤ .001) were significant predictors for intestinal perforation. Overall survival was 98% with 1 death because of head trauma. Conclusion Intraabdominal injuries in children with AWB after MVC are frequent. Associated lumbar fracture, the presence of free intraabdominal fluid, and pulse rate higher than 120 are significant predictors of intestinal injuries. An abdominal exploration should be considered in these patients.