Blunt Abdominal Trauma Guideline (Cincinnati Children's)
Guideline · Nov 2018 · 2 min read
In brief
In brief
Clinical prediction rule derived from 2,188 pediatric patients to identify children at very low risk for intra-abdominal injury after blunt abdominal trauma. Uses five clinical variables (AST, abdominal exam, chest x-ray, abdominal pain, pancreatic enzymes) to safely avoid CT imaging in 34% of patients with 99.4% negative predictive value.
- A 5-variable prediction rule (AST >200, abnormal exam, abnormal CXR, abdominal pain, abnormal pancreatic enzymes) identifies very low-risk patients.
- Children with none of the 5 variables have 99.4% NPV for IAI and 100% NPV for IAI requiring intervention—CT can be safely avoided.
- The rule applies to 34% of pediatric blunt abdominal trauma patients, potentially reducing unnecessary radiation exposure.
- Multi-center study of 2,188 children found 11.9% IAI rate and 2.8% rate of injury requiring acute intervention.
- CT use varied widely (4-96%) across centers, suggesting opportunity for standardized risk stratification to reduce overuse.
Written by the GCMD Library team from the guideline.
Background
Computed tomography is commonly used to rule out intra-abdominal injury (IAI) in children, despite associated cost and radiation exposure. Our purpose was to derive a prediction rule to identify children at very low risk for IAI after blunt abdominal trauma (BAT) for whom a CT scan of the abdomen would be unnecessary.
Study Design
We prospectively enrolled children younger than 16 years of age who presented after BAT at 14 Level I pediatric trauma centers during 1 year. We excluded patients who presented more than 6 hours after injury or underwent abdominal CT before transfer. We used binary recursive partitioning to derive a prediction rule identifying children at very low risk of IAI and IAI requiring acute intervention (IAI-I) using clinical information available in the trauma bay.
Results
We included 2,188 children with a median age of 8 years. There were 261 patients with IAI (11.9%) and 62 patients with IAI-I (2.8%). The prediction rule consisted of (in descending order of significance): aspartate aminotransferase >200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes. The rule had a negative predictive value of 99.4% for IAI and 100.0% for IAI-I in patients with none of the prediction rule variables present. The very-low-risk population consisted of 34% of the patients and 23% received a CT scan. Computed tomography frequency ranged from 4% to 96% by center.
Conclusions
A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.
REFERENCES
Streck, C. J., Vogel, A. M., Zhang, J., Huang, E. Y., Santore, M. T., Tsao, K., ... & Collaborative, P. S. R. (2017).
Identifying children at very low risk for blunt intra-abdominal injury in whom CT of the abdomen can be avoided
safely. Journal of the American College of Surgeons, 224(4), 449-458.
APPROVALS
All revisions of this guideline are approved by the Trauma Service Department. This guideline is reviewed every three
years or sooner if deemed necessary. Authority for this document resides with the Trauma Service Department. This
guideline is approved by the Trauma Services Manager and the Director of Trauma Services.
Statements in this guideline
Children who presented more than 6 hours after injury are excluded from this prediction rule.
Children who underwent abdominal CT before transfer are excluded from this prediction rule.
The overall rate of intra-abdominal injury in children presenting after blunt abdominal trauma was 11.9%.
The rate of intra-abdominal injury requiring acute intervention in children presenting after blunt abdominal trauma was 2.8%.
The prediction rule variables in descending order of significance are: aspartate aminotransferase greater than 200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes.
The prediction rule has a negative predictive value of 99.4% for intra-abdominal injury in patients with none of the prediction rule variables present.
The prediction rule has a negative predictive value of 100.0% for intra-abdominal injury requiring acute intervention in patients with none of the prediction rule variables present.
The very-low-risk population consists of 34% of patients presenting with blunt abdominal trauma.
CT can be avoided in children at very low risk for intra-abdominal injury identified by the prediction rule using history, physical examination, chest x-ray, and laboratory evaluation.
This guideline is reviewed every three years or sooner if deemed necessary.
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