Evaluation of the Pediatric Abdomen-Who needs a CT for Blunt Abdominal...
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about intraabdominal injury
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What the experts said
A bilateral iliac crest seatbelt sign should be managed differently than a true abdominal seatbelt sign
FAST exams are not effective for detecting retroperitoneal blood
FAST exam requires approximately 200cc of blood in the abdomen to be reliably positive
200cc of blood in a young child represents a significant volume that would typically present with hemodynamic instability
Mechanism of injury is critical in deciding whether to scan an intubated patient who cannot provide reliable physical exam
For intubated patients with significant mechanism but unreliable exam, AST, ALT, lipase, lactate, and base deficit help determine if CT is needed
PCARN study excluded labs and imaging from their prediction model due to lack of standardization across centers
The PCARN rule focuses only on injuries requiring urgent intervention (surgery, angiography, or transfusion), which represents only 2-3% of patients
The PCARN rule misses many clinically relevant injuries, primarily solid organ injuries that require admission, serial monitoring, or activity restriction
The multi-center study enrolled 2,188 patients over one year with mean age around 8 years
In the study population, 12% had an intraabdominal injury and 3% had an injury requiring acute intervention (surgery, angiography, or transfusion)
Death from intraabdominal injury was rare in the study population
45% of patients in the study underwent abdominal CT scan
In the 14-center study, CT utilization for similar blunt trauma patients ranged from 4% to 96% across institutions
75% of patients in the study were admitted to the hospital, primarily for orthopedic and head injuries
The five most predictive variables for intraabdominal injury were: AST >200, abnormal abdominal physical exam, abnormal chest X-ray, complaint of abdominal pain, and abnormal pancreatic enzymes
The prediction rule identified 34% of patients as very low-risk with 0.6% risk of intraabdominal injury and 0% risk of injury requiring intervention
The prediction rule had a negative predictive value of 99.4% for intraabdominal injury and 100% for injury requiring intervention
Patients with only one abnormal variable had a 4.5% risk of injury and low risk of injury requiring intervention
Abnormal physical examination (such as seatbelt sign) has the highest odds ratio for injury requiring acute intervention
AST >200 is the variable with greatest risk for injury that did not require acute intervention, primarily liver injuries
More than half (55%) of patients have less than 5% risk of injury and less than 0.3% risk of injury requiring acute intervention
97% of patients in the study had normal blood pressure for age on arrival
Pelvic plain films did not add predictive value to the model on multivariate analysis
Complaint of abdominal pain alone, particularly in a frightened child, should not mandate CT if other variables are negative
Abnormal abdominal exam for the prediction rule specifically means handlebar contusions, seatbelt contusions, or peritoneal signs—not minor bruising over iliac wings or small costal margin abrasions
Patients with one positive finding and reliable family living nearby could potentially be discharged with return precautions rather than scanned
The prediction rule's purpose is to identify patients who can safely avoid CT, not to increase scanning rates