Indications for CT Scan for Blunt Abdominal Trauma: Update Course 2017
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
97% of pediatric blunt trauma patients presenting to trauma centers are hemodynamically stable
Seatbelt contusion indicates tremendous force and should be a red flag for underlying abdominal injury, particularly bowel injury which is difficult to assess on CT
FAST ultrasound is not sensitive or specific for pediatric abdominal trauma and will not be useful until IV contrast for ultrasound becomes available
Seatbelt sign over the anterior superior iliac spine in the correct anatomic position may be observed, but seatbelt sign in the wrong location (higher on abdomen) requires more aggressive evaluation
Less than 12% of pediatric blunt trauma patients have an injury on abdominal CT
90% of pediatric trauma patients present to non-pediatric centers where pan-CT is standard practice
The PECARN model was very sensitive for injuries requiring acute intervention but missed many clinically relevant solid organ injuries
In the multi-center study, CT scan ordering rates ranged from 4% to 96% across four centers, indicating substantial opportunity for practice improvement
Five variables predict intra-abdominal injury: AST >200, abnormal abdominal physical exam, abnormal chest X-ray, complaint of abdominal pain, and elevated amylase or lipase
When all five predictor variables are negative, the risk of intra-abdominal injury is 0.6% and risk of injury requiring acute intervention is 0%
Risk of injury increases with the number of abnormal predictor variables present
At least one-third of pediatric blunt trauma patients with severe mechanisms do not need abdominal CT based on the five-variable prediction model
The negative predictive value of the five-variable model is 100% for injury requiring intervention and 99.4% for all injuries
A low-risk group (55% of population) can be identified with less than 5% risk of any injury and less than 0.3% risk of injury requiring acute intervention
Waiting one hour for lab results in stable patients with reliable exams is acceptable before deciding on abdominal CT
Multi-slice CT scanners can identify subtle findings of small bowel or hollow viscus injury even without oral contrast
Serial abdominal exams over time can help determine need for further evaluation even when CT findings are equivocal
Laparoscopy is extremely helpful for evaluating moderate free fluid in males with no hard signs of small bowel perforation
It is very rare to miss an injury during laparoscopic exploration in the current era
There is huge variability across institutions in which labs are ordered for trauma evaluation (amylase vs lipase vs both)
FAST ultrasound had 27.8% sensitivity for any intra-abdominal injury and 44% sensitivity for injury requiring intervention in the study cohort
FAST ultrasound detected only 9 of 42 liver injuries (approximately 1 in 4) in the study
FAST ultrasound detected 13 of 30 spleen injuries in the study
Of 14 centers in the study, only one used negative FAST to reduce CT rates, and two centers actually performed more CTs after FAST
FAST is not being used effectively to determine which patients can avoid CT
Every patient who required intervention (transfusion, angiography, or operation) in the study had a CT scan first, so FAST did not change management
The five-variable clinical prediction model provides guidance to the 90% of providers who don't routinely see pediatric trauma patients, indicating they don't need to scan every patient before transfer
There may be a third category of abdominal injuries that clinicians don't need to know about, particularly low-grade solid organ injuries
Grade 1 or grade 2 solid organ injuries are very unlikely to fail non-operative management
The failure rate of non-operative management for solid organ injuries is 7% when defined as requiring laparotomy
Of patients who fail non-operative management, 3.5% fail due to bowel or pancreas injury and 3.5% fail due to bleeding
Patients with isolated spleen or isolated liver injuries are incredibly unlikely to fail non-operative management; risk increases substantially when both injuries are present
Surgeons should perform FAST ultrasound themselves rather than relying on low-level residents, and 50 ultrasounds are required for qualification at some institutions
IV contrast for ultrasound is expected to be revolutionary and may replace CT for abdominal trauma evaluation
AST or ALT over 200 is used as a threshold for CT scanning in blunt abdominal trauma
Adult trauma literature suggests pan-CT is safer, has fewer missed injuries, and is more cost-effective
The PECARN study (2012) used only history and physical exam findings to predict injuries requiring acute intervention, defined as urgent surgery, angiography, transfusion, or 48-hour admission for IV fluids
A missed bowel injury, if caught within 24 hours, usually causes no increased morbidity
FAST may be helpful in hemodynamically unstable patients to identify hemoperitoneum and determine which body cavity is contributing to instability
Shock index is useful for identifying patients who are NOT in shock but may not be as reliable for predicting who needs intervention