Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely

• Published in: Journal of the American College of Surgeons Vol. 224; no. 4; pp. 449 - 458.e3
• Main Authors: Streck, Christian J., MD, FACS, Vogel, Adam M., MD, FACS, Zhang, Jingwen, MS, Huang, Eunice Y., MD, FACS, Santore, Matthew T., MD, FACS, Tsao, Kuojen, MD, FACS, Falcone, Richard A., MD, FACS, Dassinger, Melvin S., MD, FACS, Russell, Robert T., MD, FACS, Blakely, Martin L., MD, MS, FACS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-04-2017
• Subjects: Abdominal Injuries - diagnostic imaging; Adolescent; Child; Child, Preschool; Decision Support Techniques; Female; Follow-Up Studies; Humans; Infant; Infant, Newborn; Logistic Models; Male; Prospective Studies; Risk Assessment; Sensitivity and Specificity; Surgery; Tomography, X-Ray Computed; Unnecessary Procedures; Wounds, Nonpenetrating - diagnostic imaging; PECARN; blood pressure; AST; blunt abdominal trauma; emergency department; BP; IAI-I; aspartate aminotransferase; IAI; Pediatric Emergency Care Applied Research Network; intra-abdominal injury; BAT; intra-abdominal injury receiving acute intervention; ED
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2016.12.041

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.