pediatric blunt abdominal trauma does this patient need an abdominal ct?
TRANSCRIPT
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Pediatric Blunt Abdominal Trauma
Does this patient need an Abdominal CT?
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OBJECTIVES
Review Anatomic and Physiologic Differences of Pediatric Patients
Review Mechanisms of Pediatric Abdominal Trauma Discuss Prediction Rules for Severe/High Risk Abdominal
Trauma Discuss Clinical Decision Tools Used to Determine Need
for Abdominal CT Develop a Complete Clinical Approach to Pediatric Blunt
Abdominal Trauma
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Why Review Pediatric Blunt Abdominal Trauma
Trauma is the #1 cause of death and disability in children >1 year old
Head and Thoracic are the most common But…Abdominal Injuries are Most Unrecognized Cause of
Death 90% of Abdominal Injuries from Trauma are Blunt
Abdominal Injuries Understanding of management pediatric abdominal
injury important to future
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What Makes Pediatric Patients Different? Abdominal organs are relatively larger Abdominal muscles are poorly developed Less abdominal fat Ribcage compliant leads to transmission of force to liver and
spleen Greater force per BSA leads to multiple injuries Large BSA leads to Hypothermia Difficult to identify if patient in pain
Kids cry due to pain Kids cry because doctors are scary Kids cry because parents are not holding them
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Common Chief Complaints
MVC Seat-Belt Syndrome Pedestrian Struck by Motor Vehicle Falls Bicycle Injury – Handlebars (often Delayed
Presentation) Sports Injury Non-accidental Trauma
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MVC Most common cause blunt abdominal injury Inappropriately restrained child 3x more likely to suffer abdominal
injury Spleen and Liver injury most common
Seat-Belt Syndrome Etiology typically inappropriate seat-belt use Hip and Abdominal Contusions, Pelvic Fx, Lumbar Spine Injury Definition: area of erythema, ecchymosis and/or abrasion across
abdominal wall resulting from seat belt restraints Sokolove et al: RR 2.9 if seatbelt sign present
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Bicycle Injury Handlebar injury – direct impact during fall Delayed presentation – Average 34.5 hours post fall Klimek et al Retrospective review 40 patients <16 yo
8 required operative intervention
Nonaccidental Trauma If story does not sound right, high suspicion for NAT Roaten et al review of 6186 trauma patients <18 yo
7.3% injury secondary to NAT Fall with injuries >>>> mechanism Multiple Injuries Abnormal bruising patterns
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So…Who Needs a CT Scan?Why Do We Care? CT scans pose increase risk to pediatric patients Ionizing radiation increases risk of malignancy Growing tissues and organs children more sensitive to
radiation than adults Estimated risk of fatal cancer from radiation
1/1000 pediatric CT scan 0.18% lifetime risk for Abdominal CT in 1 year old
ALARA principle
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• Prospective Observational Study; One Level 1 Trauma Center• 1,119/1,324 patients enrolled with at least 1 variable – used as study sample• Utilizes 6 ‘High-Risk’ variables, if any present – concern for significant intra-
abdominal injury1.Low age-adjusted Systolic Blood Pressure2.Abdominal Tenderness3.Femur Fracture4. Increased LFTs (AST >200 U/L, ALT >125 U/L)5.Microscopic Hematuria (>5 rbc/hpf)6. Initial Hematocrit <30%
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Inclusion Criteria:
<18 y/o
Underwent Definitive Test: Abd CT, DPL, Laparotomy/Laparoscopy
Exclusion Criteria:
Penetrating Trauma
Pregnant
Trauma >24 hours prior to presentation
Primary Outcomes:
• Intra-abdominal injury – spleen, liver, GB, pancreas, adrenal, kidney, ureter, bladder, GI tract, vascular structure
• Intra-abdominal injury requiring acute specific Intervention
1. Blood Transfusion for anemia 2/2 intra-abdominal hemorrhage
2. Angiographic embolization
3. Therapeutic intervention at laparotomy
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Results: 157/1,119 (14%) had intra-abdominal injuries
754/1,119 tested positive for prediction rule
365/1,119 tested negative; 8 false negatives
Sensitivity: 94.9%
Specificity: 37.1%
Potential Strength: Utilization of prediction rule would decrease 1/3 Abd CT
Rapid identification of low risk for abdominal pain
Weaknesses: One institution No FAST exam
8 missed cases
Not included: (1) Transfers from other hospitals
(2) Patients observed without CT/DPL/Surgery
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3 patients – tenderness or trauma over costal margins
2 patients – decreased mental status (GCS 9, 12)
1 patient – underwent laparotomy but had seatbelt sign on exam, no significant intervention in OR
1 patient – other injuries
1 patient – developed tenderness during observation time in ED
7/8 only observed in hospital
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Prospective, Observational Cohort blunt torso trauma at PECARN centers
Enrollment: May 2007 – January 2010
Exclusion Criteria:
Injury >24 hours prior to presentation
Pregnancy
Transfer from outside hospital
Penetrating trauma
Preexisting neurologic condition impeding reliable exam
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Inclusion Criteria
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Primary Outcomes Intra-abdominal Injury - 761/12,044 patients (6.3%)
Radiographically or surgically apparent injury to: spleen, liver, urinary tract, GI tract, GB, pancreas, adrenal, vasculature
Underwent Acute intervention - 203 (1.7%) Death caused by injury
Therapeutic intervention at laparotomy
Angiographic embolization
Blood transfusion for anemia 2/2 hemorrhage
IV fluids for 2+ nights with pancreatic or GI injuries
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Derived Prediction Rule Variables
1. Abdominal Wall Trauma or Seat Belt Sign
2. GCS <14
3. Abdominal Tenderness
4. Evidence Thoracic Wall Trauma
5. Complaints of Abdominal Pain
6. Decreased Breath Sounds
7. Vomiting
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Limitations No FAST exam/Ultrasound utilized Abd CT/DPL/Laparoscopy not mandated so clinically
silent Intra-Abdominal Injuries may have been missed Performed at Highly Specialized Pediatric Trauma
Centers
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Volume 22, Issue 9, pages 1034–1041, September 2015
Can I Trust My Gut?
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• Prediction Rule Sn >>>> Clinical Suspicion Sn• Prediction Rule Sp <<<< Clinical Suspicion Sp• However – despite low clinical suspicion, CT abd ordered on many
patients
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Retrospective Analysis of Prospectively Collected Data One Level 1 Trauma Center, Jan 2010 – Dec 2012 Radiology Resident performed all FAST studies Primary Outcomes
Free Fluid in Abdomen
Intra-Abdominal Injury Negative Intra-Abdominal Injury determined by Neg CT or Follow-up Appt
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CONCLUSIONS History and Exam Vital for Evaluation of Pediatric Blunt Abdominal
Trauma GCS score, Seat Belt Sign, Abdominal Wall Tenderness, Distracting Injuries Vital Signs – Remember Age Adjusted cut-offs
Laboratory Tests ARE useful and can be predictive of Injury UA – gross hematuria AST/ALT CBC
Utilized adjunct Testing FAST exam
Ultimately, predictive scores are useful tools but cannot substitute for clinical judgement
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Questions???
References Available Upon Request
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