External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma

Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study

BACKGROUND

Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients.

AIM

To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT.

PATIENTS AND METHODS

This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability.

RESULTS

All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury.

CONCLUSIONS

CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.

Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study

BACKGROUND

Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured.

OBJECTIVE

This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma.

METHODS

This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios).

RESULTS

The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023.

CONCLUSIONS

This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/43027.

Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative

OBJECTIVE

Intra-abdominal injury occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when intra-abdominal injury risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma centre.

METHODS

We implemented a quality improvement initiative using the Model for Improvement in children 0-15.99 years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24 h of emergency department (ED) assessment and return to ED or hospitalization within 72 h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time.

RESULTS

The baseline period (April 1, 2016 - November 30, 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI 20.5-33.8%) in those at low risk for intra-abdominal injury. The intervention period (Dec 1, 2017-Dec 31, 2019) included 445 patients with a CT rate in low-risk patients of 6.8% (95% CI 3.2-12.6%), demonstrating an absolute reduction of 20.0% (95% CI 12.2-27.7%, p < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed.

CONCLUSIONS

This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.

Can we reduce CT scan and hospital costs in children with blunt trauma using four parameters?

Background

Blunt trauma is one of the most common causes of admission to the emergency service in childhood. Children with trauma are generally evaluated in emergency services where pediatric and adult patients are together, and difficulties are experienced in managing children exposed to trauma. CT is preferred for quick detection and grading of toracoabdominal, skeleton, and neurological injury in high energy trauma. The present study aims to determine the severity of trauma and whether CT exposure can be reduced and patient cost using four parameters.

This study was conducted with 586 pediatric patients exposed to blunt abdominal trauma. The clinical prediction rule consisted of four parameters, including abdominal pain, physical examination findings, aspartate aminotransferase (AST), and chest x-ray (CXR, which was used to predict intraabdominal injury in patients with blunt trauma. Patients with no parameters of the clinical decision rule were considered very low risk, and those with one or more parameters were considered at risk. The hospital cost of the patients with and without clinical decision rule was calculated and compared.

Results

In our study, according to the four-variable clinical prediction rule, 88.1% of the patients had a very low risk of intraabdominal injury and 11.9% of them were at risk. The sensitivity was 97.3%, specificity 98.2%, and accuracy was 97.4% in very low-risk patients with four variables clinical prediction rule. In the very low-risk patients, the abnormal CT rate was 0.3% and conservative treatment was performed. With the use of four variables, 0.17% of solid organ injuries may be overlooked. In the risk of patients, 2.9% of these patients were abnormal CT findings, while tube thoracostomy was performed in four patients with pneumothorax, conservative treatment was performed in other patients.

It was determined that routine computed tomography scan increased the patient cost by 5.5 times.

Conclusion

Patients exposed to blunt trauma with a very low risk of intra-abdominal injury can be identified with a four-variable clinical prediction rule. According to the four-variable clinical prediction rule, very low-risk patients do not require immediate CT. The hospital costs can be reduced by reducing the CT scan. However, it should be kept in mind that a small proportion of intra-abdominal injuries may be overlooked.

External validation of a pediatric decision rule for blunt abdominal trauma

INTRODUCTION

Blunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast-enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging.

METHODS

We conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non-pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values.

RESULTS

A total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16.

CONCLUSION

In a non-pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.

Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same?

BACKGROUND

Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules.

METHODS

This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test.

RESULTS

A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI.

CONCLUSIONS

The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.

Pediatric Blunt Abdominal Trauma and Point-of-Care Ultrasound

ABSTRACT

Blunt abdominal trauma (BAT) accounts for most trauma in children. Although the focused assessment with sonography in trauma (FAST) is considered standard of care in the evaluation of adults with traumatic injuries, there is limited evidence to support its use as an isolated evaluation tool for intra-abdominal injury as a result of BAT in children. Although a positive FAST examination could obviate the need for a computed tomography scan before OR evaluation in a hemodynamically unstable patient, a negative FAST examination cannot exclude intra-abdominal injury as a result of BAT in isolation. In this article, we review the evaluation of BAT in children, describe the evaluation for free intraperitoneal fluid and pericardial fluid using the FAST examination, and discuss the limitations of the FAST examination in pediatric patients.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient

BACKGROUND

The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes.

METHODS

We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality.

RESULTS

Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts.

CONCLUSION

Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

Fifteen-minute consultation: Imaging in paediatric major trauma

With trauma being a leading cause of death for children, identifying all sustained injuries remains a priority for clinicians, and imaging is a key diagnostic tool to ensure that is achieved. However, children have a greater risk of detrimental effects of ionising radiation than adults. Clinicians therefore have to balance limiting their patients' radiation exposure to 'as low as reasonably achievable' with the need for diagnostic accuracy. But what is 'reasonable' in major trauma can be confusing. This article aims to clarify the current guidance on which body part to scan and when in paediatric major trauma.

Risk assessment for intra-abdominal injury following blunt trauma in children: Derivation and validation of a machine learning model

BACKGROUND

Computed tomography is the criterion standard for diagnosing intra-abdominal injury (IAI) but is expensive and risks radiation exposure. The Pediatric Emergency Care Applied Research Network (PECARN) model identifies children at low risk of IAI requiring intervention (IAI-I) in whom computed tomography may be omitted but does not provide an individualized risk assessment to positively predict IAI-I. We sought to apply machine learning algorithms to the PECARN blunt abdominal trauma (BAT) data set experimentally to create models for predicting both the presence and absence of IAI-I for pediatric BAT victims.

METHODS

Using the PECARN data set, we derived and validated predictive models for IAI-I. The data set was divided into derivation (n = 7,940) and validation (n = 4,089) subsets. Six algorithms were tested to create 2 models using 19 clinical variables including emesis, dyspnea, Glasgow Coma Scale score of <15, visible thoracic or abdominal trauma, seatbelt sign, abdominal distension, tenderness or rectal bleeding, peritoneal signs, absent bowel sounds, flank pain, pelvic pain or instability, sex, age, heart rate, and respiratory rate (RR). Five algorithms were fitted to predict the absence (low-risk model) or presence (high-risk model) of IAI-I. Models were validated using the test subset.

RESULTS

For the low-risk model, four algorithms were significantly better than the baseline rate (2.28%) when validated using the test set. The random forest model identified 73% of children as low risk, having a predicted IAI-I rate of 0.54%. For the high-risk model, all six algorithms had added predictive power compared with the baseline rate with the highest reportable risk being 39.0%. By incorporating both models into a web application, child-specific risks of IAI-I can be estimated ranging from 0.28% to 39.0% CONCLUSION: We developed a tool that provides a child-specific risk estimate for IAI-I after BAT. This publically available model provides a powerful tool for clinicians triaging pediatric victims of blunt abdominal trauma.

LEVEL OF EVIDENCE

Prognostic, Level II.