Diagnostic accuracy of a step-up imaging strategy in pediatric patients with blunt abdominal trauma

Deep Learning for Automated Detection and Localization of Traumatic Abdominal Solid Organ Injuries on CT Scans

Computed tomography (CT) is the most commonly used diagnostic modality for blunt abdominal trauma (BAT), significantly influencing management approaches. Deep learning models (DLMs) have shown great promise in enhancing various aspects of clinical practice. There is limited literature available on the use of DLMs specifically for trauma image evaluation. In this study, we developed a DLM aimed at detecting solid organ injuries to assist medical professionals in rapidly identifying life-threatening injuries. The study enrolled patients from a single trauma center who received abdominal CT scans between 2008 and 2017. Patients with spleen, liver, or kidney injury were categorized as the solid organ injury group, while others were considered negative cases. Only images acquired from the trauma center were enrolled. A subset of images acquired in the last year was designated as the test set, and the remaining images were utilized to train and validate the detection models. The performance of each model was assessed using metrics such as the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, and negative predictive value based on the best Youden index operating point. The study developed the models using 1302 (87%) scans for training and tested them on 194 (13%) scans. The spleen injury model demonstrated an accuracy of 0.938 and a specificity of 0.952. The accuracy and specificity of the liver injury model were reported as 0.820 and 0.847, respectively. The kidney injury model showed an accuracy of 0.959 and a specificity of 0.989. We developed a DLM that can automate the detection of solid organ injuries by abdominal CT scans with acceptable diagnostic accuracy. It cannot replace the role of clinicians, but we can expect it to be a potential tool to accelerate the process of therapeutic decisions for trauma care.

Emergency whole-body CT scans in pediatric patients with trauma: patterns of injuries, yield of dual-phase scanning, and influence of second read on detection of injuries

OBJECTIVES

To describe injury patterns in children with multiple trauma (MT), evaluate the yield of dual-phase whole-body CT (WBCT), and quantify missed injuries detected on second reading.

METHODS

Remotely analyzed WBCT performed between 2011 and 2020 in 63 emergency departments on children admitted for MT were included. Second reading occurred within 24 h. Collected data included age, sex, mechanism, Injury Severity Score (ISS), radiologists' experience, time and duration of first reading, conclusion of both readings, and dosimetry. Melvin score assessed the clinical impact of missed injuries.

RESULTS

Overall, 1114 patients were included, 1982 injuries were described in 662 patients (59.4%), 452/1114 (40.6%) WBCT were negative, and 314 (28.2%) patients had MT (≥ 2 body parts injured). The most frequent injuries were pulmonary contusions (8.3%), costal fractures (6.2%), and Magerl A1 vertebral fractures (4.9%). Overall, 151 injuries were missed in 92 (8.3%) patients. Independent predictors for missed injuries were age ≤ 4 years (p = 0.03), number of injured body parts ≥ 2 (p = 0.01), and number of injuries ≥ 3 (p < 0.001). Melvin score grade 3 lesions were found in 16/92 (17.4%) patients with missed injuries (1.4% of all WBCT), where only prolonged follow-up was necessary. Thirteen active bleeding or pseudoaneurysms were detected (0.7% of injuries).

CONCLUSION

Injuries were diagnosed in 59.4% of patients. Double-reading depicted additional injuries in 8.3% of patients, significantly more in children ≤ 4 years, with ≥ 3 injuries or ≥ 2 injured body parts. As 28 % of patients had MT and 1.1% had active extravasation or pseudoaneurysm, indication for WBCT should be carefully weighted.

KEY POINTS

• When performed as a first-line imaging evaluation, approximately 41% of WBCT for MT children were considered normal. • The three most common injuries were pulmonary contusions, costal fractures, and Magerl A1 vertebral fractures, but the patterns of traumatic injuries on WBCT depended on the children's age and the trauma mechanism. • The independent predictors of missed injuries were age ≤ 4 years, number of body parts involved ≥ 2, and total number of injuries ≥ 3.

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.

Implementation of clinical effectiveness guidelines for solid organ injury after trauma: 10-year experience at a level 1 pediatric trauma center

BACKGROUND

Diagnostic imaging of pediatric blunt abdominal trauma is evolving in light of increased attention to radiation exposure. We hypothesize that the implementation of imaging guidelines has reduced total CT scans without missing clinically significant injury.

METHODS

We retrospectively reviewed blunt trauma patients age 0-17 with solid organ injury who underwent CT scan at our academic level 1 pediatric trauma center between 2005 and 2014. Variables including total annual trauma admissions and CT scans, demographics, injury characteristics, and procedures were recorded. Descriptive statistics, Fisher exact and rank sum testing were performed. p<0.05 defined significance.

RESULTS

Overall percentage of abdominal CT scans decreased significantly after protocol implementation. There were 498 solid organ injuries in 403 subjects. There was a significant decrease in the median percentage of low grade injuries (1.3% versus 0.6%; p=0.019) but no difference in high grade injuries (1.3% versus 1.1%; p=0.394). No patient had death, readmission or delayed diagnosis of injury requiring intervention.

CONCLUSION

Implementation of imaging guidelines for blunt abdominal trauma decreased the incidence of low grade solid organ injuries at our institution, but did not inhibit diagnosis and safe management of high grade injuries. Selective imaging of trauma patients decreases childhood radiation exposure and does not result in delayed bleeding or death.

LEVEL OF EVIDENCE

Level III, retrospective study.

Focused assessment with sonography for trauma: current perspectives

Focused assessment with sonography for trauma (FAST) is a part of resuscitation of trauma patients recommended by international panel consensus. The purpose of FAST is to identify free fluid, which necessarily means blood in acute trauma patients. In this article, the authors focused on various aspects of FAST in the emergency department, prehospital care, pediatric setting, training and general pearls/pitfalls. Detailed techniques and interpretation of FAST are beyond the scope of this article.