Predicting the need for laparotomy in pediatric trauma patients on the basis of the ultrasound score

The expected frequency and amount of free peritoneal fluid estimated using the abdominal FAST-applied abdominal fluid scores in healthy adult and juvenile dogs

OBJECTIVE

To estimate the frequency and amount of free peritoneal fluid in juvenile and adult dogs using the abdominal focused assessment with sonography for trauma (AFAST) abdominal fluid scoring system.

DESIGN

Prospective case series.

ANIMALS

Healthy, privately owned juvenile and adult dogs.

PROCEDURES

Dogs undergoing routine surgical sterilization were evaluated at induction with AFAST and assigned measurements and fluid scores. A surgeon scored the degree of peritoneal fluid found during ovariohysterectomy.

RESULTS

Ninety-two dogs were enrolled (46 juveniles and 46 adults). Ninety-three percent and 52% were AFAST positive for peritoneal fluid, respectively. The AFAST-positive view frequency for right lateral recumbency in juveniles was diaphragmatico-hepatic (DH) 100%, spleno-renal (SR) 20%, cysto-colic (CC) 40%, and hepato-renal (HR) 20% versus adults, DH 60%, SR 20%, CC 0%, and HR 0%, respectively. The AFAST-positive view frequency for left lateral recumbency was DH 93%, SR 44%, CC 24%, and HR 12% in juveniles, and DH 50%, SR 3%, CC 3%, and HR 10% in adults. Overall abdominal fluid scores (AFS) in juvenilles were 0 (n = 3), 1 (n = 14), 2 (n = 22), 3 (n = 6), and 4 (n = 1); and in adults, scores were 0 (n = 22), 1 (n = 18), 2 (n = 6), and 3 and 4 (n = 0). The AFS differed between adults and juveniles (P < 0.001). Most dogs had maximum fluid dimensions ≤3 × 3 mm and width of fluid stripes ≤3 mm. The AFS was positively correlated to fluid amount observed during ovariohysterectomy with fair agreement (kappa = 0.233, P = 0.012).

CONCLUSIONS AND CLINICAL RELEVANCE

This study establishes the frequency and amount of free peritoneal fluid in healthy juvenile and adult dogs during AFAST. Maximum fluid pocket dimensions of ≤3 × 3 mm and fluid stripe widths of ≤3 mm in dogs with AFS 1 and 2 may be normal. The DH view was most frequently positive.

Negative Focused Abdominal Sonography for Trauma examination predicts successful nonoperative management in pediatric solid organ injury: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas + Consortium study

BACKGROUND

Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population.

METHODS

A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI.

RESULTS

Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20.

CONCLUSION

Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting.

LEVEL OF EVIDENCE

Prognostic study, level IV; therapeutic/care management, level IV.

Delay in diagnosis and treatment of blunt intestinal perforation does not adversely affect prognosis in the pediatric trauma patient

BACKGROUND

Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to analyze whether delay in treatment in the event of perforation had an adverse affect on patient outcome.

METHODS

A multi-institutional retrospective chart review by the members of the American Pediatric Surgical Association Committee on Trauma was initiated after the approval of Institutional Review Board at each of the 18 institutions. All children

RESULTS

Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to analyze the interval between injury and operation. These were divided into six groups (<6 hours, 6-12 hours, and >12 hours) based on time from injury to intervention and whether they had perforation or not. Early and late complications as well as hospital days, injury severity score, and time to full feeds were compared in each group. There were two deaths from an abdominal source in the <6-hour nonperforation group, one in the 6-hour perforation group, and one in the 6-hour to 12-hour nonperforation group. Injury severity score was significantly greater in the <6-hour intervention group regardless of perforation status. There was no correlation between time to surgery and complication rate nor was there a significant increase in hospital days.

CONCLUSIONS

These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric blunt intestinal perforation. Appropriate observation and serial examination rather than repeat computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

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MESH Headings

• Abdominal Injuries/diagnosis
• Abdominal Injuries/mortality
• Abdominal Injuries/surgery
• Autopsy
• Chi-Square Distribution
• Child
• Female
• Hospitalization/statistics & numerical data
• Humans
• Injury Severity Score
• Intestinal Perforation/diagnosis
• Intestinal Perforation/mortality
• Intestinal Perforation/surgery
• Intestines/injuries
• Intestines/surgery
• Length of Stay
• Longitudinal Studies
• Male
• Medical Records/statistics & numerical data
• Patient Transfer
• Postoperative Complications
• Prognosis
• Retrospective Studies
• Survival Analysis
• Time Factors
• Tomography, X-Ray Computed
• Treatment Outcome
• Wounds, Nonpenetrating/diagnosis
• Wounds, Nonpenetrating/mortality
• Wounds, Nonpenetrating/surgery
• Wounds, Penetrating/diagnosis
• Wounds, Penetrating/surgery

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Affiliation(s)

Robert W Letton Section of Pediatric Surgery, Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA.
Veronica Worrell
David W Tuggle

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Delay in diagnosis and treatment of blunt intestinal injury does not adversely affect prognosis in the pediatric trauma patient

BACKGROUND

Blunt intestinal injury (BII) requiring surgical intervention in the pediatric trauma population remains difficult to diagnose. We sought to determine whether delay in treatment had an adverse affect on patient outcome.

METHODS

A multi-institutional retrospective chart review using the American Pediatric Surgical Association Committee on Trauma was initiated after Institutional Review Board approval was obtained at each of the 18 institutions. All children younger than 15 years diagnosed with a BII were identified, and only those with BII noted during surgery or autopsy from January 2002 through December 2007 were included. The data form was designed and approved before chart review, and all data were combined into one database.

RESULTS

Three hundred fifty-eight patients were accrued into the study. Two hundred fourteen patients had sufficient data to determine the interval between injury and operation. These were divided into 4 groups (<6, 6-12, 12-24, and >24 hours) based on time from injury to intervention. Early and late complications, as well as hospital days, were compared in each group. There were 3 deaths from an abdominal source in the less-than-6-hour group and 2 in the 6-to-12-hour group. Injury Severity Score was significantly greater in the less-than-6-hour intervention group. There was no correlation between time to surgery and complication rate, nor was there a significant increase in hospital days.

CONCLUSIONS

These data suggest that delay in operative intervention does not have a significant effect on prognosis after pediatric BII. Appropriate observation and serial examination rather than repeated computed tomography and/or urgent exploration would appear adequate when the diagnosis is in question.

Urban paediatric trauma due to stab wounds: an Israeli hospital experience

OBJECTIVE

To assess the incidence and types of stab wounds to hospitalized children and adolescents.

SUBJECTS

The sample consisted of patients, age 6-18 years, who were admitted to our hospital with sustained injury between 1991 and 2007.

RESULTS

In total, 83 patients were admitted as a result of penetrating (n = 51) and superficial (n = 32) injuries. Eighty-two were hospitalized, and one was declared dead upon arrival. Only 11 patients were hospitalized during the 1991-2000 period, and 71 during the 2001-2007 period. Ten patients were admitted to the intensive care unit (ICU); 23 patients were operated (hospital mortality = 0). Evacuation time (time from injury to hospital) was 10 min (mean time; maximum 35 min).

CONCLUSION

This study found higher rates of hospitalization compared with those over a decade ago. These rates reflect not only changes in hospitalization trends and/or population growth in the hospital area but also an increase of urban violence. Israeli hospitalization system deals with paediatric trauma effectively, being well trained because of permanent terrorist activity.

Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma

BACKGROUND

The current standard for the evaluation of children with blunt abdominal trauma (BAT) consists of physical examination, screening lab values, and computed tomography (CT) scan. We sought to determine if the focused assessment with sonography for trauma (FAST) combined with elevated liver transaminases (AST/ALT) could be used as a screening tool for intra-abdominal injury (IAI) in pediatric patients with BAT.

METHODS

Registry data at a level 1 trauma center was retrospectively reviewed from 1991-2007. Data collected on BAT patients under the age of 16 y included demographics, injury mechanism, ISS, GCS, imaging studies, serum ALT and AST levels, and disposition. AST and ALT were considered positive if either one was >100 IU/L.

RESULTS

Overall, 3171 cases were identified. A total of 1008 (31.8%) patients received CT scan, 1148 (36.2%) had FAST, and 497 (15.7%) patients received both. Of the 497 patients, 400 (87.1%) also had AST and ALT measured. FAST was 50% sensitive, 91% specific, with a positive predictive value (PPV) of 68%, negative predictive value (NPV) of 83%, and accuracy of 80%. Combining FAST with elevated AST or ALT resulted in a statistically significant increase in all measures (sensitivity 88%, specificity 98%, PPV 94%, NPV 96%, accuracy 96%).

CONCLUSIONS

FAST combined with AST or ALT > 100 IU/L is an effective screening tool for IAI in children following BAT. Pediatric patients with a negative FAST and liver transaminases < 100 IU/L should be observed rather than subjected to the radiation risk of CT.

Bedside ultrasound in pediatric emergency medicine

Bedside emergency ultrasound has been used by emergency physicians for >20 years for a variety of conditions. In adult centers, emergency ultrasound is routinely used in the management of victims of blunt abdominal trauma, in patients with abdominal aortic aneurysm and biliary disease, and in women with first-trimester pregnancy complications. Although its use has grown dramatically in the last decade in adult emergency departments, only recently has this tool been embraced by pediatric emergency physicians. As the modality advances and becomes more available, it will be important for primary care pediatricians to understand its uses and limitations and to ensure that pediatric emergency physicians have access to the proper training, equipment, and experience. This article is meant to review the current literature relating to emergency ultrasound in pediatric emergency medicine, as well as to describe potential pediatric applications.

Focused assessment with sonography for trauma: the FAST scan

Focused assessment with sonography for trauma or focused abdominal sonography for trauma — the FAST scan, has become a useful modality for the initial evaluation of patients with blunt abdominal trauma. The technique is used to identify free fluid in the abdomen and pelvis and to detect the presence of a pericardial effusion. FAST can be performed by any trained individual, not necessarily a sonographer or radiologist, aiding in the immediate availability of this technique in the emergency situation. We will discuss the applications and sensitivity of this technique in trauma and review the potential pitfalls and limitations which need to be understood if this technique is to be safely applied. The use of FAST for the detection of pneumothoraces in trauma and other advances in FAST scanning, such as scoring systems and paediatric FAST are also reviewed.

Pediatric major trauma: an approach to evaluation and management

Trauma is the leading cause of death in children nationwide. Proper management of the pediatric trauma patient involves many of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences in the pediatric population, clinicians will be assured the best possible outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.

Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis

OBJECTIVE

The objective of the study was to obtain the best estimates of the test performance of abdominal ultrasonography (US) for identifying children with intraabdominal injuries (IAIs).

METHODS

We gathered studies on the use of abdominal US in injured children from the following sources: a MEDLINE and Embase search, hand searches of 5 specialty journals and 4 clinical textbooks, the bibliographies of all identified articles, and contact with experts. Both prospective and retrospective studies were included if they used abdominal US for the detection of intraperitoneal fluid or IAIs in blunt trauma patients less than 18 years of age. All authors independently abstracted data from the selected studies. Disagreements between abstractors were resolved by mutual agreement.

RESULTS

Twenty-five articles met the inclusion criteria, and 3838 children evaluated with abdominal US were included. Abdominal US had the following test characteristics for identifying children with hemoperitoneum: sensitivity, 80% (95% confidence interval [CI] 76%-84%); specificity, 96% (95% CI 95%-97%); positive likelihood ratio, 22.9 (95% CI 17.2-30.5); and negative likelihood ratio, 0.2 (95% CI 0.16-0.25). Using the most methodologically rigorous studies, however, yielded the following test characteristics of abdominal US for identifying children with hemoperitoneum: sensitivity, 66% (95% CI 56%-75%); specificity, 95% (95% CI 93%-97%); positive likelihood ratio, 14.5 (95% CI 9.5-22.1); and negative likelihood ratio, 0.36 (95% CI 0.27-0.47).

CONCLUSIONS

Abdominal US has a modest sensitivity for the detection of children with hemoperitoneum; however, its test performance characteristics worsen when only the most methodologically rigorous articles are included. A negative US examination has questionable utility as the sole diagnostic test to rule out the presence of IAI. Because of the high risk of IAI, a hemodynamically stable child with a positive US examination should immediately undergo abdominal computed tomographic scanning.

Emergency diagnostic paracentesis to determine intraperitoneal fluid identity discovered on bedside ultrasound of unstable patients

Patients presenting with hypotension may be evaluated with a FAST (Focused Abdominal Sonography for Trauma) examination as recent literature has suggested its utility in the unstable patient. Those who are found to have intraperitoneal fluid on the FAST examination may have solid organ injury from unknown trauma, ruptured abdominal aortic aneurysm (AAA), hemorrhaging ovarian cyst, ruptured ectopic pregnancy, or other disease process responsible for intra-periteal blood. However, because ultrasound does not assist in fluid identification, it is possible that the fluid present is not blood, but ascites. Further, a decision may need to be made regarding emergent surgical intervention or blood transfusion vs. aggressive fluid resuscitation or pressors followed by other testing such as computed tomography. This case series illustrates the utility of an ultrasound guided, emergent diagnostic paracentesis in the management of unstable patients found to have a positive FAST examination. Six unstable patients were evaluated with the FAST examination and found to have large quantities of intraperitoneal fluid. In each case the fluid was sampled and proposed management changed due to fluid identification.

Outcomes from pediatric solid organ injury: role of standardized care guidelines

PURPOSE OF REVIEW

Recent advances in the delivery of trauma and critical care in children have resulted in improved outcome following major injuries. It is imperative that physicians who treat injured children familiarize themselves with current treatment algorithms for abdominal trauma. Important contributions have been made in the diagnosis and treatment of children with abdominal injury by radiologists and endoscopists.

RECENT FINDINGS

This report examines the impact of consensus guidelines in the treatment of blunt abdominal solid organ injuries. Consensus guidelines for treatment of children with isolated spleen and liver injury are reviewed demonstrating conformity of care and significant reduction of resource utilization without adverse sequelae. Review of large datasets indicate contrasting rates of splenectomy depending on the expertise of the institution, emphasizing the need for wide dissemination of guidelines.

SUMMARY

Clinical experience and published reports addressing specific concerns about the nonoperative treatment of children with solid organ injuries and recent radiologic and endoscopic contributions have made pediatric trauma care increasingly nonoperative. Although the trend is in this direction, the pediatric surgeon should remain the physician-of-record in the multidisciplinary care of critically injured children.

Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma

INTRODUCTION

Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum.

METHODS

We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings.

RESULTS

Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p < 0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p < 0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum.

CONCLUSION

A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.

Ultrasound in abdominal trauma

This article reviews current issues regarding the Focused Assessment with Sonography for Trauma (FAST) examination. Technical performance issues, decision-making and practice algorithms, fluid volume and scoring systems, proficiency and training, and the role of the FAST in pediatric trauma are covered. This article examines the FAST examination from a practical, evidenced-based stand-point.