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Staab V, Naganathan S, McGuire M, Pinto JM, Pall H. Gastrointestinal Perforation with Blunt Abdominal Trauma in Children. CHILDREN (BASEL, SWITZERLAND) 2024; 11:612. [PMID: 38929192 PMCID: PMC11201831 DOI: 10.3390/children11060612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/11/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
Gastrointestinal tract perforation is uncommon in children, accounting for <10% of cases of blunt abdominal trauma. Diagnosis of bowel perforation in children can be challenging due to poor diagnostic imaging accuracy. Intra-abdominal free air is found only in half of the children with bowel perforation. Ultrasound findings are nonspecific and suspicious for perforation in only two-thirds of cases. A computer tomography (CT) scan has a sensitivity and specificity of 50% and 95%, respectively. Surgical decisions should be made based on clinical examination despite normal CT results. Management of bowel perforation in children includes primary repair in 50-70% and resection with anastomosis in 20-40% of cases.
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Affiliation(s)
- Victoriya Staab
- Department of Surgery and Pediatrics, K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center, Neptune, NJ 07753, USA; (V.S.); (S.N.); (M.M.); (J.M.P.)
- Department of Surgery and Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
| | - Srividya Naganathan
- Department of Surgery and Pediatrics, K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center, Neptune, NJ 07753, USA; (V.S.); (S.N.); (M.M.); (J.M.P.)
- Department of Surgery and Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
| | - Margaret McGuire
- Department of Surgery and Pediatrics, K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center, Neptune, NJ 07753, USA; (V.S.); (S.N.); (M.M.); (J.M.P.)
- Department of Surgery and Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
| | - Jamie M. Pinto
- Department of Surgery and Pediatrics, K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center, Neptune, NJ 07753, USA; (V.S.); (S.N.); (M.M.); (J.M.P.)
- Department of Surgery and Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
| | - Harpreet Pall
- Department of Surgery and Pediatrics, K. Hovnanian Children’s Hospital at Jersey Shore University Medical Center, Neptune, NJ 07753, USA; (V.S.); (S.N.); (M.M.); (J.M.P.)
- Department of Surgery and Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
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Cunha SC, DE-Oliveira Filho AG, Miranda ML, Silva MACPDA, Pegolo PTDEC, Lopes LR, Bustorff-Silva JM. Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children. Rev Col Bras Cir 2023; 50:e20233429. [PMID: 36995834 PMCID: PMC10519698 DOI: 10.1590/0100-6991e-20233429-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/06/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years. METHODS retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children. RESULTS only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series. CONCLUSION the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.
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Affiliation(s)
- Sarah Crestian Cunha
- - Universidade Estadual de Campinas (UNICAMP), Cirurgia - Campinas - SP - Brasil
| | | | - Marcio Lopes Miranda
- - Universidade Estadual de Campinas (UNICAMP), Cirurgia - Campinas - SP - Brasil
| | | | | | - Luiz Roberto Lopes
- - Universidade Estadual de Campinas (UNICAMP), Cirurgia - Campinas - SP - Brasil
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CUNHA SARAHCRESTIAN, DE-OLIVEIRA FILHO ANTONIOGONÇALVES, MIRANDA MARCIOLOPES, SILVA MARCIAALESSANDRACAVALAROPEREIRADA, PEGOLO PATRÍCIATRABALLIDECARVALHO, LOPES LUIZROBERTO, BUSTORFF-SILVA JOAQUIMMURRAY. Análise de eficácia e segurança do tratamento conservador do trauma abdominal contuso em crianças: estudo retrospectivo. Tratamento conservador de trauma abdominal contuso em crianças. Rev Col Bras Cir 2023. [DOI: 10.1590/0100-6991e-20233429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
RESUMO Introdução: no Brasil, o trauma é responsável por 40% dos óbitos na faixa etária entre 5 e 9 anos, e 18% entre 1 e 4 anos, e o sangramento é a principal causa de prevenção morte na criança traumatizada. O manejo conservador de trauma abdominal contuso com lesão de órgãos sólidos - iniciado na década de 60 - é a tendência mundial atual, com estudos mostrando taxas de sobrevivência acima de 90%. O objetivo do presente trabalho foi avaliar a eficácia e segurança do tratamento conservador em crianças com trauma abdominal contuso tratado no Hospital das Clínicas da Universidade de Campinas, nos últimos cinco anos. Métodos: análise retrospectiva de prontuários de pacientes classificados por níveis de gravidade da lesão, em 27 crianças. Resultados: apenas uma criança foi submetida a cirurgia por falha inicial do tratamento conservador (instabilidade hemodinâmica persistente), resultando em uma taxa de sucesso global de 96% do tratamento conservador inicial. Outras cinco crianças (22%) desenvolveram complicações tardias que exigiram cirurgias eletivas: lesão na bexiga, dois casos de coleção perirenal infectada (secundária à lesão de sistema de coleta renal), um pseudocisto pancreático e um cisto esplênico. Resolução da complicação foi atingida em todas as crianças, com preservação anatômica e funcional do órgão afetado. Não houve mortes nesta série. Conclusão: a abordagem inicial conservadora no tratamento de trauma abdominal contundente foi eficaz e segura com alta resolução e baixa taxa de complicações levando a uma alta taxa de preservação dos órgãos afetados. Nível de evidência III - estudo prognóstico e terapêutico.
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Can we reduce CT scan and hospital costs in children with blunt trauma using four parameters? ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-021-00142-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Wiitala EL, Parker JL, Jones JS, Benner CA. Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers. Pediatr Emerg Care 2022; 38:e138-e142. [PMID: 32658115 DOI: 10.1097/pec.0000000000002183] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers. METHODS We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale. RESULTS There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198). CONCLUSIONS Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.
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Affiliation(s)
- Ellen L Wiitala
- From the Michigan State University College of Human Medicine
| | | | - Jeffrey S Jones
- From the Michigan State University College of Human Medicine
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Ohana-Sarna-Cahan L, Levin Y, Gross I, Hassidim A, Yuval JB, Hess A, Bala M, Hashavya S. Microhematuria as an Indicator of Significant Abdominal Injury. Pediatr Emerg Care 2021; 37:e1020-e1025. [PMID: 31283723 DOI: 10.1097/pec.0000000000001878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Trauma is one of the leading causes of morbidity and mortality in the pediatric population. In many centers, microhematuria is used as a screening tool for the presence of significant abdominal injury and as an indication for further imaging. Our objective was to evaluate the role of microhematuria by dipstick as an indicator of significant abdominal injury in children. METHODS A retrospective review of children aged 0 to 16 years admitted for a motor vehicle accident or a fall from 2007 to 2017 who had urinalyses performed. RESULTS The charts of 655 children were reviewed. Microhematuria was found in 100 children, of whom 49 (49%), 28 (28%), and 23 (23%) had small, moderate, and large amounts of hematuria, respectively. Of the children who had microhematuria, 41 underwent a computed tomography scan. Positive findings were recorded in 16 (39%) of these patients. There was a clear association between microhematuria as detected by the urine dipstick and a significant finding on the computed tomography scan (P = 0.002). The sensitivity of microhematuria for significant abdominal pathology on imaging was 66.6% and the specificity was 68.3% (positive predictive value, 39%; negative predictive value, 87.1%). Microhematuria was associated with increased length of stay in the hospital (P < 0.001), surgical interventions (P = 0.036), and admission to the pediatric intensive care unit (P < 0.001). CONCLUSIONS The diagnostic role of dipstick urine analysis in the assessment of intra-abdominal injury has low sensitivity and specificity. Nevertheless, it is still a valuable screening tool for the evaluation of the severity of injury.
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Affiliation(s)
| | | | - Itai Gross
- Department of Pediatric Emergency Medicine
| | | | | | - Amit Hess
- Department of Pediatric Emergency Medicine
| | - Miklosh Bala
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Professional practice assessment: establishment of an institutional procedure to treat blunt abdominal trauma in emergency pediatric department. Eur J Trauma Emerg Surg 2019; 47:105-112. [PMID: 31455991 DOI: 10.1007/s00068-019-01214-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/11/2019] [Accepted: 08/20/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The clinical process for the diagnosis of intra-abdominal lesion due to blunt abdominal trauma in children is not consistent. The goal of the present study was to assess the efficiency of our institutional procedure to manage hemodynamically stable pediatric patients with benign abdominal trauma and to select patients who need a radiological examination in an emergency pediatric department. MATERIAL AND METHODS This was a prospective cohort study from June 2008 to June 2010 in a pediatric emergency department. Pediatric patients with benign abdominal trauma and with stable hemodynamic parameters were included in the study. We conducted first clinical examination and clinical laboratory assessment for blood count, platelet count, hematocrit, serum glutamo-oxalacétique transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lipase and urine. A second clinical examination was performed 2 h later. Patients with biological abnormalities and/or with persistent pain underwent a computerized tomography (CT) of the abdomen. Our main criterion for judging was the presence of intra-abdominal lesion as revealed by the scan, which was considered as the gold standard. At the second clinical examination, patients without pain and with normal results for clinical laboratory assessment were sent home. A telephone call was made to the children 48 h after the visit to the hospital emergency department. The secondary criterion for judging was the absence of complication in children who did not undergo the scan. RESULTS A total of 111 children were included. Seventy-five children underwent the complete procedure. Thirty-four scans were performed. The scan revealed that 22 patients had an intra-abdominal lesion. Multivariate analysis indicated that SGOT higher than 34 IU/L and the persistence of pain for more than 2 h from the initial evaluation of trauma favored the development of intra-abdominal lesion. On the basis of these two criteria, we developed a predictive diagnostic score for post-traumatic intra-abdominal injuries with a high negative predictive value. For children who were sent home without a radiological examination, no complications were observed at 48 h after the visit to the emergency department. CONCLUSION The present protocol is a good approach to identify children at risk for intra-abdominal lesion who need a radiological examination and those who do not require any complementary examinations. The predictive diagnostic score could help young hospital doctors to assess blunt abdominal trauma.
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Casson C, Jones RE, Gee KM, Beres AL. Does Microscopic Hematuria After Pediatric Blunt Trauma Indicate Clinically Significant Injury? J Surg Res 2019; 241:317-322. [PMID: 31055157 DOI: 10.1016/j.jss.2019.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/20/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Children are more likely to have urinary system injury after blunt abdominal trauma (BAT) because of anatomical vulnerabilities. Urinalysis (UA) is often performed during initial evaluation to screen for injury. The purpose of this study was to determine how often finding microscopic hematuria after BAT leads to further testing and whether this indicates a significant injury. METHODS A retrospective review of children evaluated for BAT at Children's Health from 2013 to 2017 was performed. Patients included had microscopic hematuria on initial UA. Data collected included demographics, injury data, laboratory and imaging data, and outcomes. Analysis was performed using descriptive statistics, Fisher's exact, and independent t-test. RESULTS Of 1059 patients treated for BAT during the study period, 203 (19%) exhibited microscopic hematuria on UA during the initial workup. Most UAs resulted after imaging was completed and did not impact management (158, 78%); twenty-two (14%) of these patients had urinary injury, which were diagnosed by imaging regardless of UA results. Forty-five (22%) patients were found to have microscopic hematuria that independently led to workup for urinary injury. Of these, nine patients had a urinary system injury: 6 low-grade renal and three bladder wall injuries, none of which required surgery. Those with and without urinary injury in this group underwent similar numbers of radiographic studies. CONCLUSIONS Microscopic hematuria on screening UA after BAT may lead to extensive workup, regardless of the presence of symptoms. In patients who receive cross-sectional abdominal imaging, preceding UA adds little to the clinical workup of children with BAT.
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Affiliation(s)
- Cameron Casson
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Pediatric Surgery, Children's Health, Dallas, Texas.
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Trinci M, Piccolo CL, Ferrari R, Galluzzo M, Ianniello S, Miele V. Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma. J Ultrasound 2019; 22:27-40. [PMID: 30536214 PMCID: PMC6430291 DOI: 10.1007/s40477-018-0346-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/02/2018] [Indexed: 12/15/2022] Open
Abstract
Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics.
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Affiliation(s)
| | | | - Riccardo Ferrari
- Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy
| | - Michele Galluzzo
- Department of Emergency Radiology, S. Camillo Hospital, Rome, Italy
| | | | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, L.go G.A. Brambilla, 3, 50134, Florence, Italy.
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Springer E, Frazier SB, Arnold DH, Vukovic AA. External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma. Am J Emerg Med 2018; 37:1643-1648. [PMID: 30502218 DOI: 10.1016/j.ajem.2018.11.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/17/2018] [Accepted: 11/21/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Computed tomography (CT) is frequently used to identify intra-abdominal injuries in children with blunt abdominal trauma (BAT). The Pediatric Emergency Care Applied Research Network (PECARN) proposed a prediction rule to identify children with BAT who are at very low risk for clinically-important intra-abdominal injuries (CIIAI) in whom CT can be avoided. OBJECTIVE To determine the sensitivity of this prediction rule in identifying patients at very low risk for CIIAI in our pediatric trauma registry. METHODS Retrospective review of our institutional trauma registry to identify patients with CIIAI. CIIAI included cases resulting in death, therapeutic intervention at laparotomy, angiographic embolization of intra-abdominal arterial bleeding, blood transfusion for intra-abdominal hemorrhage, and administration of intravenous fluids for two or more nights for pancreatic or gastrointestinal injuries. Patients were identified using ICD diagnosis and procedure codes. Kappa was calculated to evaluate inter-reviewer agreement. RESULTS Of 5743 patients, 133 (2.3%) had CIIAI. 60% were male and the mean age was 8 (SD 4.4) years. One patient with CIIAI met the proposed very low risk criteria, resulting in a prediction rule sensitivity of 99%, 95% CI [96-100%]. This patient also had extra-abdominal arterial bleeding requiring revascularization, offering an alternative reason for transfusion. Kappa was 0.85, 95% CI [0.82, 0.89], indicating strong inter-rater agreement. CONCLUSIONS One out of 133 patients with CIIAI met very low risk criteria based on the PECARN prediction rule. This study supports the PECARN clinical prediction rule in decreasing CT use in pediatric patients at very low risk for CIIAI.
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Affiliation(s)
- Elise Springer
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - S Barron Frazier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Donald H Arnold
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA; Department of Pediatrics, Division of Pulmonary Medicine and the Center for Asthma Research, Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN 37232, USA
| | - Adam A Vukovic
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA.
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Indication of whole body computed tomography in pediatric polytrauma patients-Diagnostic potential of the Glasgow Coma Scale, the mechanism of injury and clinical examination. Eur J Radiol 2018; 105:32-40. [PMID: 30017296 DOI: 10.1016/j.ejrad.2018.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 05/13/2018] [Accepted: 05/20/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the diagnostic potential of the Glasgow Coma Scale (GCS), the mechanism of injury (MOI) and clinical examination (CE) for the indication of whole body computed tomography (WBCT) in pediatric polytrauma patients. MATERIALS & METHODS 100 pediatric polytrauma patients with WBCT were analysed in terms of age, gender, (MOI), GCS, detected injury, FAST, CE and Injury Severity Score (ISS). Correlations between all clinical variables and patient groups with (p+) and without (p-) injury were assessed. RESULTS Mean age was 9.13 ± 4.4 years (28% female patients). Injury was detected in 71% of the patients, most commonly of the head (43%). There was no significant correlation between type or severity of MOI and ISS (p > 0.1). None of the clinical variables had a significant predictive effect on p+. The optimum discrimination threshold of GCS was at 12.5 relating to craniocerebral injuries. Severity of MOI and FAST showed best predictive effects on thoracic and abdominal pathologies, respectively, but with only low sensitivities (<20%). CONCLUSION There is no clinical variable, which can be used as sole indication for WBCT in pediatric polytrauma patients. GCS had a significant predictive value for craniocerbral injuries and CCT is recommended at GCS ≤ 13.
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Should grade of solid organ injury determine need for hospitalization in children? J Trauma Acute Care Surg 2017; 82:109-113. [PMID: 28002386 DOI: 10.1097/ta.0000000000001303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of solid organ injuries (SOI) in children is often predicated on radiologic grade of injury. Hypothesizing that grade may not necessarily determine hospitalization need, we investigated factors associated with hospitalization in cases of isolated SOI in children. METHODS Retrospective review of all cases admitted to one pediatric trauma centre over 10 yrs revealed 86 cases with SOI established by computed tomography (CT) scan upon admission. Review of all scans by one pediatric radiologist was performed to determine SOI grade. χ and Fisher's tests were used to determine associations with presenting clinical features and SOI grade with early outcomes. RESULTS Ninety-one cases of SOI were identified. Of these, 56 were isolated to solid organs, whereas the others were multisystem; 12 were grades I and II and 44 grades III to V. Variables associated with length of stay longer than 2 days were admission hematocrit (Hct) less than 33% (p = 0.006) and need for narcotics or anti-emetics upon admission (p = 0.002; p < 0.0001). Significant associations between these features and need for narcotics or anti-emetics the following day were also observed. No features predicted a significant drop in Hct over the first 24 hours or need for transfusion. Nineteen patients did not require narcotics, anti-emetics, or transfusions; 11 of these stayed in hospital for 2 days or shorter. The CT grade was not predictive of any short term outcomes. CONCLUSIONS Clinical status, low admission Hct, and need for medications may be better predictors of admission requirements of patients with isolated SOI than CT grade. Brief emergency department observation and discharge home may be appropriate for stable patients with isolated BAT without concerning clinical features, despite findings of SOI on imaging. LEVEL OF EVIDENCE Therapeutic study, level V.
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Arbuthnot M, Armstrong LB, Mooney DP. Can we safely decrease intensive care unit admissions for children with high grade isolated solid organ injuries? Using the shock index, pediatric age-adjusted and hematocrit to modify APSA admission guidelines. J Pediatr Surg 2017; 52:989-992. [PMID: 28365104 DOI: 10.1016/j.jpedsurg.2017.03.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 03/09/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2000, the American Pediatric Surgical Association (APSA) disseminated consensus practice guidelines for the management of blunt liver and splenic injury which included intensive care unit (ICU) admission for children with grade IV injuries. We sought to determine if we could better predict which children with isolated solid organ injuries (SOI) underwent an ICU-level intervention, thus necessitating ICU admission. METHODS Children with isolated liver, spleen, or kidney injuries admitted to the ICU from November 2003 to August 2015 were identified in our trauma registry, and data were extracted from the medical record. ICU-level interventions were defined as transfusion, vasopressor use, intubation, and operative/procedural intervention. Shock index and pediatric age-adjusted (SIPA) was calculated for all patients. The sensitivity and negative predictive values (NPV) were determined. RESULTS 133 children met inclusion criteria. 19 (14.3%) required ICU-level intervention, and 114 (85.1%) did not. 95% (n=18) of the intervention group had either an elevated SIPA or a hematocrit <30% on admission compared to 22% (n=25) of patients in the no intervention group. Sensitivity was 95%, and NPV was 99%. CONCLUSIONS Limiting ICU admission in children with isolated SOI to those with an elevated SIPA or hematocrit <30% would reduce the ICU admission rate by two-thirds while maintaining patient safety. TYPE OF STUDY Diagnostic study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mary Arbuthnot
- Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States.
| | - Lindsey Bendure Armstrong
- Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States
| | - David P Mooney
- Boston Children's Hospital, Department of Surgery, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, United States
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Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma. Pediatr Surg Int 2017; 33:311-316. [PMID: 27878593 DOI: 10.1007/s00383-016-4026-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 10/24/2022]
Abstract
PURPOSE Current guidelines for computed tomography (CT) after blunt trauma were developed to capture all intra-abdominal injuries (IAI). We hypothesize that current AST/ALT guidelines are too low leading to unnecessary CT scans for children after blunt abdominal trauma (BAT). METHODS Patients who received CT of the abdomen after blunt trauma at our Level I Pediatric Trauma Center were stratified into a high risk (HR) (liver/spleen/kidney grade ≥III, hollow viscous, or pancreatic injuries) and low risk (LR) (liver/kidney/spleen injuries grade ≤II, or no IAI) groups. RESULTS 247 patients were included. Of the 18 patients in the HR group, two required surgery (splenectomy and sigmoidectomy). Transfusion was required in 30% of grade III and 50% of grade IV injuries. Eleven (5%) patients in LR group were transfused for indications other than IAI, and none were explored surgically. Both AST (r = 0.44, p < 0.001) and ALT (r = 0.43, p < 0.001) correlated with grade of liver injury. Using an increased threshold of AST/ALT, 400/200 had a negative predictive value of 96% in predicting the presence of HR liver injuries. CONCLUSION The current cutoff of liver enzymes leads to over-identification of LR injuries. Consideration should be given to an approach that aims to utilize CT in pediatric BAT that identifies clinically HR injury.
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15
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Miele V, Piccolo CL, Trinci M, Galluzzo M, Ianniello S, Brunese L. Diagnostic imaging of blunt abdominal trauma in pediatric patients. Radiol Med 2016; 121:409-30. [PMID: 27075018 DOI: 10.1007/s11547-016-0637-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 04/01/2016] [Indexed: 01/27/2023]
Abstract
Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.
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Affiliation(s)
- Vittorio Miele
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Claudia Lucia Piccolo
- Department of Medicine and Health Sciences, Università del Molise, Campobasso, Italy
| | - Margherita Trinci
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Michele Galluzzo
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Stefania Ianniello
- Department of Emergency Radiology, Azienda Ospedaliera S. Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences, Università del Molise, Campobasso, Italy
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The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers? J Pediatr Surg 2016; 51:649-53. [PMID: 26778841 DOI: 10.1016/j.jpedsurg.2015.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the management of pediatric trauma patients. METHODS We performed a two year (2011-2012) retrospective analysis of the National Trauma Data Bank. Pediatric (age≤18years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck, thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was performed. RESULTS A total of 30,667 pediatric trauma patients were included of which; 38.3% (n=11,748) were managed in designated pediatric centers. 26.1% (n=8013) patients received a WBCT. The use of WBCT scan was significantly higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p=0.001). There was no difference in mortality rate between the two groups (2.2% vs. 2.1%, p=0.37). After adjusting for all confounding factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3-2.1], p=0.001). CONCLUSIONS Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increasing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of WBCT across centers is warranted.
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17
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The use of an institutional pediatric abdominal trauma protocol improves resource use. J Trauma Acute Care Surg 2016; 80:57-63. [DOI: 10.1097/ta.0000000000000712] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Admission hematocrit predicts the need for transfusion secondary to hemorrhage in pediatric blunt trauma patients. J Trauma Acute Care Surg 2015; 79:555-62. [PMID: 26402528 DOI: 10.1097/ta.0000000000000806] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric trauma uses a substantial amount of resources. Quick and cost-effective measures that can be used to identify children with clinically relevant injuries are essential to resource allocation and optimization of patient care. Admission hematocrit is rapid and inexpensive, causes minimal harm, and can potentially aid in critical decision making. We hypothesize that admission hematocrit predicts the need for transfusion in pediatric blunt trauma patients. METHODS Records of trauma patients age 0 year to 17 years (2005-2013) who presented to a pediatric Level 1 trauma center were retrospectively reviewed. Data collected include demographics, computed tomographic scan findings, need for an intervention secondary to bleeding (blood transfusion, angioembolization, or operation), and admission hematocrit. RESULTS We found a significant decrease in admission hematocrit between patients requiring a transfusion and patients who did not (27% vs. 36%, p < 0.01). We evaluated a subset of patients who had an abdominal computed tomographic scan and found a significant decrease in admission hemocrit between those who required a transfusion for an intra-abdominal injury and those who did not (29% vs 37%, p < 0.01). In this subset, serial hematocrit values remained significantly lower in the patients requiring a transfusion up to 67 hours after admission (p = 0.04). A cutoff admission hematocrit of 35% or less has a sensitivity of 94% and a negative predictive value of 99.9% in identifying children who need a transfusion after blunt trauma. CONCLUSION An admission hematocrit of 35% or less provides a reliable screening test because of its low false negative rate and high specificity for identifying patients at an increased risk of bleeding after injury. Admission hematocrit could be widely implemented to identify patients who may need a transfusion with low expense and minimal harm for our pediatric patients and may be able to alter the entire course of their trauma resuscitation. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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Zundel S, Szavay P. Konservative vs. chirurgische Therapie des Bauchtraumas. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-015-3472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network. METHODS We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries. RESULTS A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%. CONCLUSION Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.
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Hershkovitz Y, Naveh S, Kessel B, Shapira Z, Halevy A, Jeroukhimov I. Elevated white blood cell count, decreased hematocrit and presence of macrohematuria correlate with abdominal organ injury in pediatric blunt trauma patients: a retrospective study. World J Emerg Surg 2015; 10:41. [PMID: 26379763 PMCID: PMC4570506 DOI: 10.1186/s13017-015-0034-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/19/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction Computerized tomography (CT) has become an important diagnostic modality in trauma patients. Pediatric patients are particularly susceptible to ionized radiation making liberal CT use in this age group unacceptable. We aimed to identify parameters that might predict abnormal findings on abdominal CT leading to patient management changes. Methods Data on blunt trauma patients up to 15 years of age admitted to Assaf Harofeh Medical Center from January 2007 to October 2014 was retrospectively collected. All patients with abdominal CT scan as part of initial assessment were included. Medical and surgical data were extracted from the medial charts. Patients were divided into two groups. Group I: patients whose management was changed solely based on abdominal CT findings and Group II: patients with normal abdominal CT. The groups were compared by all the data parameters. Results Overall, 182 patients were included in the study. The groups were comparable by age and mechanism of injury. Management changes based on CT findings were found in 68 (37.4 %) patients. White blood cell count >14000, abnormally low hematocrit level and macrohematuria were associated with a diagnosis of intra-abdominal injury requiring patient management changes (p < 0.05). Group I patients had longer LOS. Fifteen patients (22 %) required active intervention based solely on CT findings. Physical examination, arterial blood gases and initial radiology examinations results did not correlate with abdominal CT findings. Conclusions Elevated WBC, decreased hematocrit and presence of macrohematuria strongly correlate with abdominal CT findings and lead to changes in patient management.
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Affiliation(s)
- Yehuda Hershkovitz
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sergei Naveh
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, 38100 Israel
| | - Zahar Shapira
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Halevy
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Igor Jeroukhimov
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Izquierdo Hernández B, Gutiérrez Alonso C, González Esgueda A, Alconchel Lagranja A. [Intestinal injury due to blunt abdominal trauma. Surgical indication based on diagnostic imaging]. An Pediatr (Barc) 2014; 81:e60-1. [PMID: 24874525 DOI: 10.1016/j.anpedi.2014.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/22/2014] [Indexed: 11/16/2022] Open
Affiliation(s)
- B Izquierdo Hernández
- Servicio de Radiodiagnóstico, Sección de Radiología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - C Gutiérrez Alonso
- Servicio de Radiodiagnóstico, Sección de Radiología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A González Esgueda
- Servicio de Cirugía Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A Alconchel Lagranja
- Servicio de Radiodiagnóstico, Sección de Radiología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
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