Pediatric Blunt Abdominal Trauma

Does this patient need an Abdominal CT?

OBJECTIVES

Review Anatomic and Physiologic Differences of Pediatric Patients

Review Mechanisms of Pediatric Abdominal Trauma Discuss Prediction Rules for Severe/High Risk Abdominal

Trauma Discuss Clinical Decision Tools Used to Determine Need

for Abdominal CT Develop a Complete Clinical Approach to Pediatric Blunt

Abdominal Trauma

Why Review Pediatric Blunt Abdominal Trauma

Trauma is the #1 cause of death and disability in children >1 year old

Head and Thoracic are the most common But…Abdominal Injuries are Most Unrecognized Cause of

Death 90% of Abdominal Injuries from Trauma are Blunt

Abdominal Injuries Understanding of management pediatric abdominal

injury important to future

What Makes Pediatric Patients Different? Abdominal organs are relatively larger Abdominal muscles are poorly developed Less abdominal fat Ribcage compliant leads to transmission of force to liver and

spleen Greater force per BSA leads to multiple injuries Large BSA leads to Hypothermia Difficult to identify if patient in pain

Kids cry due to pain Kids cry because doctors are scary Kids cry because parents are not holding them

Common Chief Complaints

MVC Seat-Belt Syndrome Pedestrian Struck by Motor Vehicle Falls Bicycle Injury – Handlebars (often Delayed

Presentation) Sports Injury Non-accidental Trauma

MVC Most common cause blunt abdominal injury Inappropriately restrained child 3x more likely to suffer abdominal

injury Spleen and Liver injury most common

Seat-Belt Syndrome Etiology typically inappropriate seat-belt use Hip and Abdominal Contusions, Pelvic Fx, Lumbar Spine Injury Definition: area of erythema, ecchymosis and/or abrasion across

abdominal wall resulting from seat belt restraints Sokolove et al: RR 2.9 if seatbelt sign present

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCLO8ro7fnMgCFQgKkgod3i4Hiw&url=http://www.safercar.gov/parents/CarSeats/Right-Seat-Age-And-Size-Recommendations.htm&psig=AFQjCNFElawTO70cPTyRWt2MxmynUvQfqQ&ust=1443633248010756

Bicycle Injury Handlebar injury – direct impact during fall Delayed presentation – Average 34.5 hours post fall Klimek et al Retrospective review 40 patients <16 yo

8 required operative intervention

Nonaccidental Trauma If story does not sound right, high suspicion for NAT Roaten et al review of 6186 trauma patients <18 yo

7.3% injury secondary to NAT Fall with injuries >>>> mechanism Multiple Injuries Abnormal bruising patterns

So…Who Needs a CT Scan?Why Do We Care? CT scans pose increase risk to pediatric patients Ionizing radiation increases risk of malignancy Growing tissues and organs children more sensitive to

radiation than adults Estimated risk of fatal cancer from radiation

1/1000 pediatric CT scan 0.18% lifetime risk for Abdominal CT in 1 year old

ALARA principle

• Prospective Observational Study; One Level 1 Trauma Center• 1,119/1,324 patients enrolled with at least 1 variable – used as study sample• Utilizes 6 ‘High-Risk’ variables, if any present – concern for significant intra-

abdominal injury1.Low age-adjusted Systolic Blood Pressure2.Abdominal Tenderness3.Femur Fracture4. Increased LFTs (AST >200 U/L, ALT >125 U/L)5.Microscopic Hematuria (>5 rbc/hpf)6. Initial Hematocrit <30%

Inclusion Criteria:

<18 y/o

Underwent Definitive Test: Abd CT, DPL, Laparotomy/Laparoscopy

Exclusion Criteria:

Penetrating Trauma

Pregnant

Trauma >24 hours prior to presentation

Primary Outcomes:

• Intra-abdominal injury – spleen, liver, GB, pancreas, adrenal, kidney, ureter, bladder, GI tract, vascular structure

• Intra-abdominal injury requiring acute specific Intervention

1. Blood Transfusion for anemia 2/2 intra-abdominal hemorrhage

2. Angiographic embolization

3. Therapeutic intervention at laparotomy

Results: 157/1,119 (14%) had intra-abdominal injuries

754/1,119 tested positive for prediction rule

365/1,119 tested negative; 8 false negatives

Sensitivity: 94.9%

Specificity: 37.1%

Potential Strength: Utilization of prediction rule would decrease 1/3 Abd CT

Rapid identification of low risk for abdominal pain

Weaknesses: One institution No FAST exam

8 missed cases

Not included: (1) Transfers from other hospitals

(2) Patients observed without CT/DPL/Surgery

3 patients – tenderness or trauma over costal margins

2 patients – decreased mental status (GCS 9, 12)

1 patient – underwent laparotomy but had seatbelt sign on exam, no significant intervention in OR

1 patient – other injuries

1 patient – developed tenderness during observation time in ED

7/8 only observed in hospital

Prospective, Observational Cohort blunt torso trauma at PECARN centers

Enrollment: May 2007 – January 2010

Exclusion Criteria:

Injury >24 hours prior to presentation

Pregnancy

Transfer from outside hospital

Penetrating trauma

Preexisting neurologic condition impeding reliable exam

Inclusion Criteria

Primary Outcomes Intra-abdominal Injury - 761/12,044 patients (6.3%)

Radiographically or surgically apparent injury to: spleen, liver, urinary tract, GI tract, GB, pancreas, adrenal, vasculature

Underwent Acute intervention - 203 (1.7%) Death caused by injury

Therapeutic intervention at laparotomy

Angiographic embolization

Blood transfusion for anemia 2/2 hemorrhage

IV fluids for 2+ nights with pancreatic or GI injuries

Derived Prediction Rule Variables

1. Abdominal Wall Trauma or Seat Belt Sign

2. GCS <14

3. Abdominal Tenderness

4. Evidence Thoracic Wall Trauma

5. Complaints of Abdominal Pain

6. Decreased Breath Sounds

7. Vomiting

Limitations No FAST exam/Ultrasound utilized Abd CT/DPL/Laparoscopy not mandated so clinically

silent Intra-Abdominal Injuries may have been missed Performed at Highly Specialized Pediatric Trauma

Centers

Volume 22, Issue 9, pages 1034–1041, September 2015

Can I Trust My Gut?

• Prediction Rule Sn >>>> Clinical Suspicion Sn• Prediction Rule Sp <<<< Clinical Suspicion Sp• However – despite low clinical suspicion, CT abd ordered on many

patients

Retrospective Analysis of Prospectively Collected Data One Level 1 Trauma Center, Jan 2010 – Dec 2012 Radiology Resident performed all FAST studies Primary Outcomes

Free Fluid in Abdomen

Intra-Abdominal Injury Negative Intra-Abdominal Injury determined by Neg CT or Follow-up Appt

CONCLUSIONS History and Exam Vital for Evaluation of Pediatric Blunt Abdominal

Trauma GCS score, Seat Belt Sign, Abdominal Wall Tenderness, Distracting Injuries Vital Signs – Remember Age Adjusted cut-offs

Laboratory Tests ARE useful and can be predictive of Injury UA – gross hematuria AST/ALT CBC

Utilized adjunct Testing FAST exam

Ultimately, predictive scores are useful tools but cannot substitute for clinical judgement

Questions???

References Available Upon Request