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Papillon SC, Pennell CP, Bauer SE, DiBello A, Master SA, Prasad R, Arthur LG, Grewal H. Presence of Microscopic Hematuria Does Not Predict Clinically Important Intra-Abdominal Injury in Children. Pediatr Emerg Care 2024:00006565-990000000-00481. [PMID: 38849150 DOI: 10.1097/pec.0000000000003210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
OBJECTIVE Screening for blunt intra-abdominal injury in children often includes directed laboratory evaluation that guides need for computed tomography. We sought to evaluate the use of urinalysis in identifying patients with clinically important intraabdominal injury (ci-IAI). METHODS A retrospective chart review was performed for all patients less than 18 years who presented with blunt mechanisms at a level I trauma center between 2016 and 2019. Exclusion criteria included transfer from an outside facility, physical abuse, and death within thirty minutes of arrival. Demographics, physical exam findings, serum chemistries, urinalysis, and imaging were reviewed. Clinically important intraabdominal injury was defined as injury requiring ≥2 nights admission, blood transfusion, angiography with embolization, or therapeutic surgery. RESULTS Two hundred forty patients were identified. One hundred sixty-five had a completed urinalysis. For all patients an abnormal chemistry panel and abnormal physical exam had a sensitivity of 88.9% and a negative predictive value of 99.3%. Nine patients had a ci-IAI. Patients with a ci-IAI were more likely to have abdominal pain, tenderness on exam, and elevated hepatic enzymes. When patients were stratified by the presence of an abnormal chemistry or physical exam with or without microscopic hematuria, urinalysis did not improve the ability to identify patients with a ci-IAI. In fact, presence of microscopic hematuria increased the rate of false positives by 12%. CONCLUSIONS Microscopic hematuria was not a useful marker for ci-IAI and may lead to falsely assuming a more serious injury.
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Affiliation(s)
- Stephanie C Papillon
- From the Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St Christopher's Hospital for Children
| | - Christopher P Pennell
- From the Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St Christopher's Hospital for Children
| | | | | | - Sahal A Master
- From the Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St Christopher's Hospital for Children
| | - Rajeev Prasad
- St. Luke's University Health Network, Pediatric Surgery, Bethlehem, PA
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Pruitt P, Castillo R, Rogers A, Prabhakaran S, Muschong K, Scudder M, McCarthy DM, Holl JL, Courtney DM, Borczuk P, Naidech A. External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness. Ann Emerg Med 2024; 83:421-431. [PMID: 37725019 DOI: 10.1016/j.annemergmed.2023.08.481] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/29/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
STUDY OBJECTIVE The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool. METHODS We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record. RESULTS The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11). CONCLUSION The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.
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Affiliation(s)
- Peter Pruitt
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Richmond Castillo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew Rogers
- Department of Emergency Medicine, North Shore Health System, Evanston, IL
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Kayla Muschong
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael Scudder
- New York University Grossman School of Medicine, New York, NY
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jane L Holl
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew Naidech
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Cohen N, Cohen DM, Barbi E, Shavit I. Analgesia and Sedation of Pediatric Patients with Major Trauma in Pre-Hospital and Emergency Department Settings-A Narrative Review. J Clin Med 2023; 12:5260. [PMID: 37629302 PMCID: PMC10455791 DOI: 10.3390/jcm12165260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/18/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Children who sustain major injuries are at risk of receiving insufficient pain relief and sedation, which can have physical and psychological repercussions. Heightened emotional distress can increase the likelihood of developing symptoms of post-traumatic stress. Providing sufficient analgesia and sedation for children with major trauma presents specific challenges, given the potential for drug-related adverse events, particularly in non-intubated patients. The current literature suggests that a relatively low percentage of pediatric patients receive adequate analgesia in pre-hospital and emergency department settings following major trauma. There are only sparse data on the safety of the provision of analgesia and sedation in children with major trauma in the pre-hospital and ED settings. The few studies that examined sedation protocols in this context highlight the importance of physician training and competency in managing pediatric airways. There is a pressing need for prospective studies that focus upon pediatric major trauma in the pre-hospital and emergency department setting to evaluate the benefits and risks of administering analgesia and sedation to these patients. The aim of this narrative review was to offer an updated overview of analgesia and sedation management in children with major trauma in pre-hospital and ED settings.
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Affiliation(s)
- Neta Cohen
- Pediatric Emergency Medicine Department, Dana Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Daniel M. Cohen
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH 43210, USA;
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS Burlo Garofolo, 34137 Trieste, Italy;
- Clinical Department of Medical Surgical and Health Science, University of Trieste, 34127 Trieste, Italy
| | - Itai Shavit
- Division of Pediatrics, Hadassah Medical Center, Jerusalem 9112001, Israel;
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
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Perin I, Guetter CR, Klüppel LE, Fachin CG, Pimentel SK. CT scan in the evaluation of pediatric abdominal trauma. Rev Col Bras Cir 2022; 49:e20223246. [PMID: 36515330 PMCID: PMC10578840 DOI: 10.1590/0100-6991e-20223246-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 08/06/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE to assess the need of computed tomography (CT) for the definition of management in pediatric abdominal trauma. METHODS observational retrospective study with patients under 18 years old victims of blunt or penetrating abdominal trauma that underwent CT of the abdomen and pelvis at admission. We evaluated CT scan findings, indications and management. We calculated the sensitivity, specificity, positive predictive value and negative predictive value of clinical variables and energy of trauma for findings on CT. RESULTS among the 236 patients included in our study, 72% (n=170) did not present abnormal findings on CT. It was performed surgical treatment in 15% (n=10), conservative treatment in 54,5% (n=36) and 27% (n=18) did not receive treatment for abdominal injuries. In the assessment of CT indications, 28,8% (n=68) presented no justifications. In this group, 91% (n=62) did not show any abnormal findings. Among the six patients with positive findings, half were selected for conservative treatment, while the rest did not need any treatment for abdominal injuries. The presence of abdominal pain, hemodynamic alterations and high energy blunt trauma had low positive predictive values when isolated, whereas the negative predictive values were higher. CONCLUSION although CT is necessary in some instances, there is a possible high number of exams that did not make any difference in the management of the pediatric population.
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Affiliation(s)
- Isabella Perin
- - Universidade Federal do Paraná - Curitiba - PR - Brasil
| | - Camila Roginski Guetter
- - Universidade Federal do Paraná - Curitiba - PR - Brasil
- - Johns Hopkins Bloomberg School of Public Health - Baltimore - Maryland - Estados Unidos
| | | | | | - Silvania Klug Pimentel
- - Universidade Federal do Paraná - Curitiba - PR - Brasil
- - Hospital do Trabalhador, Cirurgia Geral - Curitiba - PR - Brasil
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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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PERIN ISABELLA, GUETTER CAMILAROGINSKI, KLÜPPEL LÚCIOEDUARDO, FACHIN CAMILAGIRARDI, PIMENTEL SILVANIAKLUG. Tomografia computadorizada na avaliação do trauma abdominal pediátrico. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RESUMO Introdução: avaliar a necessidade da tomografia computadorizada (TC) para definição de condutas em trauma abdominal pediátrico. Métodos: estudo observacional retrospectivo com pacientes menores de 18 anos vítimas de trauma abdominal contuso ou penetrante e que realizaram TC de abdome e pelve na admissão. Avaliou-se achados das tomografias, condutas e justificativas para indicação da TC. Foram calculados sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de fatores clínicos e energia do trauma para alterações na TC. Resultados: dentre os 236 pacientes incluídos, 72% (n=170) não apresentaram alterações na TC. Foi realizado tratamento cirúrgico em 15% (n=10), tratamento conservador em 54,5% (n=36) e 27% (n=18) não receberam tratamento por lesões abdominais. Na avaliação das indicações de TC, 28,8% (n=68) não apresentavam nenhuma justificativa, sendo que nesse grupo 91% (n=62) resultaram em ausência de achados. Dentre os seis pacientes com achados positivos, metade recebeu tratamento conservador, enquanto o restante não necessitou de tratamento por lesões abdominais. A presença de dor abdominal, alteração hemodinâmica e trauma contuso de alta energia apresentaram baixos valores preditivos positivos de forma isolada, enquanto os valores preditivos negativos foram mais altos. Conclusão: apesar de a TC ser necessária e justificável em alguns casos, há um possível excesso de tomografias dispensáveis para definição de condutas em população pediátrica.
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Affiliation(s)
| | - CAMILA ROGINSKI GUETTER
- Universidade Federal do Paraná, Brazil; Johns Hopkins Bloomberg School of Public Health, Estados Unidos
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Sharma G, Chatterjee N, Kaushik A, Saxena S. Clinicoradiological Predictors of Severity of Traumatic Intra-Abdominal Injury in Pediatric Patients: A Retrospective Study. Cureus 2021; 13:e17936. [PMID: 34660126 PMCID: PMC8513727 DOI: 10.7759/cureus.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/01/2022] Open
Abstract
Background Adequate assessment of traumatic injury in patients of all age groups is essential for timely intervention and prevention of mortality and morbidity. This study aimed to assess the value of certain clinical as well as radiological factors as predictors of severity of the intra-abdominal injury as detected on computed tomography (CT) and to review the guidelines, protocols, and practices followed in imaging of abdominal trauma in patients of pediatric age group. Methods This retrospective observational study included 263 pediatric patients (18 years of age or younger) who presented to the emergency department (ED) with a history of trauma to the abdomen. The study was conducted over a period of 12 months. Correlation of five variables, i.e., age of the child, focused abdominal sonography in trauma (FAST) status, mechanism of injury, presenting complaints and clinical features (hypotension, tachycardia, etc), fractures identified on trauma X-ray series, was done with CT findings (severity of injury). All five variables were statistically analyzed and p-values were derived for age, mechanism of injury, presenting complaints, clinical features, and trauma x-ray series, while parameters like sensitivity and specificity were determined for FAST status Results All variables well correlated with the severity of injury with p-values <0.05. On multivariate analysis, FAST status had the highest (47.94) odds ratio among the five variables for predicting severe intra-abdominal injury while vital signs had the lowest (0.076). Further, age group of 0-4 years was found most prone to higher grades of injury with odds ratio of 7.83. Motor vehicle crash had odds ratio of 26.6 for severe injury, the highest among mechanisms of injury. While for FAST status, sensitivity was found to be 89.4%, specificity 85%, and negative predictive value 90%, trauma series radiographs had a sensitivity of 42.27%, specificity of 77.85% and negative predictive value of 60.55%. Conclusion Clinical parameters and traditional imaging techniques can predict the severity of injury on CT and guide further imaging and intervention.
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Affiliation(s)
- Garima Sharma
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Navojit Chatterjee
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Ashish Kaushik
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Sudhir Saxena
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, IND
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Pruitt P, Naidech A, Prabhakaran S, Holl JL, Courtney DM, Borczuk P. External Validation of a Tool to Predict Neurosurgery in Patients with Isolated Subdural Hematoma. World Neurosurg 2020; 147:e163-e170. [PMID: 33309641 DOI: 10.1016/j.wneu.2020.11.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Orlando and colleagues derived a prediction tool for neurosurgical intervention, the "Orlando Tool," consisting of (a) maximum thickness of hematoma, and (b) presence of acute-on-chronic (AOC) hematoma. This study externally validated the Orlando Tool. METHODS We performed a retrospective chart review of consecutive patients aged ≥16 years with a Glasgow Coma Scale score ≥13, and a computed tomography-documented isolated, traumatic SDH, who presented to a university-affiliated, urban, 100,000-annual-visit emergency department from 2009-2015. The primary outcome was neurosurgical intervention. Thickness of hematoma and presence of AOC hematoma were abstracted from cranial computed tomography scan reports by 2 trained physician abstractors. RESULTS A total of 607 patients with isolated SDH were included in the validation dataset. Median hematoma thickness was 6 mm. AOC hematoma was noted in 13% of patients. Mortality was 2.5%, and 15.7% of patients underwent neurosurgery. The Orlando Tool had an area under the curve of 0.93 in the validation, comparable to 0.94 reported in their derivation set. At the prespecified cutoff of 9.96% risk, the tool had a 88% (95% CI, 80-94) sensitivity in the validation cohort compared with 94% in the derivation cohort. The specificity of 82% (95% CI, 78-85) was comparable with 84% in the derivation group. Negative likelihood ratio was 0.14 (95% CI, 0.08-0.25), compared with 0.09 in derivation. CONCLUSIONS The Orlando Tool accurately predicts neurosurgical intervention in patients with isolated, traumatic SDH and preserved consciousness.
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Affiliation(s)
- Peter Pruitt
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Andrew Naidech
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Ledrick D, Payvandi A, Murray AC, Leskovan JJ. Is There a Need for Abdominal CT Scan in Trauma Patients With a Low-Risk Mechanism of Injury and Normal Vital Signs? Cureus 2020; 12:e11628. [PMID: 33376642 PMCID: PMC7755665 DOI: 10.7759/cureus.11628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Clinically significant injuries are often missed in trauma patients with low-risk mechanisms of injury and lack of "red flags," such as abnormal vital signs. The purpose of this retrospective analysis was to evaluate the efficacy of computed axial tomography (CT) for identifying occult injuries in a high-volume trauma center. Methods Records from our institutional trauma registry were retrospectively extracted, examining encounters from January 2015 to October 2019. Those patients between the ages of 18 and 65 who were referred to the trauma team with a CT scan of the abdomen and had low-risk mechanisms of injury, a Glasgow Coma Scale (GCS) score of 15, and normal vital signs at presentation were included. Patients in the lowest trauma categorization (Level Three, Consult) met the study definition for the low-risk mechanism of injury. Demographic and clinical data were abstracted for all patients. For this analysis, patients were divided into two groups based on age (18 - 40 years or 40 - 65 years). Injuries found on CT, their clinical significance, and the likelihood of being missed without CT were determined. Results Of 2,103 blunt trauma patients that received a CT scan of the abdomen from January 2015 to October 2019, 134/2,103 (6.4%) met the inclusion criteria (mean age: 44.6 years; 72.3% male). Patients between the ages of 40 and 65 years comprised 61.2% (82/134) of the study population. Of the included patients, 17.2% (23/134) had at least one acute traumatic injury identified after CT imaging of the torso. Occult injuries found on CT included rib fracture with associated lung injuries (10/23, 43.5%), splenic laceration (4/23, 17.4%), liver laceration (3/23, 13.0%), gluteal hematoma with active bleeding (1/23, 4.3%), sternal fractures (3/23, 13.0%), and thoracic or lumbar spine fractures (2/23, 8.7%). An independent review of the medical records determined that 9.0% (12/134) of these patients had traumatic injuries that would have been missed based on clinical examination without CT. Conclusions Based on our experience, utilizing CT imaging of at least the abdomen as a routine screening measure for all trauma consults - even low-risk patients with normal vital signs - can rapidly and accurately identify clinically significant injuries that would have been otherwise missed in a notable portion of the population.
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Affiliation(s)
- David Ledrick
- Department of Emergency Medicine, Mercy St. Vincent Medical Center, Toledo, USA
| | - Alexander Payvandi
- Department of Emergency Medicine, Mercy St. Vincent Medical Center, Toledo, USA
| | - Adam C Murray
- Department of Emergency Medicine, Mercy St. Vincent Medical Center, Toledo, USA
| | - John J Leskovan
- Department of Trauma Surgery, Mercy St. Vincent Medical Center, Toledo, USA
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Zimmermann P, Schmidt T, Nelson J, Gosemann JH, Bassler S, Stahmeyer JT, Hirsch FW, Lacher M, Zeidler J. Pediatric solid organ injury - frequency of abdominal imaging is determined by the treating department. Medicine (Baltimore) 2020; 99:e23057. [PMID: 33157961 PMCID: PMC7647522 DOI: 10.1097/md.0000000000023057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the use of abdominal CT scanning in the management of pediatric blunt abdominal trauma in pediatric and non-pediatric departments.In this observational cohort study, anonymized data were extracted from 2 large German statutory health insurances (∼5.9 million clients) in a 7-year period (2010-2016). All patients with inpatient International Classification of Diseases (ICD) codes S36.- and S37.- (injury of intra-abdominal organs; injury of urinary and pelvic organs) aged ≤18 years were included. Demographic and clinical data were analyzed by logistic regression analysis for associations with the use of abdominal CT.A total of 524 children with blunt abdominal trauma (mean age 11.0 ± 5.2 years; 62.6% males) were included; 164 patients (31.3%) received abdominal CT-imaging. There were no significant differences in traumatic non-intraabdominal comorbidity patterns (injuries of external causes; injuries to the head or thorax). There was substantial variability in the rate of abdominal CT imaging among different medical disciplines ranging from 11.6% to 44.5%. Patients admitted to pediatric departments (Pediatrics and Pediatric Surgery) underwent abdominal CT imaging significantly less frequently (19.7%; N = 55) compared to patients treated in non-pediatric departments (General/Trauma Surgery: 44.5%; N = 109) irrespective of concomitant injuries. The estimated OR for the use of abdominal CT by General/Trauma Surgery was 6.2-fold higher (OR: 6.15 [95-%-CI:3.07-13.21]; P < .001) compared to Pediatric Surgery. Other risk factors associated with the use of abdominal CT were traumatic extra-abdominal comorbidities, increasing age, male gender, and admission to a university hospital.Abdominal CT imaging was significantly less frequently used in pediatric departments. The substantial variability of the abdominal CT rate among different medical disciplines and centers indicates a potential for reduction of CT imaging by implementation of evidence-based guidelines. Furthermore, our study underlines the need for centralization of pediatric trauma care in Germany not only to improve patient outcome but to avoid radiation-induced cancer mortality.
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Affiliation(s)
| | - Torben Schmidt
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
| | - Jana Nelson
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | | | - Stefan Bassler
- AOK PLUS - Die Gesundheitskasse für Sachsen und Thüringen, Dresden
| | | | | | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
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Abstract
OBJECTIVES Abdominal computed tomography (ACT) use in the initial evaluation of pediatric abdominal trauma is liberal in most instances. The aim of this study was to identify the predictors for a positive yield ACT scan in this population. METHODS A prospective, cohort, single-center observational study was conducted at Children's Hospital at Westmead, New South Wales, from January 2008 to June 2015 on 240 pediatric abdominal trauma patients who had abdominal computed tomography. Clinical, laboratory, imaging, and interventional variables were explored with univariate and multivariate analyses among children who sustained abdominal trauma. RESULTS Of 240 patients, positive ACT scans were found in 161 patients (67%), 112 patients (47%) had intra-abdominal injury, and 20 patients (8%) required invasive therapeutic interventions. Mortality rate was 1.7% (4 patients) due to nonabdominal causes. Multivariate analyses revealed that increasing age (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.02-1.24; P = 0.024), high injury severity score (OR, 1.14; 95% CI, 1.07-1.21; P < 0.001), abnormal abdominal examination (OR, 5.95; 95% CI, 2.08-17.01; P = 0.001), elevated alanine aminotransferase greater than 125 IU/L (OR, 46.28; 95% CI, 2.81-762.49; P = 0.007), abnormal pelvic radiograph (OR, 14.03; 95% CI, 2.39-82.28; P = 0.003), presence of gross hematuria (OR, 4.14; 95% CI, 1.04-18.23; P = 0.044), low initial hematocrit level (less than 30%) (OR, 8.51; 95% CI, 1.14-63.70; P = 0.037), and positive focused assessment with sonography for trauma (OR, 2.61; 95% CI, 1.01-7.28; P = 0.048) remained significantly associated with abnormal ACT scan. In contrast, those who required scanning of other body region(s) were less likely to have abnormal ACT scan (OR, 0.34; 95% CI, 0.14-0.86; P =0.022). CONCLUSIONS Integrating the abdominal examination findings, relevant laboratory values, and focused assessment with sonography for trauma results with the physicians' suspicion may aid in stratifying patients for ACT scan. Further efforts should be made to decrease number of normal ACT scans; yet not to increase the number of delayed or missed injures with its inherent morbidity and mortality.
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12
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Frazzetta G, Lanaia A, Smerieri N, Bonilauri S. Blunt abdominal trauma in children: Duodenal burst injury management. Asian J Surg 2020; 43:506-507. [PMID: 31932154 DOI: 10.1016/j.asjsur.2019.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Giuseppe Frazzetta
- Azienda USL-IRCCS di Reggio Emilia, Dipartimento Chirurgia Generale e Specialistiche Struttura Complessa di Chirurgia Generale e D'Urgenza, Italy.
| | - Andrea Lanaia
- Azienda USL-IRCCS di Reggio Emilia, Dipartimento Chirurgia Generale e Specialistiche Struttura Complessa di Chirurgia Generale e D'Urgenza, Italy
| | - Nazareno Smerieri
- Azienda USL-IRCCS di Reggio Emilia, Dipartimento Chirurgia Generale e Specialistiche Struttura Complessa di Chirurgia Generale e D'Urgenza, Italy
| | - Stefano Bonilauri
- Azienda USL-IRCCS di Reggio Emilia, Dipartimento Chirurgia Generale e Specialistiche Struttura Complessa di Chirurgia Generale e D'Urgenza, Italy
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Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes. J Trauma Acute Care Surg 2019; 85:451-458. [PMID: 29787555 DOI: 10.1097/ta.0000000000001974] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Computed tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the use of CT scan guidelines in the management of pediatric trauma. The study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT use before and after CT-guideline implementation. METHODS Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis using published criteria from the Pediatric Emergency Care and Research Network. There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age < 15) trauma patients seen in our TC from 2010 to 2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay, readmissions, and mortality. Categorical and continuous variables were analyzed with χ and Wilcoxon rank-sum tests, respectively. p < 0.05 was considered significant. RESULTS We identified 1,934 patients: 1,106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8%, respectively (p < 0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. CONCLUSIONS Implementation of a pediatric CT guideline significantly decreases CT use, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. LEVEL OF EVIDENCE Therapeutic study, level IV.
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External validation of a five-variable clinical prediction rule for identifying children at very low risk for intra-abdominal injury after blunt abdominal trauma. J Trauma Acute Care Surg 2019; 85:71-77. [PMID: 29659473 DOI: 10.1097/ta.0000000000001933] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A clinical prediction rule was previously developed by the Pediatric Surgery Research Collaborative (PedSRC) to identify patients at very low risk for intra-abdominal injury (IAI) and intra-abdominal injury receiving an acute intervention (IAI-I) who could safely avoid abdominal computed tomography (CT) scans after blunt abdominal trauma (BAT). Our objective was to externally validate the rule. METHODS The public-use dataset was obtained from the Pediatric Emergency Care Applied Research Network (PECARN) Intra-abdominal Injury Study. Patients 16 years of age and younger with chest x-ray, completed abdominal history and physical examination, aspartate aminotransferase (AST), and amylase or lipase collected within 6 hours of arrival were included. We excluded patients who presented greater than 6 hours after injury or missing any of the five clinical prediction variables from the PedSRC prediction rule. RESULTS We included 2,435 patients from the PECARN dataset, with a mean age of 9.4 years. There were 235 patients with IAI (9.7%) and 60 patients with IAI-I (2.5%). The clinical prediction rule had a sensitivity of 97.5% for IAI and 100% for IAI-I. In patients with no abnormality in any of the five prediction rule variables, the rule had a negative predictive value of 99.3% for IAI and 100.0% for IAI-I. Of the "very low-risk" patients identified by the rule, 46.8% underwent abdominal CT imaging. CONCLUSIONS A highly sensitive clinical prediction rule using history and abdominal physical examination, laboratory values, and chest x-ray was successfully validated using a large public-access dataset of pediatric BAT patients. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic care/management study, level IV.
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Vogel AM, Zhang J, Mauldin PD, Williams RF, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Haynes JH, Blakely ML, Russell RT, Naik-Mathuria BJ, St Peter SD, Mooney D, Upperman JS, Streck CJ. Variability in the evalution of pediatric blunt abdominal trauma. Pediatr Surg Int 2019; 35:479-485. [PMID: 30426222 DOI: 10.1007/s00383-018-4417-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT). METHODS Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed. RESULTS 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use. CONCLUSIONS Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA.
| | - Jingwen Zhang
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Regan F Williams
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | - Eunice Y Huang
- University of Tennessee Health Science Center at Memphis, Memphis, TN, USA
| | | | - Kuojen Tsao
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | | | - Robert T Russell
- University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Bindi J Naik-Mathuria
- Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX, 77030, USA
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Dillman JR, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Brown BP, Chan SS, Dorfman SR, Falcone RA, Garber MD, Nguyen JC, Peters CA, Safdar NM, Trout AT, Karmazyn BK. ACR Appropriateness Criteria ® Hematuria-Child. J Am Coll Radiol 2019; 15:S91-S103. [PMID: 29724430 DOI: 10.1016/j.jacr.2018.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 02/01/2023]
Abstract
Hematuria is the presence of red blood cells in the urine, either visible to the eye (macroscopic hematuria) or as viewed under the microscope (microscopic hematuria). The clinical evaluation of children and adolescents with any form of hematuria begins with a meticulous history and thorough evaluation of the urine. The need for imaging evaluation depends on the clinical scenario in which hematuria presents, including the suspected etiology. Ultrasound and CT are the most common imaging methods used to assess hematuria in children, although other imaging modalities may be appropriate in certain instances. This review focuses on the following clinical variations of childhood hematuria: isolated hematuria (nonpainful, nontraumatic, and microscopic versus macroscopic), painful hematuria (ie, suspected nephrolithiasis or urolithiasis), and renal trauma with hematuria (microscopic versus macroscopic). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jonathan R Dillman
- Principal Author, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Craig A Peters
- UT Southwestern Medical Center, Dallas, Texas; Society for Pediatric Urology
| | | | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Boaz K Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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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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Leeper CM, Nasr I, Koff A, McKenna C, Gaines BA. Implementation of clinical effectiveness guidelines for solid organ injury after trauma: 10-year experience at a level 1 pediatric trauma center. J Pediatr Surg 2018. [PMID: 28625692 DOI: 10.1016/j.jpedsurg.2017.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Christine M Leeper
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center. 200 Lothrop Street, Pittsburgh, PA 15213, USA; Children's Hospital of Pittsburgh of UPMC. 7th Floor, Faculty Pavilion, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Isam Nasr
- The Johns Hopkins Department of Surgery, 1800 Orleans Street Pediatric Surgery Bloomberg 7323, Baltimore, MD 2128.
| | - Abigail Koff
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center. 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Christine McKenna
- Children's Hospital of Pittsburgh of UPMC. 7th Floor, Faculty Pavilion, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Barbara A Gaines
- Children's Hospital of Pittsburgh of UPMC. 7th Floor, Faculty Pavilion, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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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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Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Russell RT, Blakely ML, Mauldin PD, Calder BW, Savoie KB, Haynes JH, Naik-Mathuria BJ, St Peter SD, Mooney DP, Onwubiko C, Upperman JS. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg 2017; 224:449-458.e3. [DOI: 10.1016/j.jamcollsurg.2016.12.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022]
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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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Jones TS, Stovall RT, Jones EL, Knepper B, Pieracci FM, Fox CJ, Moore EE, Cothren Burlew C. A negative urinalysis is associated with a low likelihood of intra-abdominal injury after blunt abdominal trauma. Am J Surg 2016; 213:69-72. [PMID: 27452187 DOI: 10.1016/j.amjsurg.2016.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 04/28/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The utility of urinalysis (UA) to diagnose intra-abdominal (IA) or genitourinary (GU) injury after blunt trauma remains controversial. The purpose of this study was to determine the significance of UA in the blunt trauma patient. METHODS A retrospective review of patients admitted for blunt abdominal trauma from 2011 to 2013. RESULTS A total of 1,795 patients sustained blunt abdominal trauma: mean age of 44 ± 21 years; mean Injury Severity Score of 13 ± 10. Overall 810 patients had a negative UA (45%). Two patients (2/810 and .2%) had a GU injury and neither required intervention. Thirty-two patients (32/810 and 4.0%) had an IA injury, and 2 (2/810 and .02%) required intervention. The sensitivity for predicting GU injury requiring intervention was 1, and IA injury requiring intervention was .96. Negative predictive values were 1 and .99. CONCLUSIONS A negative UA correlates with a low risk for GU and IA injury after blunt abdominal trauma. A negative UA should be evaluated prospectively as part of a clinical prediction score to rule out injury and avoid unnecessary radiation exposure from computed tomography imaging.
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Affiliation(s)
- Teresa S Jones
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Robert T Stovall
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Edward L Jones
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Bryan Knepper
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA.
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Berona K, Kang T, Rose E. Pelvic Free Fluid in Asymptomatic Pediatric Blunt Abdominal Trauma Patients: A Case Series and Review of the Literature. J Emerg Med 2016; 50:753-8. [DOI: 10.1016/j.jemermed.2016.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
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25
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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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Finnerty NM, Rodriguez RM, Carpenter CR, Sun BC, Theyyunni N, Ohle R, Dodd KW, Schoenfeld EM, Elm KD, Kline JA, Holmes JF, Kuppermann N. Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda. Acad Emerg Med 2015; 22:1406-16. [PMID: 26567885 DOI: 10.1111/acem.12828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.
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Affiliation(s)
- Nathan M. Finnerty
- Department of Emergency Medicine; The Ohio State University College of Medicine; Columbus OH
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California San Francisco School of Medicine; San Francisco CA
| | - Christopher R. Carpenter
- Department of Emergency Medicine; Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
| | - Nik Theyyunni
- Department of Emergency Medicine; University of Michigan Medical School; Ann Arbor MI
| | - Robert Ohle
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
- Department of Internal Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Kendra D. Elm
- Department of Emergency Medicine; University of Minnesota Medical School; Minneapolis MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
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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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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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Moons KGM, Altman DG, Reitsma JB, Ioannidis JPA, Macaskill P, Steyerberg EW, Vickers AJ, Ransohoff DF, Collins GS. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162:W1-73. [PMID: 25560730 DOI: 10.7326/m14-0698] [Citation(s) in RCA: 2795] [Impact Index Per Article: 310.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.
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Paediatric trauma imaging: Why do we need separate guidance? Clin Radiol 2014; 69:1209-13. [DOI: 10.1016/j.crad.2014.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/16/2014] [Accepted: 07/01/2014] [Indexed: 11/22/2022]
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Adelgais KM, Kuppermann N, Kooistra J, Garcia M, Monroe DJ, Mahajan P, Menaker J, Ehrlich P, Atabaki S, Page K, Kwok M, Holmes JF. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr 2014; 165:1230-1235.e5. [PMID: 25266346 DOI: 10.1016/j.jpeds.2014.08.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/02/2014] [Accepted: 08/08/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the accuracy of complaints of abdominal pain and findings of abdominal tenderness for identifying children with intra-abdominal injury (IAI) stratified by Glasgow Coma Scale (GCS) score. STUDY DESIGN This was a prospective, multicenter observational study of children with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of abdominal findings for IAI with 95% CI stratified by GCS score. We examined the association of isolated abdominal pain or tenderness with IAI and that undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of intravenous fluid therapy). RESULTS Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13 and were included in this analysis. Sensitivity of abdominal pain for IAI was 79% (95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI, 42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. Among patients with isolated abdominal pain and/or tenderness, the rate of IAI was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1% (95% CI, 1%-2%). CONCLUSION The sensitivity of abdominal findings for IAI decreases as GCS score decreases. Although abdominal computed tomography is not mandatory, the risk of IAI is sufficiently high that diagnostic evaluation is warranted in children with isolated abdominal pain or tenderness.
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Affiliation(s)
- Kathleen M Adelgais
- Department of Pediatrics, University of Colorado Denver, Aurora, CO; Department of Pediatrics, University of Utah, Salt Lake City, UT.
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Davis, CA; Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA
| | - Joshua Kooistra
- Department of Emergency Medicine, Helen DeVos Children's Hospital, Grand Rapids, MI
| | - Madelyn Garcia
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - David J Monroe
- Department of Pediatrics, Howard County Hospital, Columbia, MD
| | - Prashant Mahajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
| | - Jay Menaker
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Peter Ehrlich
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Shireen Atabaki
- Department of Emergency Medicine, Children's National Medical Center, Washington, DC
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Maria Kwok
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Davis, CA
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The BATiC score to rule out traumatic intra-abdominal injury. J Pediatr 2014; 165:1070-1. [PMID: 25441392 DOI: 10.1016/j.jpeds.2014.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hershkovitz Y, Zoarets I, Stepansky A, Kozer E, Shapira Z, Klin B, Halevy A, Jeroukhimov I. Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury. Am J Emerg Med 2014; 32:697-9. [DOI: 10.1016/j.ajem.2014.04.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/07/2014] [Indexed: 11/25/2022] Open
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Abstract
PURPOSE OF REVIEW Our objective is to highlight recent literature investigating low-radiation diagnostic strategies in the evaluation of pediatric trauma. RECENT FINDINGS In the area of minor head injury, research has focused on implementation of validated clinical decision rules into practice to reduce unnecessary computed tomography scans. Clinical observation may also serve as an adjunct to initial assessment and a potential substitute for computed tomography imaging. Subgroups of children with special needs or severe injury mechanisms may also be safely characterized by the clinical decision rule and spared radiation exposure. Physical examination techniques may be useful in diagnosing mandibular fractures. In addition, evidence suggests that plain radiography for evaluation of blunt thoracic trauma may be sufficient in many cases, and computed tomography could be reserved for those with abnormal radiographs, high-risk mechanisms, or abnormal physical findings. Clinical decision rules are able to predict intra-abdominal injury with high sensitivity. Data suggest that skeletal surveys may be modified to limit radiation exposure in the case of suspected nonaccidental trauma. SUMMARY More research is needed in development of pediatric-specific clinical decision rules and risk stratification and in testing low-radiation diagnostic modalities in the pediatric trauma population.
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External validation of the Blunt Abdominal Trauma in Children (BATiC) score. J Trauma Acute Care Surg 2014; 76:1282-7. [DOI: 10.1097/ta.0000000000000175] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Hynick NH, Brennan M, Schmit P, Noseworthy S, Yanchar NL. Identification of blunt abdominal injuries in children. J Trauma Acute Care Surg 2014; 76:95-100. [PMID: 24368362 DOI: 10.1097/ta.0b013e3182ab0dfa] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The use of computed tomography (CT) to screen for injuries in pediatric blunt abdominal trauma (BAT) is increasing, concurrent with increasing concern over long-term risk of radiation-associated malignancies. We proposed to determine features that could be identified in the early assessment of these patients, which can predict the likelihood of clinically important intra-abdominal injuries warranting imaging by CT. We further queried if these were discrepant from factors associated with the decision to obtain an abdominal CT. METHODS Data of patients admitted with BAT to one of two Level I pediatric trauma centers were reviewed retrospectively. Clinical, laboratory, radiographic, and epidemiologic data were collected. Logistic regression was used to determine associations between pre-CT findings and ultimate diagnoses of "notable" or "clinically important" intra-abdominal injuries. Similar analyses were performed to determine which findings were associated with actually receiving an abdominal CT scan. RESULTS Of 571 patients, 37% had a notable intra-abdominal injury and 18% a clinically important intra-abdominal injury. After adjusting for all covariates, hematuria (gross or microscopic), elevated serum alanine aminotransferase, and documentation of clinically concerning abdominal findings upon examination remained significant predictors (odds ratio (OR), 3.5; 95% confidence interval [CI], 1.8-6.8; OR, 10.9; 95% CI, 2.5-47, respectively) of a clinically important injury. Undergoing a CT head and the presence of hematuria were significantly associated with obtaining a CT of the abdomen (OR, 3.4; 95% CI, 1.5-7.7; OR, 2.9; 95% CI, 1.1-7.3, respectively), while concerning abdominal findings and decreased Glasgow Coma Scale (GCS) score were not. CONCLUSION Clinical variables may be used to predict intra-abdominal injuries after pediatric BAT that may warrant imaging with CT scanning. Combined with findings from similar studies, it may be possible to derive and validate a decision-making rule both sensitive and specific in predicting the need for abdominal CT scanning in these patients. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Nina H Hynick
- From the Division of Pediatric General Surgery (N.H.H., N.L.Y.) and Department of Diagnostic Imaging (P.S.), Dalhousie University, Halifax, Nova Scotia; and Department of Emergency Medicine (M.B., S.N.), Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Livingston MH, Igric A, Vogt K, Parry N, Merritt NH. Radiation from CT scans in paediatric trauma patients: Indications, effective dose, and impact on surgical decisions. Injury 2014; 45:164-9. [PMID: 23845570 DOI: 10.1016/j.injury.2013.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/28/2013] [Accepted: 06/09/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. PATIENTS AND METHODS We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient. RESULTS 157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12-75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0-16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. CONCLUSIONS CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.
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Affiliation(s)
- Michael H Livingston
- Division of General Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
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Is computed tomography necessary to determine liver injury in pediatric trauma patients with negative ultrasonography? Eur J Trauma Emerg Surg 2013; 39:641-6. [PMID: 26815549 DOI: 10.1007/s00068-013-0322-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Abdominal trauma is the third most common cause of all trauma-related deaths in children. Liver injury is the second most common, but the most fatal injury associated with abdomen trauma. Because the liver enzymes have high sensitivity and specificity, the use of tomography has been discussed for accurate diagnosis of liver injury. METHODS Our study was based on retrospective analyses of hemodynamically stabil patients under the age of 18 who were admitted to the emergency department with blunt abdominal trauma. RESULTS Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly higher as a result of liver injury. In the patients whose AST and ALT levels were lower than 40 IU/L, no liver injury was observed in the contrast-enhanced computed tomography (CT). No liver injury was detected in the patients with AST levels lower than 100 IU/L. Liver injury was detected with contrast-enhanced CT in only one patient whose ALT level was lower than 100 IU/L, but ultrasonography initially detected liver injury in this patient. CONCLUSIONS According to our findings, abdominal CT may not be necessary to detect liver injury if the patient has ALT and AST levels below 100 IU/L with a negative abdominal USG at admission and during follow-up.
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Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med 2013; 62:107-116.e2. [PMID: 23375510 DOI: 10.1016/j.annemergmed.2012.11.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 11/05/2012] [Accepted: 11/13/2012] [Indexed: 11/22/2022]
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Yen K, Kuppermann N, Lillis K, Monroe D, Borgialli D, Kerrey BT, Sokolove PE, Ellison AM, Cook LJ, Holmes JF. Interobserver agreement in the clinical assessment of children with blunt abdominal trauma. Acad Emerg Med 2013; 20:426-32. [PMID: 23672355 DOI: 10.1111/acem.12132] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. METHODS This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement. RESULTS A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. CONCLUSIONS Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.
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Affiliation(s)
- Kenneth Yen
- Department of Pediatrics; Section of Emergency Medicine; Medical College of Wisconsin ; Milwaukee; WI
| | - Nathan Kuppermann
- Department of Emergency Medicine; University of California; Davis School of Medicine ; Sacramento; CA
| | - Kathleen Lillis
- the Department of Pediatrics; Division of Emergency Medicine; State University of New York at Buffalo; Women and Children's Hospital of Buffalo ; Buffalo; NY
| | - David Monroe
- Department of Pediatrics; Howard County General Hospital ; Columbia; MD
| | - Dominic Borgialli
- Department of Emergency Medicine; University of Michigan; Hurley Medical Center ; Flint; MI
| | - Benjamin T. Kerrey
- the Department of Pediatrics; Division of Emergency Medicine; University of Cincinnati College of Medicine ; Cincinnati; OH
| | - Peter E. Sokolove
- Department of Emergency Medicine; University of California; Davis School of Medicine ; Sacramento; CA
| | - Angela M. Ellison
- Department of Pediatrics; Division of Emergency Medicine Perelman School of Medicine; University of Pennsylvania ; Philadelphia; PA
| | - Lawrence J. Cook
- Department of Pediatrics; University of Utah ; Salt Lake City; UT
| | - James F. Holmes
- Department of Emergency Medicine; University of California; Davis School of Medicine ; Sacramento; CA
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Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model? J Trauma Acute Care Surg 2012; 73:371-6; discussion 376. [PMID: 22846942 DOI: 10.1097/ta.0b013e31825840ab] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blunt trauma is a leading cause of morbidity and mortality in children. Despite the potential for malignancy, increased cost, limited small bowel injury detection sensitivity, and the low incidence of injury requiring operative intervention, the use of computed tomographic (CT) scan in pediatric blunt trauma evaluation remains common. Previous studies suggest that a clinical model using examination and laboratory data may help predict intra-abdominal injuries (IAIs) and potentially limit unnecessary CT scans in children. METHODS A retrospective chart review of all blunt "trauma alerts" for patients younger than 16 years during an 18-month period was performed at a Level I trauma center. Clinical factors, which might predict blunt IAI (hemodynamics, abdominal examination, serology, and plain radiographs), and potential limitations to performing a reliable abdominal examination (altered mental status, young age) were reviewed. A previously defined clinical prediction model based on six high-risk clinical variables for blunt IAI (hypotension, abnormal abdominal examination, elevated aspartate aminotransferase, elevated amylase, low hematocrit, and heme-positive urinalysis) was applied to each patient. RESULTS Of the 125 "trauma alert" patients who sustained blunt trauma during the study period, 97 underwent abdominal CT scan, with only 15 identified as IAI. Our prediction rule would have identified 16 of 17 patients with IAI (SE, 94%) as high-risk and missed only 1 patient (grade I spleen laceration, which did not require operation) (negative predictive value, 99%). Of the 83 patients with no risk factors for IAI based on the prediction rule, 54 underwent a negative abdominal CT scan. Of these 54 patients, only 22 had a potential limitation to a reliable abdominal examination. Application of our prediction rule could have prevented unnecessary CT scan in at least 32 patients (33%) during an 18-month period. CONCLUSION Use of a prediction model based on high-risk variables for IAI may decrease cost and radiation exposure by reducing the number of abdominal CT scans in children being evaluated for blunt abdominal trauma.
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Lindberg DM. Abusive Abdominal Trauma—An Update for the Pediatric Emergency Medicine Physician. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intra-abdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and emergency department disposition after diagnosis. RECENT FINDINGS The importance of the seat belt sign on physical examination and screening laboratory data remains controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma (FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed emergently. SUMMARY Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not require routine hospitalization after blunt abdominal trauma.
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Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC. Clinical prediction rules for children: a systematic review. Pediatrics 2011; 128:e666-77. [PMID: 21859912 DOI: 10.1542/peds.2011-0043] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The degree to which clinical prediction rules (CPRs) for children meet published standards is unclear. OBJECTIVE To systematically review the quality, performance, and validation of published CPRs for children, compare them with adult CPRs, and suggest pediatric-specific changes to CPR methodology. METHODS Medline was searched from 1950 to 2011. Studies were selected if they included the development of a CPR involving children younger than 18 years. Two investigators assessed study quality, rule performance, and rule validation as methodologic standards. RESULTS Of 7298 titles and abstracts assessed, 137 eligible studies were identified. They describe the development of 101 CPRs addressing 36 pediatric conditions. Quality standards met in fewer than half of the studies were blind assessment of predictors (47%), reproducibility of predictors (18%), blind assessment of outcomes (42%), adequate follow-up of outcomes (36%), adequate power (43%), adequate reporting of results (49%), and 95% confidence intervals reported (36%). For rule performance, 48% had a sensitivity greater than 0.95, and 43% had a negative likelihood ratio less than 0.1. For rule validation, 76% had no validation, 17% had narrow validation, 8% had broad validation, and none had impact analysis performed. Compared with CPRs for adult health conditions, quality and rule validation seem to be lower. CONCLUSIONS Many CPRs have been derived for children, but few have been validated. Relative to adult CPRs, several quality indicators demonstrated weaknesses. Existing performance standards may prove elusive for CPRs that involve children. CPRs for children that are more assistive and less directive and include patients' values and preferences in decision-making may be helpful.
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Affiliation(s)
- Jonathon L Maguire
- Department of Pediatrics, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
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Noble VE, Blaivas M, Blankenship R, Chiricolo G, Dean A, Fox JC, Gaspari R, Hoffman B, Jones R, Moore C, Sierzenski P, Tayal V, Tillotson R. Decision Rule for Imaging Utilization in Blunt Abdominal Trauma - Where is Ultrasound? Ann Emerg Med 2010; 55:487-9; author reply 489-90. [DOI: 10.1016/j.annemergmed.2009.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 11/13/2009] [Accepted: 11/16/2009] [Indexed: 11/26/2022]
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In reply. Ann Emerg Med 2010. [DOI: 10.1016/j.annemergmed.2009.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jiménez RR. Radiographic Evaluation of the Pediatric Trauma Patient and Ionizing Radiation Exposure. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2009.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Stone KP, Woodward GA. Pediatric Patients in the Adult Trauma Bay—Comfort Level and Challenges. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2009.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Pediatric Trauma: A Roadmap for Evidence-Based, Patient-Centered Coordination and Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2009.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Linzer JF. Do Routine Laboratory Tests Add to the Care of the Pediatric Trauma Patient? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2010. [DOI: 10.1016/j.cpem.2009.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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