Evaluation of an evidence-based guideline to reduce CT use in the assessment of blunt pediatric abdominal trauma

The abdomen does not lie, but the labs might: Predictors of intra-abdominal injury on computed tomography imaging in pediatric blunt trauma patients

INTRODUCTION

Multiple studies have indicated that isolated abnormal laboratory results necessitate obtaining abdominal computed tomography (CT) for pediatric patients with blunt abdominal trauma (BAT), regardless of the normal abdominal examination. This study aims to identify the predictors of intra-abdominal injury (IAI) and the role of laboratory tests in CT imaging among pediatric BAT patients.

METHODS

This is a retrospective review at a Level II pediatric trauma center (2018-2022). Children (younger than 18 years) who presented with BAT and received abdominal CT imaging were included. Outcomes were rates of IAI and interventions. Multivariable regression analysis was performed.

RESULTS

Over 5 years, 483 patients met the inclusion criteria. The mean age was 13 years, 58.2% were male, and the median Glasgow Coma Scale was 15. Overall, 19.3% had abdominal pain; 6.2%, postinjury emesis; 26.1%, abdominal tenderness; and 10.6%, pelvic tenderness. On initial imaging, 7.0% had a positive focused assessment with sonography in trauma examination, and 7.2% had an abnormal plain x-ray. On initial laboratory testing, 7.9% had abnormal serum aspartate aminotransferase (AST), 3.1% had abnormal hematocrit, 1.2% had abnormal urine analysis, and 0.8% had abnormal lipase. Seventeen percent had at least one IAI, of which 17% underwent intervention. Multivariable regression analysis identified abdominal tenderness, abnormal plain x-ray, positive focused assessment with sonography in trauma, blood transfusion requirements, and abnormal AST as independent predictors of IAI on abdominal CT imaging. Moreover, among patients with IAI, only 37.3% had abnormal laboratory results, and all had at least one of the predictors of IAI (in addition to or other than abnormal AST). Among patients with abnormal laboratory results (n = 57), nine patients had none of the predictors of IAI, out of which none were found to have IAI on abdominal CT.

CONCLUSION

More than 80% of all abdominal CT imaging had negative results. Our findings highlight the significance of clinical findings in the trauma bay, regardless of laboratory findings, when deciding to order abdominal CT imaging for pediatric BAT patients.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Pediatric Age-adjusted Shock Index (SIPA): From Injury to Outcome in Blunt Abdominal Trauma

Purpose

The Shock Index Pediatric Age-Adjusted (SIPA) score is a useful tool for identifying pediatric trauma patients at a risk of poor outcomes and for triaging. We are studying the relationship between elevated SIPA score and specific outcomes in pediatric trauma patients.

Materials and Methods

A retrospective study was conducted in which case records of 58 pediatric patients with blunt abdominal trauma were evaluated and tabulated for their SIPA scores only at the time of their initial presentation and categorized into two groups - normal SIPA and elevated SIPA. The primary outcomes were need for blood transfusion, need for any intervention, and need for emergency surgery, and the secondary outcomes were need for computed tomography (CT) scan, need for a ventilator, intensive care unit (ICU) stay, length of hospital stay, and mortality. Statistical methods were applied to find a relationship between elevated SIPA score and the primary and secondary outcomes.

Results

An elevated SIPA score was noted in 27 (46%) patients. There was a significant relationship between elevated SIPA scores and patients needing blood transfusion (68.75%, n = 11) and length of hospital stay (10.48 ± 7.54 days). A significant relationship between elevated SIPA score and need for emergency surgery (54.54%, n = 6), need for a CT scan (56%, n = 14), and ICU stay (50%, n = 2) was not found.

Conclusion

We have seen in our study that elevated SIPA scores at presentation are significantly related to need for blood transfusion and length of hospital stay. In more than half of the patients, elevated SIPA was associated with need for emergency surgery and requirement of CT scan, but it was statistically not significant. Therefore, assessment of this parameter can help in identifying such poor outcomes.

Disparities in computed tomography utilization for pediatric blunt trauma: a systematic review and meta-analysis comparing pediatric and non-pediatric trauma centers

Pediatric blunt trauma is a major cause of morbidity and mortality, and computed tomography (CT) imaging is vital for accurate evaluation and management. Pediatric trauma centers (PTCs) have selective CT practices, while non-PTCs may differ, resulting in potential variations in CT utilization. The objective of this study is to delineate disparities in CT utilization for pediatric blunt trauma patients between PTCs and non-PTCs. A systematic review and meta-analysis were conducted following established guidelines, searching PubMed, Scopus, and Web of Science up to March 3, 2023. All studies examining CT utilization in the management of pediatric (aged < 21 years) blunt trauma and specifying the type of trauma center(s) were included, and data were extracted and analyzed using STATA software version 17.0. An analysis of 30 studies revealed significant variations in CT scan utilization among pediatric blunt trauma patients across different types of trauma centers. PTCs exhibited lower pooled rates of abdominopelvic CT scans (35.4% vs. 44.9%, p < 0.01), cranial CT scans (36.9% vs. 42.9%, p < 0.01), chest CT scans (14.5% vs. 25.4%, p < 0.01), and cervical spine CT scans (23% vs. 45%, p < 0.01) compared to adult or mixed trauma centers (ATCs/MTCs). PTCs had a pooled rate of 54% for receiving at least one CT scan, while ATCs/MTCs had a higher rate of 69.3% (p < 0.05). The studies demonstrated considerable heterogeneity. These findings underscore the need to conduct further research to understand the reasons for the observed variations and to promote appropriate imaging usage, minimize radiation exposure, and encourage collaboration between pediatric and adult trauma centers.

Traumatic abdominal wall hernias in the pediatric population: a 13-year institutional review

BACKGROUND

Pediatric traumatic abdominal wall hernias are rare but potentially devastating injuries. Although classically considered to be caused by handlebar injuries from bicycle accidents, our anecdotal experience suggests pediatric traumatic abdominal wall hernias are far more likely to occur following road traffic accidents and have a high association with other significant intra-abdominal injuries.

OBJECTIVE

The purpose of this study was to determine the frequency, mechanisms of injury, and associated injuries of traumatic abdominal wall hernias in the pediatric population.

MATERIALS AND METHODS

This is a retrospective observational cohort study from two large urban level 1 trauma centers. Institutional trauma registries were queried from January 1, 2008, to December 31, 2020, for patients under 18 years of age diagnosed with traumatic abdominal wall hernias, excluding those without initial abdominopelvic CT imaging. Finalized CT reports and images were reviewed to confirm the presence of a traumatic abdominal wall hernia and document any associated secondary injuries. The medical record was reviewed to extract pertinent physical findings, interventions performed, and outcomes. Injury Severity Score (ISS) for each patient was calculated by the trauma registrar.

RESULTS

A total of 19 patients with TAWH met inclusion criteria, with an overall frequency of 0.095% and a mean age of 10.6 years (range 3-17). Eleven patients were male (57.9%) with a mean ISS of 18.6 (range 1-48, including 63.2% with ISS > 15). The most common mechanism of injury was motor vehicle collision (N = 11, 57.9%) followed by bicycle accident (N = 3, 15.8%). A total of 17 (89.5%) had associated injuries, including 11 (57.9%) with intestinal injuries, 5 (26.3%) with pelvic fractures, 4 (21.1%) with femur fractures, 3 (15.8%) with splenic injuries, 3 (15.8%) with kidney injuries, and 3 (15.8%) with Chance fractures of the lumbar spine. All patients required surgery for the traumatic abdominal wall hernias and associated injuries.

CONCLUSION

Pediatric traumatic abdominal wall hernias are more likely to be seen following motor vehicle collisions, with a majority (89.5%) having associated injuries, most frequently to the bowel (57.9%). Handlebar injuries were seen in a minority of patients (15.8%) and were less likely to be associated with additional injuries.

CLINICAL IMPACT

Pediatric patients with a traumatic abdominal wall hernia on admission CT should be thoroughly evaluated for bowel injuries, especially in the setting of a motor vehicle collision.

Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative

OBJECTIVE

Intra-abdominal injury occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when intra-abdominal injury risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma centre.

METHODS

We implemented a quality improvement initiative using the Model for Improvement in children 0-15.99 years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24 h of emergency department (ED) assessment and return to ED or hospitalization within 72 h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time.

RESULTS

The baseline period (April 1, 2016 - November 30, 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI 20.5-33.8%) in those at low risk for intra-abdominal injury. The intervention period (Dec 1, 2017-Dec 31, 2019) included 445 patients with a CT rate in low-risk patients of 6.8% (95% CI 3.2-12.6%), demonstrating an absolute reduction of 20.0% (95% CI 12.2-27.7%, p < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed.

CONCLUSIONS

This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.