Identification of Intra‐abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma

Abstract

Abstract. Objective: To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra-abdominal injuries (IAIs). Methods: The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a fouryear period. Patients were considered high-risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for IAI. The authors compared moderate-risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED. Results: Of 1,040 children with blunt trauma, 559 (54%) were high-risk and 481 (46%) were moderate-risk for IAI. 126 (23%) of the high-risk and 22 (4.6%) of the moderate-risk patients had IAIs. Among moderate-risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm 3 vs 12.8 K/mm 3 , p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate-risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations. Conclusion: In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.

The Utility of Clinical and Laboratory Data for Predicting Intraabdominal Injury Among Children

“…Some of these studies did not describe the abdominal examination findings, did not mention the mental status of the patient, or did not define an "abnormal" abdominal examination. 13,14 This shortcoming was addressed in a recent study by Holmes et al, 15 who described an increased likelihood of IAI among children presenting with abdominal abrasions or abnormal chest examination findings. These findings supported those of Allen et al, 16 who demonstrated an increased incidence of hollow viscus injury (13.5%) in pediatric blunt trauma patients presenting with abdominal wall ecchymosis.…”

“…Although studies have demonstrated a poor correlation between elevated AST or ALT and severity of liver injury, these tests have been found to predict the presence or absence of solid organ or other abdominal injury. 6,7,17,18 Holmes et al 15 found that an AST exceeding 200 or an ALT exceeding 125 alone identifies IAI in almost two thirds of pediatric trauma patients. In the current study population, 69% of the patients with IAI had an AST exceeding 131 or an ALT exceeding 105.…”

Screening for occult abdominal trauma in children with suspected physical abuse

“…24,25 Results from several previous studies indicated that hematuria might also be an accurate predictor of renal injury. 15,[26][27][28] Unfortunately, the three children identified with hematuria did not have radiologic testing to evaluate for possible renal or bladder injury. Optimal practice should include further evaluation.…”

“…This was a particular problem for the 3 children with hematuria who did not have abdominal imaging, as several studies have shown that hematuria is a good marker for intra-abdominal trauma among children with non-inflicted injury. 15,[26][27][28] We have therefore presented conservative estimates of the percentage of positive screens, assuming that none of the unscreened children had OAT, and noting the minimum percentage of children with OAT. Even with these conservative estimates, the proportion of physically abused children with OAT is high enough to warrant screening, at least for children under 3 years of age.…”

A Reliable Screening Test to Predict Liver Injury in Pediatric Blunt Torso Trauma

“…Nevertheless, it is still unknown as to who should undergo an abdominal CT in hemodynamically stable patients without the above findings. Elevations of serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) have been suggested to be indicative of liver injury [1][2][3][4][5]11]. Therefore, we conducted this study to determine the usefulness of AST and ALT as screening tests in predicting liver injuries in pediatric torso trauma patients.…”