Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries

Holmes, James F.; Lillis, Kathleen; Monroe, David; Borgialli, Dominic; Kerrey, Benjamin T.; Mahajan, Prashant; Adelgais, Kathleen; Ellison, Angela M.; Yen, Kenneth; Atabaki, Shireen M.; Menaker, Jay; Bonsu, Bema K.; Quayle, Kimberly S.; Garcia, Madelyn; Rogers, Alexander; Blumberg, Stephen; Lee, Lois; Tunik, Michael G.; Kooistra, J. Brent; Kwok, Maria Y.; Cook, Lawrence J.; Dean, Jonathan; Sokolove, Peter E.; Wisner, David H.; Ehrlich, Peter F.; Cooper, Arthur; Dayan, Peter; Wootton‐Gorges, Sandra L.; Kuppermann, Nathan

doi:10.1016/j.annemergmed.2012.11.009

“…Because of this uncertainty, and the lack of definitive research regarding specific indications for abdominal CT use, clinicians obtain abdominal CT scans in a large number of children with blunt trauma, including many who do not have intra-abdominal injuries. 19 Consistent with prior studies, the parent study of the current analysis 18 revealed the prevalence rate of intra-abdominal injury undergoing acute intervention to be less than 2% of children with blunt torso trauma, while nearly half of the children presenting with blunt torso trauma underwent abdominal CT scaning. 15,[20][21][22] In both adult and pediatric trauma patients, CT use has rapidly increased in the ED for many conditions.…”

Section: Discussionsupporting

confidence: 69%

“…16,17 A clinical prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention was recently derived. 18 It is unclear, however, how the derived clinical prediction rule compares to unstructured clinician suspicion for identifying children with these injuries.…”

Section: Discussionmentioning

confidence: 99%

“…Patients were considered positive for the clinical prediction rule if they had any one of the variables in the prediction rule (Table 1) documented as present. 18 In contrast, patients were considered to be negative (i.e., at very low risk) for the prediction rule if they did not exhibit any of the variables of the prediction rule.…”

Section: Discussionmentioning

confidence: 99%

“…Sample size for this data set was calculated based on deriving a clinical prediction rule. 18 There was no sample size calculation for this specific analysis. All statistical analyses were performed using SAS 9.3 software.…”

Section: Discussionmentioning

confidence: 99%

“…18 Clinicians (faculty physicians, fellows, nurse practitioners, or physician assistants) completed standardized data collection forms prior to abdominal CT (if performed). Faculty or fellow physicians verified the information if the form was completed by a nurse practitioner or physician assistant.…”

Section: Study Protocolmentioning

confidence: 99%

See 3 more Smart Citations

Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra‐abdominal Injuries After Blunt Torso Trauma

Mahajan

¹

,

Kuppermann

²

,

Tunik

³

et al. 2015

Academic Emergency Medicine

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Objectives: Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma.Methods: This was a planned subanalysis of a prospective, multicenter observational study of children (<18 years old) with blunt torso trauma conducted in 20 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Clinicians documented their suspicion for the presence of intra-abdominal injuries needing acute intervention as <1, 1 to 5, 6 to 10, 11 to 50, or >50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention.

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The FAST Examination for Children With Abdominal Trauma

Marin

¹

,

Fields

²

,

Tayal

³

2017

JAMA

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To the Editor: In a randomized clinical trial (RCT) of the focused assessment with sonography for trauma (FAST) examination in stable children with blunt abdominal trauma compared with standard evaluation, Dr Holmes and colleagues 1 found no difference in coprimary outcomes, including computed tomography (CT) use. There are a number of issues that limit the study's generalizability.For any test to be effective, a physician must act on its results. In the group with less than a 1% pretest probability of injury, 28% of patients received CT after the FAST examination. This disconnect between the FAST interpretation and patient management may have been due to institutional practices. This explanation is suggested by the baseline CT rate at the study site of 60%. This rate is higher than rates in multicenter studies 2,3 and is surprising given that only stable patients were included. Trauma evaluations are often protocolized, with CT being an important component. Many trauma centers engage in the practice of "pan scanning." The majority of physicians in the study also cared for adult patients, who are managed differently than children. Previous work has demonstrated that CT use for injured children at pediatric hospitals is significantly less than at nonpediatric centers. 4 Emergency physicians performed FAST examinations and were queried about before and after test probabilities; however, trauma surgeons and other specialists often request CT. 5 The study provided no insight into the decision-making process, that is, who decided to obtain CT and why. Additionally, were there specific findings that led to CT, such as bruising or elevated transaminases?Another consideration is that a high CT prevalence may lead to fewer FAST examinations performed, resulting in lower proficiency. This may explain the only moderate agreement between operators and experts who reviewed images; and may be another reason why the results of the FAST examination were seemingly not considered. Physicians who do not perform procedures routinely are not as adept at them-a central reason behind regionalized care.These factors might provide important information into whether the baseline CT rate was potentially malleable or whether the study was destined to find no difference with the FAST examination. This study raises questions regarding FAST examination use in children that will need to be explored.

show abstract

The FAST Examination for Children With Abdominal Trauma—Reply

Holmes

¹

,

Kelley

²

,

Kuppermann

³

2017

JAMA

Self Cite

0

View full text Add to dashboard Cite

To the Editor: In a randomized clinical trial (RCT) of the focused assessment with sonography for trauma (FAST) examination in stable children with blunt abdominal trauma compared with standard evaluation, Dr Holmes and colleagues 1 found no difference in coprimary outcomes, including computed tomography (CT) use. There are a number of issues that limit the study's generalizability.For any test to be effective, a physician must act on its results. In the group with less than a 1% pretest probability of injury, 28% of patients received CT after the FAST examination. This disconnect between the FAST interpretation and patient management may have been due to institutional practices. This explanation is suggested by the baseline CT rate at the study site of 60%. This rate is higher than rates in multicenter studies 2,3 and is surprising given that only stable patients were included. Trauma evaluations are often protocolized, with CT being an important component. Many trauma centers engage in the practice of "pan scanning." The majority of physicians in the study also cared for adult patients, who are managed differently than children. Previous work has demonstrated that CT use for injured children at pediatric hospitals is significantly less than at nonpediatric centers. 4 Emergency physicians performed FAST examinations and were queried about before and after test probabilities; however, trauma surgeons and other specialists often request CT. 5 The study provided no insight into the decision-making process, that is, who decided to obtain CT and why. Additionally, were there specific findings that led to CT, such as bruising or elevated transaminases?Another consideration is that a high CT prevalence may lead to fewer FAST examinations performed, resulting in lower proficiency. This may explain the only moderate agreement between operators and experts who reviewed images; and may be another reason why the results of the FAST examination were seemingly not considered. Physicians who do not perform procedures routinely are not as adept at them-a central reason behind regionalized care.These factors might provide important information into whether the baseline CT rate was potentially malleable or whether the study was destined to find no difference with the FAST examination. This study raises questions regarding FAST examination use in children that will need to be explored.

show abstract

Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries

Cited by 179 publications

References 29 publications

Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra‐abdominal Injuries After Blunt Torso Trauma

Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra‐abdominal Injuries After Blunt Torso Trauma

The FAST Examination for Children With Abdominal Trauma

The FAST Examination for Children With Abdominal Trauma—Reply

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