Pediatric Blunt Abdominal Trauma Does this patient need

Pediatric Blunt Abdominal Trauma Does this patient need an Abdominal CT?

OBJECTIVES Review Anatomic and Physiologic Differences of Pediatric Patients Review Mechanisms of Pediatric Abdominal Trauma Discuss Prediction Rules for Severe/High Risk Abdominal Trauma Discuss Clinical Decision Tools Used to Determine Need for Abdominal CT Develop a Complete Clinical Approach to Pediatric Blunt Abdominal Trauma

Why Review Pediatric Blunt Abdominal Trauma is the #1 cause of death and disability in children >1 year old Head and Thoracic are the most common But…Abdominal Injuries are Most Unrecognized Cause of Death 90% of Abdominal Injuries from Trauma are Blunt Abdominal Injuries Understanding of management pediatric abdominal injury important to future

What Makes Pediatric Patients Different? Abdominal organs are relatively larger Abdominal muscles are poorly developed Less abdominal fat Ribcage compliant leads to transmission of force to liver and spleen Greater force per BSA leads to multiple injuries Large BSA leads to Hypothermia Difficult to identify if patient in pain Kids cry due to pain Kids cry because doctors are scary Kids cry because parents are not holding them

Common Chief Complaints MVC Seat-Belt Syndrome Pedestrian Struck by Motor Vehicle Falls Bicycle Injury – Handlebars (often Delayed Presentation) Sports Injury Non-accidental Trauma

MVC Most common cause blunt abdominal injury Inappropriately Spleen restrained child 3 x more likely to suffer abdominal injury and Liver injury most common Seat-Belt Syndrome Etiology Hip typically inappropriate seat-belt use and Abdominal Contusions, Pelvic Fx, Lumbar Spine Injury Definition: area of erythema, ecchymosis and/or abrasion across abdominal wall resulting from seat belt restraints Sokolove et al: RR 2. 9 if seatbelt sign present

Bicycle Injury Handlebar Delayed Klimek 8 injury – direct impact during fall presentation – Average 34. 5 hours post fall et al Retrospective review 40 patients <16 yo required operative intervention Nonaccidental Trauma If story does not sound right, high suspicion for NAT Roaten et al review of 6186 trauma patients <18 yo 7. 3% Fall injury secondary to NAT with injuries >>>> mechanism Multiple Injuries Abnormal bruising patterns

So…Who Needs a CT Scan? Why Do We Care? CT scans pose increase risk to pediatric patients Ionizing radiation increases risk of malignancy Growing tissues and organs children more sensitive to radiation than adults Estimated risk of fatal cancer from radiation 1/1000 0. 18% pediatric CT scan lifetime risk for Abdominal CT in 1 year old ALARA principle

• Prospective Observational Study; One Level 1 Trauma Center • 1, 119/1, 324 patients enrolled with at least 1 variable – used as study sample • Utilizes 6 ‘High-Risk’ variables, if any present – concern for significant intra-abdominal injury 1. Low age-adjusted Systolic Blood Pressure 2. Abdominal Tenderness 3. Femur Fracture 4. Increased LFTs (AST >200 U/L, ALT >125 U/L) 5. Microscopic Hematuria (>5 rbc/hpf) 6. Initial Hematocrit <30%

Inclusion Criteria: <18 y/o Underwent Definitive Test: Abd CT, DPL, Laparotomy/Laparoscopy Exclusion Criteria: Penetrating Trauma Pregnant Trauma >24 hours prior to presentation Primary Outcomes: • Intra-abdominal injury – spleen, liver, GB, pancreas, adrenal, kidney, ureter, bladder, GI tract, vascular structure • Intra-abdominal injury requiring acute specific Intervention 1. Blood Transfusion for anemia 2/2 intra-abdominal hemorrhage 2. Angiographic embolization 3. Therapeutic intervention at laparotomy

Results: 157/1, 119 (14%) had intra-abdominal injuries 754/1, 119 tested positive for prediction rule 365/1, 119 tested negative; 8 false negatives Sensitivity: 94. 9% Specificity: 37. 1% Potential Strength: Utilization of prediction rule would decrease 1/3 Abd CT Rapid identification of low risk for abdominal pain Weaknesses: One institution No FAST exam 8 missed cases Not included: (1) Transfers from other hospitals (2) Patients observed without CT/DPL/Surgery

3 patients – tenderness or trauma over costal margins 2 patients – decreased mental status (GCS 9, 12) 1 patient – underwent laparotomy but had seatbelt sign on exam, no significant intervention in OR 1 patient – other injuries 1 patient – developed tenderness during observation time in ED 7/8 only observed in hospital

Prospective, Observational Cohort blunt torso trauma at PECARN centers Enrollment: May 2007 – January 2010 Exclusion Criteria: Injury >24 hours prior to presentation Pregnancy Transfer from outside hospital Penetrating trauma Preexisting neurologic condition impeding reliable exam

Inclusion Criteria

Primary Outcomes Intra-abdominal Injury - 761/12, 044 patients (6. 3%) Radiographically or surgically apparent injury to: spleen, liver, urinary tract, GI tract, GB, pancreas, adrenal, vasculature Underwent Acute intervention - 203 (1. 7%) Death caused by injury Therapeutic intervention at laparotomy Angiographic embolization Blood transfusion for anemia 2/2 hemorrhage IV fluids for 2+ nights with pancreatic or GI injuries

Derived Prediction Rule Variables 1. Abdominal Wall Trauma or Seat Belt Sign 2. GCS <14 3. Abdominal Tenderness 4. Evidence Thoracic Wall Trauma 5. Complaints of Abdominal Pain 6. Decreased Breath Sounds 7. Vomiting

Limitations No FAST exam/Ultrasound utilized Abd CT/DPL/Laparoscopy not mandated so clinically silent Intra-Abdominal Injuries may have been missed Performed at Highly Specialized Pediatric Trauma Centers

Can I Trust My Gut? Volume 22, Issue 9, pages 1034– 1041, September 2015

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

Retrospective Analysis of Prospectively Collected Data One Level 1 Trauma Center, Jan 2010 – Dec 2012 Radiology Resident performed all FAST studies Primary Outcomes Free Fluid in Abdomen Intra-Abdominal Injury Negative Intra-Abdominal Injury determined by Neg CT or Follow-up Appt

CONCLUSIONS History and Exam Vital for Evaluation of Pediatric Blunt Abdominal Trauma GCS score, Seat Belt Sign, Abdominal Wall Tenderness, Distracting Injuries Vital Signs – Remember Age Adjusted cut-offs Laboratory Tests ARE useful and can be predictive of Injury UA – gross hematuria AST/ALT CBC Utilized adjunct Testing FAST exam Ultimately, predictive scores are useful tools but cannot substitute for clinical judgement

Questions? ? ? References Available Upon Request