Identifying children at very low risk of clinically important blunt abdominal injuries

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

Research output: Contribution to journalArticle

119 Scopus citations

Abstract

Study objective: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. Methods: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/ gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Original languageEnglish (US)
JournalAnnals of Emergency Medicine
Volume62
Issue number2
DOIs
StatePublished - Aug 2013

ASJC Scopus subject areas

  • Emergency Medicine

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    Holmes Jr, J. F., Lillis, K., Monroe, D., Borgialli, D., Kerrey, B. T., Mahajan, P., Adelgais, K., Ellison, A. M., Yen, K., Atabaki, S., Menaker, J., Bonsu, B., Quayle, K. S., Garcia, M., Rogers, A., Blumberg, S., Lee, L., Tunik, M., Kooistra, J., ... Kuppermann, N. (2013). Identifying children at very low risk of clinically important blunt abdominal injuries. Annals of Emergency Medicine, 62(2). https://doi.org/10.1016/j.annemergmed.2012.11.009