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Keywords:

  • abdominal trauma;
  • pediatrics;
  • abdominal CT

Abstract

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

Objectives:  This review examines the prevalence of intra-abdominal injuries (IAI) and the negative predictive value (NPV) of an abdominal computed tomography (CT) in children who present with blunt abdominal trauma.

Methods:  MEDLINE, EMBASE, and Cochrane Library databases were searched. Studies were selected if they enrolled children with blunt abdominal trauma from the emergency department (ED) with significant mechanism of injury requiring an abdominal CT. The primary outcome measure was the rate of IAI in patients with negative initial abdominal CT. The secondary outcome measure was the number of laparotomies, angiographic embolizations, or repeat abdominal CTs in those with negative initial abdominal CTs.

Results:  Three studies met the inclusion criteria, comprising a total of 2,596 patients. The overall rate of IAI after a negative abdominal CT was 0.19% (95% confidence interval [CI] = 0.08% to 0.44%). The overall NPV of abdominal CT was 99.8% (95% CI = 99.6% to 99.9%). There were five patients (0.19%, 95% CI = 0.08% to 0.45%) who required additional intervention despite their initial negative CTs: one therapeutic laparotomy for bowel rupture, one diagnostic laparotomy for mesenteric hematoma and serosal tear, and three repeat abdominal CTs (one splenic and two renal injuries). None of the patients in the latter group required surgery or blood transfusion.

Conclusions:  The rate of IAI after blunt abdominal trauma with negative CT in children is low. Abdominal CT has a high NPV. The review shows that it might be safe to discharge a stable child home after a negative abdominal CT.

ACADEMIC EMERGENCY MEDICINE 2010; 17:469–475 © 2010 by the Society for Academic Emergency Medicine


Clinical Scenario

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

A 7-year-old male has fallen from his tree house from a height of 8 feet and has presented to the emergency department (ED) via ambulance. He landed on his left side and complains only of mild abdominal pain. His father, who witnessed the incident, denies loss of consciousness. The child is alert and appropriate and has stable vital signs. On physical examination, he has scattered abrasions and bruises throughout his body. The rest of the physical examination is unremarkable except for mild diffuse abdominal tenderness. Concerned by the mechanism of injury and presence of abdominal pain, you order a computed tomography (CT) scan of the abdomen, which reveals no intra-abdominal injury (IAI). At this point, the child states that he feels fine and wants to go home to eat dinner with his family. A repeat abdominal examination (approximately 6 hours after the initial physical examination) is normal. The nurse asks you whether the patient can be sent home. Your colleague, who is about to take over your shift, overhears this and states that he admits all pediatric patients with abdominal trauma for fear of delayed injuries, even after a negative abdominal CT. He supports his argument by mentioning a case that was recently presented at the morbidity and mortality conference. Unsure of the merits for admission and the magnitude of risk of IAI after a negative abdominal CT, you search the literature to look for the evidence regarding the negative predictive value (NPV) of a negative abdominal CT in pediatric patients with blunt abdominal trauma.

Background

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

Patients under 18 years of age account for 30 million ED visits annually. Of these, approximately one-quarter, or 7.5 million visits, are due to trauma.1 The most common mechanisms of injury are blunt trauma from unintentional falls and motor vehicle collisions.2

With the recent generation of fast and high-resolution scanners, IAI are routinely detected by abdominal CT.3,4 While there is evidence to support the discharge of an adult patient suffering from blunt abdominal trauma after a negative CT from the ED,5 there is limited evidence to support this practice in pediatric patients. Thus, many clinicians admit children with negative abdominal CTs for observation, as they fear missed or delayed IAI.6

This evidence-based review examines the rate of IAI after a negative abdominal CT and the NPV of an abdominal CT in children sustaining blunt abdominal trauma. Knowledge of this information will assist the emergency physician (EP) in deciding whether these patients can be discharged home or should be admitted to the hospital for observation.

The goal of this review is to investigate the following research question: does a negative abdominal CT exclude significant IAI in hemodynamically stable pediatric ED patients with blunt abdominal trauma?

Criteria for Considering Studies for The Review

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

The selection for relevant studies was based on the following predefined criteria to answer the research question.

Participants

Eligible study patients were 18 years old or younger who presented to the ED for blunt abdominal trauma with mechanism of injury significant enough to obtain an abdominal CT. Excluded studies were those that enrolled hemodynamically unstable patients and patients with penetrating injuries; these patients generally require immediate surgical intervention and are typically admitted to the hospital regardless of the CT findings.

Target Study Design

Prospective studies that enrolled pediatric ED patients who sustained significant blunt abdominal trauma, and reported the rates of IAI, were selected for this review. Additionally, the author was interested in studies that compared the rates of IAI in admitted versus discharged patients. This comparison required the selection of randomized controlled trials or prospective observational studies. In this review, significant trauma was defined as injuries that require diagnostic imaging, in the form of an abdominal CT. Retrospective studies were excluded (chart review or registry designs). The inherent biases and limitations associated with such designs would have made the interpretation of the results difficult.

Intervention

The intervention for this review was abdominal CT, with no restrictions set on either the use of contrast (oral or intravenous [IV]) or the resolution of the CT.

Outcomes

The primary outcome of interest was the prevalence of IAI after a negative CT. IAI was defined as any injury to a solid organ, gastrointestinal tract, urinary system, or intra-abdominal vasculature.7 CT findings indicating IAI are solid organ lacerations, fractures, hematomas, or rupture, as well as bowel discontinuity, extraluminal oral contrast, intra-abdominal free air, or extravasation of IV contrast. Patients with these findings on their initial CT were excluded from the review because they required immediate surgical intervention or admission for observation. CT findings such as isolated free peritoneal fluid, bowel wall thickening or edema, and mesenteric infiltration or hematoma were considered equivocal CT findings for IAI. In this review, the author chose a conservative approach and considered these CT findings as positive abdominal CT findings.

The secondary outcome was the number of laparotomies, angiographic embolizations, or repeat abdominal CTs after a negative initial abdominal CT. Performing any of these procedures was considered as a failure to diagnose IAI. We considered laparotomy (regardless of its diagnostic or therapeutic nature) an indicator of IAI, even if no injuries were detected. Besides the inherent morbidity and mortality of IAI, any type of laparotomy places a child at risk for postoperative complications such as bleeding and infection and prolongs recovery time.

Search Methods

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

A search of the MEDLINE database from 1983 to February 2009 and EMBASE from 1980 to August 2009 was performed. The MEDLINE search strategy is presented in Appendix 1. The Cochrane database was searched for additional citations. References of pertinent articles, as well as articles from the secondary PubMed “related articles” search, were reviewed. The primary search identified 482 articles. The number of citations was reduced, according to their relevance for this review (Figure 1). The search did not identify any randomized controlled trials. It identified 16 studies that required additional reading to determine their eligibility for this review. Twelve studies were eliminated because they violated the inclusion/exclusion criteria. Two studies7,8 met the inclusion criteria. Two additional studies were identified as having potential unpublished data.9,10 One study was eliminated because the number of enrolled children could not be abstracted from the article and its authors could not provide the specific data required for inclusion in this review.9 However, the second study was included because its unpublished data were made available after contacting the study authors.10

image

Figure 1.  The process of selecting studies suitable for inclusion in the final review.

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We performed our review on three prospective observational cohort studies.7,8,10 Awasthi et al.7 assessed for the prevalence of IAI between admitted and discharged children with a negative abdominal CT from the ED. Ruess et al.8 reported the prevalence of IAI in children who were admitted to the hospital after a negative abdominal CT. Holmes et al.,10 whose primary research question was the significance of isolated free intraperitoneal fluid in children with blunt abdominal trauma, provided the number of children with IAI with a negative abdominal CT (unpublished data).

Description of the Included Trials

A description of the included studies is presented in Table 1. Important prognostic factors such as demographic data and clinical status were addressed in the studies.7,8,10 Each study had some prognostic factors that were unique to that particular study.7,8,10 Awasthi et al.7 described physical examination findings, Ruess et al.8 collected data on the time of injury to surgical exploration, along with its complications, and Holmes et al.10 collected Pediatric Trauma Scores.

Table 1.    Characteristics of the Studies Included in the Review
StudyPopulationComparisonOutcomeDesign
  1. CT = computed tomography; GCS = Glasgow Coma Scale; IAI = intra-abdominal injury.

  2. *A total of 1,500 patients enrolled; 388 excluded from this review due to abnormal abdominal CT scans and 15 excluded due to death from other injuries (e.g. intracranial or cervical spine injuries).

  3. †Presence of solid viscous injury, bony pelvis injury, peritoneal and retroperitoneal fluid, extraluminal air, abnormally intense contrast enhancement of bowel wall, bowel wall thickening, and bowel dilatation.

  4. ‡Any identifiable injury to the spleen, liver, pancreas, kidney, adrenal glands, or the gastrointestinal tract. Isolated intraperitoneal fluid was identified in those patients with intraperitoneal fluid without solid organ injury on abdominal CT.

  5. §Injury to the spleen, liver, gallbladder, pancreas, kidneys, ureters, urinary bladder, gastrointestinal tract, or an intra-abdominal vascular structure.

Ruess et al., 19978• 1,097 children in a tertiary care pediatric hospital* • Age range: 1 month to 18 yr (mean: 7 yr) • Study period: January 1983 to April 1993 • Inclusion: blunt abdominal trauma, hemodynamically stable, presumed on clinical grounds to have abdominal organ injuries • Exclusion: not specifiedNone (reported the rate of IAI in admitted children only).IAI† confirmed by laparotomyProspective observational cohort study
Holmes et al., 200010• 414 children in an urban Level 1 regional pediatric trauma center • Age range: not cited (mean = 7.4 yr) • Pediatric Trauma Score: 10 (range = 2 to 12) • Study period: April 1996 to August 1998 • Inclusion: blunt abdominal trauma younger than 16 yr, • Exclusion: transfers from an outside medical facility, abdominal CT obtained after hospital admissionNone (reported the rate of IAI in admitted children only).IAI‡ confirmed by abdominal CT or other radiographic study, laparotomy or autopsyProspective observational study
Awasthi et al., 20087• 1,085 children in an urban Level 1 regional pediatric trauma center • Age range: not cited (mean = 9.6 yr) • GCS ≥ 14: (admitted 625/737 [85%]; discharged 33/5348 [96%]). • Study period: March 2001 to May 2004 • Inclusions: patients who undergone abdominal CT for blunt abdominal trauma • Exclusion: patients with abdominal CT performed by transferring facility; CT scan performed for penetrating trauma or nontraumatic indicationsRate of IAI between admitted and discharged patientsIAI§ confirmed by laparotomy or repeat abdominal CTProspective observational cohort study

Follow-up was performed in only two studies.7,10 Awasthi et al.7 followed the study population 30 days after discharge from the hospital, and Holmes et al.10 called patients 7 days after discharge from the ED. Admitted children were followed during their hospitalization.10 Ruess et al.8 assessed their study patients, all admitted patients, for IAI during their hospitalization.

Quality Assessment of the Included Studies

Two standardized guidelines were used to assess quality and potential biases in observational studies.11,12 A summary of the assessment and potential biases is presented in Table 2.

Table 2.    Quality Assessment of the Included Studies
StudyPopulation/Selection of ParticipantsPrognostic FactorsMethod of Ascertainment of GroupsFollow-upMethod of Determination of Outcome
  1. CQI = continuous quality improvement; CT = computed tomography; GE = General Electric; GCS = Glasgow Coma Scale; IAI = intra-abdominal injuries; ISS = Injury Severity Score; PTS = Pediatric Trauma Score.

Ruess et al., 19978Prospectively collected data. No mention of blinding.Accounted for mechanism of injury, demographic, timing of laparotomy, and laparotomy findings. GE 9800 CT scanner used. 10-mm slices were obtained. Patient prepped with IV contrast; oral contrast not routinely administered. Based on presence or absence of IAI on abdominal CT (no descriptions of who interpreted the CT)Up to hospital discharge. No mention of follow-up method for discharged patients. No mention of lost to follow-up.Prospectively collected data.
Holmes et al., 200010Prospectively collected data. No mention of any blinding.Age, mechanism of injury, vital signs, complaints of abdominal pain, indication for abdominal CT, PTS, GCS ≥ 13, abdominal findings (peritoneal signs, tenderness, abrasion, seat belt marking, contusions). GE helical CTi or fourth-generation Toshiba-900 CT scanner was used. 3-mm slices on infants (≤10 kg), 5-mm on children (10–50 kg), 7-mm on larger children and adolescents (≥50 kg). IV contrast was used; no oral contrast. Based on presence or absence of IAI on abdominal CT. CT scans were interpreted by board-certified faculty radiologist masked to clinical data.Hospitalized patients were followed as inpatients. Discharged patients from the ED had a 1-week follow-up telephone call.Prospectively collected data.
Awasthi et al., 20087Prospectively collected data. No mention of any blinding.Age, mechanism of injury, GCS score ≥ 14, initial chest tenderness in ED, and initial abdominal tenderness in ED. Lightspeed GE 16-slice scanner was used. Slice thickness not described. Patient prepped with IV contrast; no oral contrast.Based on presence or absence of IAI on abdominal CT. CT scans were interpreted by board-certified/-eligible faculty radiologist.Hospitalized patients were followed as inpatients. All study patients had their medical records reviewed at least 30 days from date of presentation for return to the ED.Prospectively collected data, medical records, and CQI reports

Results

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

The three included studies enrolled a total of 2,596 patients. The overall prevalence of IAI after a negative abdominal CT from the ED was 0.19% (95% confidence interval [CI] = 0.08% to 0.44%). The NPV of abdominal CT for diagnosing IAI was 99.8% (95% CI = 99.6% to 99.9%). The prevalence of IAI and NPV of a negative abdominal CT for the three included studies are summarized in Table 3.7,8,10

Table 3.    Rate of Intra-abdominal Injuries and NPV of an Abdominal CT
StudyRate of IAI in Admitted Patients (95% CI)Rate of IAI in Discharged Patients (95% CI)NPV (95% CI)
  1. CT = computed tomography; IAI = intra-abdominal injury; NPV = negative predictive value.

  2. *No information about discharged patients with negative abdominal CT. However, there were five patients with negative abdominal exam and small amounts of isolated intraperitoneal fluid CT. All five patients were asymptomatic at the time of telephone interview.

Ruess et al., 199781/1097 0.09% (0.02–0.51)Not reported1096/1097 99.9% (99.5–100)
Holmes et al., 2000102/414 0.48% (0.15–1.73)Not reported*412/414 99.5% (98.3–99.9)
Awasthi et al., 200872/737 0.27% (0.08–0.98)0/348 0.0% (0.0–1.05)1083/1085 99.8% (99.3–99.9)

The numbers of laparotomies and repeat abdominal CTs are presented in Table 4. Overall, among the study populations enrolled in the three included studies, five patients (0.19%, 95% CI = 0.08% to 0.45%) required either a laparotomy or a repeat abdominal CT after their initial negative CT.7,8,10 These five patients were admitted to the hospital. Awasthi et al.7 described one patient requiring a laparotomy within the first 24 hours because hypotension and tachycardia had occurred, along with a drop in the hematocrit from 37% to 31%. This patient had worsening abdominal pain from the time of ED presentation until the time of surgery. The other patient in this study was admitted for traumatic brain injury and multiple pelvic fractures.7 This patient required a second abdominal CT because the hematocrit dropped on hospital day 3.7 Ruess et al.8 identified one patient who required surgical repair for bowel injury beyond 24 hours of initial presentation. Ruess et al.8 did not describe an abdominal exam, hematocrit drop, or additional traumatic injury. Holmes et al.10 described two hospitalized patients with solid organ injuries. Neither patient required a blood transfusion or laparotomy. The time to diagnosis (i.e., repeat abdominal CT) was not available.

Table 4.    Number of Laparotomies and Repeat Abdominal CTs Required After the Initial Negative CT in Pediatric Patients Who Sustained Blunt Abdominal Trauma
StudyLaparotomyRepeat Abdominal CTTherapeutic Laparotomy
  1. CT = computed tomography.

  2. *Both children were admitted patients. One patient had a splenic injury, and the other patient had a kidney injury. Both did not require blood transfusion or laparotomy.

  3. †The first patient who was an admitted patient underwent a diagnostic laparotomy that identified mesenteric hematoma and serosal tear. The second patient who was an admitted patient underwent a repeat abdominal CT that identified a perinephric hematoma. No blood transfusion was needed. Both patients did not require therapeutic laparotomy for their injuries.

Ruess et al., 199781/109701 (repair of bowel rupture)
Holmes et al., 20001002/4140 (no surgical repair was needed)*
Awasthi et al., 200871/737 1/3480 (no surgical repair was needed)†

Follow-ups were described in two studies.7,10 Awasthi et al.7 followed up study patients after discharge either from the ED or the inpatient unit. The authors reviewed medical records and continuous quality improvement records to identify patients with delayed IAI.7 No patients had a delayed IAI, at least 30 days from discharge.7 Holmes et al. followed admitted patients during their hospitalization.10 Discharged ED patients were telephoned 7 days from the date of ED presentation.10 Five discharged patients who had isolated free intraperitoneal fluid had delayed IAI.10 Follow-up information about discharged ED patients with negative abdominal CT was not available.10

Applying The Evidence

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

Returning to the clinical scenario, the EP wondered whether he should discharge the 7-year-old boy who sustained abdominal trauma in a fall, based on a negative abdominal CT. This review provides some guidance for the EP to make an appropriate disposition. The review suggests that the risk for an IAI is low, as suggested by the high NPV of the abdominal CT.

Currently, no recommendation exists for the highest tolerable miss rate of IAI that would enable the safe discharge of a child home after a negative CT. In some areas of emergency medicine, investigators have attempted to quantify a miss rate for a diagnosis in their clinical decision-making. Clearly, no single number can be applied across all clinical entities; the more serious the condition, the lower the risk that is tolerated. The decision to discharge or admit a child (similar to the opening scenario) will need to be adjusted for each patient. However, a less than 1% risk of IAI could more easily sway the decision toward discharge.

The diagnostic capabilities of abdominal CT are influenced by early versus late generations of CT scanners, oral contrast ingestion, and types of abdominal injury. These factors can lead the clinician to miss or to delay the diagnosis of an IAI. Recent generations of multidetector row CTs are capable of scanning patients in a shorter period of time, while producing clearer images with artifact suppression. Overall, improved technology produces a higher quality of CT images.13,14 Other benefits of these CT scans are higher quality of multiplanar and three-dimensional reformation, as well as angiograms of multiple body parts.15

Oral contrast can improve the quality of the CT images. Oral contrast outlines small intramural or mesenteric hematomas. In addition, extravasation of oral contrast localizes the area of bowel rupture. However, ingestion of oral contrast increases time spent in the ED, decreases bowel motility, and increases the risk of vomiting and aspiration. Studies have shown that IV enhanced CT is sufficient to detect nearly 75% of IAI without missing any clinically significant IAI in these patients.16,17 In the papers examined in this review, the studies were performed with IV contrast; no oral contrast was used.7,8,10

Bowel and mesenteric injuries are difficult to diagnose because they have few pathognomonic CT findings. Bowel disruption or contrast extravasation confirms bowel or mesenteric injuries. These findings are exceedingly rare.18 However, the typical CT findings are bowel wall thickening, mesenteric infiltration, and free intraperitoneal fluid.19 Free intraperitoneal fluid is the most common CT finding, but is often found in patients without IAI.18 Free intraperitoneal fluid on CT, along with a normal physical exam and mental status, does not mandate an immediate laparotomy.10,20–23 Holmes et al.10 correctly identified all 17 patients without IAI, when they presented with a normal abdominal exam and had isolated free intraperitoneal fluid on CT. Christiano et al.23 identified 91 patients with normal abdominal examination and isolated free intraperitoneal fluid on CT. However, there were three patients who developed peritonitis 12 to 14 hours later. All underwent laparotomy, where one patient required repair for a jejunal perforation.23

Signs and symptoms of bowel and mesenteric injuries may take up to 24 to 72 hours to manifest. The risk of peritonitis increases when there is a delay in diagnosis. Bruny and Bensard18 cite that a controversy exists in the optimal timing for surgical intervention. Optimal timing ranges from less than 8 hours to 36 hours from diagnosis to prevent peritonitis.18 In this review, mesenteric injury was identified at different times from presentation from the ED. In the study by Ruess et al.,8 the time to surgical repair was 30 to 72 hours on average. The patients’ physical examination findings were not described in that study.8 Awasthi et al.7 identified a patient who presented with a seat belt sign, had small bowel and colonic mesenteric hematomas, and had a serosal tear of the transverse colon on hospital stay day 1.

An issue that can certainly affect the pre- or posttest probability of IAI and therefore affect the decision to admit or discharge a child with abdominal trauma is physical findings (especially serial examination). This issue was not addressed in any of the included studies.

Although this is a limitation of this review, interpretation of the abdominal examination is subjective, except in cases with physical findings, such as a seat belt sign. Descriptions of physical findings can be affected by level of clinical experience (e.g., a resident versus an attending physician) and whether the same physician performs serial abdominal exams. The inter- and intraobserver variability also could limit the use of physical findings in a clinical decision rule.

It must be noted that surgical management of IAI has become relatively uncommon in stable children. A retrospective review that combined data from three pediatric trauma centers shows that the laparotomy rate is 0.3%.24 This rate is equivalent to one laparotomy per 7 months per hospital.24

Although cost analysis was beyond the scope of this review, clearly discharging patients with very low risk of IAI from the ED optimizes resource utilization. Personnel, facility, and material costs can be limited. Nosocomial infections can be avoided when patients are discharged home. Identifying a stable and supportive home environment, as well as close follow-up, should be factored at the time of disposition.

Limitations

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

This review lacks the qualities of a rigorous meta-analysis. The quality of this review’s findings is affected by the quality of the original studies.

An important limitation is the study settings, where patients were enrolled from tertiary care hospitals. The three studies included in this review were performed in academic Level 1 trauma centers.7,8,10 Ruess et al.8 performed their study in a children’s hospital. The clinical acumen to manage pediatric trauma is not necessarily comparable between the medical staff of a Level 1 trauma center and the staff of a general or community ED. Applicability of this review to other clinical settings is limited.

Conclusions

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

This review consists of three prospective observational studies with a collective sample size of 2,596 patients. The prevalence of intra-abdominal injuries was 0.19%, and the negative predictive value of the abdominal computed tomography was 99.8%. According to the reviewed evidence, it might be safe to discharge a hemodynamically stable child with a normal physical examination and a negative abdominal CT after blunt abdominal trauma.

References

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix
  • 1
    McCraig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Advance Data 2005; 358:140.
  • 2
    Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf. Accessed Feb 24, 2010.
  • 3
    Taylor GA, Sivit CJ. Computed tomography imaging of abdominal trauma in children. Semin Pediatr Surg. 1992; 1:2539.
  • 4
    Peters E, LoSasso B, Foley J, Rodarte A, Duthie S, Senac MO Jr. Blunt bowel and mesenteric injuries in children: do nonspecific computed tomography findings reliably identify these injuries? Pediatr Crit Care Med. 2006; 7:5516.
  • 5
    Livingston DH, Lavery RF, Passannante MR, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. J Trauma. 1988; 44:27380.
  • 6
    Albanese CT, Meza MP, Gardner MJ, Smith SD, Rowe MI, Lynch JM. Is computed tomography a useful adjunct to the clinical examination for the diagnosis of pediatric gastrointestinal perforation from blunt abdominal trauma in children? J Trauma. 1996; 40:41721.
  • 7
    Awasthi S, Mao A, Wooton-Gorges SL, Wisner DH, Kuppermann N, Holmes JF. Is hospital admission and observation required after a normal abdominal computed tomography scan in children with blunt abdominal trauma? Acad Emerg Med. 2008; 15:8959.
  • 8
    Ruess L, Sivit CJ, Eichelberger MR, Gotschall CS, Taylor GA. Blunt abdominal trauma in children: impact of CT on operative and nonoperative management. AJR Am J Roentgenol. 1997; 169:10114.
  • 9
    Richards JR, Derlet RW. Computed tomography for blunt abdominal trauma in the ED: a prospective study. Am J Emerg Med. 1998; 16:33842.
  • 10
    Holmes JF, London KL, Brant WE, Kuppermann N. Isolated intraperitoneal fluid on abdominal computed tomography in children with blunt trauma. Acad Emerg Med. 2000; 7:33541.
  • 11
    Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ Guide to the Medical Literature. A Manual for Evidence-Based Clinical Practice, 2nd ed. Columbus, OH: The McGraw-Hill Companies, Inc., 2002.
  • 12
    Agency for Healthcare Research and Quality. Systems to Rate the Strength of Scientific Evidence. Available at: http://www.ahrq.gov/clinic/tp/strengthtp.htm. Accessed Mar 25, 2009.
  • 13
    Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol. 2008; 43:7282.
  • 14
    Becker CD, Poletti PA. The trauma concept: the role of MDCT in the diagnosis and management of visceral injuries. Eur Radiol Suppl. 2005; 15(Suppl 4):D1059.
  • 15
    Soto JA, Lucey BC, Stuhlfaut JW, Varghese JC. Use of 3D imaging in CT of the acute trauma patient: impact of PACS-based software package. Emerg Radiol. 2005; 11:1736.
  • 16
    Tsang BD, Panacek EA, Brant WE, Wisner DH. Effects of oral contrast administration for abdominal computed tomography in evaluation of acute blunt trauma. Ann Emerg Med. 1997; 30:713.
  • 17
    Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med. 2004; 43:1208.
  • 18
    Bruny JL, Bensard DD. Hollow viscous injury in the pediatric patient. Semin Pediatr Surg. 2004; 13:1128.
  • 19
    Hanks PW, Brody JM. Blunt injury to mesentery and small bowel: CT evaluation. Radiol Clin N Am. 2003; 41:117182.
  • 20
    Halvorsen RA, McKenney K. Blunt trauma to the gastrointestinal tract: CT findings with small bowel and colon injuries. Emerg Radiol. 2002; 9:1415.
  • 21
    Harris HW, Morabito DJ, Mackersie RC, Halvorsen RA, Schecter WP. Leukocytosis and free fluid are important indicators of isolated intestinal injury after blunt trauma. J Trauma. 1999; 46:6569.
  • 22
    Rodriguez C, Barone JE, Wilbanks TO, Rha CK, Miller K. Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management. J Trauma. 2002; 53:7985.
  • 23
    Christiano JG, Tummers M, Kennedy A. Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt trauma. J Pediatr Surg. 2009; 44:12428.
  • 24
    Green SM, Rothrock SG. Is pediatric trauma really a surgical disease? Ann Emerg Med. 2002; 39:53740.

Appendix

  1. Top of page
  2. Abstract
  3. Clinical Scenario
  4. Background
  5. Criteria for Considering Studies for The Review
  6. Search Methods
  7. Results
  8. Applying The Evidence
  9. Limitations
  10. Conclusions
  11. References
  12. Appendix

Appendix 1: Search Strategy (Pubmed)

#1 wounds, nonpenetrating [MeSH]

#2 multiple trauma [MeSH] OR polytrauma [TW]

#3 trauma [TW] OR trauma [TW]

#4 wounds and injuries [MeSH]

#5 accidents [MeSH]

#6 accidents, traffic [MeSH]

#7 seat belts [MeSH]

#8 bicycling [MeSH]

#9 motorcycles [MeSH]

#10 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR   #8 OR #9

#11 abdomen [MeSH] OR abdominal cavity [MeSH]   OR abdominal [TW] OR intraabdominal [TW]

#12 retroperitoneum [TW]

#13 spleen [MeSH] OR splenic [TW]

#14 liver [MeSH] OR hepatic [TW]

#15 #11 OR #12 OR #13 OR #14

#16 #10 AND #15

#17 tomography, x-ray computed [MeSH]

#18 CT [TW] OR CAT [TW]

#19 compute tomography [TW]

#20 #17 OR #18 OR #19

#21 #16 AND #20

#21 child [MeSH] OR children [TW]

#22 pediatrics [MeSH] OR pediatric [TW] OR   paediatric [TW]

#23 infant [MeSH] OR infant

#24 #21 OR #22 OR #23

#25 #21 AND #24