Traumatic abdominal wall hernias in children: A case for early exploration

PurposeTraumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma (BAT). We examined a series of patients suffering TAWH to evaluate its frequency, rate of associated concurrent intraabdominal injuries (CAI) and correlation with CT, management and outcomes.MethodsA Level 1 pediatric trauma center trauma registry was queried for children less than 18 years old suffering TAWH from BAT between 2009 and 2019.Results9370 patients were admitted after BAT. TAWH was observed in 11 children, at incidence 0.1%. Eight children (73%) were male, at mean age 10 years, and mean ISS of 16. Six cases (55%) were because of MVC, three (27%) impaled by a handlebar or pole, and two (18%) dragged under large machinery. Seven (64%) had a CAI requiring operative or interventional management. Patients with CAI were similar to those without other injury, with 20% and 50% CT scan sensitivity and specificity for detection of associated injury, respectively. Five patients had immediate hernia repair with laparotomy for repair of intraabdominal injury, three had delayed repair, two have asymptomatic unrepaired TAWH, and one resolved spontaneously.ConclusionsChildren with TAWH have high rates of CAI requiring operative repair. CT scans have low sensitivity and specificity for detecting associated injuries. A high suspicion of injury and low threshold for exploration must be maintained in TAWH cases.Level of evidenceIV     

Management of blunt adrenal gland injury in a community-based hospital

IntroductionInjury of the adrenal gland in blunt trauma is rare. The routine usage of the whole body computed tomography (CT) scan helps in early diagnosis. We aimed to study the incidence, mechanism of injury, management, and outcome of adrenal injury in blunt trauma patients treated in a community-based hospital.MethodsCT scan of the abdomen of all blunt trauma patients who were admitted to our institution between October 2010 and March 2018 were retrospectively reviewed. The files of all the patients with CT scan-detected adrenal injuries were retrieved. Studied variables included demography, mechanism of injury, associated injuries, GCS, ISS, Intensive Care Unit admission, hospital stay, and outcome.Results4991 blunt trauma patients were admitted to the hospital. CT scan of the abdomen was performed for 2359 (47%) patients. Blunt adrenal injuries were diagnosed in eleven male patients (0.22%). The main mechanism of injury was motor vehicle collisions in eight (72.7%) patients. Nine (81.8%) patients had right adrenal gland injury. The mean (range) ISS was 22 (6–50). All patients had intra-adrenal hematoma and periadrenal fat stranding. None of our patients had acute adrenal insufficiency. One patient died (overall mortality 9.1%).ConclusionsThe incidence of blunt adrenal injury, although rare, is similar in a community-based hospital to those reported from trauma I centers. It is associated with severe and multiple organ injuries. Blunt adrenal injuries are usually self-limiting.     

A novel streamlined trauma response team training improves imaging efficiency for pediatric blunt abdominal trauma patients

Background/purposeThe morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management.MethodsThis study is a chart review of patients < 18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition.ResultsTime from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation.ConclusionThe implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children.Type of studyTherapeuticLevel of evidenceLevel III     

Rate and prediction of traumatic injuries detected by abdominal computed tomography scan in intubated children

BACKGROUND: Recent concerns about the lifetime cancer risk associated computed tomography (CT) caused us to reevaluate the utility of this test in traumatized children. In addition, little is known regarding the utility of abdominal CT in children who have been emergently intubated. We sought to describe the injuries identified by abdominal CTs in intubated pediatric trauma patients and create a derivation set of predictors of intra-abdominal injury in this patient population. METHODS: A review was conducted of patients cared for at a Level I pediatric trauma center. Patients were included if they were emergently intubated after blunt trauma and had an emergent abdominal CT performed. Outcome measures included the presence of an intra-abdominal injury on CT, the need for exploratory laparotomy (ELAP), the findings of the ELAP, and death. Logistic regression was used to determine which variables were associated with an abnormal abdominal CT scan. RESULTS: In all, 118 met inclusion criteria; the median age was 7.2 years. Thirty- two patients (27.1%) were found to have at least one abdominal injury on CT scan. One ELAP was performed and 12 patients died. Of the variables analyzed, abdominal examination abnormalities and elevated liver function tests (LFTs) were significantly associated with injuries. When both were abnormal, 75% of patients (12/16) had abnormal scans (sensitivity = 71%, specificity = 92%, positive predictive value = 75%, negative predictive value = 91%). CONCLUSIONS: In this series, a significant number of intubated pediatric trauma victims had intra-abdominal injuries identified by CT scan. The presence of abnormal abdominal examination findings and elevated LFTs appear to predict an abnormal CT scan.     

Contrast material extravasation on contrast-enhanced helical computed tomographic scan of blunt abdominal trauma: its significance on the choice,time, and outcome of treatment

BACKGROUND: Contrast-enhanced helical computed tomographic (CT) scan of blunt abdominal trauma is valuable for detecting contrast material extravasation (CME). The aims of this study were to determine its significance and investigate factors associated with the choice, time, and outcome of management. METHODS: CT scans of 32 consecutive trauma patients who had CME were reviewed for the sources of CME, types of CME, flat inferior vena cava, and multiple abdominal injuries. The medical records were reviewed for demographics, systolic blood pressure, Injury Severity Score (ISS), choice of management, time interval between CT scan and intervention, and outcome of intervention. RESULTS: Systolic blood pressure < 100 mm Hg was the most important factor (p = 0.0064) that failed observational therapy. When proceeding to intervention treatment, patients with a flat inferior vena cava (1.6 +/- 1.1 hours) had a significantly shorter time interval between CT scan examination and intervention when compared with those with a normal cava (10.9 +/- 16.0 hours) ( p= 0.0124). The mortality rate after intervention treatment was 18.8%. High ISS, uncontained CME in the extraperitoneum, and multiple abdominal injuries were important risk factors. After adjusted for ISS and multiple abdominal injuries, the risk of dying from extraperitoneal CME remained significant when compared with intraperitoneal CME (adjusted odds ratio, 82.26; 95% confidence interval, 1.06-6,363.17). CONCLUSION: Termination of observational therapy was appropriate for trauma patients who had CME and systolic blood pressure < 100 mm Hg. The coexistence of a flat inferior vena cava and CME was associated with early intervention treatment. Despite early intervention, the mortality rate was 18.8%. High ISS and multiple abdominal injuries were important factors, but the risk of dying from uncontained extraperitoneal CME was 82 times the risk of dying from intraperitoneal CME.     

Compliance with evidence-based guidelines for computed tomography of children with head and abdominal trauma

Introduction

Recently, two large prospective clinical trials developed and validated prediction rules for children at very low risk for clinically important traumatic brain injuries (ciTBI) or abdominal injury for whom CT is unnecessary. Specific criteria/guidelines were identified which if met would obviate the need for CT scanning. The purpose of this study was to assess compliance at a level one pediatric center with these guidelines as a tool for quality improvement.

Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study

Background/PurposeOur objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma.MethodsWe queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics.ResultsThe 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333–$10,862], nonchildren's $7027 [$4230–$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439–$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status.ConclusionHospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients.Level of evidenceIII     

Abdominal computed tomography scan in pediatric blunt abdominal trauma.

The purpose of this study was to evaluate the role of abdominal CT scans in pediatric patients and correlate the findings with the clinical examination. A 2-year retrospective review of 88 patients with an abdominal CT scan after blunt trauma was performed. Seventy-two patients were identified with complete clinical examination data available. In its ability to predict the need for surgery, the CT scan had a sensitivity of 67 per cent and a negative predictive value of 98.7 per cent. The combination of the clinical examination and the CT scan findings did not miss any significant injuries. No patient with a soft, nontender abdomen and a negative CT scan required an abdominal operation. We conclude that the CT scan alone may miss clinically significant injuries. In blunt abdominal trauma in the pediatric population, the CT scan findings should be coupled with the clinical examination to ensure that no significant abdominal injuries are missed.     

Is the Grading of Liver Injuries a Useful Clinical Tool in the Initial Management of Blunt Trauma Patients?

Abstract Background:   Computed tomography (CT) has become the preferred method for evaluation of the abdomen for victims of blunt trauma. Grading of liver injuries, primarily by CT, has been advocated as a measure of severity and, by implication, the likelihood for intervention or complications. We have sought to determine if grading of liver injuries, as a clinical tool, affects immediate or extended management of patients. Methods:   We have retrospectively reviewed all patients sustaining blunt liver injuries as diagnosed by CT over a five-year period at a Level I trauma center to determine if grading of injury influenced management. The AAST organ scaling system was utilized (major grade 4–5, minor grade 1–3), as well as the ISS, AIS, mortality, morbidity, and treatment. There were 133 patients available for review. The patients were grouped into major (n = 20) and minor (n = 113) liver injuries and operative (n = 12) and nonoperative (n = 121) management. Results:   Major liver injuries had a higher ISS (39 + 13 vs. 27 + 15, p = 0.001) and were more likely to require operative intervention (5/20 vs. 7/113, p = 0.02). Mortality in this group was not different (major vs. minor), and there were no differences in the incidence of complications. Twelve patients (9%) required operation, all for hemodynamic instability, all within 24 h, and 11/12 within 6 h. At operation 8/12 patients had other sources of bleeding beside the liver injury, and 7/12 had minor hepatic injuries. The operative patients had higher ISS and AIS scores (head/neck, chest, abdomen, extremities) than those managed nonoperatively. More patients died in the operative group (6/12 vs. 8/121, p = 0.0003). There were more pulmonary (6/12 vs. 16/121, p = 0.005), cardiovascular (6/12 vs. 19/121, p = 0.01), and infectious (5/12 vs. 20/121, p = 0.049) complications in the operative group. There were 14 deaths overall; 13/14 were due to traumatic brain injury, and 8/14 required urgent operation for hemorrhage. Conclusions:   In conclusion, grading of liver injuries does not seem to influence immediate management. Physiologic behavior dictated management and need for operative intervention, as well as prognosis. However, both major hepatic injuries and need for early operation reflected overall severity and the possibility of associated injuries.     

Is the FAST exam reliable in severely injured patients?

Introduction

Highly sensitive and accurate for the detection of injuries requiring intervention in haemodynamically unstable patients, FAST may underestimate intra-abdominal injuries in stable patients with blunt abdominal trauma. Diminished accuracy of ultrasound has been reported in different cohorts of multiple injured patients. We hypothesised that multiple injured patients with a high Injury Severity Score (ISS) will have a decreased accuracy of FAST for the assessment of blunt abdominal trauma.

Methods

Data from the trauma registry of a Level 1 trauma centre were retrospectively reviewed. All haemodynamically stable blunt trauma patients who underwent both FAST and CT scan of abdomen from January 1, 2000 to January 1, 2005 were included in the cohort. All patients were divided into three groups according to their ISS: Group 1 included patients with an ISS from 1 to 14, Group 2 included patients with an ISS from 16 to 24, and Group 3 consisted of patients with ISS ≥ 25.

Results

3181 patients with blunt abdominal trauma included into the study were divided into the three groups according to the ISS. The mean ISS was 7.9 ± 3.97, 19.6 ± 2.48 and 41.3 ± 11.95 in Groups 1, 2 and 3, respectively. The accuracy of ultrasound was 90.6% in the group of patients with the highest ISS (≥25) compared with 97.5 and 97.1 for Groups 1 and 2 (p < 0.001). Similarly, ultrasound had a significantly lower sensitivity, specificity, PPV and NPV for patients in Group 3 compared with the first two groups (p < 0.001). There was a significantly lower sensitivity in Group 2 compared with Group 1 (p < 0.001), but no differences in specificity, accuracy, PPV or NPV were demonstrated.

Conclusion

Patients with high ISS are at increased risk of having ultrasound-occult injuries and have a lower accuracy of their ultrasound examination than patients with low and moderate ISS.     

Prospective study of the clinical predictors of a positive abdominal computed tomography in blunt trauma patients

BACKGROUND: CT scans are often used in the evaluation of blunt trauma patients. Many scans are negative. Clinical predictors of positive abdominal CT scans would be beneficial in patient care. METHODS: A prospective study of 213 patients at a Level I trauma center presenting with blunt trauma who underwent abdominal CT scan. Indications for CT scan were analyzed statistically, using univariate and multivariate models. RESULTS: Univariate chi2 tests showed abnormal pelvis x-ray (p = 0.0002) and an intubated patient (p = 0.03) were predictors of a positive CT scan. When subjected to multivariate logistic regression, these two indications were significant predictors of a positive CT scan, abnormal pelvis x-ray (p = 0.0005, OR=6.6, 95% CI), and an intubated patient (p = 0.02, OR=2.6, 95% CI). Univariate chi2 tests also showed that alcohol intoxication was statistically significant predictor of a negative CT scan (p = 0.03). CONCLUSION: Our data suggest that an abnormal pelvis x-ray and intubation are significant risk factors for a positive CT scan. Alcohol intoxication, mechanism of injury, and unreliable examination, without other associated indication for a scan, may warrant further study.     

Computed tomography in the evaluation of children with blunt abdominal trauma.

OBJECTIVE: This study determined the sensitivity, specificity, and accuracy of CT in pediatric patients with blunt trauma. Correlation of the CT-identified injuries and intraoperative findings with comparison to the results of DPL was performed. SUMMARY BACKGROUND DATA: Clinical evaluation frequently is unreliable in determining the presence of intra-abdominal injury in children with blunt trauma. Peritoneal lavage has been used to establish the need for operative intervention and has been found to be safe, efficient, and reliable (98%). In many institutions, abdominal CT scans are used to evaluate these children. Because most reports involve nonoperative management, operative confirmation of CT-identified injuries is available only for those children in whom nonoperative treatment is unsuccessful. METHODS: Sixty children sustaining blunt abdominal trauma were included in the study. CT scans with both oral and IV contrast were performed before open lavage, and positive results were confirmed by operation in 18 patients. RESULTS: CT had a sensitivity of 67%, however, only 60% of the actual organ injuries were identified by the scan. In contrast, DPL has a sensitivity of 94%. Both studies were equally specific (100%). DPL was also more accurate, 98% as compared with 89% for CT. CONCLUSIONS: Although the abdominal CT scan is useful in evaluating children with blunt abdominal trauma, a number of significant injuries were missed. Based on the low sensitivity of the CT, the authors suggest diagnostic peritoneal lavage may offer advantages over CT as the initial study in the evaluation of children with blunt abdominal trauma.     

CT scans for pediatric injury in a middle-income country trauma center: Are we repeating past mistakes?

PurposeSustained efforts in high-income countries have decreased the rate of unnecessary computed tomography (CT) among children, aiming to minimize radiation exposure. There are little data regarding CT use for pediatric trauma in low- and middle-income countries. We aimed to assess the pattern and utility of CT performed during evaluation of trauma patients presenting to a middle-income country (MIC) trauma center.MethodsWe reviewed pediatric (age<18) trauma admissions at a single tertiary referral center in South Africa. Patient demographics, injury details, surgical intervention(s), and mortality were abstracted from the medical record. CT indications, results, and necessity were determined by review.ResultsOf 1,630 children admitted to the trauma center, 826 (51%) had CT imaging. Children undergoing imaging were younger (median age 11 [IQR: 6, 16] vs 13 [IQR: 7, 17]) and had higher median ISS [9 [IQR: 4, 13] vs 4 [2, 9]) compared to those without imaging (both p<0.001). Overall, 1,224 scans were performed with normal findings in 609 (50%). A median of 1 scan was performed per patient (range: 1–5). The most common location was CT head (n = 695, 57%). Among patients with positive findings on CT head (n = 443), 31 (7%) underwent either intracranial pressure monitoring or surgery. CT of the cervical spine had positive findings in 12 (7%) with no patients undergoing spine surgery. Of 173 patients with abdominal CT imaging, 83 (48%) had abnormal findings and 18 (10%) required operative exploration. Thirteen (16%) patients with abnormal findings on abdominal CT had exploratory laparotomy. Of 111 children undergoing whole body CT, 8 (7%) underwent thoracic and/or abdominal operations.ConclusionUse of CT during evaluation of pediatric trauma is common in an MIC center. A high rate of normal findings and low rates of intervention following head, cervical spine, and abdominal CT suggest potential overuse of this resource.Level of EvidenceLevel III     

The role of repeat computed tomography scan in the evaluation of blunt bowel injury

The precise role of repeat abdominal computed tomography (CT) imaging in the diagnosis and management of bowel injury is unclear. We reviewed 540 patients with blunt abdominal trauma managed at a Level II trauma center over a 5-year period to better define the role of repeat imaging. One hundred patients had a repeat abdominal CT scan within 72 hours of admission. These patients were young with multisystem injuries (mean ± standard deviation age, 34 ± 15 years; Injury Severity Score, 21 ± 12; Glasgow Coma Score [GCS], 12 ± 5). There were 14 patients with bowel injuries. All bowel-injured patients survived without abdominal morbidity. Time to repeat CT was shortest in the bowel injured group (20 ± 10 hours). The repeat CT was most helpful in patients with significant closed head injury (mean GCS, 3 ± 1) and in those with occult bowel injury. The repeat scan resulted in a change in clinical management in 26 patients. Regarding the presence of bowel perforation, the follow-up scan enhanced sensitivity from 30 to 82 per cent. The repeat abdominal CT is best used selectively in patients with blunt abdominal trauma and can provide clinically useful information to exclude bowel injury.     

Age-adjusted shock index: From injury to arrival

BackgroundStudies have demonstrated the superiority of the shock index, pediatric age-adjusted (SIPA) in predicting outcomes in pediatric blunt trauma patients. However, all have utilized SIPA calculated on emergency department (ED) arrival. We sought to evaluate the utility of SIPA at the trauma scene and describe changes in SIPA from the trauma scene to the ED.MethodsWe used 2014–2016 Trauma Quality Improvement Program Data to identify blunt trauma patients 1–15 years old with an injury severity score (ISS) > 15. We calculated SIPA using vitals obtained at the trauma scene and on ED arrival. Outcome measures included ISS, transfusion within 24 h, intensive care unit (ICU), hospital length of stay (LOS), ventilator days, and mortality.ResultsWe identified 2917 patients, and 34.2% had a persistently elevated SI from the injury scene to ED arrival, whereas 17.9% had a persistently elevated SIPA. An elevated SIPA at the trauma scene was more predictive of greater ISS, LOS, and ventilator requirements. Furthermore, a SIPA that remained abnormal was associated with greater ISS, LOS, ICU admission, mechanical ventilation, and mortality.ConclusionsPrehospital SIPA values predict worse outcomes in pediatric trauma patients, and their change over time may have greater predictive utility than a single value alone.Level of EvidenceIIType of StudyPrognosis Study.     

Nonoperative Management of Blunt Splenic Trauma: Also Feasible and Safe in Centers with Low Trauma Incidence and in the Presence of Established Risk Factors

Abstract Background:   Treatment of blunt splenic trauma has undergone dramatic changes over the last few decades. Nonoperative management (NOM) is now the preferred treatment of choice, when possible. The outcome of NOM has been evaluated. This study evaluates the results following the management of blunt splenic injury in adults in a Swedish university hospital with a low blunt abdominal trauma incidence. Method:   Fifty patients with blunt splenic trauma were treated at the Department of Surgery, Lund University Hospital from January 1994 to December 2003. One patient was excluded due to a diagnostic delay of > 24 h. Charts were reviewed retrospectively to examine demographics, injury severity score (ISS), splenic injury grade, diagnostics, treatment and outcome measures. Results:   Thirty-nine patients (80%) were initially treated nonoperatively (NOM), and ten (20%) patients underwent immediate surgery (operative management, OM). Only one (3%) patient failed NOM and required surgery nine days after admission (failure of NOM, FNOM). The patients in the OM group had higher ISS (p < 0.001), higher grade of splenic injury (p < 0.001), and were hemodynamically unstable to a greater extent (p < 0.001). This was accompanied by increased transfusion requirements (p < 0.001), longer stay in the ICU unit (p < 0.001) and higher costs (p = 0.001). Twenty-seven patients were successfully treated without surgery. No serious complication was found on routine radiological follow-up. Conclusion:   Most patients in this study were managed conservatively with a low failure rate of NOM. NOM of blunt splenic trauma could thus be performed in a seemingly safe and effective manner, even in the presence of established risk factors. Routine follow-up with CT scan did not appear to add clinically relevant information affecting patient management.     

Do signs of abdominal wall injury on computed tomography predict intra-abdominal injury in trauma patients with a seatbelt sign?

BackgroundA seatbelt sign in patients with blunt abdominal injury is associated with both abdominal wall and intra-abdominal injuries. This study aimed to assess the association between signs of abdominal wall injury on computed tomography (CT) and rates of intra-abdominal injury in patients with a blunt abdominal injury and a clinical seatbelt sign.MethodsThis study includes hemodynamically stable trauma patients with blunt abdominal injury and a clinical seatbelt sign who were hospitalized in two regional trauma centers in Israel, during 2014–2019. All data were collected via the medical center's trauma registry in both centers.ResultsWe identified 123 stable blunt abdominal trauma patients with a seatbelt sign, of which 101 (82.1%) and 22 (17.9%) had a low-grade and high-grade abdominal wall injury according to CT findings, respectively. Laparotomy rates were significantly higher in patients with signs of high-grade abdominal wall injury (p<0.0001). No differences in the timing of laparotomy between low and high-grade injuries were found.ConclusionsIn stable patients with blunt abdominal trauma and a clinical seatbelt sign, the severity of abdominal wall injury, as represented by CT findings, may predict a need for surgical treatment.     

Abdominal CT scanning for trauma: how low can we go?

PURPOSE: computed tomography (CT) of the abdomen is an established, albeit expensive and perhaps overused, diagnostic modality for the evaluation of the injured patient. We developed a practice management guideline for blunt abdominal trauma intended to reduce the percentage of negative CT scans, yet minimize delayed recognition of injury and non-therapeutic laparotomy. PROCEDURES: between April 1996 and March 1997, 1147 adult patients at risk for blunt abdominal injury were admitted to our Level I trauma centre and underwent abdominal evaluation according to the practice management guideline. MAIN FINDINGS: abdominal CT was performed in 522 patients (45%), and 441 scans were negative (85%). Delayed recognition of injury and non-therapeutic laparotomy rates were low, 4% and 1.6%, respectively. PRINCIPAL CONCLUSION: abdominal CT scanning in trauma patients can achieve low non-therapeutic laparotomy and delayed recognition of injury rates but at the expense of high negative CT scan rates. Greater reliance on the physical examination and perhaps abdominal ultrasound may reduce negative CT scan rates and yet preserve low non-therapeutic laparotomy and delayed recognition of injury rates.     

Use of abdominal computed tomography in blunt trauma: Do we scan too much?

OBJECTIVES: To determine what proportion of abdominal computed tomography (CT) scans ordered after blunt trauma are positive and the applicability and accuracy of existing clinical prediction rules for obtaining a CT scan of the abdomen in this setting. SETTING: A leading trauma hospital, affiliated with the University of Ottawa. DESIGN: A retrospective cohort study. PATIENTS AND METHODS: All patients with blunt trauma admitted to hospital over a 1-year period having an Injury Severity Score (ISS) greater than 12 who underwent CT of the abdomen during the initial assessment. Recorded data included age, sex, Glasgow Coma Scale (GCS) score, ISS, type of injuries, number of abdominal CT scans ordered, and scan results. Two clinical prediction rules were found in the literature that identify patients likely to have intra-abdominal injuries. These rules were applied retrospectively to the cohort. The predicted proportion of positive CT scans was compared with the observed proportion, and the sensitivity, specificity, and accuracy were estimated. RESULTS: Of the 297 patients entered in the study, 109 underwent abdominal CT. The median age was 32 years, 71% were male and the median ISS was 24. In only 36.7% (40 of 109) of scans were findings suggestive of intra-abdominal injuries. Application of one of the clinical prediction rules gave a sensitivity of 93.8% and specificity of 25.5% but excluded 23% of patients because of a GCS score less than 11. The second prediction rule tested could be applied to all patients and was highly sensitive (92.5%) and specific (100.0%). CONCLUSIONS: The assessment of the abdomen in blunt trauma remains a challenge. Accuracy in predicting positive scans in equivocal cases is poor. Retrospective application of an existing clinical prediction rule was found to be highly accurate in identifying patients with positive CT findings. Prospective use of such a rule could reduce the number of CT scans ordered without missing significant injuries.