From
StayCurrentMD
Abdominal Evaluation: Pediatric Trauma Series 2017
With Dr. Chris Streck & Dr. Roberto Iglesias · hosted by Dr. Rich Falcone
Part of
Blunt Abdominal Trauma 8 items
Chapter 1 of 7 · Case-Based Learning
Case presentations
Case presentations and initial triage decisions
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For FAST to detect intraabdominal blood, approximately 200 cc of blood must be present in the abdomen, which is a large volume for a young child and typically indicates hemodynamic instability.
FAST is not reliable for detecting retroperitoneal blood in children or adults.
Overall 12% of the study population had an intraabdominal injury and 3% had an injury requiring acute intervention (surgery, transfusion, or angiography).
In the 14-center prospective study, 45% of blunt trauma patients underwent abdominal CT, with range across centers of 4% to 96% in similarly injured populations.
The five variables with greatest predictive value for intraabdominal injury were AST >200, abnormal abdominal physical examination, abnormal chest X-ray, complaint of abdominal pain, and abnormal pancreatic enzymes.
In 34% of patients (very low-risk population with all five variables negative), there was 0.6% risk of intraabdominal injury and 0% risk of injury requiring intervention.
The prediction rule had negative predictive value of 99.4% for any intraabdominal injury and 100% for injury requiring acute intervention.
With just one positive variable, risk of injury was 4.5% and risk of injury requiring intervention was low; risk increased significantly with multiple positive variables.
Abnormal physical examination (seatbelt sign) had the highest odds ratio for injury requiring intervention; elevated AST >200 had highest odds ratio for injury not requiring intervention.
Pelvic plain film did not add predictive value to the model on multivariate analysis and was not included in the final algorithm.
A single complaint of abdominal pain alone, without other positive variables, should not mandate CT—the patient can be re-examined after observation.
Seatbelt sign definition matters: handlebar contusion or true abdominal lap-belt contusion warrants CT, but small abrasions over iliac crest or costal margin do not mandate imaging.
97% of patients in the study had normal blood pressure for age on arrival, indicating most children with significant mechanism do not require acute intervention.
75% of blunt trauma patients are admitted for other injuries (orthopedic, head), providing opportunity for serial abdominal exams without immediate CT.
Patients with one positive variable and reliable family living nearby could potentially be discharged home with return precautions rather than admitted or scanned.
In predominantly adult hospitals, providers tend to learn one set of guidelines and apply adult behavioral patterns to pediatric patients because learning multiple age-stratified protocols is difficult.
In adult trauma centers, radiation concerns rarely factor into CT decision-making, whereas in pediatric care radiation exposure is often the primary concern.
In a study comparing adolescent trauma care at adult versus pediatric centers, outcomes were equivalent or slightly better at pediatric centers with less imaging, shorter length of stay, and lower implied costs.
Chest CT rarely changes management in pediatric trauma patients with normal chest X-ray or minor pulmonary contusions on plain film.
Pan-CT protocols may have a role in centers with limited trauma experience or resources where providers see trauma patients infrequently.
CT scanners represent a sunk cost with low variable costs per scan but generate significant billing revenue for hospitals and radiologists, which may influence imaging decisions.
For a 12-year-old with bilateral iliac crest tenderness but benign abdominal exam after MVC, observation with chest X-ray, screening labs, PO challenge for 1-2 hours, then discharge home if reliable family is appropriate—CT not required.
Most pediatric trauma is cared for at adult trauma centers, not pediatric centers, so convincing adult surgeons of selective imaging protocols is essential to reducing unnecessary CT use.
One or two episodes of emesis at the scene increases concern but may not mandate CT if subsequent exam remains benign; could admit for serial exams rather than scan.
Delaying next abdominal exam for 6-8 hours in an admitted patient is not harmful for detecting delayed small bowel injury, which is well-tolerated in pediatric literature.
Adult trauma surgeons who take trauma call have higher malpractice insurance premiums than general surgeons who do not, driven by risk of missed injuries.
Adult surgeons caring for pediatric trauma patients may feel greater medicolegal vulnerability for missed injuries in children outside their specialty, which may drive more liberal CT use.
In the very low-risk population, you would need to scan 250 patients to find one intraabdominal injury.
Mechanism of injury (rollover, prolonged extrication) was not predictive of intraabdominal injury in multivariate analysis in both PECARN and the 14-center study.
PECARN rule (history and physical only) has excellent negative predictive value for injury requiring urgent intervention (surgery, angio, transfusion) but misses many clinically relevant solid organ injuries that warrant admission or activity restriction.
Caputo 2014 meta-analysis of ~25,000 adult trauma patients showed mortality reduction with whole-body CT (16.9%) versus selective CT (23.3%) in severely injured patients (ISS ~29).
REACT-2 randomized trial (2016) of ~1,400 adult trauma patients found no statistically significant difference in in-hospital mortality between total body CT and selective CT approaches.
In REACT-2, radiation dose was increased with total body CT and time to diagnosis was faster with total body CT compared to selective approach.
Adult trauma literature reports missed injury rates of 10-15% with selective imaging, up to 20% in some studies, which is used to justify pan-CT protocols.
In REACT-2, 46% of patients assigned to selective CT group crossed over and eventually received sequential scans that became a pan-CT.