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Three Part Question

In [pediatric trauma patients] is [physical exam combined with laboratory values] a feasible alternative to [exclude intrabdominal injury] compared to abdominal computed tomography?

Clinical Scenario

A 14 year old restrained male was involved in a MVA. He has a fractured forearm but no other significant injuries. He is currently alert and oriented times three and does not complain of abdominal pain. Is physical exam combined with laboratory studies sufficient to exclude any significant intraabdominal injury (IAI) in this child?

Search Strategy

Medline 1950-05/11 using OVID interface, Cochrane Library (2011), PubMed clinical queries
[exp abdominal injuries/diagnosis] AND [exp physical Examination/]. Limit to English language and all child (0 to 18 years)

Search Outcome

54 papers were identified, four of which were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Isacman et al 1993 USA	Phase I - 285 consecutive level II trauma patients with physical exam and laboratory values recorded. Phase II - 91 trauma patients identified by ICD-9 code as having IAI to confirm sensitivity of physical exam and urinalysis	Retrospective review, single center, data included mechanism of injury, GCS, trauma score, pediatric trauma score, physical exam findings, CBC, CMP, amylase, lipase, and urinalysis	Physical exam + U/A with >5rbc/hpf	Sens 100%, spec 64% PPV 13% NPV 100%	Retrospective review, low prevalence of disease (4.8%), potential bias of physical exam in phase II as these patients were previously known to have IAI, lack of generalizability to younger patients and those with neurologic impairment, lack of universal lab testing (only 59% of pts had AST/ALT done)
			Physical exam + hgb<11, AST or ALT>40, amylase>100, lipase>200, or u/a with 5rbcs/hpf	Sens 100% spec 37% PPV 8% NPV 100%
			Physical exam + hbg<11, AST or ALT>130, amylase>100, lipase>200, or U/a with >5rbcs/hpf	Sens 10%, spec 53% PPV 10% NPV 100%
Holmes et al, 1999 USA	1040 children less than fifteen years old with blunt trauma categorized as high risk for IAI if abd pain or tenderness, decreased LOC, gross hematuria or moderate risk without any of these findings	Retrospective cohort of consecutive admissions, single center, four year period, single-blinded	Moderate risk for IAI	4.6% had IAI	Retrospective, potential bias in ED charting, lack of universal laboratory testing( AST/ALT not routinely drawn), all patients were hospitalized therefore not generalizable to well-appearing children potentially going home,
			High risk for IAI	23% had IAI
			Moderate risk with IAI compared to moderate risk without IAI	Significantly more likely to have abdominal abrasion (p=0.008), abnormal chest exam (p=0.01) elevated WBC count (p=<0.001), mean concentration of AST and ALT (p=<0.001-0.002), microscopic hematuria (p=0.02)
Cotton et al, 2004 USA	351 children (<16yrs) with possible blunt abdominal trauma, 23 variables potentially associated with IAI were determined and logistic regression and recursive partitioning were used to identify variables and develop predictive models	Retrospective chart review, single center, all class I and II pediatric blunt traumas	Abdominal tenderness	OR 40.7 (10.7-155), p <0.01	Retrospective study, no uniformity in laboratory and CT scan testing, management by trauma surgeon may have lead to bias, small sample size, difficult to interpret decision tree
			Abdominal abrasion	OR 16.8 (3.4-83.8), p<0.0001
			Abdominal ecchymosis	OR 15.8 (1.7-142.3), p<0.05
			ALT	OR 1.0 (1.01-1.03), p<0.0001
			Injury related to MVA	OR 0.2 (0.1-0.6), p<0.01
			Hematocrit	OR 0.9 (0.8-0.9), p<0.05
			Abnormal abdominal exam +AST>131	88% of children with sens 100% spes 87%
Holmes et al 2002 USA	1095 children <16 years old who sustained blunt trauma and were at risk for IAI had physical exam and laboratory data collected	Prospective observation study, children had complete physical exam, CBC, AST, ALT, and urinalysis and CT or laparotomy at physician's discretion	Low systolic BP + abdominal tenderness + femur fracture + ALT >125 or AST >200 + HEMATOCRIT <30% + hematuria >5RBC/HPF	Sens 98% spec 49% PPV 17% NPV 99.6%	Not all children had abdominal CT possibly creating evaluation bias, single-centered, low prevalence of disease
			Low systolic BP	Sens 10% spec 98% PPV 42% NPV 91%
			Abd tenderness	Sens 58% spec 71% PPV 18% NPV 94%
			Femur fracture	Sens 10% spec 98% PPV 19% NPV 91%
			ALT >125 or AST>200	Sens 50% spec 96% PPV 54% NPV 95%
			Urinalysis >5rbc/hpf	Sens 50% spec 89% PPV 32% NPV 94%

Comment(s)

All the studies were single-centered with relatively small prevalence and were unblinded, possibly creating bias. Most common findings suggesting IAI included abdominal pain or abnormal abdominal exam, microscopic haematuria and elevated hepatic transaminases. They were unable to generalise the results to preverbal children (<3 years old) and to children with decreased level of consciousness (GCS <13).

Clinical Bottom Line

In paediatric blunt trauma patients over 3 years old with a GCS of 15, physical examination combined with laboratory testing such as CBC, AST/ALT, and U/A are a good predictor of IAI and, if normal, abdominal CT in not warranted.

References

1. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of Routine Laboratory Testing for Detecting Intra-abdominal Injury in the Pediatric Trauma Patient Pediatrics November 1993; Vol 92, No 5 pp692-694
2. Holmes JF, Sokolove PE, Land C et al, Identification of Intra-abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma Academic Emergency Medicine August 1999; Vol 6, No 8 pp799-806
3. Cotton BC, Beckert BW, Smith MK et al. The Utility of Clinical and Laboratory Data for Predicting Intraabdominal Injury Among Children The Journal of Trauma May 2004; Vol 56 No 5, pp1068-1075
4. Holmes JF, Sokolove PE, Brant WE, et al. Identification of Children with Intra-Abdominal Injuries After Blunt Trauma Annals of Emergency Medicine May 2002 39:5 pp 500-509