Is physical exam and laboratory data sufficient to exclude intrabdominal injury (IAI) in the pediatric trauma patient?
Date First Published:
June 27, 2011
Last Updated:
February 23, 2012
Report by:
Drue Orwig, DO, Resident Physician (Grand Rapids Medical Education Partners/Michigan State University)
Search checked by:
James DeCou, MD, Grand Rapids Medical Education Partners/Michigan State University
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)
[exp abdominal injuries/diagnosis] AND [exp physical Examination/]. Limit to English language and all child (0 to 18 years)
Outcome:
54 papers were identified, four of which were relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Utility of Routine Laboratory Testing for Detecting Intra-abdominal Injury in the Pediatric Trauma Patient Isaacman DJ, Scarfone RJ, Kost SI, 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% | ||||
| Identification of Intra-abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma Holmes JF, Sokolove PE, Land C 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) | ||||
| The Utility of Clinical and Laboratory Data for Predicting Intraabdominal Injury Among Children Cotton BC, Beckert BW, Smith MK 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% | ||||
| Identification of Children with Intra-Abdominal Injuries After Blunt Trauma Holmes JF, Sokolove PE, Brant WE, 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% |
Author Commentary:
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).
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:
- Isaacman DJ, Scarfone RJ, Kost SI, et al. . Utility of Routine Laboratory Testing for Detecting Intra-abdominal Injury in the Pediatric Trauma Patient
- Holmes JF, Sokolove PE, Land C et al,. Identification of Intra-abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma
- Cotton BC, Beckert BW, Smith MK et al.. The Utility of Clinical and Laboratory Data for Predicting Intraabdominal Injury Among Children
- Holmes JF, Sokolove PE, Brant WE, et al. . Identification of Children with Intra-Abdominal Injuries After Blunt Trauma