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BET 4: Is physical exam and laboratory data sufficient to exclude intra-abdominal injury in the paediatric trauma patient?

Abstract

A short-cut review was carried out to establish whether physical and laboratory data can exclude intra-abdominal injury in children. A total of 54 papers was found using the reported search, of which three represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that physical and laboratory data review may decrease the need for abdominal CT in the paediatric population.

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Report by: Drue Orwig, Resident Physician

Search checked by: James DeCou, Pediatric Trauma Director, Helen DeVos Children's Hospital

Institution: Grand Rapids Medical Education Partners/Michigan State University Grand Rapids, USA

Three-part question

In (paediatric trauma patients) is (physical exam combined with laboratory values) a feasible alternative to (exclude intrabdominal injury) compared to abdominal CT?

Clinical scenario

A 14-year-old restrained boy was involved in a motor vehicle accident. 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 intra-abdominal 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

Fifty-four papers were identified, four of which were relevant (see table 5).

Table 5

Physical exam in the paediatric trauma patient

Comments

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.

▶ Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics 1993;92:692–4.

▶ Holmes JF, Sokolove PE, Land C, et al. Identification of intra-abdominal injuries in children hospitalized following blunt torso trauma. Acad Emerg Med 1999;6:799–806.

▶ Cotton BC, Beckert BW, Smith MK, et al. The utility of clinical and laboratory data for predicting intraabdominal injury among children. J Trauma 2004;56:1068–75.

▶ Holmes JF, Sokolove PE, Brant WE, et al. identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002;39:500–9.

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