2018 UF ED/Trauma Symposium

2. Nothing to disclose

3. Outline
 Acknowledgements
 Objectives
 Patient scenario
 Development of prediction rules
 UF- Jax algorithm

4. Acknowledgements
Lori Gurien, MD
Phyllis Hendry, MD, FAAP, FACEP
Anne Dziwulski, BSN, RN, CSTR
Shameka King, BSN, RN, CCRN
David Meysenburg, BSN, RN, TCRN
Julia Paul, MSN, ARNP
David Skarupa, MD, FACS
Lisa Teel, MSN, RN, CPEN
Todd Wylie, MD, MPH
Brian Yorkgitis, DO

5. Objectives
 Discuss prediction rules that identify children at
low-risk for intraabdominal injuries
 Review UF-Jax algorithm for pediatric blunt
abdominal trauma

6. Scenario
You are on trauma call
EMS: “a high speed crash on the
interstate 95 and you will be
receiving 2 patients.”
You: “OK. Proceed.”

7. Scenario
EMS: “You will receive 1 adult
and 1 child. There is severe
damage to the vehicle and it
was a prolonged extrication to
get both of the victims out of
the car.”

8. Scenario: Adult Patient 1
 47 yo restrained driver who is reported to be
intoxicated.
 Vitals: GCS 14; BP 116/76; P 106 RR 20
 Exam:
 Abrasion on the left chest from the shoulder to the
RUQ of the abdomen.
 Abdomen is soft but distended.
 Left femur is deformed and normal distal pulses in
the foot.

9. What is the imaging plan?

10. Sensitivity
80-86%
Specificity
97-99%
PPV
92-98%
NPV
92-97%

11. Whole body CT scan results in
lower mortality
Caputo ND, et al. J Trauma ACS. 2015

12. Odds ratio (OR) for Mortality Following Whole-body CT
Caputo ND, et al. J Trauma ACS. 2015

13. Scenario: Child Patient 2
 10 yo restrained front seat passenger. The
patient was wearing a lap and shoulder belt.
The patient had a LOC for several minutes.
The patient has the following vital signs:
 Vitals: GCS 13; BP 108/68; P 114; RR 22
 Exam:
 Abdomen is soft and nontender
 Abrasion across the right hip.
 Open tibia fracture.

14. What is the imaging plan?

15. Pediatric Trauma
Kids are just small adults?

17. How do we decide on imaging?
Right diagnosisLow radiation dose
CT scanFAST
Whole body imagingMRI

18. Should we care about radiation?

19. The “C” word

20. Brenner, D.J. Ped Radiol (2002) 32: 228.
CT Scan
risk
Younger age = higher risk!

21. ALARA Principle

22. ALARA Principle

23. PPE: Shielding

24. Can we really skip CT scan???

25. CT scan ABD/PELVIS

26. PECARN
 Pediatric Emergency Care Applied Research
Network
 Created a clinical prediction rule to identify
children at very low risk for intraabdominal
injury requiring intervention
 Based on history and physical exam only

27.  Prospective, Observational Cohort blunt torso trauma at PECARN
centers
 Enrollment: May 2007 – January 2010
 Exclusion Criteria:
 Injury >24 hours prior to presentation
 Pregnancy
 Transfer from outside hospital
 Penetrating trauma
 Preexisting neurologic condition impeding reliable exam

28. Inclusion Criteria

29. History and Physical Exam Can Be Useful

30. Primary Outcomes
 Intra-abdominal Injury - 761/12,044 patients (6.3%)
 Radiographically or surgically apparent injury to: spleen, liver,
urinary tract, GI tract, GB, pancreas, adrenal, vasculature
 Underwent Acute intervention - 203 (1.7%)
 Death caused by injury
 Therapeutic intervention at laparotomy
 Angiographic embolization
 Blood transfusion for anemia 2/2 hemorrhage
 IV fluids for 2+ nights with pancreatic or GI injuries

31. Derived Prediction Rule Variables
1. Abdominal Wall Trauma or Seat Belt Sign
2. GCS <14
3. Abdominal Tenderness
4. Evidence Thoracic Wall Trauma
5. Complaints of Abdominal Pain
6. Decreased Breath Sounds
7. Vomiting
Absence of these findings is
highly predictive of NO
significant intra-abdominal
injury requiring
intervention

32. Prediction rule

33. Prediction rule misses

34.  Limitations
 No FAST exam/Ultrasound utilized
 Abd CT/DPL/Laparoscopy not mandated so clinically silent
Intra-Abdominal Injuries may have been missed
 Performed at Highly Specialized Pediatric Trauma Centers

35. Any adjuncts that can help?

36.  Prospective observational cohort
 Pediatric patients with blunt abdominal trauma at
Level I Pediatric Trauma Centers

37. 11.9%
2.8%

38. Five variables in prediction rule
 AST > 200
 Abnormal abdominal physical examination
 Abnormal chest x-ray
 Complaint of abdominal pain
 Abnormal pancreatic enzymes (amylase or lipase)

39. Prediction rule
 Most blunt abdominal injuries in children are nonoperative!
 Do we care about identifying any intraabdominal injury?
 Or identifying an intraabdominal injury that requires acute intervention?

40. Prediction rule
NO CT SCAN
INDICATED

41. Management of Pediatric Blunt Abdominal Trauma
Primary Survey
Chest/pelvis XR
Observe and reevaluate
in ED
Consider discharge +
FAST#
Observe and reevaluate in ED
Vs
Admit to Trauma service
AST >200, ALT > 125
UA > 5 RBC, Hct <30
Abnormal Lipase/Amylase
Any sign of:
Seatbelt mark/sign
Abdominal abrasions,
bruising, distension or
tenderness
Thoracic wall trauma
AMS or unevaluable
Vomiting >1 time
Surgical consult
20 mL/kg bolus of
isotonic fluids
Surgical consult/Admit
Labs and
observation/reevaluation
Consider CT of abdomen
and pelvis with IV contrast
Surgical consult/Admit
Observation/reevaluation, Repeat labs,
Consider CT of Abdomen and pelvis
with IV contrast
Fluid resuscitation to
max of 60 mL/kg
Consider 10-20 mL/kg
of blood
FAST#
OR
Consider other
sources of
hemorrhage
CT scan with IV
contrast, IR or OR
+ Discharge
criteria: stable VS,
resolution of pain,
negative imaging (if
done), attending
approval
*Hemodynamically
unstable based on
HR, BP, and
capillary refill > 2
sec
Systolic BP < 70 +
(age in years x 2)
Hemodynamically stable *Hemodynamically unstable
StableNo
No
Remains unstable
Positive
Positive
Yes
Yes
Negative
Negative
Excludes abuse and
non-accidental trauma
# sensitivity↓ in children
Updated
January 2018

42. Conclusions
 Kids are not little adults
 Radiation risk is real
 CT can be useful:
 Abnormal exam
 Abnormal labs
 Physical exam & observation can be
appropriate