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A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma
James F Holmes1, Peter E Sokolove, William E Brant
1Division of Emergency Medicine, Department of Internal Medicine, University of California-Davis School of Medicine, Sacramento, CA 95817-2282, USA. jfholmes@ucdavis.edu
Insights
This study identified key predictors for thoracic injuries in children with blunt torso trauma. These factors can help clinicians quickly identify at-risk children, improving diagnosis and care.
Area of Science:
- Pediatric Trauma Surgery
- Emergency Medicine
- Clinical Prediction Modeling
Background:
- Blunt torso trauma is a significant concern in pediatric emergencies.
- Identifying thoracic injuries in children requires accurate diagnostic tools.
Purpose of the Study:
- Determine the prevalence of thoracic injuries in pediatric blunt torso trauma.
- Develop a clinical prediction rule to identify children with these injuries.
Main Methods:
- Prospective enrollment of pediatric patients (<16 years) with blunt torso trauma.
- Standardized clinical data collection and chest radiography.
- Logistic regression and recursive partitioning for rule generation.
Main Results:
- 8.1% of 986 children sustained thoracic injuries.
- Key predictors identified: low systolic blood pressure, elevated respiratory rate, abnormal thoracic exam, abnormal auscultation, femur fracture, and low Glasgow Coma Scale (GCS) score.
- 98% of injured children had at least one predictor; 0.6% had injuries requiring no intervention.
Conclusions:
- Established predictors can form a clinical decision rule for thoracic injuries in pediatric blunt torso trauma.
- This rule aids in identifying children needing further evaluation and intervention.
Study Objective:
We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries.
Methods:
We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries.
Results:
Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention.
Conclusion:
Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.