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Implications of a negative abdominal CT in the management of pediatric blunt abdominal trauma
Sarah Braungart1, Thomas Beattie2, Paula Midgley2
1Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, UK; Child Life and Health, University of Edinburgh, UK.
Insights
Children with negative CT scans after blunt abdominal trauma (BAT) can often be discharged directly from the emergency department (ED). This practice is safe, as CT scans have a very high negative predictive value (NPV) for detecting intra-abdominal injuries (IAI).
Area of Science:
- Pediatric Trauma Surgery
- Diagnostic Imaging in Emergency Medicine
- Abdominal Injury Assessment
Background:
- Management of children with negative computed tomography (CT) scans after blunt abdominal trauma (BAT) lacks consensus.
- Asymptomatic children are often admitted for observation despite negative CT scans, raising concerns about unnecessary resource utilization.
- Current practices may not be evidence-based, necessitating an investigation into the safety of early discharge.
Purpose of the Study:
- To determine the feasibility of discharging children directly from the emergency department (ED) after a negative CT scan for blunt abdominal trauma (BAT).
- To evaluate the negative predictive value (NPV) of CT scans in detecting intra-abdominal injuries (IAI) in pediatric patients.
- To provide evidence-based recommendations for the management of pediatric blunt abdominal trauma.
Main Methods:
- A retrospective audit was conducted at a UK pediatric major trauma center.
- A comprehensive literature review of observational cohort studies and systematic reviews was performed.
- Data analysis focused on patients with negative CT scans following blunt abdominal trauma.
Main Results:
- In the audit, 108 children with BAT were analyzed; 40 had normal CT scans, with 6 discharged directly from the ED.
- None of the 108 children experienced missed intra-abdominal injuries (IAI) or re-presented with suspected IAI.
- The literature review, encompassing 9149 patients, indicated a CT NPV of 99.6%-100% for detecting IAI, with <0.1% requiring surgery for missed injuries.
Conclusions:
- Asymptomatic children with negative abdominal CT scans following blunt abdominal trauma (BAT) have a very low likelihood of intra-abdominal injury (IAI).
- The negative predictive value (NPV) of CT scans for IAI in this population is high (96%-100%).
- Direct discharge from the ED is a safe and feasible option for asymptomatic children with negative CT scans, provided no other admission criteria exist, and should include safety-net advice.
Background:
No consensus exists on management of children with a negative trauma CT following blunt abdominal trauma (BAT). Asymptomatic children are frequently "admitted for observation" following negative CT owing to concerns about missing an intraabdominal injury (IAI) without evidence for this practice. We aimed to investigate the feasibility of discharge following a negative CT scan in children sustaining blunt abdominal trauma.
Methods:
Retrospective audit at a UK paediatric major trauma center and review of the literature.
Results:
108 patients were included (median age 11y; 60% male). Commonest mechanisms of injury: road traffic collisions (61 patients; 56%) and falls from a height (37; 34%). 40 (37%) had a normal CT scan, of whom 6 (15%) were discharged from ED. The remaining 34 patients were admitted, of whom 14 (41%) were discharged within 24h. The other 20 children were admitted for other specialty input. None of the 108 children had a missed IAI or reattended with suspicion of IAI. The NPV for CT to detect IAI was 100% (95% CI: 96%-100%). The literature search identified 3 observational cohort studies and 2 patient groups contained in a systematic review (total of 9149 patients with normal CT abdomen after BAT). Only 9 (<0.1%) patients required operative intervention for missed IAI. The NPV for CT to detect IAI was 99.6%-99.8% (95% CI 99%-100%).
Conclusion:
Our study and literature review demonstrate that asymptomatic children with a normal abdominal CT scan in the ED are very unlikely to have IAI and that the NPV of CT is very high (96%-100%). Direct discharge from the ED is possible for asymptomatic children with a negative CT following blunt abdominal trauma, as long as no other reasons for admission exist and should be accompanied by safety-net advice.
Level Of Evidence Statement:
This is a level II evidence study. In itself it is a retrospective study, with the literature review including one large, high-quality prospective cohort study, and further prospective cohort studies of ordinary quality.
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