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An R-Based Landscape Validation of a Competing Risk Model
Published on: September 16, 2022
External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma
Elise Springer1, S Barron Frazier1, Donald H Arnold2
1Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA.
Insights
The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule accurately identifies children with blunt abdominal trauma (BAT) at very low risk for clinically-important intra-abdominal injuries (CIIAI). This rule can help avoid unnecessary computed tomography (CT) scans in pediatric patients.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Diagnostic Imaging
Background:
- Computed tomography (CT) is a common tool for diagnosing intra-abdominal injuries in children with blunt abdominal trauma (BAT).
- The Pediatric Emergency Care Applied Research Network (PECARN) developed a prediction rule to identify low-risk pediatric patients, potentially avoiding CT scans.
- Clinically-important intra-abdominal injuries (CIIAI) require prompt medical or surgical intervention.
Purpose of the Study:
- To evaluate the sensitivity of the PECARN prediction rule in identifying children with BAT who are at very low risk for CIIAI within a pediatric trauma registry.
- To assess the rule's effectiveness in reducing the need for CT scans in this population.
Main Methods:
- A retrospective review of an institutional trauma registry was conducted to identify patients with CIIAI.
- CIIAI were defined by specific criteria including death, laparotomy, angiographic embolization, blood transfusion for hemorrhage, or prolonged IV fluids for certain injuries.
- Patients were identified using ICD codes, and inter-reviewer agreement was assessed using Kappa statistics.
Main Results:
- Out of 5743 patients, 133 (2.3%) experienced CIIAI.
- The PECARN prediction rule demonstrated a sensitivity of 99% (95% CI [96-100%]) for identifying patients at very low risk for CIIAI.
- Only one patient with CIIAI met the very low-risk criteria, and this patient also had an extra-abdominal injury.
Conclusions:
- The study supports the validity and utility of the PECARN prediction rule in clinical practice.
- Implementing this rule can significantly decrease the use of CT scans in children with blunt abdominal trauma who are deemed at very low risk for intra-abdominal injuries.
- Accurate identification of low-risk patients can lead to more efficient resource allocation and reduced radiation exposure in pediatric trauma care.
Background:
Computed tomography (CT) is frequently used to identify intra-abdominal injuries in children with blunt abdominal trauma (BAT). The Pediatric Emergency Care Applied Research Network (PECARN) proposed a prediction rule to identify children with BAT who are at very low risk for clinically-important intra-abdominal injuries (CIIAI) in whom CT can be avoided.
Objective:
To determine the sensitivity of this prediction rule in identifying patients at very low risk for CIIAI in our pediatric trauma registry.
Methods:
Retrospective review of our institutional trauma registry to identify patients with CIIAI. CIIAI included cases resulting in death, therapeutic intervention at laparotomy, angiographic embolization of intra-abdominal arterial bleeding, blood transfusion for intra-abdominal hemorrhage, and administration of intravenous fluids for two or more nights for pancreatic or gastrointestinal injuries. Patients were identified using ICD diagnosis and procedure codes. Kappa was calculated to evaluate inter-reviewer agreement.
Results:
Of 5743 patients, 133 (2.3%) had CIIAI. 60% were male and the mean age was 8 (SD 4.4) years. One patient with CIIAI met the proposed very low risk criteria, resulting in a prediction rule sensitivity of 99%, 95% CI [96-100%]. This patient also had extra-abdominal arterial bleeding requiring revascularization, offering an alternative reason for transfusion. Kappa was 0.85, 95% CI [0.82, 0.89], indicating strong inter-rater agreement.
Conclusions:
One out of 133 patients with CIIAI met very low risk criteria based on the PECARN prediction rule. This study supports the PECARN clinical prediction rule in decreasing CT use in pediatric patients at very low risk for CIIAI.
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