Clinical Decision Rule to Identify Children with Intra-Abdominal Injuries

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Trauma is the leading cause of death in children and intra-abdominal injuries (IAI) are a frequent cause of morbidity and mortality due to trauma. Some IAIs are difficult to identify and failure to identify these injuries results in preventable morbidity and mortality. Abdominal computerized tomography (CT) is the reference standard for the diagnosis of IAl. CT scanning, however, has important risks, primarily the risk of development of radiation-induced malignancy. For every 1,500 children undergoing abdominal CT scanning, approximately one child will die from a malignancy induced by the radiation and up to three additional children will develop non-fatal malignancies from this exposure. Only approximately 10% of abdominal CT scans currently performed on children with trauma demonstrate IAIs, thus CT scanning is used inefficiently. Objectives: The objective of this study is to develop highly sensitive, specific and generalizable decision rules for the evaluation of children seen in emergency departments (EDs) with blunt abdominal trauma. These decision rules may then serve to generate evidence-driven guidelines for the evaluation of these children, and when implemented will result in more efficient use of CT scans. Study Design: This will be a prospective, multicenter, observational study of children with blunt abdominal trauma. Setting: Children with blunt abdominal trauma seen at one of 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) will be enrolled over a two year period. The EDs of the PECARN evaluate more than 900,000 children of diverse geographic and racial/ethnic background annually. Participants: We will enroll approximately 9,774 children with significant blunt torso trauma, including 900 children with IAl. Outcome Measures: The primary outcome for this study will be IAI in need of acute intervention (IAI resulting in death, or an IAI in need of any of the following: laparotomy, blood transfusion, angiographic embolization, or IV hydration). Interventions/Data analysis: The patients' history, physical examination findings and laboratory results at ED evaluation will be analyzed using recursive partitioning to generate a clinical decision rule(s) for the identification of children at high risk and near-zero risk of IAI in need of acute intervention. The decision rule (s) will lead to more efficient use of abdominal CT in those children at risk for IAIs, and a decrease in use in those at near-zero risk of IAI, ultimately resulting in more efficient, safe and effective care of injured children.