EAST 2018 #5: Predicting Absence Of Pediatric Abdominal Injury

More on prediction systems today! The authors of this abstract used good old mathematics, albeit very fancy math, instead of a machine learning algorithm. The specifics of this tool were described in an article published in JACS earlier this year (see reference).

The authors were interested in finding a way to decrease the use of CT scan for evaluating blunt abdominal trauma in children. After developing the model using prospectively collected data from 14 Level I pediatric trauma centers, they sought to validate it using a public dataset from the Pediatric Emergency Care Applied Research Network (PECARN). This dataset contained more than 2,400 records, and included 10% of patients who had an intra-abdominal injury (IAI), and 2.5% with an IAI that required intervention (IAI-I).

Here are the factoids:

  • There were five prediction rule variables: complaint of abdominal pain, tenderness / distension / or contusion on exam, abnormal chest x-ray, AST > 200, elevated pancreatic enzymes)
  • Prediction rule sensitivity was 98% and specificity was 37% for IAI, and 100% / 35% for IAI-I
  • The negative predictive value for finding any abdominal injury was 99.3%, and for injury requiring intervention was 100%
  • Unfortunately, nearly half of the very low risk children underwent CT scanning anyway!

Bottom line: This is a nice validation study for a well-designed prediction tool. It builds on previous work published earlier this year. The variables make clinical sense. Although the number of patients with injury were relatively small, I believe these results should be considered for incorporation in our blunt pediatric trauma evaluation protocols now!

Here are some questions for the authors to consider before their presentation:

  • The liver function and pancreatic enzyme tests results take some time to perform. How much do they contribute to the negative predictive value, since they are relatively uncommon injuries?
  • What are considered abnormal chest x-ray findings?
  • How do you recommend incorporating this into the care of trauma activation patients? Wait for 30 minutes in the trauma bay for the lab tests to come back? Evaluation in patients undergoing a more routine evaluation for abdominal trauma would not be unduly delayed.
  • Be prepared to explain how you derived the decision rule in very simple language.

References:

  • EAST 2018 Podium paper #7.
  • Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. JACS 224(4):449-458.

Source: The Trauma Professionals’s Blog