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Ruling Out Abdominal Organ Injury in Children with Blunt Trauma

A new clinical score identified nearly all children with abdominal organ injury after trauma.

History and physical exam provide limited information for detecting intra-abdominal injury in children with blunt abdominal trauma. A reliable method for identifying children who require abdominal computed tomography (CT) would decrease radiation and contrast exposure and improve efficiency of care. In a prospective observational study, these authors used clinical data for 147 consecutive children with blunt abdominal trauma who were admitted to a Swiss tertiary care hospital to develop a decision rule for excluding intra-abdominal organ injuries.

All patients underwent extensive laboratory testing and abdominal ultrasound for assessment of renal artery Doppler flow by a radiologist; patients with abnormal laboratory or ultrasound findings underwent abdominal CT. The Blunt Abdominal Trauma in Children (BATiC) score assigns points as follows:

• 4 points for an abnormal Doppler evaluation of the renal arteries on abdominal ultrasound
  
• 2 points each for abdominal pain, signs of peritoneal irritation on physical exam, hemodynamic instability, aspartate aminotransferase (AST) >60 IU/L, and alanine aminotransferase (ALT) >25 IU/L
  
• 1 point each for peripheral white blood cell count >9.5 g/L, lactate dehydrogenase >330 IU/L, lipase >30 IU/L, and creatinine >50 µg/L
  

Overall, 31 patients (21%) were diagnosed with abdominal organ injury. A BATiC score 7 had a 97% negative predictive value for abdominal organ injury. Two patients with scores 7 had injuries (1 splenic, 1 renal) that were detected by CT performed to evaluate persistent abdominal pain 24 hours after admission; neither required intervention.

Comment: The BATiC score is a promising clinical decision rule. If the method is validated in large prospective multicenter studies, its use could decrease exposure to contrast CT and increase detection of abdominal organ injuries in children with blunt abdominal trauma. Larger studies in other settings would also help determine which children with blunt abdominal trauma are eligible for use of the rule. Fine-tuning might eliminate colinear predictors, such as AST and ALT, and nonspecific indicators, such as the peripheral white blood cell count.

— Daniel J. Pallin, MD, MPH

Dr. Pallin is an attending physician in the Department of Emergency Medicine at Brigham and Women's Hospital in Boston and in the Division of Emergency Medicine at Children's Hospital Boston. He is also an Assistant Professor of Medicine (Emergency Medicine) and of Pediatrics at Harvard Medical School.

Published in Journal Watch Emergency Medicine July 17, 2009

Citation(s):

Karam O et al. Blunt abdominal trauma in children: A score to predict the absence of organ injury. J Pediatr 2009 Jun; 154:912.

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