Tenderness and Risk for Intra-abdominal Injury in Children with - PowerPoint PPT Presentation

Importance of Costal Margin Tenderness and Risk for Intra-abdominal Injury in Children with Blunt Abdominal Trauma Katherine T. Flynn- O’Brien, MD, MPH Nathan Kupperman, MD, MPH James F. Holmes, MD, MPH Pediatric Trauma Society Scottsdale, AZ | November 6-7, 2015

Disclosures  I have no disclosures.

Background  Risk of radiation exposure from CT imaging  Suspected intra-abdominal injury (IAI)  History & physical exam (H&P) findings assist physician’s decision  PECARN prediction rule  7 H&P findings to identify children with low risk for IAI  Costal margin tenderness (CMT) was not identified as an independent predictor

Background Abdominal wall trauma GCS <14 Vomiting Absent or Abdominal IAI decreased tenderness BS Costal c/o margin Abdominal tenderness pain Thoracic wall trauma

Objective Determine the risk of IAI in 1) children with:  Isolated costal margin tenderness (CMT)  Non-isolated CMT (+other PECARN) Quantify potentially avoidable CT 2) scans in children with CMT and low risk for IAI

Methods  Planned secondary analysis  Large prospective multicenter cohort study  May 2007-Jan 2010  12,044 children <18 years  B lunt torso trauma/”non - trivial” abd trauma  761 children with IAI; 203 IAI with acute intervention  Limited to GCS 14-15

Methods  Descriptive statistics  Comparison of binomial proportions with exact confidence intervals (CI)  2-sided p-value 0.05 or 1-sided p-value 0.025  Relative risk  Risk difference

12,044 patients 999 excluded for GCS: enrolled 995 GCS 3-13 4 missing data for GCS 11,045 patients with GCS 14-15 107 missing data for CMT 1,764 excluded due to missing data for PECARN predictors: 9,174 patients with Abd. trauma/seat belt sign (n = 334) data for costal margin Abd. tenderness (n = 558) Thoracic wall trauma (n = 66) tenderness and all C/o abd. pain (n = 1077) PECARN predictor Absent/dec. breath sounds ( n = 195) variables Vomiting (n = 188)

9,174 patients with data for costal margin tenderness and PECARN predictor variables 7,907 without CMT 1,267 CMT 177 isolated CMT 1,090 CMT and 1+ PECARN variables

9,174 patients with data for costal margin tenderness and PECARN predictor variables 7,907 without CMT 1,267 CMT 177 isolated CMT 1,090 CMT and 1+ PECARN variables 4,103 without CMT; but 3,804 without CMT or with 1+ PECARN var. PECARN variables

9,174 patients with data for costal margin tenderness and PECARN predictor variables 7,907 without CMT 1,267 CMT 177 isolated CMT 1,090 CMT and 1+ PECARN variables 4,103 without CMT; but 3,804 without CMT or with 1+ PECARN var. PECARN variables

Results Isolated CMT Non-isolated CMT Demographics Age, years 14 (10, 16) 13 (10, 16) Male 112 (63.3) 712 (65.3) Mechanism of Injury MVC 52 (29.4) 263 (24.1) Ped v. MVC 14 (7.9) 117 (10.9) ATV/scooter 5 (2.8) 55 (5.1) Bicycle 6 (3.4) 86 (7.9) Fall from elev 18 (10.2) 119 (10.9) Fall from stairs 7 (4.0) 10 (1.8) Abd struck 23 (13.0) 206 (18.9)

Results Isolated CMT Non-isolated CMT Other PECARN variables Abdominal trauma n/a 272 (25.0) Abd. tenderness n/a 837 (76.8) Thoracic wall trauma n/a 445 (40.8) C/o abdominal pain n/a 839 (77.0) Absent/dec. BS n/a 56 (5.1) Vomiting n.a 119 (10.9)

Results  1267 with CMT  187 patients with IAI  36 patients with IAI requiring acute intervention

Results: CMT +/- PECARN vars  1267 with CMT  187 patients with IAI  36 patients with IAI requiring acute intervention 1,090 CMT and 1+ 177 isolated CMT PECARN variables 0% 17.2% (15-19.5%) IAI 3.3% (2.3-4.5%) IAI requiring acute intervention

Results: Any IAI (n = 507) No./No. % (95% CI) Relative Risk (95% CI) Isolated CMT 0/177 0.0 (0.0-2.2) -- CMT, 1+ 187/1090 17.2 (15.0-19.5) 16.3 (11.7-22.8) PECARN No CMT, 1+ 280/4103 6.8 (6.1-7.6) 6.5 (4.7-9.0) PECARN No CMT, 40/3804 1.1 (0.8-1.4) Ref no PECARN

Results: IAI acute interv. (n = 113) No./No. % (95% CI) Relative Risk (95% CI) Isolated CMT 0/177 0.0 (0.0-2.2) -- CMT, 1+ 36/1090 3.3 (2.3-4.5) 20.9 (8.8-49.6) PECARN No CMT, 1+ 71/4103 1.7 (1.4-2.2) 11.0 (4.8-25.3) PECARN No CMT, 6/3804 0.2 (0.0-0.3) Ref no PECARN

Results: Risk difference Exposed Unexposed RD = Risk exposed – Cases a b Risk unexposed Non-cases c d CMT + PECARN RD = PECARN var only Risk CMT/PECARN var – Risk PECARN IAI a b variable only No IAI c d

Results: Risk difference Risk e Risk u RD (95 CI%) p-value Abd. trauma 8.3% 3.0% 5% (10,21) 0.297 Abd. tenderness 7.9% 5.1% 3% (-6,12) 0.487 Thoracic wall tr. 3.4% 1.4% 2% (-1,5) 0.063 C/o abd. pain 5.3% 2.5% 3% (-5,10) 0.336 Absent/dec BS 0% 3.4% -3% (-10,3) 0.673 Vomiting 0% 1.8% -2% (-3,-.2) 0.700 Attributable risk of IAI due to CMT = low

Results: CT scan use  3,947 scans of the abdomen & pelvis  40.7% of the population  Isolated CMT  36/177 (20.3; 14.6-27.0)

Conclusions  Isolated CMT is associated with very low risk of IAI  Attributable risk due to CMT for IAI above and beyond other PECARN risk factors is likely minimal  In the setting of isolated CMT, abdominal CT scan for evaluation of IAI can likely be avoided

Limitations  Missing data  Small n, limited power  Secondary analysis, increase type I error  Generalizability

Thank you Questions? flynnobr@uw.edu

Results N Any IAI IAI req. acute N = 507 intervention No./No. (%; 95% N = 113 CI) No./No. (%; 95% CI) Isolated CMT 177 0/177 (0.0; 0.0-2.2) 0/177 (0.0; 0.0-2.2) CMT and only 1 PECARN var. Abd. trauma 12 1/12 (8.3; 0.2-38.5) 1/12 (8.3; 0.2-38.5) Abd. tenderness 38 3/38 (7.9; 1.7-21.4) 0/38 (0.0; 0.0-9.3) Thoracic wall tr. 119 4/119 (3.4; 0.9-8.4) 1/119 (0.8; 0.0-4.6) C/o abd. pain 38 2/38 (5.3; 0.6-17.7) 0/38 (0.0; 0.0-9.3) Absent/dec BS 5 0/5 (0.0; 0.0-52.2) 0/5 (0.0; 0.0-52.2) Vomiting 8 0/8 (0.0; 0.0-36.9) 0/8 (0.0; 0.0-36.9)