Annals of Emergency Medicine
Volume 54, Issue 4 , Pages 575-584 , October 2009

Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma

Presented at the SAEM annual meeting, Chicago, IL, May 2007.

  • James F. Holmes, MD, MPH

      Affiliations

    • Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
    • Corresponding Author InformationAddress for reprints: James F. Holmes, MD, MPH, UC Davis Medical Center, Department of Emergency Medicine, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817-2282; 916-734-1533, fax 916-734-7950
    • ,
  • David H. Wisner, MD

      Affiliations

    • Department of Surgery, UC Davis School of Medicine, Sacramento, CA
    • ,
  • John P. McGahan, MD

      Affiliations

    • Department of Radiology, UC Davis School of Medicine, Sacramento, CA
    • ,
  • William R. Mower, MD, PhD

      Affiliations

    • Division of Emergency Medicine, UCLA School of Medicine, Los Angeles, CA
    • ,
  • Nathan Kuppermann, MD, MPH

      Affiliations

    • Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
    • Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA

Received 8 September 2008 ,Revised 28 March 2009 ,Accepted 15 April 2009.

References 

  1. Minino AM, Heron MP, Murphy SL, et al. Deaths: final data for 2004. Natl Vital Stat Rep. 2007;55:1–119
  2. Perez FG, O'Malley KF, Ross SE. Evaluation of the abdomen in intoxicated patients: is computed tomography scan or peritoneal lavage always indicated?. Ann Emerg Med. 1991;20:500–502
  3. Poletti PA, Mirvis SE, Shanmuganathan K, et al. Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. J Trauma. 2004;57:1072–1081
  4. Rodriguez A, DuPriest RW, Shatney CH. Recognition of intra-abdominal injury in blunt trauma victims (A prospective study comparing physical examination with peritoneal lavage). Am Surg. 1982;48:457–459
  5. Schurink GW, Bode PJ, van Luijt PA, et al. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury. 1997;28:261–265
  6. Salim A, Sangthong B, Martin M, et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg. 2006;141:468–473discussion 473-475
  7. Griffin XL, Pullinger R. Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe screening investigations for hemodynamically stable patients after blunt abdominal trauma? (A review of the literature). J Trauma. 2007;62:779–784
  8. Heilbrun ME, Chew FS, Tansavatdi KR, et al. The role of negative CT of the abdomen and pelvis in the decision to admit adults from the emergency department after blunt trauma. J Am Coll Radiol. 2005;2:889–895
  9. Holmes JF, Harris D, Battistella FD. Performance of abdominal ultrasonography in blunt trauma patients with out-of-hospital or emergency department hypotension. Ann Emerg Med. 2004;43:354–361
  10. Richards JR, Derlet RW. Computed tomography and blunt abdominal injury: patient selection based on examination, haematocrit and haematuria. Injury. 1997;28:181–185
  11. Stuhlfaut JW, Anderson SW, Soto JA. Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury. Semin Ultrasound CT MR. 2007;28:115–129
  12. Jhirad R, Boone D. Computed tomography for evaluating blunt abdominal trauma in the low-volume nondesignated trauma center: the procedure of choice?. J Trauma. 1998;45:64–68
  13. Miller LA, Shanmuganathan K. Multidetector CT evaluation of abdominal trauma. Radiol Clin North Am. 2005;43:1079–1095viii
  14. Garber BG, Bigelow E, Yelle JD, et al. Use of abdominal computed tomography in blunt trauma: do we scan too much?. Can J Surg. 2000;43:16–21
  15. Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176:289–296
  16. Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening. Radiology. 2004;232:735–738
  17. Prokop M. Cancer screening with CT: dose controversy. Eur Radiol. 2005;15(suppl 4):D55–D61
  18. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357:2277–2284
  19. Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343:100–105
  20. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma (National Emergency X-Radiography Utilization Study Group). N Engl J Med. 2000;343:94–99
  21. Mower WR, Hoffman JR, Herbert M, et al. Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005;59:954–959
  22. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357:1391–1396
  23. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841–1848
  24. Grieshop NA, Jacobson LE, Gomez GA, et al. Selective use of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma. 1995;38:727–731
  25. Mackersie RC, Tiwary AD, Shackford SR, et al. Intra-abdominal injury following blunt trauma (Identifying the high-risk patient using objective risk factors). Arch Surg. 1989;124:809–813
  26. Catre MG. Diagnostic peritoneal lavage versus abdominal computed tomography in blunt abdominal trauma: a review of prospective studies. Can J Surg. 1995;38:117–122
  27. Mele TS, Stewart K, Marokus B, et al. Evaluation of a diagnostic protocol using screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma. J Trauma. 1999;46:847–852
  28. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174
  29. Brieman L, Friedman JH, Olshen RA. Classification and Regression Trees. Washington, DC: Chapman & Hall; 1984;
  30. Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med. 1999;33:437–447
  31. Adili A, Bhandari M, Lachowski RJ, et al. Organ injuries associated with femoral fractures: implications for severity of injury in motor vehicle collisions. J Trauma. 1999;46:386–391
  32. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195:1–10
  33. Ferrera PC, Verdile VP, Bartfield JM, et al. Injuries distracting from intraabdominal injuries after blunt trauma. Am J Emerg Med. 1998;16:145–149
  34. Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury?. Ann Emerg Med. 2005;46:232–236
  35. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002;39:500–509
  36. Reiff DA, McGwin G, Metzger J, et al. Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture. J Trauma. 2002;53:1139–1145
  37. Shweiki E, Klena J, Wood GC, et al. Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients. J Trauma. 2001;50:684–688
  38. Velmahos GC, Tatevossian R, Demetriades D. The “seat belt mark” sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents. Am Surg. 1999;65:181–185
  39. Wu SR, Shakibai S, McGahan JP, et al. Combined head and abdominal computed tomography for blunt trauma: which patients with minor head trauma benefit most?. Emerg Radiol. 2006;13:61–67
  40. Vergouwe Y, Steyerberg EW, Eijkemans MJ, et al. Substantial effective sample sizes were required for external validation studies of predictive logistic regression models. J Clin Epidemiol. 2005;58:475–483
  41. Sahdev P, Garramone RR, Schwartz RJ, et al. Evaluation of liver function tests in screening for intra-abdominal injuries. Ann Emerg Med. 1991;20:838–841
  42. Reilly BM, Evans AT. Translating clinical research into clinical practice: impact of using prediction rules to make decisions. Ann Intern Med. 2006;144:201–209
  43. Livingston DH, Lavery RF, Passannante MR, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. J Trauma. 1998;44:273–280discussion 280-282
  44. Fakhry SM, Brownstein M, Watts DD, et al. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma. 2000;48:408–414discussion 414-415
  45. Miller PR, Croce MA, Bee TK, et al. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma. 2002;53:238–242discussion 242-244
  46. Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52:420–425
  47. Winslow JE, Hinshaw JW, Hughes MJ, et al. Quantitative assessment of diagnostic radiation doses in adult blunt trauma patients. Ann Emerg Med. 2008;52:93–97
  48. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol. 2002;32:228-223; discussion 242-244
  49. Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol. 2001;176:1385–1388
  50. Parfrey PS, Griffiths SM, Barrett BJ, et al. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both (A prospective controlled study). N Engl J Med. 1989;320:143–149
  51. Laupacis A, Sekar N, Stiell IG. Clinical prediction rules (A review and suggested modifications of methodological standards). JAMA. 1997;277:488–494
  52. McGinn TG, Guyatt GH, Wyer PC, et al. Users' guides to the medical literature: XXII: how to use articles about clinical decision rules (Evidence-Based Medicine Working Group). JAMA. 2000;284:79–84
  53. Porter RS, Zhao N. Patterns of injury in belted and unbelted individuals presenting to a trauma center after motor vehicle crash: seat belt syndrome revisited. Ann Emerg Med. 1998;32:418–424
  54. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics. 1993;92:691–694
  55. Sirlin CB, Brown MA, Andrade-Barreto OA, et al. Blunt abdominal trauma: clinical value of negative screening US scans. Radiology. 2004;230:661–668

 Provide feedback on this article at the journal's Web site, www.annemergmed.com.

 Supervising editor: Judd E. Hollander, MD

 Author contributions: JFH was responsible for the study concept and supervision, analyzing and interpreting the data, and drafting the article. JFH, WRM, and NK were responsible for the study design. JFH, DHW, and JPM acquired the data. All authors were responsible for critical revision of the article for important intellectual content. JFH and NK provided statistical expertise and obtained funding. JH takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funded in part by the Society for Academic Emergency Medicine Research Training Grant.

 Publication date: Available online May 19, 2009.

PII: S0196-0644(09)00398-9

doi: 10.1016/j.annemergmed.2009.04.007

Annals of Emergency Medicine
Volume 54, Issue 4 , Pages 575-584 , October 2009

Article Tools

* Image Usage & Resolution