Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries

      Study objective

      We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated.


      We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability.


      We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).


      A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.
      To read this article in full you will need to make a payment
      ACEP Member Login
      ACEP Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Heron M.
        Deaths: leading causes for 2007.
        Natl Vital Stat Rep. 2011; 59: 1-95
        • Blackwell C.D.
        • Gorelick M.
        • Holmes J.F.
        • et al.
        Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time.
        Ann Emerg Med. 2007; 49: 320-324
        • Broder J.
        • Fordham L.A.
        • Warshauer D.M.
        Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006.
        Emerg Radiol. 2007; 14: 227-232
        • Broder J.
        • Warshauer D.M.
        Increasing utilization of computed tomography in the adult emergency department, 2000-2005.
        Emerg Radiol. 2006; 13: 25-30
        • Korley F.K.
        • Pham J.C.
        • Kirsch T.D.
        Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998-2007.
        JAMA. 2010; 304: 1465-1471
        • 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
        • Jindal A.
        • Velmahos G.C.
        • Rofougaran R.
        Computed tomography for evaluation of mild to moderate pediatric trauma: are we overusing it?.
        World J Surg. 2002; 26: 13-16
        • Neish A.S.
        • Taylor G.A.
        • Lund D.P.
        • et al.
        Effect of CT information on the diagnosis and management of acute abdominal injury in children.
        Radiology. 1998; 206: 327-331
        • Stuhlfaut J.W.
        • Anderson S.W.
        • Soto J.A.
        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
        • Taylor G.A.
        • O'Donnell R.
        • Sivit C.J.
        • et al.
        Abdominal injury score: a clinical score for the assignment of risk in children after blunt trauma.
        Radiology. 1994; 190: 689-694
        • Larson D.B.
        • Johnson L.W.
        • Schnell B.M.
        • et al.
        Rising use of CT in child visits to the emergency department in the United States, 1995-2008.
        Radiology. 2011; 259: 793-801
        • Brenner D.J.
        • Hall E.J.
        Computed tomography—an increasing source of radiation exposure.
        N Engl J Med. 2007; 357: 2277-2284
        • Frush D.P.
        • Frush K.S.
        The ALARA concept in pediatric imaging: building bridges between radiology and emergency medicine: consensus conference on imaging safety and quality for children in the emergency setting, Feb. 23-24, 2008, Orlando, FL—executive summary.
        Pediatr Radiol. 2008; 38: S629-S632
        • Committee to Assess Health Risks From Exposure to Low Levels of Ionizing Radiation NRC
        Health Risks From Exposure to Low Levels of Ionizing Radiation: BEIR VII, Phase 2.
        National Academies Press, Washington, DC2006
        • Cotton B.A.
        • Beckert B.W.
        • Smith M.K.
        • et al.
        The utility of clinical and laboratory data for predicting intraabdominal injury among children.
        J Trauma. 2004; 56 (discussion 1074–1075): 1068-1074
        • Holmes J.F.
        • Mao A.
        • Awasthi S.
        • et al.
        Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma.
        Ann Emerg Med. 2009; 54: 528-533
        • Holmes J.F.
        • Sokolove P.E.
        • Brant W.E.
        • et al.
        Identification of children with intra-abdominal injuries after blunt trauma.
        Ann Emerg Med. 2002; 39: 500-509
        • Isaacman D.J.
        • Scarfone R.J.
        • Kost S.I.
        • et al.
        Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient.
        Pediatrics. 1993; 92: 691-694
      1. The Pediatric Emergency Care Applied Research Network (PECARN): rationale, development, and first steps.
        Acad Emerg Med. 2003; 10: 661-668
        • Stiell I.G.
        • Wells G.A.
        Methodologic standards for the development of clinical decision rules in emergency medicine.
        Ann Emerg Med. 1999; 33: 437-447
        • Brieman L.
        • Friedman J.H.
        • Olshen R.A.
        • et al.
        Classification and Regression Trees.
        Chapman & Hall, Washington, DC1984
        • Gorelick M.H.
        Bias arising from missing data in predictive models.
        Acad Emerg Med. 2002; 9: 483-484
        • Gorelick M.H.
        • Atabaki S.M.
        • Hoyle J.
        • et al.
        Interobserver agreement in assessment of clinical variables in children with blunt head trauma.
        Acad Emerg Med. 2008; 15: 812-818
        • Holmes J.F.
        Clinical prediction rules.
        in: Li G. Baker S.P. Injury Research: Theories, Methods, Approaches. Springer, New York, NY2012: 317-336
        • Kuppermann N.
        • Holmes J.F.
        • Dayan P.S.
        • et al.
        Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
        Lancet. 2009; 374: 1160-1170
        • Yen K.
        • Kuppermann N.
        • Lillis K.
        • et al.
        Inter-observer agreement in clinical assessment of children with blunt abdominal trauma.
        Acad Emerg Med. 2013; (In press)
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Holmes J.F.
        • Sokolove P.E.
        • Land C.
        • et al.
        Identification of intra-abdominal injuries in children hospitalized following blunt torso trauma.
        Acad Emerg Med. 1999; 6: 799-806
        • Taylor G.A.
        • Eichelberger M.R.
        • O'Donnell R.
        • et al.
        Indications for computed tomography in children with blunt abdominal trauma.
        Ann Surg. 1991; 213: 212-218
        • Holmes J.F.
        • Gladman A.
        • Chang C.H.
        Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis.
        J Pediatr Surg. 2007; 42: 1588-1594
        • Nigrovic L.E.
        • Schunk J.E.
        • Foerster A.
        • et al.
        The effect of observation on cranial computed tomography utilization for children after blunt head trauma.
        Pediatrics. 2011; 127: 1067-1073
        • US Department of Health and Human Services NIH, National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program
        The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.
        in: National Heart, Lung, & Blood Institute, Bethesda, MD2005: 8-15
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness.
        Lancet. 1974; 2: 81
        • James H.E.
        Neurologic evaluation and support in the child with an acute brain insult.
        Pediatr Ann. 1986; 15: 16-22