Do Abdominal Pain and Tenderness Predict Injury in Children with Blunt Abdominal Trauma?

Published in J Pediatr 2014 Dec 165:1230

Authors: Adelgais KM et al.

Abdominal tenderness, more than abdominal pain, predicted intra-abdominal injury and need for acute intervention.

To evaluate the accuracy of patient-reported abdominal pain and physician-assessed abdominal tenderness for predicting intra-abdominal injuries in children, investigators conducted a planned secondary analysis of patients <18 years of age presenting with blunt abdominal trauma to one of 20 emergency departments participating in the Pediatric Emergency Care Applied Research Network (PECARN). Accuracy of findings was compared for patients with Glasgow Coma Scale (GCS) scores of 13, 14, and 15.

Of 11,277 patients (median age, 11 years), 665 (6%) had intra-abdominal injuries, and 143 (1%) required acute intervention. Multivariable analyses controlling for the PECARN predictors of intra-abdominal injury (NEJM JW Emerg Med Mar 15 2013) found that both pain and tenderness predicted intra-abdominal injury. Moderate and severe abdominal pain predicted doubled odds of intra-abdominal injury (adjusted odds ratio, 2). Increasing intensity of abdominal tenderness predicted increasing odds (aORs for mild, moderate, and severe tenderness: 2, 5, and 12, respectively). Moderate and severe tenderness also predicted need for acute intervention (aORs, 12 and 18, respectively). As GCS score decreased from 15 to 13, prevalence of intra-abdominal injuries increased from 5% to 12%, while sensitivity of abdominal findings for predicting injury decreased from 79% to 32% (pain) and from 79% to 37% (tenderness).

Comment

Children with blunt abdominal trauma presenting with abdominal pain or tenderness or GCS scores <15 require additional risk stratification for intra-abdominal injuries. Clinicians should choose method(s) of risk stratification (e.g., computed tomography, serial exams, liver function tests, bedside ultrasound) based on patient stability and level of clinical concern for intra-abdominal injury, recognizing that children with moderate to severe abdominal tenderness are at particularly high risk.