Department of Surgery, University of Washington, Seattle, WA.
Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA.
Acad Emerg Med. 2018 Jul;25(7):776-784. doi: 10.1111/acem.13426. Epub 2018 May 16.
The risk of radiation exposure from computed tomography (CT) imaging in children is well recognized. Patient history and physical examination findings, including costal margin tenderness (CMT), influence a physician's decision to image a child with blunt torso trauma. The objective of this study was to determine the importance of CMT for identifying children with intraabdominal injuries (IAI) found on CT and IAI undergoing acute intervention.
We conducted an analysis of the Pediatric Emergency Care Applied Research Network (PECARN) IAI public use data set, representing a large prospective multicenter cohort study from May 2007 to January 2010. Isolated CMT was defined as CMT without other identified PECARN risk factors for IAI (i.e., abdominal or thoracic wall trauma, abdominal tenderness or pain, decreased breath sounds, or vomiting). Logistic regression was used to calculate adjusted odds of IAI in children presenting with isolated and nonisolated CMT. Risk differences were calculated to estimate the risk of IAI independently attributable to CMT in the setting of isolated PECARN risk factors. Finally, CT use among exposure groups was estimated to quantify potentially avoidable imaging.
Among 9,174 children with Glasgow Coma Scale scores of 14 or 15 who sustained blunt torso trauma, 1,267 (13.8%) had CMT. Among those with CMT, 177 (14.0%) had isolated CMT and 1,090 (86.0%) had nonisolated CMT. No children (0/177; 0%, 95% confidence interval [CI] = 0.0%-2.1%) with isolated CMT had IAI, compared to 17.2% (187/1,090; 95% CI = 15.0%-19.5%) of those with nonisolated CMT. The risk differences were not statistically significant. 36/177 (20.3%; 95% CI = 14.7%-27.0%) children with isolated CMT underwent abdominal CT scans.
The risk of IAI associated with isolated CMT is minimal. For children with blunt abdominal trauma and isolated CMT, abdominal CT scan is of low yield.
人们已经充分认识到儿童计算机断层扫描（CT）成像带来的辐射风险。病史和体格检查结果，包括肋缘压痛（CMT），影响医生对钝性胸部创伤患儿进行影像学检查的决策。本研究的目的是确定 CMT 对识别 CT 发现的腹部损伤（IAI）和接受急性干预的 IAI 的重要性。
我们对儿科急诊护理应用研究网络（PECARN）IAI 公共使用数据集进行了分析，该数据集代表了 2007 年 5 月至 2010 年 1 月期间的一项大型前瞻性多中心队列研究。孤立性 CMT 定义为无其他 PECARN 确定的 IAI 危险因素的 CMT（即腹部或胸壁创伤、腹部触痛或疼痛、呼吸音减弱或呕吐）。采用逻辑回归计算孤立性和非孤立性 CMT 患儿 IAI 的调整比值比。计算风险差异以估计在孤立性 PECARN 危险因素的情况下，CMT 对 IAI 的独立归因风险。最后，估计暴露组的 CT 使用量以量化潜在可避免的成像。
在格拉斯哥昏迷量表评分为 14 或 15 的 9174 名钝性胸部创伤患儿中，1267 例（13.8%）有 CMT。在有 CMT 的患儿中，177 例（14.0%）有孤立性 CMT，1090 例（86.0%）有非孤立性 CMT。在 177 例孤立性 CMT 患儿中，无一例（0/177；0%，95%置信区间[CI]为 0.0%-2.1%）有 IAI，而 1090 例非孤立性 CMT 患儿中有 17.2%（187/1090；95%CI 为 15.0%-19.5%）有 IAI。风险差异无统计学意义。在 177 例孤立性 CMT 患儿中，有 36 例（20.3%；95%CI 为 14.7%-27.0%）进行了腹部 CT 扫描。
孤立性 CMT 相关 IAI 的风险很小。对于钝性腹部创伤且孤立性 CMT 的患儿，腹部 CT 扫描的收益较低。
