Utilization of a clinical prediction rule for abdominal–pelvic CT scans in patients with blunt abdominal trauma

Abstract

This study aims to determine if a clinical prediction (CP) rule to identify patients at low risk for intra-abdominal injury (IAI) is being utilized in patients undergoing abdominal computed tomography (CT) following blunt abdominal trauma. A retrospective review of adult patients with blunt abdominal trauma undergoing abdominal CT scans was performed. The CP rule was positive if any of the following were present: systolic blood pressure <90 mmHg; urinalysis >25 red blood cells/high power field; Glasgow Coma Scale score <14; abdominal tenderness; costal margin tenderness; femur fracture; hematocrit <30 %; or pneumothorax or rib fracture on chest X-ray. The CP rule was negative if all variables were negative. Acute intervention was defined as therapeutic laparotomy or angiographic embolization. All variables in the CP rule were obtained in 218/262 (83 %; 95 % confidence interval (CI), 78, 88 %) patients. Of the 44 patients without complete CP rule assessment, 1 (2.3 %; 95 % CI, 0.1 %, 12.0 %) had an IAI but did not undergo therapeutic intervention. IAI was present in 11 (6.7 %; 95 % CI, 3.4, 11.6 %) of the 165 patients with at least one CP rule positive and 4 (36 %; 95 % CI, 11, 69 %) underwent therapeutic intervention. In the CP rule-negative patients, IAI was identified in 1/53 (1.9 %; 95 % CI, 0, 10.1 %) and no therapeutic intervention was required. An important percentage of patients undergoing abdominal CT are not assessed for or have a negative CP rule. Improved implementation of this CP rule may reduce unnecessary abdominal CT scans in patients presenting with blunt abdominal trauma.

US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain

“…21 Since the initiation of the Image Gently campaign, clinical decision guidelines have been developed to minimize ionizing radiation exposure in children. 7,8,21 A causal relationship cannot be confirmed between the Image Gently campaign and the plateau of CT use. However, it is important to acknowledge that increased efforts by stakeholders within the radiology, pediatric, and quality-measurement specialties to alter diagnostic protocols and practice are potential driving forces behind the shift in the imaging modality trends observed in this study.…”

Variation in Utilization of Computed Tomography Imaging at Tertiary Pediatric Hospitals

“…Some hypothesized reasons for this decline include increased media attention, the national educational campaign of Image Gently, [14][15][16] and clinical decision guidelines 17,18 that raised awareness for minimizing ionizing radiation exposure in children. Efforts to implement multiinstitutional standards and protocols to reduce variation in the prescribing of CT scans may decrease variability and improve overall care.…”

Routine whole body CT of high energy trauma patients leads to excessive radiation exposure

“…With present routines, most trauma patients exposed to high energy trauma undergo WBCT. The rationale for WBCT is based on studies indicating high risk of clinically significant missed injuries in trauma patients [7, 8]. Imaging comes with a risk as WBCT exposes the patient to a dose of ionizing radiation >20 mSv.…”

“…In recent years there has been a shift from indiscriminate referral to WBCT of trauma patients exposed to high energy trauma, to a more risk/benefit-oriented approach suggesting clinical prediction rules to safely omit WBCT [8]. Some studies point out that WBCT can safely be omitted if certain criteria are fulfilled [9].…”