Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025 Date: May 7, 2025 Dr. Sandi Angus Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education. Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?” Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately. The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms. Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1]. To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule. These seven variables were: Evidence of abdominal wall trauma or seat belt sign GCS 24 hours before ED presentation, penetrating trauma, pre-existing neurological disorder preventing reliable abdominal exam, pregnancy, transfer from another hospital with prior abdominal imaging. All patients who were negative for the original PECARN prediction rule or had more than two variables present. Intervention: Application of the PECARN intraabdominal injury prediction rule with one or two positive variables Comparison: None Outcome: Primary Outcome: Intraabdominal injury undergoing acute intervention (death caused by IAI, therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of IV fluids). Secondary Outcomes: Any intraabdominal injury (injuries to the liver, spleen, urinary tract, gastrointestinal tract, pancreas, gallbladder, adrenals, vasculature, or fascial defects). Trial: Planned secondary analysis of a prospective multicenter observational study Authors’ Conclusions: “Few children with blunt torso trauma and one or two PECARN predictor variables present have IAIAI. Those with GCS score <14, however, are at highest risk for IAI.” Quality Checklist for Clinical Decision Rules: Did the study population include or focus on those in the emergency department? Yes Where was the study conducted (external validity)? Six emergency departments in the United States Were the patients included in the study representative of those with the problem? Yes Were all important predictor variables and outcomes explicitly specified? Yes Is this a prospective, multicenter study including a broad spectrum of patients and clinicians (Level II study)? Yes Did clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately? Unsure (not detaile
