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PEM Divisional Journal

Club
Adam Vukovic, MD
Thursday, December 12, 2013

Uh oh

Previously-healthy 7 yo female presents as TVAL through


trauma bay
Thrown from ATV being driven by father approximately
35 minutes prior to presentation
No helmet, no LOC
Boarded and collared, PIV access obtained prior to
arrival
T 36.8 C, P 115, RR 16, BP 90/55, SpO2 99% (RA)

Yup, moms not happy

Mildly tachycardic with no signs of cardiovascular


compromise, normal peripheral perfusion and mentation,
no respiratory distress
Complains of some left shoulder pain, decreased ROM,
bony crepitus with manipulation of mid-clavicle, which is
not particularly distressing to patient
Abrasion over left ASIS, minimally tender abdomen that
is non-distended, normal bowel sounds. Tenderness is
predominantly RUQ without rebound or guarding.

Oh, sweet, we got this.


Oh look, a young Dr. Falcone
showed up!
The two of you discuss the
patients presentation and
examination.
Being relatively reassured by
her appearance, you suggest a
FAST scan as the imaging
modality of choice to evaluate
for intra-abdominal trauma,
hoping to save the patient some
radiation exposure.

What do you think???

Lets be honest

Id probably put a probe on the patient, but is it worth


it?
How effective is abdominal ultrasound (FAST scans) at
assessing for intra-abdominal injuries in pediatric
patients presenting with blunt abdominal trauma?

Learning Objectives

Understand the process of constructing a meta-analysis


Be more comfortable with assessing the quality of a
meta-analysis
Apply those principles to a clinical query regarding FAST
scans in pediatric patients presenting with blunt
abdominal trauma

Evaluating the paper

JAMAevidence Learning Tool


Are the results valid?
Did the review address a sensible clinical question?

Underlying biology & sociology


Ensure the systematic review is not too broad or narrow
Are results likely to be similar?
Are they likely to be similar in the range of ways outcomes
were tested?
Were they in fact similar? (TBD)

Inclusion & exclusion criteria

Evaluating the paper

JAMAevidence Learning Tool

Are the results valid?


Was the search for relevant documents detailed and
exhaustive?
Were source of evidence and search strategies specified in
sufficient detail for duplication?
Was the likelihood and direction of publication bias considered?

Evaluating the paper

JAMAevidence Learning Tool

Are the results valid?


Were the primary studies of high methodological quality?
Were clear methodological selection criteria specified?
Were all included studies assessed by these criteria?

Were selection and assessments of studies reproducible?


Was an explicit approach used to select and extract data from
all included studies?
Were study selection and assessment validated by a blinded
second observer?

Included studies

Evaluating the paper

JAMAevidence Learning Tool

What are the results?


Were the results similar from study to study?
How similar were point estimates?
Do confidence intervals (CIs) overlap between studies?

What are the overall results of the study?


Were results weighted both quantitatively and qualitatively in
the study?

How precise were the results?


What is the confidence interval for the summary of cumulative
effect size?

Were the results similar from


study to study?

What are the overall results of


the review?

Were the results weighted both quantitatively and


qualitatively in summary estimates?
Quantitative weighting
Pooling of data from individual studies (i.e., meta-analysis)
Provides single best estimate of effect from weighted averages
of the results of individual studies
Depends on sample size of studies (the number of events)

A Quick Refresher

Who doesnt love a two-by-two???

Sensitivity
DISEASE

TE
ST

TP

FP

FN

TN

Specificity
DISEASE

TE
ST

TP

FP

FN

TN

Likelihood ratio +
DISEASE

TE
ST

TP

FP

FN

TN

The ratio of two


probabilities of the
same event under
different hypotheses

Likelihood ratio DISEASE

TE
ST

TP

FP

FN

TN

The ratio of two


probabilities of the
same event under
different hypotheses

How precise were the results?

How precise were the results?

How precise were the results?

JAMAevidence Learning Tool

How can I apply the results to patient care?


Were all patient-important outcomes considered?
Did the review omit outcomes that could change decisions?

Are any postulated subgroup effects credible?


What is the overall quality of the evidence?
Were prevailing study design, size, and conduct reflected in a
summary of the quality of evidence?

Are the benefits worth the potential risk?


Does the cumulative effect size cross a test or therapeutic
threshold?

Back to our case

Utilizing this paper


Is it useful (is it a quality paper? Do we like their
methodology?)
Are the studies comparable? (Was it appropriate to pool the
data? Was this apples and oranges?)
Is there missing data? (publication bias)

Pre-test Probability
How, and how accurately, do clinicians estimate pre-test
probability?
What can explain clinicians difficulties in estimating pretest probability?
What are consequences of inaccurate estimates of pretest probability?
Could evidence from clinical care research help us
estimate pre-test probability?
When should we use evidence to guide our estimates of
pre-test probability?

Richardson, W. S. (2002). Five uneasy pieces about pre-test probability. Journal of General
Internal Medicine. 17(11). 891-892. doi:10.1046/j.1525-1497.2002.20916.x

Lets think about this.

Previous studies have estimated approximately 10% risk


of pediatric patient having intra-abdominal injury (IAI)
after blunt abdominal trauma
Thus our pre-test probability is 10%

Holmes, J.F., Sokolove, P.E., Brant, W.E., Palchak, M.J., Vance, C.W., Owings, J.T., Kuppermann, N.
(2002). Identification of children with intra-abdominal injuries after blunt trauma. Annals of
Emergency Medicine, 39(5), 500-509.

Lets think about this.

Lets think about this.

So lets answer our question.


Their conclusions:
Given the high LR+, any abdominal U/S examination
demonstrating intra-peritoneal fluid should prompt an
immediate CT scan (assuming the child is HDS).
Negative abdominal U/S only has a modest LR Previous slide demonstrates not a huge pre- to post-test change
(though its about , its from 10% to 5%, suggesting a
persistent risk of IAI).
Thus, we have to decide what our threshold for scanning is
Potentially, we could reassure ourselves in patients with a low
likelihood of IAI
Does this add anything to the picture? Does this change our
management?

So what was up with that girl?


So it turns out, she didnt actually come through the
trauma bay
Roomed in A7
Initially, resident wanted to get a shoulder x-ray
On my examination, noted the clavicular fracture
Patient had abdominal pain now (per resident not
reported)
Given mechanism, we decided to CT scan in addition to x-ray
of clavicle/shoulder
Had a healing mid-clavicular fracture on the left
Had a grade II splenic laceration, probably resulting in her
referred shoudler pain as well as evolving abdominal pain
Admitted to trauma service

Questions/Comments/Discussion

Dont Forget!!!

Cinci Zoo Lights


12/16/13
Meeting here at CCHMC to grab dinner at 6:00, then its
off to see the lights!