The Use of A Pediatric Abdominal Trauma Protocol Improves Resource Utilization

The Use of a Pediatric Abdominal
Trauma Protocol Improves

Resource Utilization
Bindi Naik-Mathuria MD, Sara Fallon MD,
Fariha Sheikh MD, Mary Frost RN, Daniel
Christopher RN, David Delemos MD
Divisions of Pediatric Surgery and Pediatric

Emergency Medicine
Trauma Services, Texas Children’s Hospital
Baylor College of Medicine, Houston, TX
Background
• After failure to control the airway, blunt abdominal

trauma (BAT) is the second most frequent cause of
preventable death in pediatric trauma patients
• Evaluation of pediatric BAT can be challenging

• External signs may be few
• Physical examination can be unreliable
• CT is over-utilized and poses radiation risk
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Surgical
Trauma Services
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Background
• Young level I trauma center

(certified in 2010)
• Large institution: multiple EM

and Surgery providers leads to
variability in
evaluation/management
• New protocol in Aug 2011 –

primary evaluation level 2
activations by EM staff;
trauma surgeon consulted
only when necessary
Page 2
Surgical
Trauma Services
Objectives
• QI project: Development of an evidence-based

protocol to evaluate abdominal trauma in EC
• To standardize care among multiple providers
• To ensure appropriate and timely surgery consultation
• To decrease unnecessary CT and lab use in evaluation of
abdominal trauma
• To maintain or improve safety and quality of care of
trauma patients
Page 3
Surgical
Trauma Services
ABDOMINAL TRAUMA PROTOCOL
BLUNT TRAUMA - UNCONSCIOUS
Unconscious child (GCS <=8), significant

mechanism
(ex. High speed MVC, fall >10 ft, suspected NAT)
Call Surgery STAT if not already present
Hemodynamically UNSTABLE Hemodynamically STABLE
FAST if available
CT abd/pel w/ IV contrast
Look for other sources
of hypotension,
fluid resuscitation
OR if clinical or FAST Admit to Trauma

evidence of abdominal for OR vs. Non-
Admit to Trauma operative mgmt
bleeding
Service in PICU
BLUNT TRAUMA- CONSCIOUS, RELIABLE EXAM
Conscious child (GCS 14-15), significant
mechanism
Reliable abdominal examination
Abdominal tenderness or distention
CONSULT SURGERY
FAST if available (per surgery discretion)
OR if clinical or FAST
Observe in EC, OK to discharge
evidence of Admit to Trauma for if pain-free, tolerating PO and
abdominal bleeding OR vs. Non-operative no additional injuries needing
mgmt admission
BLUNT TRAUMA- CONSCIOUS, UNRELIABLE EXAM
Conscious child, significant mechanism
Unreliable or equivocal abdominal examination
(ex. GCS 9-13 or distracting injury)
CONSULT SURGERY
FAST if available FAST if available

LABS: AST/ALT, CBC,
ALT/AST > 100, Hgb <10 or Amy/Lip, UA w micro
Hct <30%, Amy/Lip
OR if clinical or FAST elevated, UA >50 RBC/HPF
evidence of
intraabdominal
bleeding Repeat abd exam
(per surgery discretion)
Admit to Trauma for Discharge (only if GCS 15) vs.

OR vs. observation admit to trauma service for
obs for pain or anxiety control
BLUNT TRAUMA- ABDOMINAL WALL BRUISING
Seatbelt Sign or other abdominal wall bruising (ex.
Handlebar injury)
Log roll, for exam ,

CONSULT SURGERY maintain on board until
spine imaging completed
Hemodynamically UNSTABLE and/or

signs of peritonitis Hemodynamically STABLE
Don’t need
FAST if available
CT abd/pel w/ IV contrast additional
spinal CT
2-view lumbar spine
before moving patient
to r/o fracture
OR if clinical or FAST Admit to Trauma for
evidence of OR vs. observation
abdominal bleeding or
bowel injury
Methods
• Protocol implementation
• Prospective, longitudinal
study
• Comparison of outcomes
Pre/Post Protocol (POST 1)
• Protocol revision based on
review of outcomes
• Comparison of outcomes
following revision (POST 2)
Page 8
Surgical
Trauma Services
2011 2012 2013 2014
JAN JAN MAR
P2 AUG SEPT
SEPT
P1 DEC
Pre-Protocol Post-Protocol v1 Post-Protocol v2

(n = 117) (n = 148) (n = 56)
Page 9
Surgical
Trauma Services
Methods
• Study population:
• Patients who presented to EC with mechanism for
abdominal trauma who received CT at our institution
• Exclusion criteria:
• Neonates
• Prior abdominal imaging at another facility
• Suspected non-accidental trauma
• Remote injuries (> 24 hours)
• Significant congenital anomalies
Page 10
Surgical
Trauma Services
Pre (n=117) Post 1 (n=148) Post 2 (n=56) P-value
Male gender 61% 63% 55% 0.62
Admission rate 73% 83% 82% 0.24
Mean age at 8.4 (5.2) 9.1 (4.8) 7.8 (5.3) 0.21

admission (SD)
Median ISS 5 6 9 0.11

(Range 0-75)
Median Hosp LOS 1.5 2 3 0.05

(Range 1-57
days)
Survival (%) 98% 100% 98% 0.27
Page 11
Surgical
Trauma Services
Mechanism of Injury
Mechanism Pre Post 1 Post 2

MVA 30% 22% 36%
Auto-ped 22% 27% 22%
Fall 21% 19% 16%
Blunt object 13% 13% 13%
ATV/Bike 6% 14% 6%
Sports 6% 3% 7%
Page 12
Surgical
Trauma Services
POST 1 Results: Before and After
35%
30% 33% % Positive Scans
25%
20% 24%
24%
23%
15% 19%
10% % Clinically
13%
Significant Scans
5%
0%
Pre-Protocol
Jan 2011- Transition
Sept 2011- Post-Protocol
Jan 2012- Decv1
Aug 2011 Dec 2011 2012
Page 13
Surgical
Trauma Services
Protocol Deviation
• Some step of the protocol was not followed 30% of the

time. Most common:
• CT based on mechanism alone
• CT before surgeon evaluation most common
• 46 CT scans (36%) may have been avoided if protocol

had been followed
• Clinically significant CT scans when protocol followed =

43% vs. 11% when not followed (p = 0.001)
Page 14
Surgical
Trauma Services
POST 1 Laboratory Use
 The cost of ER laboratory tests ordered for these patients did
not change after protocol implementation (mean $254 vs. $269
per patient, p=0.50)
100
90
80
70
60
50
40
30
20
10
0
CBC Amy/Lip LFTs UA w micro Chem 10 T+S PT/PTT Chem 7 AST/ALT H/H BUN/Cr
Page 15
Surgical
Trauma Services
BLUNT TRAUMA - UNCONSCIOUS
Unconscious child (GCS <=8), significant

mechanism for abdominal trauma
Hemodynamically Stable
Call Surgery STAT if not already present
No initial
CT abd/pel w/ IV Abdominal
contrast labs needed
Admit to Admit to Trauma for

Trauma Service OR vs. non-operative
in PICU management
CONSCIOUS, RELIABLE EXAM
Conscious child, GCS 14-15, significant mechanism

Reliable Abdominal Examination and Hemodynamically Stable
Abdominal tenderness?
Obtain Stable
AT lab panel TENDER NON-TENDER
CONSULT SURGERY NO
Abdominal
labs needed
OK to discharge if
pain-free, tolerating
PO and no additional
Admit to Trauma
injuries needing
for OR vs. Non-
admission
operative mgmt
CONSCIOUS, UNRELIABLE EXAM
Conscious child, significant mechanism for abdominal trauma

Unreliable or equivocal abdominal examination
(ex.Young age, distracting injury, GCS 9-13),
CONSULT SURGERY
Repeat abdominal
ALT/AST > 100, Hb <10 exam if reliable
or Hct <30%, Amy/Lip > Obtain Stable
100, UA >50 RBC/HPF
and GCS 15. If
AT lab panel unreliable,
consider evidence
TENDER for head injury
NON-TENDER
OK to discharge if
Admit to Trauma for tolerating po and no other
OR vs. observation injuries requiring admission
ABDOMINAL WALL BRUISING
Seatbelt Sign or other abdominal wall bruising

(ex. Handlebar injury), Hemodynamically Stable
CONSULT SURGERY Obtain Stable

AT lab panel
Maintain strict
spinal precautions
for seatbelt sign
until imaging CT abd/pelvis w/ IV contrast*
complete – if no (per surgery discretion)
CT, then obtain T/L
spine x rays * CT A/P with
reconstruction is enough to
evaluate spine – additional
spinal CT is NOT necessary
Admit all
patients to
Trauma for OR
vs. observation
Abdominal Trauma Lab Panel
Abdominal Trauma Lab Panel Hemodynamically Unstable
H/H
Amylase/Lipase
H/H AST/ALT
Amylase/Lipase UA w/ micro
AST/ALT UPT for teen female
UA w/ micro PT/PTT
UPT for teen female T+S
BUN/Cr
Page 20
Surgical
Trauma Services
POST 2 Results: Improved CT Utilization
60%
*
50%
49% % Positive Scans
40%
**
* p=0.003
30%
32% 32%
20%
23% 21% % Clinically
Significant Scans
10% 14%
** p=0.03
0%
Pre-Protocol Protocol v1 Protocol v2
N=117 N=148 N=56
Page 21
Surgical
Trauma Services
Balance Measures
Time to CT scan and ER Length of Stay
350.00
300.00
250.00
Avg. ER Stay
Time (mins)
200.00
150.00 Avg. Time to

CT Scan
100.00
50.00
0.00
Pre-Protocol
Jan 2011-
Dec 2011
Protocol
Jan 2012-
Aug 2013
v1 Protocol
Sept 2013-
Mar 2014
v2
There were no missed injuries during these time periods
Page 22
Surgical
Trauma Services
Laboratory Cost Analysis
Pre (n-117) Post 1 Post 2 P value

(n=148) (n=56)
Mean total cost 244 (149) 273 (137) 202 (140) 0.006
of labs (SD)
Component 4% 19% 63% < 0.001
CBC (%)
Component 6% 0% 54% < 0.001
Chemistry (%)
Component 21% 31% 74% < 0.001
LFTs (%)
Page 23
Surgical
Trauma Services
Conclusion
• An institutional protocol to streamline evaluation of

children with suspected blunt abdominal trauma was
effective in decreasing unnecessary CT use and
laboratory costs
• Future directions include further protocol refinement

to decrease the role of CT in the evaluation algorithm
Page 24
Surgical
Trauma Services
Thank You!
Page 25
Surgical
Trauma Services

The Use of A Pediatric Abdominal Trauma Protocol Improves Resource Utilization

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The Use of A Pediatric Abdominal Trauma Protocol Improves Resource Utilization

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The Use of a Pediatric Abdominal

Trauma Protocol Improves

Divisions of Pediatric Surgery and Pediatric

• After failure to control the airway, blunt abdominal

• Evaluation of pediatric BAT can be challenging

• Young level I trauma center

• Large institution: multiple EM

• New protocol in Aug 2011 –

• QI project: Development of an evidence-based

Unconscious child (GCS <=8), significant

Call Surgery STAT if not already present

Hemodynamically UNSTABLE Hemodynamically STABLE

OR if clinical or FAST Admit to Trauma

Abdominal tenderness or distention

Hemodynamically UNSTABLE Hemodynamically STABLE

Hemodynamically UNSTABLE Hemodynamically STABLE

FAST if available FAST if available

Admit to Trauma for Discharge (only if GCS 15) vs.

Log roll, for exam ,

Hemodynamically UNSTABLE and/or

JAN JAN MAR

Pre-Protocol Post-Protocol v1 Post-Protocol v2

Admission rate 73% 83% 82% 0.24

Mean age at 8.4 (5.2) 9.1 (4.8) 7.8 (5.3) 0.21

Median ISS 5 6 9 0.11

Median Hosp LOS 1.5 2 3 0.05

Survival (%) 98% 100% 98% 0.27

Mechanism Pre Post 1 Post 2

• Some step of the protocol was not followed 30% of the

• 46 CT scans (36%) may have been avoided if protocol

• Clinically significant CT scans when protocol followed =

Unconscious child (GCS <=8), significant

Call Surgery STAT if not already present

Admit to Admit to Trauma for

Conscious child, GCS 14-15, significant mechanism

Conscious child, significant mechanism for abdominal trauma

Seatbelt Sign or other abdominal wall bruising

CONSULT SURGERY Obtain Stable

150.00 Avg. Time to

There were no missed injuries during these time periods

Pre (n-117) Post 1 Post 2 P value

• An institutional protocol to streamline evaluation of

• Future directions include further protocol refinement

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