AAST 2014 PLENARY PAPER

The validity of abdominal examination in blunt trauma patients

with distracting injuries
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Jack Rostas, MD, Benton Cason, MD, Jon Simmons, MD, Mohammed A. Frotan, MD,
Sidney B. Brevard, MD, and Richard P. Gonzalez, MD
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BACKGROUND: Many trauma care providers often disregard the abdominal clinical examination in the presence of extra-abdominal distracting
injuries and mandate abdominal computed tomographic scan in these patients. Ignoring the clinical examination may incur undue
expense and radiation exposure. The purpose of this study was to assess the efficacy of abdominal clinical examination in patients
with distracting injuries.
METHODS: During a 1-year period, all awake and alert blunt trauma patients with Glasgow Coma Scale (GCS) score of 14 or 15 were
entered into a prospective study. Abdominal clinical examination was performed and documented prospectively on all patients.
Abdominal clinical examination included four-quadrant anterior abdominal palpation, flank palpation, lower thoracic pal-
pation, pelvis examination, and palpation of the thoracolumbar spine. Following examination documentation, all patients
underwent computed tomographic scan of the abdomen and pelvis with intravenous contrast.
RESULTS: A total of 803 patients were enrolled: 451 patients had distracting injuries, and 352 patients did not. Of the 352 patients without
distracting injuries, 19 (5.4%) had intra-abdominal injuries, of whom 2 (10.5%) had negative clinical examination result. Of the
451 patients with distracting injuries, 48 (10.6%) were diagnosed with intra-abdominal injury, of whom 5 (10.4%) had negative
clinical examination result. All five missed injuries in patients with distracting injuries were solid organ injuries, none of which
required surgical intervention or blood transfusion. The sensitivity and negative predictive value of abdominal examination for
patients with distracting injuries were 90.0% and 97.0%, respectively. The sensitivity and negative predictive value of ab-
dominal examination for surgically significant and transfusion-requiring injuries were both 100%.
CONCLUSION: Distracting injuries do not seem to diminish the efficacy of clinical abdominal examination for the diagnosis of clinically
significant abdominal injury. These data suggest that clinical examination of the abdomen is valid in awake and alert blunt
trauma patients, regardless of the presence of other injuries. (J Trauma Acute Care Surg. 2015;78: 1095Y1101. Copyright *
2015 Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Diagnostic study, level III.
KEY WORDS: Distracting injuries; abdomen; trauma; clinical examination.

F ollowing blunt trauma, a thorough examination of the ab-

domen is an important component of the initial patient
assessment. Findings of the abdominal examination can often
dictate prioritization of patient care. Successful care of the
blunt trauma patient is based on timely and accurate diagnosis
as inaccurate and delayed diagnosis may lead to unnecessary
morbidity and mortality. The abdomen has long been recog-
nized as a site for occult bleeding, especially in patients who
present with hemodynamic stability. Unrecognized injuries can
challenge the most experienced care providers. Avoiding these
situations is best accomplished by applying a systematic ap-
proach using clinical examination in concert with diagnostic
technology to identify life-threatening injury. The question
remains what is the ideal systematic approach to diagnose
abdominal trauma that has superior sensitivity for identification
Submitted: October 7, 2014, Revised: March 2, 2015, Accepted: March 9, 2015.
From the Division of Trauma and Surgical Critical Care (J.R., B.C., J.S., J.S., S.B.B.),
Department of Surgery, University of South Alabama, Mobile, Alabama;
Department of Surgery (M.A.F.), Texas Health Presbyterian, Dallas, Texas; and
Division of Trauma, Surgical Critical Care, Burns (R.P.G.), Department of
Surgery, Loyola University Medical Center, Maywood, Illinois.
This study was presented at the 73rd Annual Meeting of the American Association for
the Surgery of Trauma, September 9Y13, 2014, in Philadelphia, Pennsylvania.
Address for reprints: Richard P. Gonzalez, MD, United States; email:
rgonzalez@health.southalabama.edu.
DOI: 10.1097/TA.0000000000000650
J Trauma Acute Care Surg
Volume 78, Number 6
of life-threatening injury yet is cost-effective and limits patient
exposure to radiologic testing.
There are two main approaches or strategies used by
trauma care providers for the diagnosis of abdominal trauma.
The first approach is the use of abdominal clinical examination
complemented by a selective use of abdominal computed to-
mography (CT) scanning. The second approach is abdominal
clinical examination complemented by routine abdominal CT
scan. It has yet to be determined which methodology is optimal
for the diagnosis of intra-abdominal injury.
With continuous technical improvements, greater speed,
and ease of availability, routine use of CT scanning is more
commonplace in trauma centers. These factors may foster
overuse of CT scanning and often cause providers to negate the
significance of the abdominal clinical examination for blunt
trauma. Several authors suggest than pan-scanning of trauma
patients is an effective method for identifying injuries that have
potential to impact morbidity and mortality.1Y4 CT scan is an
excellent diagnostic tool for assessing abdominal trauma;
however, it is costly, exposes the patient to radiation, and often
requires transporting the patient to the relatively unsafe envi-
ronment of the CT scan suite.
Clinical examination of the abdomen has previously
been shown to be highly sensitive for the diagnosis of blunt
abdominal injury.5Y9 In a recent prospective study, Smith et al.6
concluded that clinical examination was sensitive in ruling out
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Rostas et al.
serious injuries in high-acuity patients. In a prospective ob-
servational study, Schauer et al.8 concluded that abdominal CT
scanning has a low yield in trauma patients who undergo ab-
dominal evaluation for urgent abdominal surgery.
Protocols that selectively use abdominal CT scan for
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screening blunt trauma patients cite distracting injuries as a
contraindication to using the abdominal clinical examination as
the screening method to rule out abdominal injury.10Y13 The
question as to whether distracting injuries negate the abdominal
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clinical examination in blunt trauma patients has yet to be
studied using CT scan as the comparator for abdominal clinical
examination sensitivity.
The purpose of this study was to prospectively assess the
efficacy and sensitivity of abdominal clinical examination in
awake and alert blunt trauma patients with distracting injuries.
PATIENTS AND METHODS
During the 12-month period from December 1, 2012, to
December 1 2013, data were prospectively collected from all
hemodynamically stable blunt trauma patients who were ad-
mitted as trauma activations at the University of South Alabama
Trauma Center. All patients older than 13 years with a Glasgow
Coma Scale (GCS) score of 14 or greater who sustained blunt
trauma were entered into the study protocol. Patients were en-
tered into the study regardless of ethanol level or presence of
distracting injuries.
The University of South Alabama Investigational Re-
view Board approved this study and approved waiver of con-
sent for entry into this study. Data with regard to demographics
and abdominal clinical examination were prospectively col-
lected and documented in a data study form before perfor-
mance of indicated CT evaluation.
For patients with GCS score of 14 or greater, clinical
assessment for neurologic injury was performed by questioning
the patient for the presence of pain and movement of all ex-
tremities. Physical examination was performed to assess for
spinal cord neurologic deficits. If neurologic deficits were not
identified, clinical examination of the abdomen was per-
formed. Abdominal clinical examination consisted of question-
ing the patient for the presence of abdominal pain or back pain
and physical examination of the abdomen. Physical examina-
tion included four-quadrant anterior abdominal palpation, flank
palpation, lower thoracic palpation (anterior and posterior),
pelvis examination (posterior and inward compression of iliac
wings, compression of symphysis pubis, rectal examination) and
palpation of the thoracolumbar spine. Following documentation
of the clinical examination, all patients underwent CT scan of the
abdomen/pelvis with intravenous contrast. Patients who had
thoracic spine tenderness also underwent CT scan of the chest
to assess the thoracic spine. All CT scan imaging was re-
formatted to allow for the examination of the thoracolumbar
spine in three dimensions.
The CT scanner used was a Somatom Plus 4 (Siemens,
Erlangen, Germany) 64-slice helical CT at 5-mm thickness
with 2.5-mm reconstructions. Patients who were deemed to
have a negative clinical examination result were cleared based
on a GCS score of 14 or greater and assessed to have clini-
cal examination findings inconsistent with abdominal injury.
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J Trauma Acute Care Surg
Volume 78, Number 6
Significance and number of distracting injuries were not a
factor in the determination of clinical examination sensitivity,
and clinical examination was considered valid without regard
to the extent or presence of distracting injuries. No patient
was removed from the study because of the extent or severity of
extra-abdominal distracting injuries, and no patient was pre-
vented from entering into the study because of the extent or
severity of distracting injuries. GCS score of 14 or greater
dictated entry into the study.
Blood ethanol levels and urine drug screens were not
routinely performed on patients entered into this study, and any
results from these laboratory tests if performed had no bearing
on the management of abdominal findings or patient entry into
the study.
Clinical examinations were performed by general sur-
gery house staff consisting of first-year to fifth-year general
surgery residents. Board-certified attending radiologists per-
formed final radiologic study interpretation of CT scans, and
these interpretations were the only interpretations used for
CT scan interpretation and data collection.
All injuries sustained by patients were recorded on the
data study form. Distracting injuries as previously defined by
Rose et al.14 were divided into three categories as follows: head,
torso, and extremity injuries (Table 1).
RESULTS
Eight hundred three patients were enrolled during the
study period; 448 (68%) enrolled patients were male, and 255
(32%) were female. The average age of the entire study pop-
ulation was 36.7 years. The average age of those without
distracting injuries was 33.8 years, and those with distracting
injuries, 39.0 years. Of the 352 patients without distracting
injuries entered into the study, 301 (86%) had a GCS score of
TABLE 1. Classification of Distracting Injuries
Head Injuries
Skull fracture
92 facial bone fractures
Mandible fracture
Intracranial injury (SDH, EOH, SAH, IVH, parenchymal hemorrhage;
identified on CT scan)
Torso injuries
92 rib fractures
Clavicle fracture
Scapula fracture
Sternal fracture
Pelvic fracture
Thoracolumbar spine fracture
Long bone fractures
Femur fracture
Tibia/fibula fracture
Humerus fracture
Radius/ulna fractures
Hip/shoulder dislocation
EOH, epidural hematoma; IVH, intraventricular hemorrhage; SAH, subarachnoid
hemorrhage; SDH, subdural hematoma.
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 J Trauma Acute Care Surg
Volume 78, Number 6 Rostas et al.

without distracting injuries, 169 patients (48%) had a positive

TABLE 2. Distracting Injuries Patients
clinical examination finding (Fig. 1). Nineteen patients (5.4%)
All Patients Patients With without distracting injuries were found to have intra-abdominal
(451 Patients; Intra- Abdominal Injuries injuries (Fig. 1, Table 3). Two (10.5%) of the patients without
Distracting Injuries 700 Injuries) (48 Patients; 95 Injuries)
distracting injuries and diagnosed with abdominal injuries had
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Head injuries negative clinical examination results (Fig. 1, Table 3).

Skull fractures 27 (6%) 0 Of the 451 patients with distracting injuries, 232 (51%)
92 facial bone fractures 41 (9%) 3 (6%) had a positive clinical examination result (Fig. 1, Table 3).
Mandible fracture 14 (3%) 1 (2%) Forty-eight patients (10.6%) with a distracting injury had an
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Intracranial injuries 61 (14%) 6 (13%) intra-abdominal injury diagnosed by CT scan (Table 3). Five
Torso injuries patients (10.4%) who had negative clinical examination result
92 rib fractures 118 (26%) 24 (50%) with distracting injuries were diagnosed with an intra-abdominal
Clavicle fractures 21 (5%) 5 (10%) injury (Table 3). A total of 95 distracting injuries were diag-
Scapula fractures 32 (7%) 7 (15%) nosed in the 48 patients who had abdominal injuries and
Sternal fractures 19 (4%) 6 (13%) distracting injuries (Table 2).
Pelvic fractures 66 (15%) 11 (23%) The unidentified injuries by clinical examination in the
Thoracolumbar 95 (21%) 12 (25%) two patients without distracting injuries were both solid organ
spine fractures injuries (Table 3). Neither of these injuries required blood
Long bone fractures transfusion or operative intervention. The sensitivity of ab-
Femur fractures 61 (14%) 10 (21%) dominal clinical examination for patients without distracting
Tibia/fibula fractures 65 (14%) 3 (6%) injuries was 89.5%. The sensitivity and negative predictive
Humerus fractures 26 (6%) 4 (8%) value of abdominal examination in patients without distracting
Radius/ulna fractures 40 (9%) 3 (6%) injuries for surgically significant and transfusion-requiring
Hip/shoulder dislocations 14 (3%) 0 injuries were both 100%.
All of the intra-abdominal injuries unidentified by clin-
15 and 51 (14%) had a GCS score of 14. Of the 451 patients ical examination in the five patients with distracting injuries
with distracting injuries, 387 (86%) had a GCS score of 15 and were solid organ injuries (Table 4). Distracting injuries asso-
64 (14%) had a GCS score of 14. The most common mecha- ciated with the five clinically missed abdominal injuries are
nism of injury was motor vehicle crash, 419 (52%), followed by described in Table 4. None of injuries missed by clinical
falls (105, 13%), motorcycle crashes (79, 10%), pedestrians examination in those five patients required surgical inter-
versus motor vehicle (66, 8%), all-terrain vehicle crash (52, 7%), vention or blood transfusion. The sensitivity and negative
and assaults (34, 4%). predictive value of abdominal clinical examination for pa-
A total of 700 injuries were diagnosed in the 451 patients tients with distracting injuries were 89.6% and 97.0%, re-
who had distracting injuries (Table 2). Of the 352 patients spectively. The sensitivity and negative predictive value of

Figure 1. Distribution of patients by distracting injury and clinical examination.

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Rostas et al.
TABLE 3. Abdominal Injuries and Clinical Examination Findings
No Distracting No Distracting Injuries
Injuries With Positive With Negative Clinical
Intra-abdominal Clinical Examination Examination Result
Injury Result (Patients, n = 17) (Patients, n = 2)
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Liver 8 1
Spleen 7 1
Kidney 2 3
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Bladder
Small bowel
Mesentery
abdominal examination in patients with distracting injuries for
surgically significant and transfusion-requiring injuries were
both 100%.
DISCUSSION
Because of the wide availability and easy access of CT
scans, routine use of this diagnostic tool has become more
prevalent in many trauma centers. CT scan for abdominal
trauma is an excellent diagnostic method; however, cost and
unnecessary patient radiation exposure should mandate judi-
cious use of this technology. Health care providers are con-
tinually coaxed into a more cost-effective use of health care
resources, which has created the need for more sensible pro-
tocols and diagnostic methodologies that optimally treat pa-
tients with less resource use. In addition, protocols that
mandatorily use CT scan as a screening modality subject pa-
tients to amounts of radiation that are unnecessary and may
have detrimental effects on the future health of trauma patients.
In the past, distracting injuries have been used as ratio-
nale for repudiating the validity of abdominal clinical exami-
nation in blunt trauma patients.10Y13 This rationale combined
with the ease with which a CT scan can be obtained has caused
many trauma care providers to downplay the utility of clinical
abdominal examination in this patient population. Most pa-
tients who present to busy trauma centers have distracting
injuries, and these patients are often relegated to receive ab-
dominal CT scans with little emphasis placed on findings of the
clinical abdominal examination.
Our data have shown that the abdominal clinical exam-
ination for patients with distracting injuries has 90% sensitivity
for abdominal injuries but more importantly 100% sensitivity
for injuries that are surgically significant or require blood
transfusion. These data are similar to the data we garnered for
patients without distracting injuries. Sensitivity for the diag-
nosis of intra-abdominal injuries for patients without distracting
injuries was identical to those with distracting injuries. This leads
us to conclude that distracting injuries do not have an adverse
effect on the sensitivity of the abdominal clinical examination.
None of the ‘‘missed’’ abdominal injuries in either patient group
were clinically significant. Blood transfusion or surgical inter-
vention was not required in any of the patients whose ab-
dominal injuries were not identified on clinical examination. In
addition, the vast majority of patients who have distracting
injuries described in this article require hospital admission to
address their extra-abdominal injuries. This would allow for
1098
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J Trauma Acute Care Surg
Volume 78, Number 6
Distracting Injuries Distracting Injuries
With Positive Clinical With Negative Clinical
Examination Result Examination Result
(Patients, n = 43) (Patients, n = 5)
17
16 4
1
2
2
3
further observation of these patients. Pundits of this approach
may question what would happen to patients with distracting
injuries who have undiagnosed abdominal injuries? Similar
outcomes would be seen in those patients without distracting
injuries that had abdominal injuries undiagnosed. Minor solid
organ injuries that do not require transfusion or surgical inter-
vention rarely go on to require surgical intervention. Long-term
follow-up on these injures is unnecessary because the vast sur-
gical experience with such injuries tells us that further inter-
vention is rarely necessary.15Y19 In a retrospective series by
McCray et al.,15 53 Grade 1 splenic injuries were successfully
treated by nonoperative management, and of 260 Grade 1 and 2
splenic injuries, 2 (0.8%) failed nonoperative management. In a
retrospective review of 140 patients with low-grade splenic in-
juries that were successfully treated with simple observation,
Haan et al.19 concluded follow-up abdominal CT scan confers
no benefit.
During the past two decades, CT scan has become the
diagnostic tool of choice for the diagnosis of abdominal injury.
Before this, diagnostic peritoneal lavage (DPL) was the crite-
rion standard for abdominal injury screening. Given that DPL
is invasive and a minor surgical procedure, it was used much
more judiciously relative to the manner in which CT scan is
used today. Clinical examination was a significant factor in
determining the need to perform DPL.20Y22 Minor injuries were
most likely missed as is the case in the data presented herein;
however, these unidentified injuries have minimal clinical
impact. In a recent retrospective series of 542 patients, Millo
et al.23 concluded that the clinical yield of performing ab-
dominal CT scan in blunt trauma patients with normal clinical
examination result was minimal. Poletti et al.24 found that
clinical examination in concert with other clinical criteria can
obviate the need for CT scan in 22% of the patients. They
TABLE 4. Missed Abdominal Injuries and Distracting Injuries
Intra-abdominal
Injury (5 patients) Distracting Injuries
Grade 3 spleen injury Femur fracture
Grade 2 spleen injury Rib, radius/ulna fractures
Grade 1 kidney injury Radius/ulna, tibia/fibula, humerus fractures
Grade 1 spleen injury Rib, pelvis, tibia/fibula, T-spine fractures
Grade 1 spleen injury Skull, mandible, facial, femur, radius/ulna fractures
Intracranial hemorrhage (subdural hematoma)
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 J Trauma Acute Care Surg
Volume 78, Number 6
concluded minor injuries may be missed but were clinically
insignificant. In a prospective observational study, Holmes et
al.12 derived clinical predictors that identify patients at low risk
for intra-abdominal injury and unlikely to benefit from ab-
dominal CT scan. In a previous retrospective series at our in-
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stitution, we found that 155 blunt trauma patients with negative
abdominal examination results who required emergent extra-
abdominal surgery had 99% negative abdominal screening
study results (CT scan or DPL) before their emergent surgery.25
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In the present study, we have shown that a thorough clinical
examination in awake and alert blunt trauma patients with
distracting injuries can obviate the need for abdominal CT
scan. We believe that the key to identification of intra-
abdominal injuries is a careful abdominal examination that
involves all four abdominal quadrants, costal margins both
anteriorly and posteriorly, flank, pelvis (posterior and inward
compression of iliac wings, compression of symphysis pubis,
rectal examination), and thoracolumbar spine. Careful exam-
ination and palpation of these areas will identify the vast ma-
jority of intra-abdominal injuries. The benefit of thorough
examination of the areas mentioned is supported by the fact that
the most common distracting injuries associated with intra-
abdominal injuries were rib fractures, thoracolumbar spine
fractures, and pelvic fractures (Table 2). As a rule, these injures
evoke a positive clinical examination, allowing for the iden-
tification of associated intra-abdominal injuries.
The use of CT scanning has increased dramatically in the
United States during the past two decades. In the United States,
between 1995 and 2007, the number of CT scans performed
during emergency department visits increased from 2.7 million
to 16.2 million.26 That was a sixfold increase during that 12-year
span. CT scanning must be used judiciously to avoid unnec-
essary patient radiation exposure because increased radiation
exposure carries an increased lifetime risk of cancer.27,28
Approximately 75% of radiologic induced patient radiation
exposure is the result of CT scanning with an estimated cancer-
induced mortality risk of 12.5 deaths per 10,000 CT scans.2,29
Considering the exponential increase in the number of CT
scans performed in the United States and the associated cancer
risk, a more prudent approach to the use of this technology is
warranted.
The data presented in this study demonstrate that the
number of abdominal/pelvic CT scans performed on all awake
and alert blunt trauma patients with distracting injuries would
have decreased by 49% (219 of 451) during the 12-month
period. Based on a $1,451 hospital charge for an abdominal/
pelvis spine CT scan and $226 radiologist service fee at the
University of South Alabama, this would have decreased total
patient charges by $367,263 during the 12-month period.
A limitation of this study is that it is underpowered and
cannot prove or disprove equivalence of abdominal clinical
examination in patients with and without distracting injuries.
Although our study size is not large enough to prove equiva-
lence, of the 800 patients studied, none of the missed injuries in
those with or without distracting injuries required surgical or
radiologic intervention, and either group did not require blood
transfusion. For this study to be powered at 80% (1 j A) with
a probability (>) of 0.05, the population size of the study
would have to be approximately 7,000 patients. Clearly, a larger
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Rostas et al.
multi-institutional study will be required to prove equivalence
of clinical examination in these two patient populations.
CONCLUSION
To our knowledge, this is the first study that prospec-
tively compares the efficacy of CT scan to abdominal clinical
examination in patients with distracting injuries. Distracting
injuries do not seem to diminish the efficacy of clinical ab-
dominal examination for the diagnosis of clinically significant
abdominal injury. These data suggest that clinical examination
of the abdomen is valid in awake and alert blunt trauma pa-
tients, regardless of the presence of other injuries. A large
multi-institutional trial will be required to prove that distracting
injuries do not impact the sensitivity of abdominal clinical
examination in awake and alert blunt trauma patients
AUTHORSHIP
J.R., J.S., M.A.F., S.B.B., and R.B.G. contributed to study creation. All
authors contributed to data collection, data entry, and manuscript review.
DISCLOSURE
The authors declare no conflicts of interest.
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DISCUSSION
Dr. Andrew Kirkpatrick (Calgary, Alberta, Canada):
This is a very thought-provoking article from the Department
of Surgery in Mobile which, philosophically, is a call to arms to
get out of bed and properly examine our patients rather than
just wait for the call from the radiologist or, more likely, ra-
diology resident with a list of reported injuries.
Thus, the authors report that by performing diligent
physical examinations of awake and alert patients that these
negative physical assessments, even in the presence of
distracting injuries, are 90% sensitive and carried a 97%
negative predictive value. More practically, though, there was a
100% sensitivity and a 100% negative predictive value for
injuries requiring us to do something.
While I am certainly no statistician, I have had enough
rejection letters to know that likelihood ratios are the most
1100
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg
Volume 78, Number 6
important descriptors of the true value of diagnostic tests
which, in this manuscript, the physical exam is appropriately
considered to be.
So while not formally reported as such in the manuscript,
plugging the raw data into standard formulas reveals that the
likelihood ratio of a negative test in this population was 0.20 for
ruling out any abdominal injury which is actually not an ideal
test with a ratio of 0.1 being considered such. However, the
likelihood ratio of a negative test in ruling out any significant
injury requiring therapy was 0.0 which we consider ‘‘perfect’’
for this indication.
Thus, reverting back to a good, old-fashioned, meticulous
examination apparently seems to be simply good practice and
obvious from this, for us to accept. But I recognize this is a very
controversial area with strong opinions that are all over the map.
There are various previous reports that concluded that
significant abdominal injuries may be completely asymptom-
atic, or that distracting injuries associate with intra-abdominal
injury, or that such distracting injuries mask abdominal inju-
ries, noting that the most-referenced source of this sentiment
based this on only 10 patients. To put a name to it, this phe-
nomenon is known as counterirritation or extinction of pain
sensitivity, somewhat akin to the process where rubbing the
skin of your arm makes the broken bone feel better.
Before any diagnostic tests can be adopted by any other
groups, all considering adopting need to consider the issue of
generalizability. Could the good results of physical examina-
tion in Mobile be expected to occur in Calgary, Philadelphia, or
Helsinki?
Thus, I believe, one critical piece of information that the
authors can hopefully provide us is to understand the Injury
Severity Scores for the population so we can judge how ap-
plicable these patients are to our own experiences back home.
I appreciate that the authors provided aggregate details of
the other associated injuries, but I would still like to know how
severely injured each patient was, as this pre-test probability
greatly affects the usefulness of any tests, including the
physical examination.
A couple of other more hypothetical questions may re-
veal my own personal biases. In Mobile the physical exami-
nation is obviously performed to the highest standard. In my
mind, using ultrasound is an additional physical sense to that of
palpation described by the authors. Do you use point-of-care
ultrasound? Do you consider part of a good exam a diagnostic
test? Both or neither?
In very severely-injured patients do you think there can
be enough other injuries that you might consider these other
injuries not just as potential distractors but as overall markers of
injury severity which would then raise the overall likelihood of
visceral injuries so high that, then, further abdominal imaging
is warranted, regardless of the abdominal exam?
And, again, you reported that the vast majority of these
patients required admission. Previous RCTs from Dr. Livingston
have reported that not only did 19% of that cohort have positive
CT scans and no tenderness but, more important economically,
that those with negative CT scans could be discharged earlier.
You mentioned that the numbers aren’t that big but can you
drill down in any way to understand how many, if any, of your
patients were admitted just for observation of the abdomen?
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 J Trauma Acute Care Surg
Volume 78, Number 6
Overall, great work and thank you very much for the
privilege of this discussion.
Dr. Nathaniel McQuay (Baltimore, Maryland): Did I
see that correctly that you had seatbelt as a part of your positive
exam? Can you tell me how did you come to that conclusion?
Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX
Who was actually doing the exam because we know it is
somewhat subjective? Was it the PGY1-level or the attendings?
And were the exams protocolized, meaning that every exam
was done the exact same way? Thank you.
1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 03/08/2023
Dr. Richard Mullins (Portland, Oregon): Very nice
paper. I’ve done a few thousand physical exams through the
years. I agree with your conclusions but I have to take one
exception: I find 10Y20% of patients I exam have, what I
conclude, is unreliable, even though their GCS is 13. They’re
intoxicated, or they’re depressed or embarrassed, or they don’t
like the look of me, or maybe they speak a language that I can’t
share with them.
I think that assuming a physical examination in all
trauma patients have the same reliability and validity ignores
the fact that there are some patient exams that the doctor should
conclude; ‘‘I can’t really reliably communicate with this indi-
vidual.’’ Do you agree there is some patient-related variation in
the reliability of physical exam in your trauma center?
Dr. Benton Cason (Mobile, Alabama): Thank you,
Dr. Kirkpatrick, and others for your comments and questions
regarding this.
In regard to the Injury Severity Score, I don’t have those
numbers in front of me, but they are very easily obtainable from
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Rostas et al.
our trauma database. However, one would predict that the Injury
Severity Score would be fairly high in these patients with
distracting injuries due to the fact that most of these patients had
multiple injuries in addition to any intra-abdominal injury found.
With regard to the use of ultrasound in the trauma bay, we
do utilize a FAST exam as indicated in the evaluation of un-
stable patients with blunt trauma to the abdomen which, in
some cases, does impact the decision to scan these patients but
it is versus the decision to take them straight to the OR. The
patients that would have had positive findings on an FAST
exam after being unstable were not enrolled as they did not
receive a CT to verify findings on the physical exam.
With regard to specific distracting injuries, again, we
believe that further numbers are necessary before we can make
any recommendations based on that.
Regarding admission for observation, how many of these
patients were admitted? Although I don’t have the numbers in front
of me, most of these patients had severe enough distracting injuries
that they would have warranted treatment for that injury itself and
not for the abdominal exam or not for the abdominal injury.
The reason we select seatbelt sign is that it is a positive
sign that there is definitive trauma to the abdomen which in-
dicates that they do need further evaluation. And we considered
that a positive finding.
I have no numbers to be able to speak to any commu-
nication issues that arose within patients but that could be
something we could look at in the future.
Thank you.
1101