A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma

Abstract

Study Objective: We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. Methods: We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries. Results: Nine hundred eighty-six patients with a mean age of 8.3±4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention. Conclusion: Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries. [Holmes JF, Sokolove PE, Brant WE, Kuppermann N. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med. May 2002;39:492-499.]

Introduction

Thoracic injuries account for 14% of pediatric trauma-related deaths and are second only to head injuries as a cause of death in pediatric patients experiencing blunt trauma.¹ After physical examination, chest radiography is the initial diagnostic test for the identification of thoracic injuries.² Chest radiographs, however, may not be necessary for all pediatric patients with blunt trauma.

Although chest radiography is noninvasive and relatively inexpensive, it becomes costly if universally applied to patients at low risk for thoracic injuries. In addition, chest radiography exposes the patient to radiation and requires either transportation of the patient to the radiographic suite or a radiology technician to be present at the patient's bedside. Identification of predictors of thoracic injury, therefore, may provide clinicians with useful information to enhance clinical and cost efficiency.

The objectives of this study were to determine the prevalence of thoracic injuries in a population of pediatric patients presenting to the emergency department after blunt torso trauma and to create a clinical decision rule to identify children with these injuries.