From the 2018 HVPAA National Conference
Clifton Lee (Virginia Commonwealth University School of Medicine)
Non-accidental trauma (NAT) is a leading cause of injury and death in children in the United States. Infants less than 12 months are at a significantly increased risk. Studies have shown that up to 10% of patients with closed head and/or bony injuries were found to have abdominal injuries.
The objectives of this study were to review the NAT cases in patients younger than 12 months of age to determine the incidence of intra-abdominal injury, to assess the incidence of laboratory studies, imaging, and pediatric surgery consultation, and to consider the necessity of these evaluations on a routine basis.
The Virginia Commonwealth University Medical Center Child Protection Team’s database of children evaluated for NAT was utilized to retrospectively review the medical records of infants less than 12 months of age with NAT evaluations in the setting of presumed head trauma. Data was collected from 2012 to 2015 with a total of 105 patients included. The charts were reviewed for trauma evaluations including those who underwent laboratory, imaging, pediatric surgery consultation, and management based on intra-abdominal injuries.
Of the 105 patients identified, 38 patients received pediatric surgery consults (36%); 73 patients had abdominal trauma labs (70%); and 9 patients had abdominal imaging including plain films, abdominal ultrasounds, or abdominal CTs (11%). Of those patients, 6% had abnormal lab result. Four patients had physical examination findings of abrasions or bruising to the chest and/or abdomen; however, 69 additional patients underwent laboratory evaluation without physical findings. Only 1 patient had abdominal pathology (liver laceration) which was detected on abdominal CT and managed conservatively. Six patients without abnormal labs had imaging performed. Twenty-seven surgical consults were obtained without positive physical examination or abnormal laboratory findings.
Of the 105 patients included in this study, only one patient was found to have abdominal injury with abrasions to the chest and increased liver function test results. While NAT is a leading cause of morbidity and mortality in children under the age of 12 months, and it is imperative to appropriately evaluate and manage these patients, it is also important to minimize interventions in children to avoid further psychological/emotional trauma. Through this study, routine evaluation for intra-abdominal injury in our patient population is not warranted. There is evidence that the evaluation of these children can be better defined with laboratory evaluation to those with abnormal physical examination findings and imaging and surgical consultation for those with either physical examination findings and/or laboratory findings.
Implications for the Patient
Potentially unnecessary testing can be eliminated in children less than 12 months of age presenting to the emergency department for suspected NAT with avoidance of further psychological and emotion trauma as well as unnecessary radiation.