Diagnostik des stumpfen Abdominaltraumas des Kindes – ein systematisches Review mit Metaanalyse

Zusammenfassung

Zielsetzung: Das Ziel dieses systematischen Reviews war, die Diagnostik des stumpfen kindlichen Abdominaltraumas zu untersuchen. Methoden: Es wurde eine Literaturrecherche in folgenden Quellen durchgeführt: MEDLINE/Pubmed, Embase und Cochrane. Wo möglich, erfolgte eine Metaanalyse der vorhandenen Daten. Für alle Publikationen wurde die Qualität nach den Oxford-Kriterien ermittelt. Ergebnisse: Indikatoren für eine intraabdominelle Verletzung (IAV) sind erhöhte Transaminasen, ein pathologischer Untersuchungsbefund, ein erniedrigter systolischer Blutdruck, ein reduzierter Hämatokrit und Mikrohämaturie. Der Nachweis einer IAV mittels FAST (focused assessment with sonography for trauma) hatte eine Sensitivität von 56,5 %, eine Spezifität von 94,68 %, eine positive Likelihood Ratio von 10,63 und eine negative Likelihood Ratio von 0,46. Die Genauigkeit lag bei 84,02 %. Bei hämodynamisch instabilen Kindern lagen die Sensitivität und die Spezifität bei 100 %. Die Prävalenz von IAV bei einer negativen abdominellen CT betrug 0,19 %. Der NPV (negative prädiktive Wert) der Abdomen-CT zum Nachweis einer IAV war 99,8 %. Die Laparotomierate bei Kindern mit Nachweis von isolierter freier abdomineller Flüssigkeit (IFF) in einer Region betrug 3,48 %, wohingegen die Laparotomierate bei mehr als einer Region auf 56,52 % anstieg. Schlussfolgerung: FAST hat aufgrund der geringen Sensitivität als alleiniges Diagnostikum nach einem stumpfen Abdominaltrauma bei Kindern eine nur sehr eingeschränkte Aussagekraft. Die ambulante Weiterbehandlung von Kindern nach einem stumpfen Bauchtrauma und einer negativen Abdomen-CT erscheint sicher zu sein. Wenn IFF ohne Nachweis einer IAV in der Abdomen-CT nachgewiesen wird, ist es entscheidend, wie viele Bereiche betroffen sind. Bei einer Region ist eine IAV eher unwahrscheinlich. Ab 2 Regionen steigt die Laparotomierate signifikant an.

Abstract

Objective: The objective of this systematic review was to investigate the diagnostic management in paediatric blunt abdominal injuries. Methods: A literature research was performed using following sources: MEDLINE, Embase and Cochrane. Where it was possible a meta-analysis was performed. Furthermore the level of evidence for all publications was assigned. Results: Indicators for intraabdominal injury (IAI) were elevated liver transaminases, abnormal abdominal examinations, low systolic blood pressure, reduced haematocrit and microhematuria. Detecting IAI with focused assessment with sonography for trauma (FAST) had an overall sensitivity of 56.5 %, a specificity of 94.68 %, a positive likelihood ratio of 10.63 and a negative likelihood ratio of 0.46. The accuracy was 84.02 %. Among haemodynamically unstable children the sensitivity and specificity were 100 %. The overall prevalence of IAI and negative CT was 0.19 %. The NPV of abdominal CT for diagnosing IAI was 99.8 %. The laparotomy rate in patients with isolated intraperitoneal fluid (IIF) in one location was 3.48 % and 56.52 % in patients with IIF in more than one location.Conclusions: FAST as an isolated tool in the diagnostics after blunt abdominal injury is very uncertain, because of the modest sensitivity. Discharging children after blunt abdominal trauma with a negative abdominal CT scan seems to be safe. When IIF is detected on CT scan, it depends on the number of locations involved. If IIF is found only in 1 location, IAI is uncommon, while IIF in two or more locations results in a high laparotomy rate.

Schlüsselwörter

Kinderchirurgie - bildgebende Verfahren - stumpfes Bauchtrauma - FAST - CT

Key words

paediatric surgery - imaging procedures - blunt abdominal trauma - focused assessment with sonography for trauma (FAST) - CT

• Literatur

• 1 Statistisches Bundesamt. Unfälle, Gewalt, Selbstverletzung bei Kindern und Jugendlichen: Ergebnisse der amtlichen Statistik zum Verletzungsgeschehen 2008. 2010 Im Internet: https://www.destatis.de/DE/Publikationen/Thematisch/Gesundheit/Gesundheitszustand/UnfaelleGewaltKinder5230001089004.pdf?_blob=publicationFile Stand: 01/2012
• 2 Rhodes M, Aronson J, Moerkirk G et al. Quality of life after the trauma center. J Trauma 1988; 28: 931-938
• 3 Miniño AM, Heron MP, Murphy SL et al. Deaths: final data for 2004. Nati Vital Stat Rep 2007; 55: 1-119
• 4 Federle MP, Goldberg HI, Kaiser JA et al. Evaluation of abdominal trauma by computed tomography. Radiology 1981; 138: 637-644
• 5 Karp MP, Cooney DR, Berger PE et al. The role of computed tomography in evaluation of blunt abdominal trauma in children. J Pediatr Surg 1981; 16: 316-323
• 6 Peitzman AB, Makaroun MS, Slasky BS et al. Prospective study of computed tomography in initial management of blunt abdominal trauma. J Trauma 1986; 26: 585-592
• 7 Rutledge R, Hunt JP, Lentz CW et al. A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury. Ann Surg 1995; 222: 311-322
• 8 Huber-Wagner S, Lefering R, Qvick LM et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009; 373: 1455-1461
• 9 Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002; 32: 228-233
• 10 Jindal A, Vemahos GC, Rofougaran R. Computed tomography for evaluation of mild to moderate pediatric trauma: are we overusing it?. World J Surg 2002; 26: 13-16
• 11 Mueller DL, Hatab M, Al-Senan R et al. Pediatric radiation exposure during the initial evaluation of blunt trauma. J Trauma 2011; 70: 724-731
• 12 Berrington de Gonzalez A, Mahesh M, Kim KP et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009; 169: 2071-2077
• 13 Goske MJ, Strauss KJ, Coombs LP et al. Diagnostic reference ranges for pediatric abdominal CT. Radiology 2013; Mar 19 [Epub ahead of print]
• 14 Khan K, Kunz R, Kleijnen J. Systematic Reviews to support Evidence-based Medicine. 2nd. ed. London: Royal Society of Medicine Press Ltd. Arnold, Hodder Education; 2011
• 15 OCEBM Levels of Evidence Working Group. The Oxford 2009 Levels of Evidence Oxford Centre for Evidence-Based Medicine. Im Internet: http://www.cebm.net/index.aspx?o=1025 Stand: 10/2011
• 16 Taylor GA, OʼDonnell R, Sivit CJ et al. Abdominal injury score: a clinical score for the assignment of risk in children after blunt trauma. Radiology 1994; 190: 689-694
• 17 Holmes JF, Sokolove PE, Brant WE et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002; 39: 500-509
• 18 Cotton BA, Beckert BW, Smith MK et al. The utility of clinical and laboratory data for predicting intrabdominal injury among children. J Trauma 2006; 56: 1068-1074
• 19 Flood RG, Mooney DP. Rate and prediction of traumatic injuries detected by abdominal computed tomography scan in intubated children. J Trauma 2006; 61: 340-345
• 20 Sola JE, Cheung MC, Yang R et al. Pediatric FAST and elevated liver transaminases: an effective screening tool in blunt abdominal trauma. J Surg Res 2009; 157: 103-107
• 21 Karam O, Sanchez O, Chardot C et al. Blunt abdominal trauma in children: a score to predict the abscence of organ injury. J Pediatr 2009; 154: 912-917
• 22 Holmes JF, Mao A, Awasthi S et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009; 54: 528-533
• 23 Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007; 42: 1588-1594
• 24 Akgür FM, Aktuğ T, Kovanhkaya A et al. Initial evaluation of children sustaining blunt abdominal trauma: ultrasonography vs. diagnostic peritoneal lavage. Eur J Pediatr Surg 1993; 3: 278-280
• 25 Thourani VH, Pettitt BJ, Schmidt JA et al. Validation of surgeon-performed emergency abdominal ultrasonography in pediatric trauma patients. J Pediatr Surg 1998; 33: 322-328
• 26 Coley BD, Mutabagani KH, Martin LC et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma 2000; 48: 902-906
• 27 Benya EC, Lim-Dunham JE, Landrum O et al. Abdominal sonography in examination of children with blunt abdominal trauma. AJR Am J Roentgenol 2000; 174: 1613-1616
• 28 Emery KH, McAneney CM, Racadio JM et al. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. J Pediatr Surg 2001; 36: 565-569
• 29 Suthers SE, Albrecht R, Foley D et al. Surgeon-directed ultrasound for trauma is a predictor of intra-abdominal injury in children. Am Surg 2004; 70: 164-167
• 30 Tas F, Ceran C, Atalar MH et al. The efficacy of ultrasonography in hemodynamically stable children with blunt abdominal trauma: a prospective comparison with computed tomography. Eur J Radiol 2004; 51: 91-96
• 31 Fox JC, Boysen M, Gharahbaghian L et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18: 477-482
• 32 Holmes JF, Brant WE, Bond WF et al. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. J Pediatr Surg 2001; 36: 968-973
• 33 Task Force on Blood Pressure Control in Children. Report of the Second Task Force on Blood Pressure Control in Children-1987: National Heart, Lung, and Blood Institute, Bethesda, MD. Pediatrics 1987; 79: 1-25
• 34 Horn J. The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography. Acad Emerg Med 2010; 17: 469-475
• 35 Ruess L, Sivit CJ, Eichelberger MR et al. Blunt abdominal trauma in children: impact of CT on operative and nonoperative management. AJR Am J Roentgenol 1997; 169: 1011-1014
• 36 Holmes JF, London KL, Brant WE et al. Isolated intraperitoneal fluid on abdominal computed tomography in children with blunt trauma. Acad Emerg Med 2000; 7: 335-341
• 37 Awasthi S, Mao A, Wooton-Gorges SL et al. Is hospital admission and observation required after a normal abdominal computed tomography scan in children with blunt abdominal trauma?. Acad Emerg Med 2008; 15: 895-899
• 38 Federle MP, Jeffrey RB. Hemoperitoneum studied by computed tomography. Radiology 1983; 148: 187-192
• 39 Taylor GA, Sivit CJ. Posttraumatic peritoneal fluid: is it a reliable indicator of intraabdominal injury in children?. J Pediatr Surg 1995; 30: 1644-1648
• 40 Hulka F, Mullins RJ, Leonardo V et al. Significance of peritoneal fluid as an isolated finding on abdominal computed tomographic scans in pediatric trauma patients. J Trauma 1998; 44: 1069-1072
• 41 Beierle EA, Chen MK, Whalen TV et al. Free fluid on abdominal CT after blunt trauma does not mandate exploratory laparotomy in children. J Pediatr Surg 2000; 35: 990-993
• 42 Venkatesh KR, McQuay N. Outcomes of management in stable children with intra-abdominal free fluid without solid organ injury after blunt abdominal trauma. J Trauma 2007; 62: 216-220
• 43 Christiano JG, Tummers M, Kennedy A. Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma. J Pediatr Surg 2009; 44: 1242-1248
• 44 Newman KD, Eichelberger MR, Randolph JG. Abdominal injury. In: Eichelberger MR, Pratsch GL, eds. Pediatric Trauma Care. Rockville, MD: Aspen; 1988: 101-104
• 45 Johnson C, Riveria FP, Soderberg R et al. Children in car crashes: analysis of data for injury and use of restraints. Pediatrics 1994; 93: 960-965
• 46 Howard A, McKeag AM, Rothman L et al. Ejections of young children in motor vehicle crashes. J Trauma 2003; 55: 126-129
• 47 Kaufman RA, Towbin R, Babcock DS et al. Upper abdominal trauma in children: Imaging evaluation. AJR Am J Roentgenol 1984; 142: 449-460
• 48 Fenton SJ, Hansen KW, Meyers RL et al. CT scan and the pediatric trauma patient: Are we overdoing it?. J Pediatr Surg 2004; 39: 1877-1881