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Does this adult patient have a blunt intra-abdominal injury?

Publication ,  Journal Article
Nishijima, DK; Simel, DL; Wisner, DH; Holmes, JF
Published in: JAMA
April 11, 2012

CONTEXT: Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma. OBJECTIVE: To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma. DATA SOURCES: We conducted a structured search of MEDLINE (1950-January 2012) and EMBASE (1980-January 2012) to identify English-language studies examining the identification of intra-abdominal injuries. A separate, structured search was conducted for studies evaluating bedside ultrasonography. STUDY SELECTION: We included studies of diagnostic accuracy for intra-abdominal injury that compared at least 1 finding with a reference standard of abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve studies on clinical findings and 22 studies on bedside ultrasonography met inclusion criteria for data extraction. DATA EXTRACTION: Critical appraisal and data extraction were independently performed by 2 authors. DATA SYNTHESIS: The prevalence of intra-abdominal injury in adult emergency department patients with blunt abdominal trauma among all evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI, 2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of injuries. The presence of a seat belt sign (likelihood ratio [LR] range, 5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2; 95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding (LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of abdominal tenderness to palpation does not rule out an intra-abdominal injury (summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or organ injury on bedside ultrasound assessment is more accurate than any history and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46); conversely, a normal ultrasound result decreases the chance of injury detection (adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the likelihood of intra-abdominal injury include a base deficit less than -6 mEq/L (LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2), hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in combination, particularly in identification of patients who do not need further diagnostic workup. CONCLUSIONS: Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.

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Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

April 11, 2012

Volume

307

Issue

14

Start / End Page

1517 / 1527

Location

United States

Related Subject Headings

  • Wounds, Nonpenetrating
  • Ultrasonography
  • Sensitivity and Specificity
  • Radiography
  • Point-of-Care Systems
  • Physical Examination
  • Middle Aged
  • Male
  • Hypotension
  • Humans
 

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Nishijima, D. K., Simel, D. L., Wisner, D. H., & Holmes, J. F. (2012). Does this adult patient have a blunt intra-abdominal injury? JAMA, 307(14), 1517–1527. https://doi.org/10.1001/jama.2012.422
Nishijima, Daniel K., David L. Simel, David H. Wisner, and James F. Holmes. “Does this adult patient have a blunt intra-abdominal injury?JAMA 307, no. 14 (April 11, 2012): 1517–27. https://doi.org/10.1001/jama.2012.422.
Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA. 2012 Apr 11;307(14):1517–27.
Nishijima, Daniel K., et al. “Does this adult patient have a blunt intra-abdominal injury?JAMA, vol. 307, no. 14, Apr. 2012, pp. 1517–27. Pubmed, doi:10.1001/jama.2012.422.
Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA. 2012 Apr 11;307(14):1517–1527.
Journal cover image

Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

April 11, 2012

Volume

307

Issue

14

Start / End Page

1517 / 1527

Location

United States

Related Subject Headings

  • Wounds, Nonpenetrating
  • Ultrasonography
  • Sensitivity and Specificity
  • Radiography
  • Point-of-Care Systems
  • Physical Examination
  • Middle Aged
  • Male
  • Hypotension
  • Humans