(photo by Erin O. Smith)
A new multicenter study found that observing children with blunt abdominal trauma in the emergency department, for a period of time, before ordering imaging can safely reduce unnecessary CT scans without increasing the risk of missed injuries.
Blunt abdominal trauma accounts for nearly 8 million pediatric emergency department visits annually in the United States. CT scans have long been considered the gold-standard for diagnosing internal abdominal injuries, but they carry risks. Imaging exposes children to ionizing radiation, which increases the lifetime risk of developing cancer particularly among younger children due to greater tissue sensitivity and longer life expectancy. Imaging can also cause stress and require sedation.
The study, “Emergency department observation and computed tomography use in children with blunt abdominal trauma,” was published in the Annals of Emergency Medicine. Researchers found that observing children with blunt abdominal trauma before making imaging decisions reduced CT use by 16.7% compared with immediate decision-making.
“For children with blunt abdominal trauma, the default has often been to image first and ask questions later,” said Jeffrey S. Upperman, MD, chair of Pediatric Surgery at Monroe Carell Jr. Children’s Hospital at Vanderbilt and a co-author of the study. “This research tells us something important: Taking time to observe a child’s clinical course — watching whether their pain improves or worsens — can meaningfully guide our imaging decisions and spare children unnecessary radiation, without putting them at risk.”
Upperman participated in this study as an investigator at his previous institution, Children’s Hospital Los Angeles, and contributed to the completion of the work after joining Monroe Carell.
Investigators analyzed data from 7,442 children, under age 18, who were treated for blunt abdominal trauma at six Level 1 pediatric trauma centers between December 2016 and September 2021. They found that children who underwent a period of observation before imaging decisions were less likely to receive CT scans compared to those who were immediately scanned. CT imaging was used in 20.5% of observed patients, compared with 37.1% of patients who were not observed first.
Finds from the study showed that observation was most beneficial for children in the intermediate-risk category — those for whom a clinician’s suspicion of injury was somewhere between 1% and 50%. Among these patients, observation was strongly associated with lower CT use, while maintaining safety outcomes. By contrast, observation had little impact for the lowest-risk children (less than 1% suspicion), and observation made no meaningful difference in CT rates — those children were already unlikely to receive imaging. For the highest-risk patients (greater than 50% suspicion), clinicians appropriately moved quickly to CT regardless of the observation designation.
Importantly, no child who was observed and sent home without a CT scan later needed treatment for a serious abdominal injury. While observation added an average of 21 minutes to emergency department stays, researchers said the increase was unlikely to meaningfully disrupt ED operations.
One of the largest studies in this topic area, the analysis was conducted as a planned secondary analysis of a larger prospective validation study of the Pediatric Emergency Care Applied Research Network clinical prediction rules for abdominal and head injury in children.
Looking ahead, the authors recommend further research to explore how observation periods could be optimized with additional diagnostic tools like point-of-care ultrasound or lab testing. They noted that the “… findings of this study should be interpreted as evaluating the role of observation as a management strategy, rather than as defining a complete diagnostic pathway.”
Participating institutions included University of California San Diego, UCSF Benioff Children’s Hospital Oakland, University of Texas Southwestern Medical Center, University of Chicago, and Children’s Hospital Los Angeles.
The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Award Number R01HD084674).
