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Screening US for Blunt Abdominal Trauma: Objective Predictors of False-Negative Findings and Missed Injuries¹

¹ From the Departments of Radiology (C.B.S., M.A.B., O.A.A.B., G.C.), Family and Preventive Medicine (R.D.), and Surgery (D.A.F., D.B.H.), University of California, San Diego, UCSD Medical Center, 200 W Arbor Dr, MC 8756, San Diego, CA 92103. Presented at the 2002 RSNA scientific assembly. Received February 20, 2003; revision requested May 14; revision received June 4; accepted July 23. R.D. supported in part by National Institutes of Health grant M01 RR00827. Address correspondence to C.B.S. (e-mail: csirlin@ucsd.edu).

View larger version (26K): [in a new window]   Figure 1. Graph shows absolute risk for missed abdominal injuries according to risk group and for the study population. Bars show the percentages of low-risk and high-risk patients with surgical or nonsurgical abdominal injuries detected after negative screening US and the percentage of all patients with such injuries. Patients in the high-risk group were significantly more likely than those in the low-risk group to have a missed abdominal injury after negative findings at screening US (P < .001).

View larger version (21K): [in a new window]   Figure 2. Graph shows relative risk for missed abdominal injuries in the high-risk patient group; the low-risk group is the reference. Lines indicate 95% CIs. High-risk patients were 16-32 times more likely than low-risk patients to have a missed abdominal injury, depending on the type of injury.

View larger version (24K): [in a new window]   Figure 3. Comparison of the delay between negative findings at US and identification of missed injury according to patient risk group. Bars indicate the number of abdominal injuries detected in low-risk versus high-risk patient groups at various time intervals after initial screening US. All eight (100%) low-risk patients versus 26 (87%) of 30 high-risk patients with missed abdominal injuries had their missed injuries detected within 24 hours of screening US.

View larger version (41K): [in a new window]   Figure 4. Graph shows absolute risk for missed injury for patients with each hypothetical predictor. Bars show the percentages of patients with no predictors; patients with fractures of the lower ribs, lumbar spine, or pelvis; and patients with hematuria in whom surgical or nonsurgical abdominal injuries were detected after negative findings at screening US. Patients with at least one hypothetical predictor were significantly more likely to have a missed abdominal injury than patients with no predictors, and patients with hematuria were significantly more likely to have a missed injury than patients with any other predictor. Fx = fracture, LS = lumbar spine, Rib = lower rib.

View larger version (27K): [in a new window]   Figure 5. Graph shows relative risk for missed abdominal injury in high-risk patients by predictor of missed injury. The low-risk patient group is the reference. Vertical lines indicate 95% CIs. Fx = fracture, LS = lumbar spine, Rib = lower rib. Depending on the specific predictor, high-risk patients had a risk of missed injury 21-62 times higher than that of low-risk patients.

View larger version (25K): [in a new window]   Figure 6. Graph shows risk for missed injury as a function of risk score (score of 0, 1, 2, or 3+). Bars indicate the percentage of patients with no, one, two, or three or more individual predictors of missed injury in whom abdominal injury was detected after negative findings at screening US. Because of small sample sizes, surgical and nonsurgical injuries were pooled for each risk score. The risk for missed injury increased significantly as the risk score increased.

View larger version (26K): [in a new window]   Figure 7. Flow chart of proposed procedure for triaging patients who are believed to have blunt abdominal trauma. Patients who have or are suspected of having predictors of missed injury (ie, patients at high risk) should be screened immediately with CT. Patients who do not have predictors of missed injury (ie, patients at low risk) should be screened with US. Patients with negative findings at screening US should be admitted for observation. If predictors of missed injury are discovered after findings at screening US were interpreted as negative, patients should undergo confirmatory CT to exclude missed abdominal injury. BAT = blunt abdominal trauma, Lap = laparotomy.