a b s t r a c t

Background: Computed tomography of the abdomen (CT) is used as the gold standard for detecting solid Organ injuries (SOI) after blunt abdominal trauma (BAT). However, patient selection for CT is still controversial due to its potential risks. In this study, we aimed to investigate the usefulness of laboratory tests in the detection or exclusion of SOI in pediatric patients evaluated in the emergency department due to BAT. Methods: The study was planned as a prospective, observational study and was conducted in the emergency de- partment of a university hospital between February 2018 and February 2019. Patients under the age of 18 who were evaluated for BAT in the emergency department were included in the study. In the study, the diagnostic value of abnormal laboratory tests in detecting SOI was calculated by accepting CT results as the gold standard. Results: Of the 323 patients included in the study, 118 (36%) were male. There were 283 patients who underwent CT. SOI was detected in 18 (6%) patients. Abnormal alanine aminotransferase, aspartate aminotransferase, amy- lase and lipase tests were found to be statistically significant in predicting SOI (p < 0.05). However, none of the tests were found to have sufficient sensitivity and specificity. Hemoglobin, hematocrit, lactate and base excess values were not found to be statistically significant in predicting SOI (p > 0.005).

Conclusions: The hematologic laboratory tests are insufficient to rule out solid organ injury in pediatric patient

with BAT.

(C) 2022

1. Introduction

Blunt abdominal trauma (BAT) is the third most common cause of trauma-related death after head and chest injuries in children, and it is the most common cause of initially unrecognized fatal injuries [1]. Intraabdominal injuries (IAI) are difficult to detect initially in chil- dren with multiple injuries, depressed consciousness, agitation, and in those in the prespeech period. While physical examination provides limited information, focused assessment with sonography for trauma , which has become a standard part of adult trauma patient management, has a low sensitivity and negative pre- dictive value in pediatric patients [2]. Computed tomography (CT) of

* Corresponding author at: Emergency Department, Yildirim Beyazit University, Yenimahalle Training and Research Hospital, Yeni Bati, 2026. Street, No:4, 06370 Batikent /Yenimahalle/Ankara, Turkey.

E-mail address: [email protected] (C. Kuas).

the abdomen is used as the gold standard imaging test for detecting IAI in pediatric patients [3]. However, patient selection for advanced imaging is an ongoing debate. Unnecessary exposure of a pediatric patient to radiation increases the risk of malignancy in addition to in- creasing treatment costs [4]. Emergency physicians should always consider this risk and be careful when making a decision of perform- ing CT in pediatric patients.

Laboratory tests are frequently used by clinicians to select pa- tients for advanced imaging. Clinicians should consider laboratory testing as a diagnostic aid in the clinical evaluation of critically in- jured children. [5]. However, there is no generally accepted routine laboratory test offering high sensitivity and specificity [6,7]. Elevated transaminases are generally considered to be well correlated with liver injury, but different threshold values have been reported in the literature [6]. Conversely, it has been reported that severe injury can occur even with low transaminase levels [3]. There are different publications in the literature that hemoglobin (Hb) and hematocrit

https://doi.org/10.1016/j.ajem.2022.04.039

0735-6757/(C) 2022

(Htc) levels are useful [8] or not useful [6] in predicting intra- Abdominal injury.

Table 1

Demographic data, characteristics and tests performed.

February 2018 and February 2019. The center where the study was con-

The aim of the present study is to determine the diagnostic and All Patients predictive accuracy of laboratory tests used in the evaluation of pediat- (n:327)			CT + (n:283)	SOI + (n:18)	CT - (n:44)
ric patients with BAT in predicting intraabdominal solid organ injuries Age, median [IQR]		10 [IQR 7-15]	11 [IQR	14 [IQR	10 [IQR
(SOI).			7-15]	7-16]	6-13]
Male, n (%)		118(36)	106(37)	6(33)	12(27)
2. Material and methods trauma mechanism, n (%)
Accidental fall		91(28)	75(27)	4(22)	16(36)
Motor vehicle traffic		68(21)	65(23)	4(22)	3(7)
2.1. Study design crash
Nonvehicle traffic		57(17)	57(20)	3(17)	0
This study is a prospective observational study. The study was con- crashes
ducted in the emergency department of a university hospital between Bicycle crash		37(11)	27(10)	3(17)	10(23)
Direct blunt abdominal		33(10)	22(8)	2(11)	11(25)
ducted is the Adult and Pediatric Level One Trauma Center. Annually,	motorcycle crash	26(8)	25(9)	1(6)	1(2)
approximately 6800 pediatric patients with trauma are admitted to	Non-accidental fall	10(3)	7(2)	1(6)	3(7)
the study center. Before the study, approval was obtained from local ethics committee.	Sports injury Laboratory tests, n (%) CBC	5(2) 321 (98)	5(2) 283 (100)	0 18(100)	0 38 (86)

trauma

We determined all patients under the age of 18 who were evaluated in the emergency department for BAT during the specified study period as the study population. Exclusion criteria were pregnancy status, loss of consciousness, unstable vital signs, and not accepting the study. Written informed consent was obtained from the parents of the patients. Consent forms were also obtained from patients who could read and write. No specific predetermined protocol was followed for the routine laboratory tests and imaging investigations in the study; they were performed at the discretion of the attending physician. In the study center, the care of pediatric patients with trauma is carried out in accor- dance with the recommendations of the Advanced Trauma Life Support guidelines [9].

The attending physician recorded patient demographics, mecha- nism and duration of injury, vital signs, physical examination findings, laboratory values, and CT findings using a structured data collection form. Hb, Htc, alanine aminotransferase (ALT), aspartate aminotransfer- ase (AST), amylase, lipase, lactate, base excess , and red blood cell (RBC) values detected by complete urinalysis were recorded.

2.2. Statistical analysis

Continuous variables were expressed as mean, standard deviation, and 95% confidence interval (CI) or as median and interquartile range (IQR) according to their distribution pattern, and categorical variables were expressed as frequency and rate. The predictive value of labora- tory parameters in predicting SOI and the area under the curve (AUC) in receiver operating characteristic (ROC) analysis were calculated using the Med Calc (version 18) software considering CT as the gold standard. Similarly, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR⁺), negative likelihood ratio (LR^-), and odds ratio of the laboratory param- eters in predicting SOI were calculated considering CT as a gold stan- dard. SPSS version 20.0 (SPSS for windows, IBM Corp., Armonk, NY, USA) was used in statistical analysis.

1. Results

During the study period, 332 pediatric patients were evaluated in

ALT and AST	311 (95)	273 (96)	18(100)	38 (86)
Amylase	307 (94)	270 (95)	18(100)	37 (84)
Lipase	40 (12)	38 (13)	18(100)	2 (5)
Lactate and BE	252 (77)	224 (79)	18(100)	28 (64)
Urinalysis	122 (37)	101 (36)	18(100)	21 (48)

A significant relationship was found between the presence of an exter- nal lesion (14%), abdominal tenderness (17%), and abdominal rigidity (2%) in the abdominal region detected by physical examination and the presence of SOI (p = 0.001). At least one laboratory test was re- quested from 321 (98%) patients. We found that CBC were examined in 321 (98%) patients, transaminases in 311 (95%) patients, amylase in

307 (94%) patients, blood gases in 252 (77%) patients, and urinalysis in 122 (37%) patients. Demographic data of the patients, characteristic features, and the tests requested in the emergency department are pre- sented in Table 1. SOI was detected in 18 (6%) patients on CT. The most common injuries were to the liver (3%), spleen (1%) and kidney (1%) (Table 2).

The analysis of the laboratory results according to the CT findings of the patients is presented in Table 3. ALT, AST, amylase, and lipase values were found to be higher in patients with SOI (p = 0.001). The mean RBC value detected in complete urinalysis was 447 red blood cells/high power field (RBCs/HPF) in patients with kidney injury and 15 RBCs/ HPF in other patients (p = 0.005). At least 27 RBCs/HPF were detected in urinalysis of patients with Renal damage. In 33 (12%) patients without renal damage, 5 or more RBCs/HPF were detected.

In ROC curve analysis, the cut-off value for ALT was 72.4 U/L with an AUC of 0.762 (95% CI: 0.7-0.8), a sensitivity of 61% (95% CI: 36%-83%),

and specificity of 97% (95% CI: 94%-99%). The cut-off value for AST was 136.3 U/L with an AUC of 0.727 (95% CI: 0.6-0.8), a sensitivity of 61% (95% CI: 36%-83%), and specificity of 96% (95% CI: 93%-98%). The ROC curve analysis of laboratory parameters is presented in Table 4. The ROC curves for ALT and AST are presented in Fig. 1.

We found that 108 (33%) of the patients included in the study were treated in the hospital, and 22 (7%) of these patients were followed up

Table 2

Pathological findings detected on CT.

the emergency department due to BAT. Five patients were excluded

from the study because consent could not be obtained. A total of 327 patients were included in the study. Of them, 118 (36%) were male. The median age was 10 years (IQR: 7-15). The most common Trauma mechanisms were accidental falls (28%), motor vehicle traffic crash (21%), and nonvehicle traffic crashes (17%). There was no significant relationship between the trauma mechanism and SOI (p = 0.241). The most common presenting symptoms were abdominal pain (20%) and nausea and vomiting (4%), and a significant relationship was found between these symptoms and SOI (p = 0.001, p = 0.041).

CT Findings, n (%)

Solid organ injury 18 (6)

Liver injury 8 (3)

Kidney injury 3 (1)

Spleen injury 3 (1)

Pancreatic injury 2 (1)

adrenal gland injury 2 (1)

Intra-abdominal fluid 14 (5)

Intra-abdominal hematoma 2 (1)

Bowel injury 2 (1)

Table 3

Analysis of laboratory results according to CT result.

Test	Normal Value Range	SOI +		SOI -	p
		Median [IQR]		Median [IQR]
Hb	13.3-17.2 g/dL	13 (12-14)		13 (12-14)	0.710
Htc	%38.9-50.9	37 (34-40)		37.4 (36-39)	0.566
ALT	0-41 U/L	111 (18-249)		15.5 (12-24)	0.000
AST	0-37 U/L	164 (28-375)		32 (25-42)	0.001
Amylase	28-100 U/L	91 (54-122)		65 (49-79)	0.023
Lipase	0-60 U/L	48 (34-694)		21 (17-28)	0.006
Lactate	0.56-2 mmol/L	3 (2-4)		2.1 (2-3)	0.279
BE	-5-1.8 mmol/L	-3 (-4 - -2)		-2.4 (-4 - -1)	0.805

in the intensive care unit. After discharge, there was no recurrence due to trauma-related injuries. All study patients who were found to have SOI were treated conservatively. No patient required transfusion during the follow-up.

1. Discussion

One of the most important points to be clarified in a pediatric patient presenting to the emergency department after sustaining BAT is whether SOI is present or not. After the initial evaluation, the necessary laboratory and imaging tests to be performed should be decided quickly. CT is the gold standard imaging tool having a high sensitivity in detect- ing SOI [10]. However, due to the possible risks of CT in pediatric pa- tients, laboratory tests are frequently used to determine the need for further imaging tests in pediatric patients with BAT. In this study, we in- vestigated the accuracy of laboratory tests in detecting SOI that are used to evaluate pediatric patients presenting to the emergency department with BAT. In our study, elevation in ALT and AST values had a higher di- agnostic accuracy than other tests in predicting SOI. The LR^- values of abnormal laboratory tests ranged from 0.4 to 1.2, indicating that a nor- mal value does not adequately predict a Normal CT scan. Laboratory tests should not be used as a screening tool for SOI in pediatric patients with BAT. Specific laboratory tests for the suspected injury may be use- ful in the individual care of patients with trauma.

In this study, we found that laboratory tests are frequently used in the evaluation of pediatric patients admitted to the emergency depart- ment due to BAT. We found that CBC (98%) was used most frequently. The Htc value, which is determined by the commonly used CBC, is an important parameter for the physicians to decide whether or not to per- form CT in case of pediatric patients presenting with BAT [11]. However, the studies have reported variable results for the diagnostic accuracy of Hb and Htc, which are considered as the indicators of IAI in patients with BAT. An initial Htc value of <30 seen in the emergency department has been reported to be associated with IAI, and further assessment of these patients with CT scans has been recommended [8,12]. At the same time, low Htc value detected at the beginning in a pediatric patient with trauma correlates with the amount of blood loss in the patient; however, low Htc value is weakly associated with bleeding in a clinically stable patient [13]. Conversely, some studies have reported that Htc value does not have sufficient diagnostic accuracy in predicting IAI [6,14]. In their study, Golden et al. showed that there was only a 2%

difference between the baseline Htc values of the two groups with and without IAI, and it was stated that the Htc value was insufficient to predict injuries [15]. At the same time, it is suggested that Htc follow-up, which is frequently performed for children sustaining trauma, is of no significance, and that control Htc values must be seen in patients with deterioration in the clinical condition [16,17]. The pres- ent study found no clinically significant relationship between low Hb and Htc values determined by CBC and the presence of SOI. The cut- off values determined by ROC curve analysis had low sensitivity and specificity. Variable results reported in the literature on this subject may be due to the different trauma severity of the evaluated patient groups, the variability of the patients’ admission times, and the differ- ences in the focus of the studies (IAI, need for transfusion, need for op- eration, etc.). In our study, the fact that Hb and Htc values did not predict SOI risk at the beginning may be explained by the fact that the study patients did not have severe injuries and the patients were admit- ted to the emergency room in the early period. As a result, the knowl- edge of initial Hb and Htc values of the patients would be beneficial despite their low diagnostic accuracy in predicting SOI because the de- terioration in clinical condition of the patients may take up to 24 h [16]. When the diagnostic accuracy of laboratory tests were examined ac- cording to the cut-off values of ROC curve analysis, we found that the di- agnostic accuracy of ALT and AST tests in predicting SOI were higher than the other tests. In the literature, there are different data on the di- agnostic accuracy of ALT and AST tests in predicting IAI. In a study by Capraro et al., the sensitivity values for abnormal ALT and AST values in detecting IAI were found to be 52% and 63%, respectively, with a spec- ificity of 71% and 48%, respectively [6]. In their study, Bevan et al. found that an ALT value >104 U/L had a sensitivity of 96% and a specificity of 80% in predicting IAI. They also suggested that there is no need for fur- ther imaging studies if the ALT value is <104 U/L [18]. Holmes et al. found that an AST value >200 U/L and an ALT value >125 U/L suggest a high risk for IAI [8]. There are many studies reporting that transami- nases alone are insufficient to rule out SOI if they are found to be within normal ranges [6,18,19]. Similar to the literature data, the present study found a significant relationship between abnormal ALT and AST values and the presence of SOI, and values within the normal ranges do not have sufficient diagnostic accuracy in ruling out SOI. The cut-off values found in the present study being different from those reported in the lit- erature is due to the inclusion of patients with IAI in other studies, the differences in the severity of injuries in the studied patients, and the variability in the criteria used to detect IAI. As a result, ALT and AST tests contribute significantly to the identification of children with SOI after sustaining BAT. If ALT and AST are above the cut-off values deter- mined in our study, the risk of SOI is considerably high, and these pa-

tients should be evaluated further with CT scans.

Abnormal amylase and lipase values have been reported to have a sensitivity of 6% and 17% and specificity of 95% and 96%, respectively, in detecting IAI [6]. In our study, amylase and lipase values were higher in patients with SOI. However, they had low diagnostic accu- racy in assessing the risk of SOI. Since pancreatic injury was detected in only two patients, statistical analysis on the diagnostic accuracy of amylase and lipase in detecting Pancreatic injuries could not be performed.

Table 4

ROC analysis of laboratory tests.

Test	Cut-off value	Sensitivity, % (%95 GA)	Specificity, % (%95 GA)	LR+ (%95 GA)	LR- (%95 GA)	AUC (%95 GA)	OR (%95 GA)
Hb	<11.8	28(10-54)	88(83-92)	2.2 (1-5)	0.8 (0.6-1.1)	0.527(0.5-0.6)	1.6(0.4-6.1)
Htc	<38	67(41-87)	46(40-52)	1.2(0.9-1.7)	0.7(0.4-1.4)	0.551(0.5-0.6)	0.9(0.3-2.7)
ALT	>72.4	61(36-83)	97(94-99)	19(9-42)	0.4(0.2-0.7)	0.762(0.7-0.8)	76(20.2-285)
AST	>136.3	61(36-83)	96(93-98)	17(8-36)	0.4(0.2-0.7)	0.727(0.6-0.8)	30.6(8.5-110)
Amylase	>86	56(31-79)	81(76-86)	3(1.8-4.7)	0.6(0.3-0.9)	0.660(0.6-0.7)	6.1(2-18)
Lactate	>2.4	61(36-83)	66(59-72)	1.8(1.2-2.7)	0.6(0.3-1.1)	0.604(0.5-0.7)	2.7(0.9-8.1)
BE	<-1.8	89(65-99)	32(25-39)	1.3(1.1-1.6)	0.4(0.1-1.3)	0.551(0.5-0.6)	2.9(0.6-13.3)

Fig. 1. ROC analysis curve of ALT (a) and AST (b) values.

There are many studies in the literature showing that lactate and BE values significantly predict organ injuries, recognize shock in the early period, and determine the severity of injury in adult patients. However, there are insufficient data on Pediatric trauma patients. The present study found no clinically significant relationship between lactate and BE values and the presence of SOI. Unlike our study, it was reported that a lactate value >4.7 mmol/L indicates the presence of a serious in- jury, whereas a lactate value less than 2 mmol/L largely rules out Serious injuries [20]. In a study evaluating pediatric patients with trauma, it was shown that the rate of mortality and the need for blood transfusion were higher in patients with BE below -8 mmol/L [21]. Since patients with stable vital signs were evaluated in our study and there were no patients who were seriously injured and required transfusion or opera- tion during follow-up, detailed statistics on lactate and BE could not be made. Based on the findings of the present study, we suggest that lactate and BE values should not be used to decide whether to perform addi- tional imaging studies for SOI.

• 1. Limitations

There are some limitations in our study. Our study was a single- center study and due to its cross-sectional study design, no follow-up was performed to determine the subsequent clinical course of the pa- tients. Since the selection of laboratory and imaging tests is at the dis- cretion of a clinician, standardization in the management of patients has not been achieved. For example, lipase test was requested in only 12% of the patients. Such missing data may have affected our analysis. Patients who did not undergo CT were not included in the diagnostic ac- curacy analysis of laboratory tests. This may have significantly affected our measurements. Since the diagnostic accuracy analysis was per- formed by including only patients with and without SOI, injuries other than SOI (intestinal injuries, intraabdominal vascular injuries, pelvic in- juries, etc.) that may have changed the laboratory parameters may have affected the study results.

1. Conclusion

Laboratory tests have limited utility in evaluating the risk of SOI after sustaining BAT. High ALT and AST values are significantly associated with SOI. ALT and AST values do not have sufficient diagnostic accuracy in ruling out SOI if they are found within normal ranges. Other labora- tory tests used in this study have low diagnostic accuracy in predicting

SOI and should not be used alone for selecting patients for further diagnostic imaging. The discovery of biomarkers with higher diagnostic accuracy is needed for clinical evaluation in pediatric trauma patients.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Credit authorship contribution statement

Caglar Kuas: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing - original draft, Writing - review & editing. Nurdan Acar: Conceptualization, Methodology, Project administration, Supervision, Writing - review & editing. Engin Ozakin: Data curation, Formal analysis, Methodology, Resources, Supervision. Evvah Karakilic: Conceptualization, Data curation, Funding acquisition, Supervision, Writing - review & editing. Mehmet Surhan Arda: Conceptualization, Formal analysis, Investiga- tion, Methodology. Betul Tiryaki Bastug: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation. Gizem C. Yuksel: Data curation, Investigation, Resources. Mustafa Emin Canakci: Supervision, Writing - original draft, Writing - review & editing.

Declaration of Competing Interest

The authors declare they have no competing interests and no potential financial conflicts.

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