title: A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma.
abstract: OBJECTIVE
  We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries.
  
  
  METHODS
  We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries.
  
  
  RESULTS
  Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention.
  
  
  CONCLUSIONS
  Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.
authors.affiliation: Division of Emergency Medicine, Department of Internal Medicine, University of California-Davis School of Medicine, Sacramento, CA 95817-2282, USA. jfholmes@ucdavis.edu
authors.forename: James F
authors.initials: JF
authors.lastname: Holmes
authors.forename: Peter E
authors.initials: PE
authors.lastname: Sokolove
authors.forename: William E
authors.initials: WE
authors.lastname: Brant
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
mesh_terms: D000058:Accidental Falls; D000063:Accidents, Traffic; D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D004796:Clinical Enzyme Tests; D016001:Confidence Intervals; D003288:Contusions / Q000175:diagnosis; D003937:Diagnosis, Differential; D004630:Emergencies; D015600:Glasgow Coma Scale; D006491:Hemothorax / Q000175:diagnosis; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D055370:Lung Injury; D008478:Mediastinal Emphysema / Q000175:diagnosis; D016017:Odds Ratio; D011030:Pneumothorax / Q000175:diagnosis; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011860:Radiography, Abdominal; D013902:Radiography, Thoracic; D012253:Rib Fractures / Q000175:diagnosis; D012680:Sensitivity and Specificity; D013898:Thoracic Injuries / Q000175:diagnosis*; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D014949:Wounds, Nonpenetrating / Q000175:diagnosis*