'Seat-Belt Sign' Indicates Hidden Abdominal Injury Risk

BOSTON – Children who present to the emergency department with the classic "seat-belt sign" may have intra-abdominal injuries that warrant further investigation, even when they do not exhibit abdominal pain or tenderness, reported investigators at the annual meeting of the Pediatric Academic Societies.

The seat-belt sign – a continuous area of erythema, ecchymosis, or contusion caused by seat-belt pressure during a vehicle collision or impact – was significantly associated with risk for any intra-abdominal injury, reported Dr. Angela Ellison, an emergency physician at the Children’s Hospital of Philadelphia.

One-third of children with the seat-belt sign did not have abdominal pain or tenderness, yet 10% of those who also had an abdominal CT scan were found to have an intra-abdominal injury.

"Children with seat-belt sign are at high risk of intra-abdominal injury, primarily gastrointestinal injury, and are more likely to undergo acute intervention for intra-abdominal injury," Dr. Ellison said, speaking on behalf of colleagues in the Pediatric Emergency Care Applied Research Network.

The investigators analyzed a subset of patients from a prospective multicenter study of children presenting to 20 emergency departments with blunt torso trauma. They identified 3,740 children younger than 18 years with blunt abdominal trauma from a motor vehicle collision, excluding those with injuries older than 24 hours, those with preexisting neurologic disorders, and those transferred with prior abdominal images.

To scan or not to scan was left to the discretion of the treating physician, and clinical data, including findings of the presence or absence of a seat-belt sign, were collected. Patients were followed with a telephone call at 1 week if they were discharged after treatment or with medical records if they were admitted.

The authors found that 585 children (16%) had the seat-belt sign, and 3,155 (84%) did not. In all, 443 patients with the sign (76%) had an abdominal CT, compared with 1,415 (45%) of those lacking the sign (P less than .001). In total, 50% of the study population had an abdominal CT.

Among the patients who underwent CT, 19% of those with the seat-belt sign had some form of intra-abdominal injury, compared with 11% of those who had CT scans but no seat-belt sign (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3-2.1). Gastrointestinal injuries were the most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8; 95% CI, 5.5-17.4). There were no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

In multivariate analysis, they found that factors significantly associated with a risk for any intra-abdominal injury were the seat-belt sign (RR, 1.7; P less than .01), hypotension (RR, 2.6; P less than .01), Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01), decreased breath sounds (RR, 1.7; P = .03), abdominal tenderness (RR, 1.6; P less than .01), and evidence of thoracic trauma (RR, 1.4; P = .03).

Patients with the seat-belt sign were significantly more likely to undergo any acute intervention for intra-abdominal injury (RR, 4.5; 95% CI, 3.0-6.8), nothing-by-mouth orders and intravenous fluids for more than 2 nights (RR, 14.6; 95% CI, 7.1-29.9), laparotomy (RR, 9.5; 95% CI, 5.6-16.1), or blood transfusion (RR, 2.9; 95% CI, 1.6-5.1).

Of the 196 patients with the seat-belt sign but no abdominal pain or tenderness (34%), 103 had abdominal CT and, of this group, 11 (10.7%) had an intra-abdominal injury diagnosed. Of all 196 patients, 4 (2%) required an acute intervention for their injuries.

"Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients," Dr. Ellison said.

The study was supported by the National Center for Injury Prevention and Control and the Health Resources and Services Administration. Dr. Ellison and coauthors reported having no conflicts of interest.

BOSTON – Children who present to the emergency department with the classic "seat-belt sign" may have intra-abdominal injuries that warrant further investigation, even when they do not exhibit abdominal pain or tenderness, reported investigators at the annual meeting of the Pediatric Academic Societies.

The seat-belt sign – a continuous area of erythema, ecchymosis, or contusion caused by seat-belt pressure during a vehicle collision or impact – was significantly associated with risk for any intra-abdominal injury, reported Dr. Angela Ellison, an emergency physician at the Children’s Hospital of Philadelphia.

One-third of children with the seat-belt sign did not have abdominal pain or tenderness, yet 10% of those who also had an abdominal CT scan were found to have an intra-abdominal injury.

"Children with seat-belt sign are at high risk of intra-abdominal injury, primarily gastrointestinal injury, and are more likely to undergo acute intervention for intra-abdominal injury," Dr. Ellison said, speaking on behalf of colleagues in the Pediatric Emergency Care Applied Research Network.

The investigators analyzed a subset of patients from a prospective multicenter study of children presenting to 20 emergency departments with blunt torso trauma. They identified 3,740 children younger than 18 years with blunt abdominal trauma from a motor vehicle collision, excluding those with injuries older than 24 hours, those with preexisting neurologic disorders, and those transferred with prior abdominal images.

To scan or not to scan was left to the discretion of the treating physician, and clinical data, including findings of the presence or absence of a seat-belt sign, were collected. Patients were followed with a telephone call at 1 week if they were discharged after treatment or with medical records if they were admitted.

The authors found that 585 children (16%) had the seat-belt sign, and 3,155 (84%) did not. In all, 443 patients with the sign (76%) had an abdominal CT, compared with 1,415 (45%) of those lacking the sign (P less than .001). In total, 50% of the study population had an abdominal CT.

Among the patients who underwent CT, 19% of those with the seat-belt sign had some form of intra-abdominal injury, compared with 11% of those who had CT scans but no seat-belt sign (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3-2.1). Gastrointestinal injuries were the most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8; 95% CI, 5.5-17.4). There were no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

In multivariate analysis, they found that factors significantly associated with a risk for any intra-abdominal injury were the seat-belt sign (RR, 1.7; P less than .01), hypotension (RR, 2.6; P less than .01), Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01), decreased breath sounds (RR, 1.7; P = .03), abdominal tenderness (RR, 1.6; P less than .01), and evidence of thoracic trauma (RR, 1.4; P = .03).

Patients with the seat-belt sign were significantly more likely to undergo any acute intervention for intra-abdominal injury (RR, 4.5; 95% CI, 3.0-6.8), nothing-by-mouth orders and intravenous fluids for more than 2 nights (RR, 14.6; 95% CI, 7.1-29.9), laparotomy (RR, 9.5; 95% CI, 5.6-16.1), or blood transfusion (RR, 2.9; 95% CI, 1.6-5.1).

Of the 196 patients with the seat-belt sign but no abdominal pain or tenderness (34%), 103 had abdominal CT and, of this group, 11 (10.7%) had an intra-abdominal injury diagnosed. Of all 196 patients, 4 (2%) required an acute intervention for their injuries.

"Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients," Dr. Ellison said.

The study was supported by the National Center for Injury Prevention and Control and the Health Resources and Services Administration. Dr. Ellison and coauthors reported having no conflicts of interest.

BOSTON – Children who present to the emergency department with the classic "seat-belt sign" may have intra-abdominal injuries that warrant further investigation, even when they do not exhibit abdominal pain or tenderness, reported investigators at the annual meeting of the Pediatric Academic Societies.

The seat-belt sign – a continuous area of erythema, ecchymosis, or contusion caused by seat-belt pressure during a vehicle collision or impact – was significantly associated with risk for any intra-abdominal injury, reported Dr. Angela Ellison, an emergency physician at the Children’s Hospital of Philadelphia.

One-third of children with the seat-belt sign did not have abdominal pain or tenderness, yet 10% of those who also had an abdominal CT scan were found to have an intra-abdominal injury.

"Children with seat-belt sign are at high risk of intra-abdominal injury, primarily gastrointestinal injury, and are more likely to undergo acute intervention for intra-abdominal injury," Dr. Ellison said, speaking on behalf of colleagues in the Pediatric Emergency Care Applied Research Network.

The investigators analyzed a subset of patients from a prospective multicenter study of children presenting to 20 emergency departments with blunt torso trauma. They identified 3,740 children younger than 18 years with blunt abdominal trauma from a motor vehicle collision, excluding those with injuries older than 24 hours, those with preexisting neurologic disorders, and those transferred with prior abdominal images.

To scan or not to scan was left to the discretion of the treating physician, and clinical data, including findings of the presence or absence of a seat-belt sign, were collected. Patients were followed with a telephone call at 1 week if they were discharged after treatment or with medical records if they were admitted.

The authors found that 585 children (16%) had the seat-belt sign, and 3,155 (84%) did not. In all, 443 patients with the sign (76%) had an abdominal CT, compared with 1,415 (45%) of those lacking the sign (P less than .001). In total, 50% of the study population had an abdominal CT.

Among the patients who underwent CT, 19% of those with the seat-belt sign had some form of intra-abdominal injury, compared with 11% of those who had CT scans but no seat-belt sign (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3-2.1). Gastrointestinal injuries were the most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8; 95% CI, 5.5-17.4). There were no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

In multivariate analysis, they found that factors significantly associated with a risk for any intra-abdominal injury were the seat-belt sign (RR, 1.7; P less than .01), hypotension (RR, 2.6; P less than .01), Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01), decreased breath sounds (RR, 1.7; P = .03), abdominal tenderness (RR, 1.6; P less than .01), and evidence of thoracic trauma (RR, 1.4; P = .03).

Patients with the seat-belt sign were significantly more likely to undergo any acute intervention for intra-abdominal injury (RR, 4.5; 95% CI, 3.0-6.8), nothing-by-mouth orders and intravenous fluids for more than 2 nights (RR, 14.6; 95% CI, 7.1-29.9), laparotomy (RR, 9.5; 95% CI, 5.6-16.1), or blood transfusion (RR, 2.9; 95% CI, 1.6-5.1).

Of the 196 patients with the seat-belt sign but no abdominal pain or tenderness (34%), 103 had abdominal CT and, of this group, 11 (10.7%) had an intra-abdominal injury diagnosed. Of all 196 patients, 4 (2%) required an acute intervention for their injuries.

"Children with seat-belt sign and no abdominal pain or tenderness have a high risk of acute abdominal injury and a non-negligible risk of undergoing acute interventions for intra-abdominal injury. Therefore, we recommend that clinicians strongly consider additional evaluation in this subpopulation of patients," Dr. Ellison said.

The study was supported by the National Center for Injury Prevention and Control and the Health Resources and Services Administration. Dr. Ellison and coauthors reported having no conflicts of interest.