CONTINUING MEDICAL EDUCATION Continuing Medical Education Activity in Academic Emergency Medicine

Objectives: The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. Methods: This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (j) statistic for categorical variables and weighted j for ordinal variables. Variables with 95% lower confidence limits (LCLs) j 0.4 (moderate agreement or better) were considered to have acceptable agreement. Results: A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, j ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL j < 0.4. For the 17 objective findings, j ranged from –0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for j was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. Conclusions: Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intraabdominal injury in children with blunt trauma. ACADEMIC EMERGENCY MEDICINE 2013; 20:426–432 © 2013 by the Society for Academic Emergency Medicine From the Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin (KY), Milwaukee, WI; the Department of Emergency Medicine, University of California, Davis School of Medicine (NK, PES, JFH), Sacramento, CA; the Department of Pediatrics, Division of Emergency Medicine, State University of New York at Buffalo, Women and Children’s Hospital of Buffalo (KL), Buffalo, NY; the Department of Pediatrics, Howard County General Hospital (DM), Columbia, MD; the Department of Emergency Medicine, University of Michigan, Hurley Medical Center (DB), Flint, MI; the Department of Pediatrics, Division of Emergency Medicine, University of Cincinnati College of Medicine (BTK), Cincinnati, OH; the Department of Pediatrics, Division of Emergency Medicine Perelman School of Medicine, University of Pennsylvania (AME), Philadelphia, PA; and the Department of Pediatrics, University of Utah (LJC), Salt Lake City, UT. PECARN sites and acknowledgements are listed in Appendix A. Received August 22, 2012; revision received October 30, 2012; accepted October 31, 2012. Presented at the Pediatric Academic Societies annual meeting, Vancouver, BC, May 2010. This study was supported by Grant R49 CE001002-01 from the Centers for Disease Control and Prevention. PECARN is supported by cooperative agreements from HRSA/MCHB Emergency Medical Services for Children (EMSC) Program: U03MC00001, U03MC00007, U03MC00006, U03MC00003, and U03MC00008. The authors have no conflicts of interest to report. Supervising Editor: Shariar Zehtabchi, MD. Address for correspondence and reprints: Kenneth Yen, MD, MS; e-mail: [email protected]. 426 PII ISSN 1069-6563583 doi: 10.1111/acem.12132 ISSN 1069-6563 © 2013 by the Society for Academic Emergency Medicine Trauma remains the leading cause of death and disability in children in the United States, with intra-abdominal injury (IAI) the third leading cause of traumatic death (following injuries to the head and thorax). Rapid and appropriate evaluation of children at risk for IAI is therefore critical to the evaluation of injured children. The use of computed tomography (CT) has increased substantially over the past decade. Inappropriate use of CT exposes children to unnecessary ionizing radiation, and this exposure is linked to rises in the rates of leukemia and tumors. To limit unnecessary abdominal CT scanning, clinical prediction rules can help identify which children are at nonnegligible risk of IAI and therefore should be considered for CT scan. The first step in the development of a clinical prediction rule is the identification of historical and physical examination variables with acceptable reliability. Limited data, however, exist regarding the interobserver agreement of clinical variables in children with blunt abdominal trauma. The objective of this study was to assess the interobserver agreement of historical and physical examination variables elicited during the emergency department (ED) evaluations of children with blunt abdominal trauma.