Journal Club

Pediatric Blunt Trauma

By Sang •

Washington University Emergency Medicine Journal Club – September 8, 2026

Dr. Brian Cohn

Hello all,

This month our pediatric emergency medicine colleagues will be leading us in a great discussion on evaluation of pediatric blunt trauma. The PGY-1, PGY-3, and PGY-4 papers will be appraised using the Clinical Decision Rule appraisal form, while the PGY-2 paper will be appraised using the Meta-Analysis form.

Vignette

An 8-year-old girl is brought in by EMS as an unrestrained back-seat passenger following a high-speed motor vehicle collision with rollover. She was awake but confused on EMS arrival, and a cervical collar was placed prior to transport.

On arrival, her vital signs are: HR 118 bpm, BP 102/64 mmHg, RR 24/min, SpO2 98% on room air, afebrile. She is awake but dazed (GCS 14), complaining of neck and diffuse abdominal pain. Exam reveals bilateral periorbital ecchymosis, a faint abrasion across her lower abdomen concerning for a seatbelt-type mechanism, moderate abdominal tenderness without rebound, and midline posterior neck tenderness without focal neurologic deficits. Breath sounds are clear bilaterally and her pelvis is stable.

As the team begins her workup, the attending poses several questions: Does she need a CT abdomen, or is her risk low enough to defer imaging? Should a FAST be performed, and how much weight should the result carry? Do her periorbital ecchymosis and rollover mechanism warrant CTA screening for blunt cerebrovascular injury? And does her neck pain and tenderness mandate C-spine CT, or would plain films — or clinical exam — be appropriate under a validated pediatric rule? Given how much pediatric-specific decision tools have refined these answers in recent years, you decide to search the literature when the next opportunity arises…

PICO Question


Population: Children presenting to the emergency department with blunt trauma
(torso, head/face/neck, or overall polytrauma)


Intervention: Use of validated clinical decision rules / structured screening criteria
(PECARN IAI rule, POCUS/FAST-P stewardship framework, A+ BCVI criteria,
PECARN C-spine rule)


Comparison: Unstructured clinician gestalt or routine/liberal imaging


Outcome: Reduction in unnecessary CT/imaging utilization while maintaining high
sensitivity (and negative predictive value) for clinically important injury

Article 1: Holmes JF, Lillis K, Monroe D, et al; Pediatric Emergency Care Applied
Research Network (PECARN). Identifying children at very low risk of clinically
important blunt abdominal injuries. Ann Emerg Med. 2013 Aug;62(2):107-116.e2.
[Answer Key].


Article 2: Montoya K, Weinstein R, Kharasch S, Gottlieb M, Shokoohi H. A POCUS
stewardship framework for optimizing pediatric FAST in trauma: A conceptual
model and evidence synthesis. Am J Emerg Med. 2026 Jul;105:39-44. [Answer Key].


Article 3: Nickoles TA, Eubanks JW 3rd, Lewit RA, et al. The A+ criteria for pediatric
blunt cerebrovascular injury: An ATOMAC+ multicenter study. J Trauma Acute Care
Surg. 2025 Sep 1;99(3):404-411. [Answer Key].


Article 4: Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical
spine imaging of children presenting to the emergency department with blunt
trauma: a multicentre prospective observational study. Lancet Child Adolesc Health.
2024 Jul;8(7):482-490. [Answer Key].

Bottom Line

We reviewed four articles addressing clinical decision-making regarding injury screening in pediatric blunt trauma, spanning intra-abdominal injury, cerebrovascular injury, cervical spine injury, and point-of-care ultrasound (POCUS) use. Across all four sources, there was an emphasis on refining risk stratification to reduce unnecessary imaging in pediatric blunt trauma while maintaining high sensitivity to avoid missing clinically significant injury.

A prospective observational cohort using data from the Pediatric Emergency Care Applied Research Network (PECARN) at 20 centers, derived a clinical decision rule using 12,044 cases to identify children at very low risk for intra-abdominal injury requiring acute intervention. The derived 7-variable rule included the following:

  1. no evidence of abdominal wall trauma/seat belt sign
  2. GCS >13
  3. no abdominal tenderness
  4. no thoracic wall trauma
  5. no abdominal pain
  6. no decreased breath sounds
  7. no vomiting

The rule achieved a sensitivity of 97% (197/203), specificity of 42.5%, NPV of 99.9%, and negative likelihood ratio of 0.07. While this was a purely derivation study  (Level 4 clinical decision rule), the rule has since been validated in multiple studies (Holmes 2024, Frederick 2025).

A conceptual, non-systematic narrative review and evidence synthesis was conducted proposing a POCUS stewardship framework built on clinical indication, pre-test probability, spectrum effect, and dynamic sensitivity/specificity. Of roughly 340 identified articles, 35 were included in the narrative synthesis. The authors conclude that FAST-P (Focused Assessment with Sonography in Trauma-Pediatric) should be used as a rule-in tool in appropriate clinical contexts (unstable patients or high pre-test probability) rather than a rule-out test in low-risk patients. No quality assessment of included studies was performed, and the framework itself still requires prospective validation.

The ATOMAC+ study, a secondary analysis of prospectively collected data from six level 1 pediatric trauma centers (1,327 of 2,283 enrolled patients with adequate follow-up), found an overall blunt cerebrovascular injury (BCVI) incidence of 1.8%. BCVI was strongly associated with higher mortality and stroke risk. Multivariable analysis identified five independent predictors (temporal, sphenoid, and orbital roof fractures; C1–4 fractures; and cervical ligamentous injury) which were combined into proposed “A+” screening criteria. These criteria had a sensitivity of 91.7% for BCVI; specificity and likelihood ratios could not be calculated from the data provided. This is also a Level 4, unvalidated derivation study, and over 40% of enrolled patients were excluded from analysis for inadequate follow-up.

A prospective, observational, cohort study conducted at 18 PECARN-affiliated, level-1 pediatric trauma centers across the USA sought to derive and validate a clinical prediction rule to help guide radiographic screening for cervical spine injury among children. There 22,430 total pediatric cases involved, with 11,857 in the  derivation cohort and 10,573 in the validation cohort. A nine-factor prediction rule for cervical spine injury was derived:

High-risk factors

  1. Glasgow Coma Scale scores of 3-8
  2. Unresponsiveness to on the AVPU scale
  3. Abnormal airway/breathing/circulation
  4. Focal neurologic deficits

CART-derived risk factors

  1. Altered mental status
  2. Substantial head
  3. Substantial torso injury
  4. Midline neck pain
  5. Midline neck tenderness

In the proposed algorithm, patients with high-risk factors present would undergo CT scanning, while those with CART-derived risk factors by no high-risk factors would undergo plain x-ray. Those with no risk factors would be clinically cleared without additional imaging. This rule demonstrated a 94.3% sensitivity (95% CI 90.7–97.9), 60.4% specificity, 99.9% NPV, and a negative likelihood ratio of 0.094 in the validation cohort. Retrospective application of the rule-based algorithm was projected to reduce CT use from 17.2% to 6.9% of children without increasing plain x-ray use. Because this study included both derivation and validation cohorts, it qualifies as a more advanced Level 2 clinical decision rule