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Simma L, Fornaro J, Stahr N, Lehner M, Roos JE, Lima TVM. Optimising whole body computed tomography doses for paediatric trauma patients: a Swiss retrospective analysis. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022; 42:021521. [PMID: 35354135 DOI: 10.1088/1361-6498/ac6274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/30/2022] [Indexed: 06/14/2023]
Abstract
We aimed to evaluate the impact of a low-dose whole-body computed tomography (WBCT) protocol on radiation doses in paediatric major trauma patients. Retrospective cohort study of paediatric trauma patients (<16 years) at a national level 1 paediatric trauma centre (PTC) over a 6 year period prior and post introduction of a low-dose WBCT protocol (2014-2019). Demographic data, patient characteristics, CT device, and exposure information including scan range, dose-length product, and volume CT dose index were collected. Effective dose (ED) and exposure parameters were compared before and after protocol introduction. Forty-eight patients underwent WBCT during the study period. Prior to introduction of the low-dose protocol (n= 18), the ED was 20.6 mSv (median 20.1 ± 5.3 mSv [range 12.5-30.7]). After introduction of the low-dose WBCT protocol (n= 30), mean ED was 4.8 mSv (median 2.6 ± 5.0 [range: 0.8-19.1]). This resulted in a reduction of 77% in mean ED (pvalue <0.001). Significant radiation dose reduction of 77% can be achieved with low-dose WBCT protocols in PTCs.
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Affiliation(s)
- Leopold Simma
- Emergency Department, Children's Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Emergency Department, University Children's Hospital Zurich, University of Zurich, Steinwiessstrasse 75, Zurich, CH 8032, Switzerland
| | - Juergen Fornaro
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Nikolai Stahr
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Pediatric Radiology Department, Children's Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Markus Lehner
- Pediatric Surgery Department, Children's Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Justus E Roos
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Thiago Viana Miranda Lima
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Institute of Radiation Physics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Fromm J, Meuwly E, Wendling-Keim D, Lehner M, Kammer B. Clival fractures in children: a challenge in the trauma room setting! Childs Nerv Syst 2021; 37:1199-1208. [PMID: 33245407 DOI: 10.1007/s00381-020-04963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A clival fracture is a rare but life-threatening traumatic brain injury in the adult and pediatric populations. To date, there are very few conclusive recommendations in the literature concerning the diagnosis and treatment of pediatric clival fractures. METHODS In 2014 and 2015, two pediatric patients with severe blunt head trauma and clival fractures were evaluated and treated at a level I trauma center. Both cases are documented and supplemented by an extensive review of the literature focusing on the diagnostic workup, classification, and clinical course of clival fractures in children. RESULTS The clinical course of two children (8 and 9 years old) with clival fractures in concert with other intra- and extracranial injuries was analyzed. A total of 17 papers encompassing 37 patients (age range, 1-18 years) were included for a systematic review. The literature review revealed a mortality rate of 23% in pediatric patients with a clival fracture. Over 50% of the patients presented with cranial nerve damage, and two-thirds suffered from intracranial vascular damage or intracerebral bleeding. CONCLUSIONS Clival fractures are a very rare but severe consequence of blunt head trauma in the pediatric population and may be challenging to diagnose, especially in cases with an unfused sphenooccipital synchondrosis. Vascular damage following clival fractures appears to be as common in pediatric patients as in adults. Therefore, contrast-enhanced CT of the cervical spine and head and/or magnetic resonance angiography is strongly recommended to rule out vascular injury of the extra- and intracranial brain-supplying vessels within the trauma room setting.
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Affiliation(s)
- Julian Fromm
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Eliane Meuwly
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland
| | - Danielle Wendling-Keim
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Markus Lehner
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany. .,Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland.
| | - Birgit Kammer
- Pediatric Radiology, Department of Clinical Radiology, Ludwig-Maximilians-University Munich, Lindwurmstr. 4, 80337, Munich, Germany
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Polytraumaversorgung im Kindesalter – praktische und pragmatische Zusammenfassung der neuen Leitlinie. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Simma L, Stocker M, Lehner M, Wehrli L, Righini-Grunder F. Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study. Front Pediatr 2021; 9:721646. [PMID: 34708009 PMCID: PMC8544259 DOI: 10.3389/fped.2021.721646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission. Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018-2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital. Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%). Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.
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Affiliation(s)
- Leopold Simma
- Emergency Department, Children's Hospital Lucerne, Lucerne, Switzerland.,Emergency Department, University's Children Hospital Zurich, Zurich, Switzerland
| | - Martin Stocker
- Neonatal and Pediatric Intensive Care, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Markus Lehner
- Department of Pediatric Surgery, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Lea Wehrli
- Department of Pediatric Surgery, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Franziska Righini-Grunder
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
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Wendling-Keim DS, Hefele A, Muensterer O, Lehner M. Trauma Scores and Their Prognostic Value for the Outcome Following Pediatric Polytrauma. Front Pediatr 2021; 9:721585. [PMID: 34540770 PMCID: PMC8446435 DOI: 10.3389/fped.2021.721585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/04/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose: The management and prognostic assessment of pediatric polytrauma patients can pose substantial challenges. Trauma scores developed for adults are not universally applicable in children. An accurate prediction of the severity of trauma and correct assessment of the necessity of surgical procedures are important for optimal treatment. Several trauma scores are currently available, but the advantages and drawbacks for use in pediatric patients are unclear. This study examines the value of the trauma scores Injury Severity Score (ISS), Pediatric Trauma Score (PTS), National Advisory Committee for Aeronautics (NACA), and Glasgow Coma Score (GCS) for the assessment of the polytraumatized child. Methods: In a retrospective study, 97 patients aged 0-17 years who presented with polytrauma and an ISS ≥16 in the trauma bay were included in the study. Patient records including radiological studies were analyzed. Pathological imaging findings and emergency surgery were assessed as outcome variables and the predictive value of the trauma scores were analyzed using receiver operator characteristic (ROC) curves. Statistical significance was set at an alpha level of P ≤ 0.05. Results: In this study, 35 of the 97 studied children had pathological cranial computed findings. These either underwent craniectomy or trepanation or a parenchymal catheter was placed for intracranial pressure monitoring. Abdominal trauma was present in 45 patients, 16 of which were treated surgically. Forty-three patients arrived with thoracic injuries, 10 of which received a thoracic drainage. One child underwent an emergency thoracotomy. Predictive accuracy for emergency surgery calculated using receiver-operator characteristic (ROC) curves was highest for ISS and NACA scores (0,732 and 0.683, respectively), and lower for GCS (0.246) and PTS (0.261). Conclusion: In our study cohort, initial ISS and NACA scores better predicted operative interventions and outcome than PTS or GCS for polytraumatized pediatric patients.
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Affiliation(s)
- Danielle S Wendling-Keim
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Anja Hefele
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Oliver Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Markus Lehner
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany.,Department of Pediatric Surgery, Children's Hospital, Luzerner Kantonsspital, Lucerne, Switzerland
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Lehner M, Deininger S, Wendling-Keim D. Management des Schädel-Hirn-Traumas im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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