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Curtis K, Kennedy B, Lam MK, Mitchell RJ, Black D, Burns B, Dinh M, Smith H, Holland AJ. Emergency department management of severely injured children in New South Wales. Emerg Med Australas 2021; 33:1066-1073. [PMID: 34105264 DOI: 10.1111/1742-6723.13805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury. METHODS The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included. RESULTS There were 491 injured children who received treatment at 64 EDs, half (49.4%, n = 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n = 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n = 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n = 63) had two or more observations outside the normal range. CONCLUSION A small proportion of children arriving in the ED post-major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia.,Injury Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Belinda Kennedy
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mary K Lam
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Deborah Black
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brian Burns
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Greater Sydney Area HEMS, NSW Ambulance, Sydney, New South Wales, Australia
| | - Michael Dinh
- NSW Institute of Trauma and Injury Management, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Holly Smith
- Paediatric Emergency, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Andrew Ja Holland
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Abstract
OBJECTIVES Pediatric cervical spine injuries (CSIs) are rare but potentially fatal injuries. Plain radiographs (x-rays) and computed tomography (CT) are used to diagnose CSIs. Given concerns related to radiation exposure, the utility of x-rays in diagnosing CSIs compared with other forms of imaging must be examined. METHODS Patients younger than 19 years presenting with possible CSI to an urban tertiary care hospital who received imaging for possible CSI between January 1, 2011, and December 31, 2013, were included. The dose-length product was abstracted from the PACS system. Test performance for x-ray, CT, and MRI were calculated and effective radiation dose by age group was analyzed using the Kruskal-Wallis Test. RESULTS A total of 671 patient charts were reviewed, 574 children were included in the study cohort. Median age of enrolled children was 9.70 (interquartile range, 4.78-13.83) years; 42.5% were female. Test performance of x-ray, CT, and MRI to detect CSI were calculated. Cervical x-rays performed only slightly inferior to CT. Sensitivity was 83% (95% confidence interval [CI], 36-99%), and specificity was 97% (95% CI, 96%-99%) versus 100% (95% CI, 96%-100%) for CT. Median effective dose of radiation for cervical CTs was 4.51 mSv (interquartile range, 3.84-5.59 mSv). Median dose significantly increased with age (2.94-5.10 mSv, P < 0.001). CONCLUSIONS Plain radiographs were largely sufficient to screen for CSIs, indicating their utility as a screening tool for CSIs. The incidence of CSIs in our sample was similar to prior reports. The effective radiation dose delivered during pediatric head and cervical CTs were lower than previously published estimates.
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Hershkovitz Y, Zoarets I, Stepansky A, Kozer E, Shapira Z, Klin B, Halevy A, Jeroukhimov I. Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury. Am J Emerg Med 2014; 32:697-9. [DOI: 10.1016/j.ajem.2014.04.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/07/2014] [Indexed: 11/25/2022] Open
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Livingston MH, Igric A, Vogt K, Parry N, Merritt NH. Radiation from CT scans in paediatric trauma patients: Indications, effective dose, and impact on surgical decisions. Injury 2014; 45:164-9. [PMID: 23845570 DOI: 10.1016/j.injury.2013.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/28/2013] [Accepted: 06/09/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. PATIENTS AND METHODS We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient. RESULTS 157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12-75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0-16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. CONCLUSIONS CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.
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Affiliation(s)
- Michael H Livingston
- Division of General Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
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