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Appelhaus S, Schönberg SO, Weis M. CT in pediatric trauma patients. ROFO-FORTSCHR RONTG 2024. [PMID: 39074798 DOI: 10.1055/a-2341-7559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
The decision as to whether to perform a computed tomography (CT) examination in severe pediatric trauma poses a challenge. The therapeutic benefit of computed tomography in injured children is lower compared to adults, while the potential negative effects of ionizing radiation may be higher. Thus, the threshold for CT should be higher. Centers that less frequently treat pediatric cases tend to conduct more whole-body CT examinations than dedicated pediatric trauma centers, indicating a clinical overestimation of injury severity with subsequently unnecessary imaging due to inexperience. On the other hand, a CT scan that is not performed but is actually necessary can also have negative consequences if an injury is detected with a delay. An injured child presents a challenging situation for all involved healthcare providers, and thus requires a structured approach to decision-making.Selective literature review of the benefits and risks of CT in injured children, as well as indications for whole-body and region-specific CT imaging.This article provides an overview of current guidelines, recent insight into radiation protection and the benefits of CT in injured children, and evidence-based decision criteria for choosing the appropriate modality based on the mechanism of injury and the affected body region. · Whole-body CT has less of an influence on treatment decisions and mortality in severely injured children than in adults.. · For radiation protection reasons, the indication should be determined more conservatively in children than in adult trauma patients.. · The indication for CT should ideally be determined separately for each region of the body.. · Ultrasound and MRI are a good alternative for the primary diagnostic workup in many situations.. · Appelhaus S, Schönberg SO, Weis M. CT in pediatric trauma patients. Fortschr Röntgenstr 2024; DOI 10.1055/a-2341-7559.
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Affiliation(s)
- Stefan Appelhaus
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Mannheim, Germany
| | - Stefan O Schönberg
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Mannheim, Germany
| | - Meike Weis
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Mannheim, Germany
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Groszman L, McCook KM, Xiang L, Parker L, Villamor LL, Koganti D, Smith RN, Sola R. Understanding Chest CT Scan Usage Among Adolescent Blunt Trauma Patients at Adult Trauma Centers. Am Surg 2024; 90:220-224. [PMID: 37619987 DOI: 10.1177/00031348231198121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE The utility of chest computed tomography (CCT) is not well established in the diagnostic algorithm of adolescent blunt trauma patients. Our study's aim was to review CCT usage in the initial evaluation of adolescent blunt trauma. METHODS We retrospectively reviewed adolescent blunt trauma patients treated at our urban level 1 adult trauma center from 2015 to 2019. Our primary outcome was the rate of positive CCT findings. Univariate and multivariate logistic regression analyses were performed. RESULTS There were 288 patients that met our inclusion criteria and 153 positive CCT and 135 negative CCT. There was no statistically significant difference between both groups in terms of age, gender, and race. Those with a positive CCT were found to have a statistically significant higher ISS than the negative CCT group (20.6 ± 12.3 vs 12.3 ± 7.6; P < .01). Those with a positive CCT were more likely to have a GCS <15 (40% vs 25%), have a positive CXR (38% vs 2%), have chest pain (16% vs 7%), and have an abnormal chest exam (27% vs 7%) than those with a negative CCT (P < .01). On multivariate analysis, positive CXR (P < .05, OR = 13.96) and ISS (P < .05, OR = 3.10) were independently associated with a positive CCT. CONCLUSION While CCT may provide valuable information, clinical exam coupled with low-ionizing radiographic imaging (i.e., CXR) may sufficiently identify chest trauma after blunt mechanisms. This shift in management can potentially reduce the risk of radiation without compromising the care of adolescent trauma patients at adult trauma centers.
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Affiliation(s)
- Lilly Groszman
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - Kem-Maria McCook
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - Laurel Xiang
- Center for Data Science, New York University, New York, NY, USA
| | - Laurel Parker
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Deepika Koganti
- Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
| | | | - Richard Sola
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
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Negus S, Bouamra O, Roland D. Have the UK Pediatric Trauma Protocols resulted in a reduction in chest computed tomography imaging for children presenting with major blunt trauma? J Am Coll Emerg Physicians Open 2023; 4:e13041. [PMID: 37736133 PMCID: PMC10509599 DOI: 10.1002/emp2.13041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023] Open
Abstract
Objectives To observe variation in imaging requests after publication of the Royal College of Radiologists UK Paediatric Trauma Protocols in 2014, recommending limited use of thoracic computed tomography (CT) to appropriately clinically risk stratified children. Method A retrospective observational study using data from the Trauma Audit & Research Network in the United Kingdom, for children (0-16 years of age) for the years 2012-2021. Percentages were calculated to facilitate comparison between year groups (under 1 year of age, 1-10 years of age, 11-15 years of age), and CT imaging categories reviewed: (1) whole-body CT (WBCT); (2) abdominopelvic CT (CTAP) with chest radiograph (CXR); (3) chest, abdomen, and pelvic CT (CTCAP) with CXR; (4) CTCAP without CXR; and (5) other imaging. Results Increased use of the recommended protocol (CXR with CTAP) was observed after guidance publication but was not sustained: infants under 1 year old, 0.0% in 2012, 7% in 2017, 0.0% in 2021; 1-10-year-olds, 4% in 2012, 13.9% in 2017, 5.5% in 2021; 11-15-year-olds, 7.1% in 2012, 10.2% in 2017, 6.6% in 2021. Requests for WBCT increased from 2012-2021 (all age groups, 2.4%, 2012, to 5.3%, 2021) and requests for CTCAP were consistently at a higher level than that of the recommended protocol. Conclusion The increased use of CXR with CTAP after publication of the guidelines, was not sustained with a decreasing trend observed from ∼2017, raising concern for the ionizing radiation burden in this population.
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Affiliation(s)
| | - Omar Bouamra
- The Trauma Audit & Research NetworkUniversity of ManchesterManchesterUK
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) GroupChildren's Emergency DepartmentLeicester Royal InfirmaryLeicesterUK
- SAPPHIRE GroupHealth SciencesLeicester UniversityLeicesterUK
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Lynch P, Samoilov L, Brahm G. Thoracic Imaging in Pediatric Trauma: Are CTs Necessary? Pediatr Emerg Care 2023; 39:98-101. [PMID: 36719391 DOI: 10.1097/pec.0000000000002896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Imaging algorithms for assessment of thoracic trauma in pediatric patients remain controversial, attempting to balance radiation dose and its associated risk with the need for thorough assessment of patients' injuries. This study reviewed the value of chest radiography in detecting traumatic injuries, and the impact that computed tomography (CT) had on clinical management. METHODS A retrospective review of pediatric trauma patients undergoing chest radiography and thoracic CT over a 2-year period at a level 1 trauma center was performed. The incidence of various traumatic injuries was documented, with measures of sensitivity and specificity on radiography. Clinical notes were reviewed to identify any changes in care based on CT findings. RESULTS Eighty-one pediatric trauma patients underwent thoracic CT over a 2-year period, with 60 patients meeting the inclusion criteria. Radiographs identified 47 traumatic injuries out of 117 seen on the subsequent CT examinations for a sensitivity of 41% and specificity of 91%. Radiographs were most sensitive in detecting osseous injuries with a sensitivity of 54%. Additional CT findings changed management in 2 of 60 cases, or 3.3% of the time. CONCLUSIONS Use of thoracic CT in pediatric trauma patients identifies a significantly greater number of injuries compared with than radiography but significantly increases radiation dose while changing management in only a very small proportion of cases. Despite the relatively small sample size, the findings reflect 2 years of experience at a level 1 trauma center, and this study suggests that it may be reasonable to decrease the frequency of cross-sectional imaging.
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Affiliation(s)
- Peter Lynch
- From the Department of Medical Imaging, Victoria Hospital, London
| | - Lucy Samoilov
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Gary Brahm
- From the Department of Medical Imaging, Victoria Hospital, London
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Mahdi E, Toscano N, Pierson L, Ndikumana E, Ayers B, Chacon A, Brayer A, Chess M, Davis C, Dorman R, Livingston M, Arca M, Wakeman D. Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients. J Pediatr Surg 2023; 58:111-117. [PMID: 36272813 DOI: 10.1016/j.jpedsurg.2022.09.027] [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: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE "Pan-scanning" pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children. METHODS In July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016-06/2017) and post-implementation (07/2017-08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles. RESULTS During the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation. CONCLUSIONS Quality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.
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Affiliation(s)
- Elaa Mahdi
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Nicole Toscano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Lauren Pierson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Eric Ndikumana
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Brian Ayers
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Alexander Chacon
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Anne Brayer
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Mitchell Chess
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Colleen Davis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Robert Dorman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Michael Livingston
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Marjorie Arca
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Derek Wakeman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States.
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Application of a Thoracic CT Decision Rule in the Evaluation of Injured Children: A Quality Improvement Initiative. J Trauma Nurs 2023; 30:48-54. [PMID: 36633345 DOI: 10.1097/jtn.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Differences in injury patterns in children suggest that life-threatening chest injuries are rare. Radiation exposure from computed tomography increases cancer risk in children. Two large retrospective pediatric studies have demonstrated that thoracic computed tomography can be reserved for patients based on mechanism of injury and abnormal findings on chest radiography. OBJECTIVE Implement a decision rule to guide utilization of thoracic computed tomography in the evaluation of pediatric blunt trauma, limiting risk of unnecessary radiation exposure and clinically significant missed injuries. METHODS A protocol for thoracic computed tomography utilization in pediatric blunt trauma was implemented using a Plan-Do-Study-Act cycle at our Level I pediatric trauma center, reserving thoracic computed tomography for patients with (1) mediastinal widening on chest radiography or (2) vehicle-related mechanism and abnormal chest radiography. We modified our resuscitation order set to limit default imaging bundles. The medical record and trauma registry data were reviewed for all pediatric blunt trauma patients (younger than 18 years) over a 30-month study period before and after protocol implementation (May 2017 to July 2018 and February 2019 to April 2020), allowing for a 6-month implementation period (August 2018 to January 2019). RESULTS During the study period, 1,056 blunt trauma patients were evaluated with a median (range) Injury Severity Score of 5 (0-58). There were no significant demographic differences between patients before and after protocol implementation. Thoracic computed tomography utilization significantly decreased after implementation of the protocol (26.4% [129/488] to 12.7% [72/568; p < .05]), with no increase in clinically significant missed injuries. Protocol compliance was 88%. CONCLUSIONS Application of decision rules can safely limit ionizing radiation in injured children. Further limitations to thoracic computed tomography utilization may be safe and warrant continued study due to the rarity of significant injuries.
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Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
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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: 0] [Impact Index Per Article: 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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Wiitala EL, Parker JL, Jones JS, Benner CA. Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers. Pediatr Emerg Care 2022; 38:e138-e142. [PMID: 32658115 DOI: 10.1097/pec.0000000000002183] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers. METHODS We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale. RESULTS There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198). CONCLUSIONS Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.
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Affiliation(s)
- Ellen L Wiitala
- From the Michigan State University College of Human Medicine
| | | | - Jeffrey S Jones
- From the Michigan State University College of Human Medicine
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10
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Esser M, Tsiflikas I, Kraus MS, Hess S, Gatidis S, Schaefer JF. Effectiveness of Chest CT in Children: CT Findings in Relation to the Clinical Question. ROFO-FORTSCHR RONTG 2021; 194:281-290. [PMID: 34649290 DOI: 10.1055/a-1586-3023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To estimate the effectiveness and efficiency of chest CT in children based on the suspected diagnosis in relation to the number of positive, negative, and inconclusive CT results. MATERIALS AND METHODS In this monocentric retrospective study at a university hospital with a division of pediatric radiology, 2019 chest CT examinations (973 patients; median age: 10.5 years; range: 2 days to 17.9 years) were analyzed with regards to clinical data, including the referring department, primary questions or suspected diagnosis, and CT findings. It was identified if the clinical question was answered, whether the suspected diagnosis was confirmed or ruled out, and if additional findings (clinically significant or minor) were detected. RESULTS The largest clinical subgroup was the hematooncological subgroup (n = 987), with frequent questions for inflammation/pneumonia (66 % in this subgroup). Overall, CT provided conclusive results in 97.6 % of all scans. In 1380 scans (70 %), the suspected diagnosis was confirmed. In 406/2019 cases (20 %), the CT scan was negative also in terms of an additional finding. In 8 of 9 clinical categories, the proportion of positive results was over 50 %. There were predominantly negative results (110/179; 61 %) in pre-stem cell transplant evaluation. In the subgroup of trauma management, 81/144 exams (57 %) showed positive results, including combined injuries (n = 23). 222/396 (56 %) of all additional findings were estimated to be clinically significant. CONCLUSION In a specialized center, the effectiveness of pediatric chest CT was excellent when counting the conclusive results. However, to improve efficiency, the clinical evaluation before imaging appears crucial to prevent unnecessary CT examinations. KEY POINTS · Pediatric chest CT in specialized centers has a high diagnostic value.. · CT identifies relevant changes besides the working hypothesis in clinically complex situations.. · Pre-CT clinical evaluation is crucial, especially in the context of suspected pneumonia.. CITATION FORMAT · Esser M, Tsiflikas I, Kraus MS et al. Effectiveness of Chest CT in Children: CT Findings in Relation to the Clinical Question. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1586-3023.
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Affiliation(s)
- Michael Esser
- Diagnostic and Interventional Radiology, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Ilias Tsiflikas
- Diagnostic and Interventional Radiology, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Mareen Sarah Kraus
- Diagnostic and Interventional Radiology, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Sabine Hess
- Diagnostic and Interventional Radiology, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Sergios Gatidis
- Diagnostic and Interventional Radiology, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Jürgen F Schaefer
- Diagnostic and Interventional Radiology, Universitätsklinikum Tübingen, Tübingen, Germany
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11
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Austin JR, Ye C, Lee MO, Chao SD. Does shock index, pediatric age-adjusted predict mortality by trauma center type? J Trauma Acute Care Surg 2021; 91:649-654. [PMID: 34559163 DOI: 10.1097/ta.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric trauma patients are treated at adult trauma centers (ATCs), mixed pediatric and ATCs (MTC), or pediatric trauma centers (PTCs). Shock index, pediatric age-adjusted (SIPA) can prospectively identify severely injured children. This study characterized the differences in mortality and hospital length of stay (LOS) among pediatric trauma patients with elevated SIPA (eSIPA) at different trauma centers types. METHODS Pediatric patients (1-14 years) were queried from the 2013 to 2016 National Trauma Data Bank. Patients with eSIPA were included for analysis. The primary outcome was mortality. Secondary outcomes included rates of splenectomy, computed tomography chest scans, laparotomy, and hospital LOS. Unadjusted frequencies and multivariable regression analyses were performed. An alpha level of 0.01 was used to determine significance. RESULTS Out of 189,003 pediatric trauma patients, 15,832 were included for analysis. After controlling for age, race, sex, payment method, Injury Severity Score, Glasgow Coma Scale score, hospital teaching status, and number of hospital beds, there was no significant difference in mortality among eSIPA patients at ATCs (odds ratio [OR], 0.753; p = 0.078) and MTCs (OR, 1.051; p = 0.776) when compared with PTCs. This remained true even among the most severely injured eSIPA patients (Injury Severity Score > 25). Splenectomy rates were higher at ATCs (OR, 3.234; p = 0.005), as were computed tomography chest scan rates (ATC OR, 4.423; p < 0.001; MTC OR, 6.070; p < 0.001) than at PTCs. There was a trend toward higher splenectomy rates at MTCs (OR, 2.910; p = 0.030) compared with PTCs, but this did not reach statistical significance. Laparotomy rates and hospital LOS were not significantly different. CONCLUSION Among eSIPA pediatric trauma patients, there was no difference in mortality between trauma center types. However, other secondary findings indicate that specialty care at PTCs may help optimize the care of pediatric trauma patients. LEVEL OF EVIDENCE Retrospective cohort study, level IV.
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Affiliation(s)
- John R Austin
- From the Division of Pediatric Surgery, Department of Surgery (J.R.A., C.Y., S.D.C.) and Department of Emergency Medicine (M.O.L.), Stanford University School of Medicine, Stanford, California
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Wu A, Edwards MJ, Le R, Ata A, Adderly J, Savage C, Rosati C, Edwards K, Duncan L. Pediatric evidence-based imaging guidelines for adult trauma providers significantly reduces radiation exposure to children. TRAUMA-ENGLAND 2021. [DOI: 10.1177/14604086211028452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction Evidence suggests that stand-alone pediatric trauma centers outperform adult and combined adult/pediatric trauma centers in limiting radiation exposure to injured children. We sought to determine the impact of implementing evidence-based guidelines for pediatric imaging at a combined adult (level 1) and pediatric (level 2) center. The initiative focused on trauma/critical care surgeons as the pediatric surgeons did not participate in the resuscitation and initial evaluation of injured children. Methods Imaging guidelines were developed from existing clinical studies. After 3 months of education, guidelines were implemented, and regular feedback was given to providers regarding compliance. Data were collected from the trauma registry for all pediatric patients (aged less than 15 years), in calendar years 2017 (pre-guideline) and 2019 (post-guideline). All admissions were analyzed, with subgroup analysis of children with multisystem trauma admitted to the trauma surgery service. Results Following guideline implementation, mean computed tomography (CT) scans per injured child fell by over 50% (.93 vs .45). For patients admitted to the trauma service, the mean fell by 58% (1.82 vs 0.76). The number of patients receiving more than 1 CT significantly decreased for all children (26% vs 10%), and particularly those admitted to the trauma service (52% vs 17%). During this time, there was only one injury missed at the initial admission, which was clinically insignificant (non-displaced skull fracture). Conclusions Implementation of evidence-based guidelines for imaging eliminates disparity in practices between a combined adult/pediatric trauma center and stand-alone pediatric trauma centers.
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Affiliation(s)
- Anna Wu
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Mary J Edwards
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Rachel Le
- Department of Emergency Medicine, Albany Medical College and Center, Albany, NY, USA
| | - Ashar Ata
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Jasmine Adderly
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Colleen Savage
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Carl Rosati
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Kurt Edwards
- Department of Surgery, Albany Medical College and Center, Albany, NY, USA
| | - Luke Duncan
- Department of Emergency Medicine, Albany Medical College and Center, Albany, NY, USA
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Henry R, Ghafil C, Pott E, Liasidis PK, Golden A, Henry RN, Matsushima K, Clark D, Inaba K, Strumwasser A. Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient. J Surg Res 2021; 266:284-291. [PMID: 34038850 DOI: 10.1016/j.jss.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/12/2021] [Accepted: 04/10/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. METHODS We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. RESULTS Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. CONCLUSION Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.
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Affiliation(s)
- Reynold Henry
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA.
| | - Cameron Ghafil
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
| | - Emily Pott
- Department of Emergency Medicine, University of California, San Diego, CA
| | | | - Adam Golden
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
| | - Rachel N Henry
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
| | - Damon Clark
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
| | - Aaron Strumwasser
- Division of Acute Care Surgery, University of Southern California; Los Angeles, CA
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Ugalde IT, Prater S, Cardenas-Turanzas M, Sanghani N, Mendez D, Peacock J, Guvernator G, Koerner C, Allukian M. Chest x-ray vs. computed tomography of the chest in pediatric blunt trauma. J Pediatr Surg 2021; 56:1039-1046. [PMID: 33051082 DOI: 10.1016/j.jpedsurg.2020.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Chest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR. METHODS This retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR. RESULTS In 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p < .0001), pneumothorax (23% vs 9%; p < .0001), rib fracture (18% vs 7%; p < .0001), other fracture (20% vs 10%; p < .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p < .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5-61.2) and 90.2% (95% CI: 86.8-93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively. CONCLUSION CXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children. LEVEL OF EVIDENCE Level III, diagnostic test.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX.
| | - Samuel Prater
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Marylou Cardenas-Turanzas
- School of Biomedical Informatics and McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Nipa Sanghani
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Donna Mendez
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - John Peacock
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Grace Guvernator
- Department of Anesthesiology, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Christine Koerner
- Department of Emergency Medicine, McGovern Medical School at UT Health Sciences Center, Houston, TX
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery and the Trauma Center at the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Marcu LG, Chau M, Bezak E. How much is too much? Systematic review of cumulative doses from radiological imaging and the risk of cancer in children and young adults. Crit Rev Oncol Hematol 2021; 160:103292. [DOI: 10.1016/j.critrevonc.2021.103292] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/20/2021] [Accepted: 02/27/2021] [Indexed: 01/18/2023] Open
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Shahi N, Phillips R, Acker SN, Meier M, Goldsmith A, Shirek G, Ladd P, Moulton SL, Bensard D. Enough is enough: Radiation doses in children with gastrojejunal tubes. J Pediatr Surg 2021; 56:668-673. [PMID: 32921427 DOI: 10.1016/j.jpedsurg.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies. METHODS All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy). RESULTS We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period. CONCLUSIONS Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy. LEVEL OF EVIDENCE IV TYPE OF STUDY: Treatment study.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Patricia Ladd
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Radiology, Children's Hospital Colorado
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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Yanchar NL, Lockyer L, Ball CG, Assen S. Pediatric versus adult paradigms for management of adolescent injuries within a regional trauma system. J Pediatr Surg 2021; 56:512-519. [PMID: 32933764 DOI: 10.1016/j.jpedsurg.2020.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/07/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We aimed to examine process and outcome indicators for adolescents with specific injury patterns managed in pediatric versus adult paradigms within the same trauma system. METHODS Adolescents (15-17 years old) admitted to the region's adult trauma center (ATC) or pediatric trauma center (PTC) with an abdominal injury, femur fracture or traumatic brain injury (TBI) were reviewed retrospectively. Global and injury-specific process and outcome indicators were compared. RESULTS Of 141 ATC and 69 PTC patients, injury patterns differed significantly with more TBI and abdominal injuries at the ATC and femur fractures at the PTC. Overall injury severity was greater at the ATC. Patients with solid organ injuries appeared more likely to undergo embolization or splenectomy at the ATC; however, higher injury grade and later time period were the only variables significantly associated with this. Computed tomography (CT) was used significantly more frequently at the ATC overall, most notable with panscanning and head CTs for major TBI. Time to operative management did not differ for patients with isolated femur fractures. Neuropsychological follow up after minor TBI was documented more often at the PTC than the ATC; there was no difference for those with more severe TBIs. CONCLUSIONS Management varies for adolescents between PTCs and ATCs with more exposure to radiation and less neuropsychological follow-up of less severe TBIs at the ATC. This presents distinct opportunities to identify best policies for triage and sharing of management practices within a single regional inclusive trauma system in order to optimize short and long-term outcomes for this population. TYPE OF STUDY Retrospective cohort. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Natalie L Yanchar
- Alberta Children's Hospital Trauma Program, 28 Oki Drive NW, Calgary, Alberta, Canada, T3B6A8; Department of Surgery, University of Calgary, 3333 Hospital Drive NW, Calgary, Alberta, Canada, T2N4N1.
| | - Lisette Lockyer
- Alberta Children's Hospital Trauma Program, 28 Oki Drive NW, Calgary, Alberta, Canada, T3B6A8
| | - Chad G Ball
- Foothills Medical Center Trauma Program, 1403 29 St NW, Calgary, Alberta, Canada, T2N2T9; Department of Surgery, University of Calgary, 3333 Hospital Drive NW, Calgary, Alberta, Canada, T2N4N1
| | - Scott Assen
- Department of Surgery, University of Calgary, 3333 Hospital Drive NW, Calgary, Alberta, Canada, T2N4N1
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Azari S, Hoover T, Dunstan M, Harrison TJ, Browne M. Review, monitor, educate: A quality improvement initiative for sustained chest radiation reduction in pediatric trauma patients. Am J Surg 2020; 220:1327-1332. [PMID: 32928539 DOI: 10.1016/j.amjsurg.2020.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We hypothesize that in pediatric trauma patients, CT scans after normal chest x-rays do not add information that alters clinical decision making. METHODS A retrospective review of trauma patients < 15 years with chest imaging evaluated at a pediatric trauma center between 1/2013 and 6/2019 was performed. Imaging was reviewed for significant findings that could affect care. A guideline was established in January 2017 which emphasized x-rays prior to CTs and no CTs after normal x-rays. A prospective review was performed from 1/2017-6/2019. Pre and post guideline groups were compared. RESULTS From 2013 to 2016, 246 patients met inclusion. 29.5% had a chest CT after a normal x-ray, only 1.8% (1/57) had a significant result. From 2017 to 2019, 188 patients were reviewed post guideline; only 9.4% received a CT after normal x-ray, of which 6.3% (1/16) were significant. Neither changed clinical management. CONCLUSIONS Chest CT following normal chest x-ray does not change clinical management in pediatric trauma patients. Monitoring and education following guideline implementation improves long term outcomes.
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Affiliation(s)
- Sarah Azari
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Travis Hoover
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Michele Dunstan
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Timothy J Harrison
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Lehigh Valley Reilly Children's Hospital, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA.
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Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States. J Pediatr Surg 2020; 55:1766-1772. [PMID: 32029235 DOI: 10.1016/j.jpedsurg.2020.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/20/2019] [Accepted: 01/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Liberal use of CT scanning in children with blunt trauma risks unnecessary radiation exposure and cost. Recent literature questions the utility of whole-body CT in stable children without clinical evidence of significant injury, but this is often done based on injury mechanism. The purpose of this study is to quantify the utilization of CT scans of the head, chest, abdomen, and pelvis based on injury severity in these body regions and to assess the impact of American College of Surgeons (ACS) pediatric trauma center designation on CT utilization in children with minor or no injuries. METHODS We queried the National Trauma Databank for 2014, 2015, and 2016 to identify all patients 14 years and younger. Using Abbreviated Injury Scale (AIS) score as a proxy for injury severity, we analyzed the number of head, thoracic, and abdominal CT scans done for patients at low levels of injury severity (AIS 0-2) in each of these body regions and according to trauma center level designation (ACS I, II, III, standalone pediatric I or II, and non ACS accredited). RESULTS Of 257,661 children who were entered into the database for any reason, overall CT utilization was 20% for head, 5% for the chest and 9% for the abdomen and pelvis. Children with no injuries or minimal injury to the head were scanned 7% and 46% of the time, respectively, for the chest 3% and 13% and for the abdomen 6% and 30%. For all body regions and all levels of injury severity, level 1 stand-alone pediatric centers displayed significantly lower CT utilization rates than others. CONCLUSION CT scan rates for children with minimal or no injuries to the head, chest, abdomen and pelvis are significant. Level 1 stand-alone pediatric trauma centers are least likely to perform these studies. Widespread education and acceptance of clinical guidelines for imaging in stable patients throughout trauma systems could alleviate this disparity. LEVEL OF EVIDENCE Level III retrospective comparative study.
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20
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Nicholas NW, Shaw DR, Puppala S. Pictorial review on the endovascular management of paediatric aortic injuries. Br J Radiol 2020; 93:20190017. [PMID: 31899661 DOI: 10.1259/bjr.20190017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Paediatric aortic trauma is a rare injury which can be fatal if not identified and managed appropriately. Surgical repair remains the gold-standard in moderate to severe aortic injuries. In the last decade however, endovascular treatment has gained popularity in children who have suitable vascular anatomy for intervention and are either not fit for surgery or in whom, endovascular intervention is the only alternative that will make a difference in the clinical outcome. Children pose a unique set of challenges to endovascular therapy. In this article, we aim to illustrate the different endovascular options that are available for the treatment of acute traumatic aortic injury and visceral thromboembolisation through pictorial representation. We will also demonstrate the feasibility and the limitation of this technique.
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Affiliation(s)
- Neville W Nicholas
- Department of Interventional Radiology, Leeds Teaching Hospital NHS Trust, Leeds, UK
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21
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Abstract
INTRODUCTION Given the concern for radiation-induced malignancy in children and the fact that risk of severe chest injury in children is low, the risk/benefit ratio must be considered in each child when ordering a computed tomography (CT) scan after blunt chest trauma. METHODS The study included pediatric blunt trauma patients (age, <15 years) with chest radiograph (CR) before chest CT on admission to our adult and pediatric level I trauma center. Surgeons were asked to view the blinded images and reads and indicate if they felt CT was warranted based on CR findings, if their clinical management change based on additional findings on chest CT, and how they might change management. RESULTS Of the 127 patients identified, 64.6% had no discrepancy between their initial CR and chest CT and 35.4% of the children's imaging contained a discrepancy. The majority of the pediatric and general trauma surgeons felt CT was indicated in 6 of 45 patients based on CR. In 87% of patients with a discrepancy in findings on CR and CT, the majority of surgeons agreed that their management would not change based on the additional information. In the 6 patients in which the CT was considered indicated, 4 of the 6 would have triggered a management change. CONCLUSIONS Our study suggests that chest CT scans frequently serve as confirmatory diagnostic tools and in the pediatric blunt chest trauma patient and can be withheld in many cases without hindering the management of an injured child.
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Blunt traumatic scapular fractures are associated with great vessel injuries in children. J Trauma Acute Care Surg 2019; 85:932-935. [PMID: 29787531 DOI: 10.1097/ta.0000000000001980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patients with stable blunt great vessel injury (GVI) can have poor outcomes if the injury is not identified early. With current pediatric trauma radiation reduction efforts, these injuries may be missed. As a known association between scapular fracture and GVI exists in adult blunt trauma patients, we examined whether that same association existed in pediatric blunt trauma patients. METHODS Bluntly injured patients younger than 18 years old were identified from 2012 to 2014 in the National Trauma Data Bank. Great vessel injury included all major thoracic vessels and carotid/jugular. Demographics of patients with and without scapular fracture were compared with descriptive statistics. The χ test was used to examine this association using SAS Version 9.4 (SAS Institute, Inc, Cary, NC). RESULTS We found a significant association between pediatric scapular fracture and GVI. Of 291,632 children identified, 1,960 had scapular fractures. Children with scapular fracture were 10 times more likely to have GVI (1.2%) compared to those without (0.12%, p < 0.0001). Most common GVI seen were carotid artery, thoracic aorta, and brachiocephalic or subclavian artery or vein. Children with both scapular fracture and GVI were most commonly injured by motor vehicles (57% collision, 26% struck). CONCLUSIONS Injured children with blunt scapular fracture have a 10-fold greater risk of having a GVI when compared to children without scapular fracture. Presence of blunt traumatic scapular fracture should have appropriate index of suspicion for a significant GVI in pediatric trauma patients. LEVEL OF EVIDENCE Epidemiologic and prognostic study, level III; Therapeutic, level IV.
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Predictors for Pediatric Blunt Cerebrovascular Injury (BCVI): An International Multicenter Analysis. World J Surg 2019; 43:2337-2347. [DOI: 10.1007/s00268-019-05041-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Trauma is the leading cause of morbidity and mortality in the pediatric population. Due to a variety of factors, many pediatric trauma patients are initially evaluated and stabilized at adult hospitals that lack pediatric specific emergency medicine and surgical expertise. While similar to adult patients, the initial evaluation and resuscitation of pediatric patients does differ. Many of these key differences contribute to missed injury and susceptibility to error in the treatment of children. Here, we highlight a variety of differences between pediatric and adult trauma patients and clarify reasoning for these differences. Error traps that are discussed include missed cases of non-accidental trauma, missed blunt cerebrovascular injury, over use of CT (computed tomography) scans with unnecessary radiation exposure, missed small bowel or mesenteric injury, and unrecognized hemodynamic instability.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Ann M Kulungowski
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA.
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Lodwick DL, Cooper JN, Gonzalez DO, Lawrence AE, Lee C, Krishnamurthy R, Minneci PC, Deans KJ. Disparities in Radiation Burden from Trauma Evaluation at Pediatric Versus Nonpediatric Institutions. J Surg Res 2018; 232:475-483. [DOI: 10.1016/j.jss.2018.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/13/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
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Anton-Martin P, Willis BC, Nigro JJ, Budolfson K, Raz D, Jamshidi R. Complete traumatic aortic transection. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Does the incidence of thoracic aortic injury warrant the routine use of chest computed tomography in children? J Trauma Acute Care Surg 2018; 86:97-100. [PMID: 30278020 DOI: 10.1097/ta.0000000000002082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thoracic aortic injury is a potentially life-threatening injury associated with rapid deceleration mechanisms. Diagnosis is made by chest computed tomography (CT), which is associated with a risk of radiation-induced malignancy. We sought to determine the incidence of aortic injuries in the pediatric population to weigh against the risk of CT imaging. METHODS The Pediatric Health Information Systems was queried for children ≤18 years with discharge diagnosis code of thoracic aortic injury (901.0) between December 2004 and 2014. Data abstracted included patient age, gender, diagnosis and procedure codes, and discharge disposition, where available. We also queried for imaging codes to determine what type of chest imaging the child received. RESULTS Between December 2004 and 2014, 311,850 children were admitted to Pediatric Health Information Systems hospitals with traumatic injury. Of these patients, 46 (0.015%) were coded with a thoracic aortic injury and an accompanying E-code. Twenty-seven patients (58.7%) were male, and the median age was 13 years. The most common mechanism of injury was motor vehicle collision (63%, n = 29). Eighteen hospitals (41.9%) had no patients with a thoracic aortic injury in the 10-year period. In children with a thoracic aortic injury, the mortality rate was 11% (n = 5) and 22 (47.8%) underwent a chest CT during their hospitalization. Forty percent (124,909) of all trauma patients underwent chest CT, with a positive rate for aortic injury of 1.8/10,000. The reported estimated cancer risk from a chest CT scan is 25/10,000 for girls and 7.5/10, 000 in boys, greater than the positive CT rate. CONCLUSION Thoracic aortic injuries are rare in children in the United States. The risk of cancer associated with screening chest CT is greater than the likelihood of identifying an aortic injury. Therefore, screening chest CT scans are unwarranted in injured children. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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Katayama Y, Kitamura T, Hirose T, Kiguchi T, Matsuyama T, Sado J, Kiyohara K, Izawa J, Tachino J, Ebihara T, Yoshiya K, Nakagawa Y, Shimazu T. Delay of computed tomography is associated with poor outcome in patients with blunt traumatic aortic injury: A nationwide observational study in Japan. Medicine (Baltimore) 2018; 97:e12112. [PMID: 30170440 PMCID: PMC6392548 DOI: 10.1097/md.0000000000012112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
According to guidelines from the Eastern Association for the Surgery of Trauma, computed tomography (CT) with intravenous contrast is strongly recommended to diagnose clinically significant blunt traumatic aortic injury (BTAI). However, it remains unclear whether the timing of CT scanning is associated with the prognosis of BTAI patients.We extracted data on emergency patients who suffered a BTAI in the chest and/or the abdomen from 2004 to 2015 from the Japanese Trauma Data Bank, a nationwide trauma registry. The primary outcome was death in the emergency department (ED) and secondary outcome was discharge to death. In addition, we assessed the relationship between death in the ED and the timing of CT scanning by shock status in subgroup analysis. We divided these patients into the tertile groups of early (≤26 minutes), middle (27-40 minutes), and late (≥41 minutes) phases based on the time interval from hospital arrival to start of first CT scanning, and assessed death of BTAI patients in the ED by CT scanning time with the use of a multivariable logistic regression model.In total, 421 patients who suffered BTAI in the chest and/or the abdomen were eligible for our analysis. The proportion of patients dying at hospital admission was 7.7% (11/142) in the early group, 11.1% (15/135) in the middle group, and 17.6% (25/144) in the late group. In a multivariable logistic regression adjusted for confounding factors, the adjusted odds ratio (AOR) of death in the ED was 1.833 (95% confidence interval [CI]: 0.601-5.590, P = .287) in the middle group and 2.832 (95% CI: 1.007-7.960, P = .048) in the late group compared with the early group. Compared with the early group, the late group tended to have a higher rate of discharge to death (AOR: 1.438, 95% CI: 0.735-2.813). In the patients with shock, the AOR was 3.292 (95% CI: 0.495-21.902) in the middle group and 6.039 (95% CI: 0.990-36.837) in the late group compared with the early group.This study revealed that a longer time interval from hospital arrival to CT scanning was associated with higher mortality in the ED in patients with BTAI.
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Affiliation(s)
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine
- Emergency and Critical Care Center, Osaka Police Hospital, Osaka
| | | | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto
| | - Junya Sado
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita
| | - Kosuke Kiyohara
- Department of Public Health, Tokyo Women's Medical University
| | - Junichi Izawa
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | | | - Yuko Nakagawa
- Department of Traumatology and Acute Critical Medicine
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Kiragu AW, Dunlop SJ, Mwarumba N, Gidado S, Adesina A, Mwachiro M, Gbadero DA, Slusher TM. Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions. Front Pediatr 2018; 6:155. [PMID: 29915778 PMCID: PMC5994692 DOI: 10.3389/fped.2018.00155] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/09/2018] [Indexed: 12/15/2022] Open
Abstract
Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3-6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.
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Affiliation(s)
- Andrew W. Kiragu
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
| | - Stephen J. Dunlop
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- Division of Global Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Njoki Mwarumba
- Department of Political Science, Oklahoma State University, Stillwater, OK, United States
| | - Sanusi Gidado
- Department of Surgery, Bingham University Teaching Hospital, Jos, Nigeria
| | - Adesope Adesina
- Department of Surgery, Bowen University Teaching Hospital, Ogbomosho, Nigeria
| | | | - Daniel A. Gbadero
- Department of Pediatrics, Bowen University Teaching Hospital, Ogbomosho, Nigeria
| | - Tina M. Slusher
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
- Division of Global Pediatrics, University of Minnesota, Minneapolis, MN, United States
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Abstract
Thoracic injuries account for less than one-tenth of all pediatric trauma-related injuries but comprise 14% of pediatric trauma-related deaths. Thoracic trauma includes injuries to the lungs, heart, aorta and great vessels, esophagus, tracheobronchial tree, and structures of the chest wall. Children have unique anatomic features that change the patterns of observed injury compared with adults. This review article outlines the clinical presentation, diagnostic testing, and management principles required to successfully manage injured children with thoracic trauma.
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Affiliation(s)
- Stacy L Reynolds
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, 3rd Floor Medical Education Building, Charlotte, NC 28203, USA.
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Sharma S, Mishra B, Gupta A, Soni KD, Aggarwal R, Kumar S. Challenges in Management of Pediatric Life-threatening Neck and Chest Trauma. J Indian Assoc Pediatr Surg 2018; 23:10-15. [PMID: 29386758 PMCID: PMC5772087 DOI: 10.4103/jiaps.jiaps_49_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Introduction: Neck and thoracic trauma in children pose unforeseen challenges requiring variable management strategies. Here, we describe some unusual cases. Patients and Methods: Pediatric cases of unusual neck and thoracic trauma prospectively managed from April 2012 to March 2014 at a Level 1 trauma center were studied for management strategies, outcome, and follow-up. Results: Six children with a median age of 5.5 (range 2–10) years were managed. Mechanism of injury was road traffic accident, fall from height and other accidental injury in 2, 3 and 1 patient respectively. The presentation was respiratory distress and quadriplegia, exposed heart, penetrating injury in neck, dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases respectively. Injuries included lung laceration, open chest wall, vascular injury of the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis. One patient had a flare of miliary tuberculosis. Immediate management included chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal stapling, and feeding jejunostomy (followed by gastric pull-up 8 months later). Chest tube insertion and total parenteral nutrition was required in one each. 2 and 4 patients required tracheostomy and mechanical ventilation. The patient with gastric pull-up developed a stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. At follow-up of 40–61 months, five patients are well. One patient with penetrating neck injury suffered from blindness due to massive hemorrhage from the vascular injury in the neck and brain ischemia with only peripheral vision recovery. Conclusion: Successful management of neck and chest wall trauma requires timely appropriate decisions with a team effort.
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Affiliation(s)
- Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Intensive and Critical Care, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Richa Aggarwal
- Department of Intensive and Critical Care, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Trauma Surgery, JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Stephens CQ, Boulos MC, Connelly CR, Gee A, Jafri M, Krishnaswami S. Limiting thoracic CT: a rule for use during initial pediatric trauma evaluation. J Pediatr Surg 2017; 52:2031-2037. [PMID: 28927984 DOI: 10.1016/j.jpedsurg.2017.08.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite increases in imaging guidelines for other body-regions during initial trauma assessment and the demonstrated utility of chest radiographs (CXR), guidelines for use of thoracic computed-tomography (TCT) are lacking. We hypothesized that TCT utilization had not decreased relative to other protocolized CTs, and mechanism and CXR could together predict significant injury independent of TCT. METHODS We performed a retrospective review of blunt trauma patients ≤18 y.o. (2007-2015) at two level-1 trauma centers who received chest imaging. Baseline characteristics and incidences of body region-specific CT were compared. Injury mechanism, intrathoracic pathology, and interventions among other data were examined (significance: p<0.05). RESULTS Although other body-region CT incidence decreased (p<0.05), TCT incidence did not change (p=0.65). Of the 2951 patients, 567 had both CXR and TCT, 933 received TCT-only, and 1451 had CXR-only. TCT altered management in 17 patients: 2 operations, 1 stent-placement, 1 medical management, 9 thoracostomy tube placements, and 4 negative diagnostic workups. All clinically significant changes were predicted by vehicle-related mechanism and abnormal CXR findings. CONCLUSIONS TCT utilization has not decreased over time. All meaningful interventions were predicted by CXR and mechanism of injury. We propose a rule, for prospective validation, reserving TCT for patients with abnormal CXR findings and severe vehicle-related trauma. LEVEL OF EVIDENCE Diagnostic study, Level III.
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Affiliation(s)
- Caroline Q Stephens
- Oregon Health & Science University, Department of Surgery, Division of Pediatric Surgery, Portland, OR.
| | - Meredith C Boulos
- Oregon Health & Science University, Department of Surgery, Division of Pediatric Surgery, Portland, OR
| | - Christopher R Connelly
- Oregon Health & Science University, Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Portland, OR
| | - Arvin Gee
- Oregon Health & Science University, Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Portland, OR
| | - Mubeen Jafri
- Oregon Health & Science University, Department of Surgery, Division of Pediatric Surgery, Portland, OR; Legacy Emanuel Medical Center-Randall Children's Hospital, Portland, OR
| | - Sanjay Krishnaswami
- Oregon Health & Science University, Department of Surgery, Division of Pediatric Surgery, Portland, OR; Legacy Emanuel Medical Center-Randall Children's Hospital, Portland, OR
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Examining the role of follow-up skeletal surveys in non-accidental trauma. Am J Surg 2017; 213:606-610. [DOI: 10.1016/j.amjsurg.2016.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 12/09/2016] [Indexed: 11/23/2022]
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Abstract
Pediatric thoracic trauma is relatively uncommon but results in disproportionately high levels of morbidity and mortality when compared with other traumatic injuries. These injuries are often more devastating due to differences in children׳s anatomy and physiology relative to adult patients. A high index of suspicion is of utmost importance at the time of presentation because many significant thoracic injuries will have no external signs of injury. With proper recognition and management of these injuries, there is an associated improved long-term outcome. This article reviews the current literature and discusses the initial evaluation, current management practices, and future directions in pediatric thoracic trauma.
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Affiliation(s)
- Erik G Pearson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Matthew T Santore
- Section of Pediatric Surgery, Department of Surgery, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Third Floor Surgical Offices, 1405 Clifton Rd, Atlanta, Georgia 30322.
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Limiting chest computed tomography in the evaluation of pediatric thoracic trauma. J Trauma Acute Care Surg 2016; 81:271-7. [DOI: 10.1097/ta.0000000000001110] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Walther AE, Falcone RA, Pritts TA, Hanseman DJ, Robinson BR. Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents. J Pediatr Surg 2016; 51:1346-50. [PMID: 27132539 PMCID: PMC5558261 DOI: 10.1016/j.jpedsurg.2016.03.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/06/2016] [Accepted: 03/29/2016] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE This study aims to investigate differences in imaging, procedure utilization, and clinical outcomes of severely injured adolescents treated at adult versus pediatric trauma centers. METHODS The National Trauma Data Bank was queried retrospectively for adolescents, 15-19years old, with a length of stay (LOS) >1day and Injury Severity Score (ISS) >25 treated at adult (ATC) or pediatric (PTC) Level 1 trauma centers from 2007 to 2011. Patient demographics and utilization of imaging and procedures were analyzed. Univariate and multivariate regression analysis was used to compare outcomes. RESULTS Of 12,861 adolescents, 51% were treated at ATC. Older age and more nonwhites were seen at ATC (p<0.01). Imaging and invasive procedures were more common at ATC (p<0.01). Shorter LOS (p=0.03) and higher home discharge rates (p<0.01) were seen at PTC. ISS and mortality did not differ. Age, race, ATC care (all p<0.01), and admission systolic blood pressure (SBP) (p=0.03) were predictors of CT utilization. ISS, SBP, and race (p<0.01) were risk factors for overall mortality; SBP (p=0.03) and ISS (p<0.01) predicted death from penetrating injury. CONCLUSIONS Severely injured adolescents experience improved outcomes and decreased imaging and invasive procedures without additional mortality risk when treated at PTC. PTC is an appropriate destination for severely injured adolescents.
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Affiliation(s)
- Ashley E. Walther
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Timothy A. Pritts
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Dennis J. Hanseman
- Division of Trauma and Critical Care, Department of Surgery, University of Cincinnati College of Medicine, USA
| | - Bryce R.H. Robinson
- Division of Trauma, Critical Care, and Burns, Department of Surgery, University of Washington, USA,Corresponding author at: Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA, 98104-2499, USA. Tel.: +1 206 744 8485; fax: +1 206 744 3656
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de la Morandiere K. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET: Is CT thorax necessary to exclude significant injury in paediatric patients with blunt chest trauma? Emerg Med J 2016. [PMID: 26195475 DOI: 10.1136/emermed-2015-205158.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A shortcut review was carried out to establish if CXR had sufficient sensitivity to rule out significant thoracic injury in haemodynamically stable, paediatric patients with a significant mechanism of trauma. No studies were found that directly answered the three-part question, but 13 studies were found which were considered relevant. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that important thoracic injuries may not be clinically apparent and that CT scans have a significantly higher sensitivity than CXR in detecting such injuries.
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The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers? J Pediatr Surg 2016; 51:649-53. [PMID: 26778841 DOI: 10.1016/j.jpedsurg.2015.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the management of pediatric trauma patients. METHODS We performed a two year (2011-2012) retrospective analysis of the National Trauma Data Bank. Pediatric (age≤18years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck, thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was performed. RESULTS A total of 30,667 pediatric trauma patients were included of which; 38.3% (n=11,748) were managed in designated pediatric centers. 26.1% (n=8013) patients received a WBCT. The use of WBCT scan was significantly higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p=0.001). There was no difference in mortality rate between the two groups (2.2% vs. 2.1%, p=0.37). After adjusting for all confounding factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3-2.1], p=0.001). CONCLUSIONS Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increasing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of WBCT across centers is warranted.
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Abstract
Purpose of review In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs. Recent findings In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes. Summary Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.
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Marin JR, Wang L, Winger DG, Mannix RC. Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits. J Pediatr 2015; 167:897-904.e3. [PMID: 26233603 PMCID: PMC4881390 DOI: 10.1016/j.jpeds.2015.06.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/25/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. STUDY DESIGN This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use. RESULTS Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs. CONCLUSION There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.
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Affiliation(s)
- Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Rebekah C Mannix
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Computed tomography-related radiation exposure in children transferred to a Level I pediatric trauma center. J Trauma Acute Care Surg 2015; 78:1134-7. [PMID: 26151513 DOI: 10.1097/ta.0000000000000645] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Pediatric trauma patients presenting to referring facilities (RF) often undergo computed tomography (CT) scans to identify injuries before transfer to a Level I pediatric trauma center (PTC). The purpose of our study was to evaluate RF compliance with the American College of Radiology (ACR) guidelines to minimize ionizing radiation exposure in pediatric trauma patients and to determine the frequency of additional or repeat CT imaging after transfer to a PTC. METHODS After institutional review board approval, a retrospective review of all pediatric trauma admissions from January 2010 to December 2011 at our American College of Surgeons Level I PTC was performed. Patient demographics, means of arrival, Injury Severity Score, and disposition were analyzed. Patients who underwent CT were grouped by means of arrival: those who were transferred from an RF versus those who presented primarily to the PTC. Compliance with ACR guidelines and need for additional or repeat CT scans were assessed for both groups. RESULTS Six hundred ninety-seven children (aged <18 years) were identified, with a mean age of 10.6 years. Three hundred twenty-one (46%) patients presented primarily to the PTC. Three hundred seventy-six (54%) were transferred from an RF, of which 90 (24%) patients underwent CT imaging before transfer. CT radiation dosing information was available for 79 (88%) of 90 patients. After transfer, 8 (9%) of 90 of children imaged at an RF required additional CT scans. In comparison, 314 (98%) of 321 patients who presented primarily to the PTC and underwent CT received appropriate pediatric radiation dosing. Mean radiation dose at PTC was approximately half of that at RF for CT scans of the head, chest, and abdomen/pelvis (p < 0.01). CONCLUSION Pediatric trauma patients transferred from RF often undergo CT scanning with higher than recommended radiation doses, potentially placing them at an increased carcinogenic risk. Fortunately, few RF patients required additional CT scans after PTC transfer. Finally, compliance with ACR radiation dose limit guidelines is better achieved at a PTC. LEVEL OF EVIDENCE Care management study, level IV.
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Acker SN, Stewart CL, Roosevelt GE, Partrick DA, Moore EE, Bensard DD. When is it safe to forgo abdominal CT in blunt-injured children? Surgery 2015; 158:408-12. [DOI: 10.1016/j.surg.2015.03.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/13/2015] [Accepted: 03/17/2015] [Indexed: 11/28/2022]
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McFadden D, Souba WW. Change is good! The Journal of Surgical Research: 2014-2015. J Surg Res 2015; 197:1-4. [PMID: 25982043 DOI: 10.1016/j.jss.2015.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David McFadden
- Department of Surgery, University of Connecticut Health Center, Hartford, CT.
| | - Wiley W Souba
- Department of Surgery, Dartmouth College of Medicine, Hanover, NH
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Westra SJ, Thacker PG, Podberesky DJ, Lee EY, Iyer RS, Hegde SV, Guillerman RP, Mahani MG. The incidental pulmonary nodule in a child. Part 2: Commentary and suggestions for clinical management, risk communication and prevention. Pediatr Radiol 2015; 45:634-9. [PMID: 25655370 DOI: 10.1007/s00247-014-3269-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 11/19/2014] [Accepted: 12/19/2014] [Indexed: 12/21/2022]
Abstract
The incidental detection of small lung nodules in children is a vexing consequence of an increased reliance on CT. We present an algorithm for the management of lung nodules detected on CT in children, based on the presence or absence of symptoms, the presence or absence of elements in the clinical history that might explain these nodules, and the imaging characteristics of the nodules (such as attenuation measurements within the nodule). We provide suggestions on how to perform a thoughtfully directed and focused search for clinically occult extrathoracic disease processes (including malignant disease) that may present as an incidentally detected lung nodule on CT. This algorithm emphasizes that because of the lack of definitive information on the natural history of small solid nodules that are truly detected incidentally, their clinical management is highly dependent on the caregivers' individual risk tolerance. In addition, we present strategies to reduce the prevalence of these incidental findings, by preventing unnecessary chest CT scans or inadvertent inclusion of portions of the lungs in scans of adjacent body parts. Application of these guidelines provides pediatric radiologists with an important opportunity to practice patient-centered and evidence-based medicine.
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Affiliation(s)
- Sjirk J Westra
- Division of Pediatric Radiology, Massachusetts General Hospital, 34 Fruit St., White 246A, Boston, MA, 02114, USA,
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Sharp NE, Svetanoff WJ, Alemayehu H, Desai A, Raghavan MU, Sharp SW, Brown JC, Rivard DC, St Peter S, Holcomb GW. Lower radiation exposure from body CT imaging for trauma at a dedicated pediatric hospital. J Pediatr Surg 2014; 49:1843-5. [PMID: 25487497 DOI: 10.1016/j.jpedsurg.2014.09.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/06/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE We compare radiation exposure from body CT imaging for blunt trauma performed at outside hospitals (OH) versus our children's hospital (CH). METHODS We performed a retrospective chart review of all children transferred to our facility for management of trauma after undergoing a body CT scan at an OH from June 2011 to August 2013. Radiation from OH images was compared to our CH by matching to age, gender, and nearest date. Radiation measures included dose length product (DLP), computed tomography dose index (CTDI), and size-specific dose estimate (SSDE). RESULTS Fifty-one children were transferred from 39 OH. Abdomen/pelvis and chest/abdomen/pelvis imaging was performed in 30 and 21 children, respectively. Demographics are shown in Table 1. Results are illustrated in Tables 2 and 3. Contrast was utilized in 45 (1 oral, 41 IV, 3 both) and 51 (49 IV, 2 both). CT scans were performed at OH and CH, respectively (P=0.03). CONCLUSIONS Children receive significantly less radiation exposure with body CT imaging for blunt trauma when performed at our dedicated CH. CT scans were significantly more likely to be ordered with appropriate contrast at our CH.
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Affiliation(s)
- Nicole E Sharp
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Wendy J Svetanoff
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Hanna Alemayehu
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Amita Desai
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | | | - Susan W Sharp
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - James C Brown
- Department of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Douglas C Rivard
- Department of Radiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shawn St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA.
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Abstract
PURPOSE OF REVIEW Our objective is to highlight recent literature investigating low-radiation diagnostic strategies in the evaluation of pediatric trauma. RECENT FINDINGS In the area of minor head injury, research has focused on implementation of validated clinical decision rules into practice to reduce unnecessary computed tomography scans. Clinical observation may also serve as an adjunct to initial assessment and a potential substitute for computed tomography imaging. Subgroups of children with special needs or severe injury mechanisms may also be safely characterized by the clinical decision rule and spared radiation exposure. Physical examination techniques may be useful in diagnosing mandibular fractures. In addition, evidence suggests that plain radiography for evaluation of blunt thoracic trauma may be sufficient in many cases, and computed tomography could be reserved for those with abnormal radiographs, high-risk mechanisms, or abnormal physical findings. Clinical decision rules are able to predict intra-abdominal injury with high sensitivity. Data suggest that skeletal surveys may be modified to limit radiation exposure in the case of suspected nonaccidental trauma. SUMMARY More research is needed in development of pediatric-specific clinical decision rules and risk stratification and in testing low-radiation diagnostic modalities in the pediatric trauma population.
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Mhanna MJ, Iyer NP. Routine chest computed tomography scans in pediatric blunt thoracic injuries. J Surg Res 2014; 186:93-4. [DOI: 10.1016/j.jss.2013.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 12/01/2022]
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