Clinical Predictors for the Selective Use of Chest Radiographs in Pediatric Blunt Trauma Evaluations

Predicting Thoracic Injury in Children With Multitrauma

OBJECTIVES

Previous pediatric trauma studies focused on predictors of abnormal chest radiographs or included patients with low injury severity. This study identified predictors of thoracic injury (TI) diagnoses in a high-risk population and determined TI rate without predictors.

METHODS

This study was a retrospective trauma registry analysis of previously healthy children aged 0 to 17 years with multisystem blunt trauma requiring trauma team activation and chest radiography who were divided into those with and without TI. Plausible TI predictors included Glasgow Coma Scale score of 13 or less, abnormal thoracic symptoms/signs, abnormal chest auscultation, respiratory distress/ rate higher than the 95th percentile, oxygen saturation less than 95%, abnormal abdominal signs/symptoms, tachycardia higher than the 95th percentile, blood pressure lower than the 5th percentile, and femur fracture.

RESULTS

One hundred forty-one (29%) of 493 eligible patients had TI. Independent TI predictors include thoracic symptoms/signs (odds ratio [OR], 6.0; 95% confidence interval [CI], 3.6-10.1), abnormal chest auscultation (OR, 3.5; 95% CI, 2.0-6.2), saturation less than 95% (OR, 3.1; 95% CI, 1.8-5.5), blood pressure lower than the 5th percentile (OR, 3.7; 95% CI, 1.1-12.2), and femur fracture (OR, 2.5; 95% CI, 1.2-5.4). Six (5%) of 119 children (95% CI, 0.01-0.09) without predictors had TI.

CONCLUSIONS

Predictors of TI include thoracic symptoms/signs, abnormal chest auscultation, saturation less than 95%, blood pressure lower than the 5th percentile, and femur fracture. Because an important portion of children without predictors had TI, chest radiography should remain part of pediatric trauma resuscitation.

Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations

BACKGROUND

Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure.

OBJECTIVE

To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature.

METHODS

We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation.

RESULTS

Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%).

CONCLUSIONS

Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness.

Clinical decision rule to prevent unnecessary chest X-ray in patients with blunt multiple traumas

BACKGROUND

Since the diagnostic yield of chest X-ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients.

METHODS

Stable multiple blunt trauma patients referring to the ED were included. The clinical and radiographic findings of all the patients were collected and the relationships between these variables analysed. Finally, based on the regression coefficients (β) of the variables, the Thoracic Injury Rule-out Criteria (TIRC) were designed.

RESULTS

A total of 2607 patients were included (males: 78.9%, mean age: 34.1 ± 15.0 years). Age over 60 (β = 0.8; 95% CI: 0.27-1.34; P = 0.003), crepitation (β = 4.33; 95% CI: 1.65-7.0; P < 0.001), loss of consciousness (β = 3.16; 95% CI: 2.44-3.88; P < 0.001), decrease in pulmonary sounds (β = 2.67; 95% CI: 1.73-3.6; P < 0.001), chest wall pain (β = 2.12; 95% CI: 1.63-2.61; P < 0.001) and tenderness (β = 1.78; 95% CI: 1.26-2.27; P < 0.001), dyspnea (β = 1.3; 95% CI: 0.41-2.18; P = 0.004) and abrasion (β = 0.5; 95% CI: 0.22-0.83; P = 0.03) were independent factors predicting thoracic injury. CXR in stable conscious multiple blunt trauma patients under 60 years, without chest wall pain and tenderness, decrease in pulmonary sounds, crepitation, skin abrasion, and dyspnea did not provide any additional findings.

CONCLUSIONS

Based on TIRC, it seems that CXR in stable multiple blunt trauma patients who are conscious and under 60 and have no decrease in pulmonary sounds, no dyspnea, no thoracic skin abrasion, and no crepitation can be ignored.

Nuking the radiation: minimizing radiation exposure in the evaluation of pediatric blunt trauma

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.

Criteria for the selective use of chest computed tomography in blunt trauma patients

PURPOSE

The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.

METHODS

This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.

RESULTS

We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.

CONCLUSION

Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.

Effect of emergency department care on outcomes in pediatric trauma: what approaches make a difference in quality of care?

Deriving evidence-based best practice for each phase or setting of trauma care is necessary to maximize best outcomes. There is a paucity of studies examining the association of provider training on pediatric trauma outcomes. Pivotal decisions (whether and where to transfer, diagnostic workup, and initial resuscitation) occur in this setting, yet there is little evidence relating to best practices in those areas. Classic process-performance measures such as time intervals during care (e.g., time to computerized tomography scan, time to operating room, etc.) or utilization measures (American College of Surgeons designation) are commonly used in the trauma center certification process, yet process-outcome links relevant to children are lacking. Although great advances have been made in the trauma care delivered to children, scientific proof is lacking and much more needs to be done to establish the evidence-based need to deliver the highest quality of pediatric trauma care.

Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?

OBJECTIVE

The purpose of this study was to determine if statistical models for prediction of chest injuries would outperform the clinician's (MD) ability to identify injured patients at risk for a thoracic injury diagnosed by chest radiograph (CXR).

DESIGN

A prospective observational study was done during a 12-month period.

SETTING

The study was conducted in a level I trauma center.

PATIENTS

Injured patients meeting trauma team activation criteria were enrolled to the study.

INTERVENTIONS

Physical examination findings by a clinician were interpreted and CXR was performed.

OUTCOME MEASURES

The accuracy of 2 mathematical models is compared against the accuracy of clinician's clinical judgment in predicting an injury by CXR. Two newly constructed multivariate models, binary logistic regression (LR) and classification and regression tree (CaRT) analysis, are compared to previously published data of clinician clinical assessment of probability of thoracic injury identified by CXR.

RESULTS

Data for 757 patients were analyzed. Classification and regression tree analysis developed a stepwise decision tree to determine which signs/symptoms were indicative of an abnormal CXR finding. The sensitivity (CaRT, 36.6%; LR, 36.3%; MD, 58.7%), specificity (CaRT, 98.3%; LR, 98.2%; MD, 96.4%), and error rates (CaRT, 0.93; LR, 0.94; MD, 0.82) show that the mathematical decision aids are less sensitive and risk more misclassification compared to clinician judgment in predicting an injury by CXR.

CONCLUSION

Clinician judgment was superior to mathematical decision aids for predicting an abnormal CXR finding in injured patients with chest trauma.

[Chest injury. Part I: Significance--symptoms--diagnostic procedures]

Chest injuries can be sustained in isolation or in association with multiple injuries. Life-threatening complications may ensue because organs that are vital to survival of the organism are situated within the thoracic cavity. These complications include airway obstruction, tension pneumothorax, wide open pneumothorax, flail chest, cardiac tamponade and massive hemothorax. The mortality of patients hospitalized with chest injury can be as high as 10%. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential, and standard chest X-ray, ultrasound and thoracic computed tomography may also be needed for the diagnosis. The first part of this serial paper on the management of chest injuries focuses on anatomical aspects, pathophysiology and symptoms, but mainly on the indications for the standard diagnostic procedures and further high-tech examinations.

A trauma series in the injured child: do we really need it?

BACKGROUND

To study the use of trauma series radiographs in children that required activation of a trauma call.

METHODS

A retrospective review of patients younger than 16 years who presented to The Children's Hospital at Westmead between January and December 2004 with an injury that required activation of the trauma team. Patients transferred from other institutions were excluded.

RESULTS

Two hundred seventy-four children were included in the study, with 166 boys. The mean age was 8 years, and average Injury Severity Score was 4. Sixteen children had an Injury Severity Score of above 15. One hundred thirty-one children had a complete trauma series performed; 104 had one or more of the series performed, whereas 39 had no radiographs. Data analysis revealed that patients with findings in a chest radiograph (13) had either chest wall contusion(s) or reduced air entry on the involved side. Logistic regression analyses identified features that were significantly associated with a positive finding on the radiographs of the anteroposterior chest including a distracting injury in the chest area (odds ratio [OR], 10.49; 95% confidence interval [CI], 2.98-36.97), abnormal air entry on auscultation (OR, 31.86; 95% CI, 2.80-365.12), and need for intubation (OR, 6.23; 95% CI, 1.56-24.91). However, no clinical variable(s) showed a statistically significant correlation with abnormal radiographic findings on the lateral cervical spine (2) or anteroposterior pelvis (4).

CONCLUSIONS

This study suggests that selective use of individual components of the full trauma series in the conscious pediatric patient, when an adequate clinical examination can be performed, would be safe. This approach should reduce the exposure to ionizing radiation of pediatric trauma patients and hospital staff.

Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients?

BACKGROUND

The ATLS Course advocates that injured patients have a chest x-ray (CXR) to identify potential injuries. The purpose of this study was to correlate clinical indications and clinician judgment with CXR results to ascertain if a selective policy would be beneficial.

METHODS

Patients treated at a Level I trauma center over 12 months were prospectively evaluated. Before obtaining a CXR, signs, symptoms, and history suggestive of thoracic injury were identified. Additionally, a trauma surgeon (TS) recorded whether in their judgment a CXR was clinically indicated. These findings were compared with final CXR diagnoses. The sensitivity of individual clinical indicators, combinations of clinical indicators, and TS judgment for CXR abnormalities were calculated with a 95% confidence interval.

RESULTS

During the twelve-month study period, data were acquired on 772 patients (age 0-102 years). Seventy percent were male and 86.0% were injured by blunt force. Only 29% (N = 222) of the patients manifested one or more of the clinical indicators (signs and symptoms). The negative predictive value for the TS judgment was 98.2% which was superior to the clinical indicators. Reliance on the opinion of the TS to determine the need for a CXR would have eliminated 49.9% of CXRs and avoided hospital and radiologist reading charges totaling $100,078.22.

CONCLUSION

Mandatory CXR for all trauma patients has a low yield for abnormal findings. A selective policy relying on surgical judgment guided by clinical indicators is safe and efficacious while reducing cost and conserving resources.

Trauma and the paediatric lung

Thoracic injury is a serious cause of morbidity and mortality in paediatric patients. This review will present cases to assist the clinician in the epidemiology, assessment and management of airway injury, pulmonary contusion, rib fracture, musculoskeletal injury and pneumothorax.

Imaging Evaluation of Pediatric Chest Trauma

Following a discussion of the various imaging manifestations of pediatric chest trauma by anatomic location, the authors discuss their diagnostic approach to the pediatric multitrauma patient with an emphasis on chest imaging.