Use of Chest Computed Tomography for Blunt Pediatric Chest Trauma: Does It Change Clinical Course?

Have the UK Pediatric Trauma Protocols resulted in a reduction in chest computed tomography imaging for children presenting with major blunt trauma?

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.

Application of a Thoracic CT Decision Rule in the Evaluation of Injured Children: A Quality Improvement Initiative

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.

Effectiveness of Chest CT in Children: CT Findings in Relation to the Clinical Question

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.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient

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.