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Loftus CJ, Schmidt JC, Nguyen AM, Skokan AJ, Hagedorn JC. Evaluating Adherence to Guideline-based Injury Grading in Pediatric Renal Trauma: How Are Patients Being Worked Up Prior to Transfer to a Level 1 Trauma Center? Urology 2024; 183:236-243. [PMID: 37866649 DOI: 10.1016/j.urology.2023.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To determine whether children with renal trauma who are transferred to a level I trauma center (TC) receive appropriate imaging studies before transfer and whether this impacts care. The American Urologic Association (AUA) Urotrauma guidelines state clinicians should perform IV contrast-enhanced CT with immediate and delayed images when renal trauma is suspected. Adherence to these guidelines in pediatric patients is unknown. METHODS Children treated for renal trauma at our TC between 2005 and 2019 were identified. Comparisons between patients with initial imaging at a transferring hospital (TH) and patients with initial imaging at our TC were performed using logistic regression. RESULTS Of the included 293 children, 67% (197/293) were transferred into our TC and 61% (180/293) received initial imaging at the TH. Patients with initial imaging at the TH were more likely to have higher-grade renal injuries (P = .001) and were less likely to have guideline-recommended imaging (31% vs 82%, P < .001). Of patients who were imaged at the TH, 28% (50/180) underwent an additional CT imaging shortly after transfer. When imaging was incomplete at the TH, having an additional scan upon transfer was associated with emergent urologic surgery (P = .004). CONCLUSION Adherence to the AUA Urotrauma guidelines is low, with most pediatric renal trauma patients not receiving complete staging with delayed-phase imaging before transfer to a TC. Furthermore, patients initially imaged at THs were more likely to receive more CT scans per admission and were exposed to higher amounts of radiation. There is a need to improve imaging protocols for complete staging of renal trauma in children before transfer.
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Affiliation(s)
| | - Jackson C Schmidt
- Department of Urology, Oregon Health & Sciences University, Portland, OR
| | - Amanda M Nguyen
- University of Washington School of Medicine, Salt Lake City, UT
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Ulloa E, Archie J, Slevakumar S, Levy M, Elkbuli A, Plumley D. The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care. Am Surg 2023; 89:5786-5794. [PMID: 37158806 DOI: 10.1177/00031348231175111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Patients are at risk of missed or delayed injuries in the setting of multisystem trauma, which may be identified with a tertiary trauma survey (TTS). There is limited literature to support the utilization of a TTS in pediatric trauma population. We aim to assess the impact of the TTS as a quality and performance improvement tool in identifying missed or delayed injuries and improving the quality of care among pediatric trauma population. METHODS A retrospective study assessing a quality improvement/performance improvement (QI/PI) project focusing on the administration of tertiary surveys to pediatric trauma patients was conducted at our level 1 trauma center between 08-2020 and 08-2021. Patients with injury severity scores (ISS) greater than 12 and/or an anticipated hospital stay greater than 72 hours met inclusion criteria and were included. RESULTS Of the 535 trauma patients admitted to the pediatric trauma service during the study period, 85 (16%) patients met the criteria and received a TTS. Thirteen unaddressed or undertreated injuries were found in 11 patients: 5 cervical spine injuries, 1 subdural hemorrhage, 1 bowel injury, 1 adrenal hemorrhage, 1 kidney contusion, 2 hematomas, and 2 full thickness abrasions. Following TTS, 13 patients (15%) had additional imaging, which identified 6 of the 13 injuries. CONCLUSION The TTS is a valuable quality and performance improvement tool in the comprehensive care of trauma patients. Standardization and implementation of a tertiary survey have the potential to facilitate the prompt detection of injuries and improve the quality of care for pediatric trauma patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Emily Ulloa
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
| | - Jessica Archie
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
| | - Sruthi Slevakumar
- NSU NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Marc Levy
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
| | - Donald Plumley
- Arnold Palmer Children's Hospital at Orlando Health, Orlando, FL, USA
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Hajibandeh J, Peacock ZS. Pediatric Mandible Fractures. Oral Maxillofac Surg Clin North Am 2023; 35:555-562. [PMID: 37517978 DOI: 10.1016/j.coms.2023.05.001] [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: 08/01/2023]
Abstract
The management of pediatric facial fractures requires several considerations by the treating surgeon. Pediatric facial fractures occur less commonly than in adults. Among fracture patterns in children, studies have repeatedly demonstrated that mandible fractures are the most common facial fracture particularly the condyle. Most fractures in children are amenable to nonsurgical or closed treatment; however, certain indications exist for open treatment. The literature describing epidemiology, treatment trends, and long-term outcomes are limited in comparison with adult populations. The purpose of the article is to review the etiology, workup, and management of mandible fractures in children.
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Affiliation(s)
- Jeffrey Hajibandeh
- Massachusetts General Hospital, Division of Oral & Maxillofacial Surgery, Warren 1201, 55 Fruit Street, Boston, MA 02127, USA.
| | - Zachary S Peacock
- Massachusetts General Hospital, Division of Oral & Maxillofacial Surgery, Warren 1201, 55 Fruit Street, Boston, MA 02127, USA
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Impact of a statewide computed tomography scan educational campaign on radiation dose and repeat CT scan rates for transferred injured children. J Clin Transl Sci 2021; 5:e129. [PMID: 34367674 PMCID: PMC8327550 DOI: 10.1017/cts.2021.793] [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: 02/16/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign's impact on injured children received radiation dose. Methods All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. Results Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). Conclusion A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.
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Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury 2019; 50:142-148. [PMID: 30270009 DOI: 10.1016/j.injury.2018.09.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 09/01/2018] [Accepted: 09/18/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma is a common indication for computed tomography (CT) in children. However, children are particularly vulnerable to CT radiation and its associated cancer risk. Identifying differences in CT usage across trauma centers and among specific populations of injured children is needed to identify where quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children. We evaluated computed tomography (CT) rates among injured children treated at pediatric (PTC), mixed (MTC), or adult trauma centers (ATC) and estimated the resulting differential in potential cancer risk. METHODS We identified children age ≤18 years with blunt injury AIS ≥2 treated from 2010 to 2013 at 130 U.S trauma centers participating in the Trauma Quality Improvement Program. CT rates were compared across center types using Chi-square analysis. Stratified analyses in children with varying injury severity, mechanism, and age were performed. We estimated the impact of differential rates of CT scans on cancer risk using published attributable risks. RESULTS Among 59,010 children identified, CT rates were higher among injured children treated at ATC and MTC versus PTC. Findings were consistent after stratified analyses and were most striking in children with chest and abdomen/pelvis CT, adolescent age, low injury severity and fall injury mechanism. We estimated that for every 100,000 injured children, imaging practices in ATC and MTC would lead to an additional 17 and 16 lifetime cancers, respectively, when compared to PTC. CONCLUSION CT use among injured children is higher at ATC and MTC compared to PTC. Children with low injury severity, fall injury mechanism, and adolescent age are most vulnerable to differential imaging practices across centers. Quality improvement initiatives aimed at reducing heterogeneity in CT usage across trauma centers are required to mitigate pediatric radiation exposure and cancer risk.
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Schears RM, Farzal Z, Farzal Z, Fischer AC. The radiation footprint on the pediatric trauma patient. Int J Emerg Med 2018; 11:18. [PMID: 29541949 PMCID: PMC5852158 DOI: 10.1186/s12245-018-0175-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/15/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The actual baseline of radiation exposure used in evaluating pediatric trauma is not known and has relied on estimates in the literature that may not reflect clinical reality. Our objectives were to determine the baseline amount of radiation delivered in a pediatric trauma evaluation and correlate radiation exposure with trauma activation status to identify the cohort most at risk. METHODS We retrospectively evaluated trauma patients (N = 1050) at an independent Level I children's hospital for each level of trauma activation (consults, alerts, stats) from June 2010 to January 2011. Those patients with full dosimetry (N = 215) were analyzed for demographics, mechanism of injury, Injury Severity Score, imaging modalities, and total effective radiation dosages during the full trauma assessment from the time of injury to discharge. RESULTS Demographics included gender (143 males, 72 females) and average age (5.5 years [range < 1-16]). The most radiation was conferred from CTs and greatest in trauma stats, followed by alerts, then consults (p < 0.001 for stat and alert doses compared to consults). Repeated imaging was common: 35% of stats had 2-3 CTs and 40% had 4-10 CTs (range 0-10 CTs). The average non-accidental trauma consult utilized four times as many CTs as the average consult (p = 0.002). Most outside hospital CTs (66%) delivered more radiation: 50.0% were at least double the standard pediatric dosage. CONCLUSIONS This study is the first to identify the actual baseline of radiation exposure for one trauma evaluation and correlate radiation exposure with trauma activation status. Factors associated with highest radiation include stat activations, suspected non-accidental traumas (NAT), and outside hospital system imaging.
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Affiliation(s)
- Raquel M. Schears
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Zainab Farzal
- Department of Otolaryngology, University North Carolina, Children’s Hospital, 101 Manning Drive, Chapel Hill, NC USA
| | - Zehra Farzal
- Department of Neurology, MedStar Georgetown University Hospital, Reservoir Rd NW, Washington, DC, 3800 USA
| | - Anne C. Fischer
- Florida Atlantic University/St. Mary’s Medical Center, 927 45th Street, Suite 301, West Palm Beach, FL 33407 USA
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Missed Opportunities to Decrease Radiation Exposure in Children with Renal Trauma. J Urol 2018; 199:552-557. [DOI: 10.1016/j.juro.2017.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/22/2022]
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Nabaweesi R, Ramakrishnaiah RH, Aitken ME, Rettiganti MR, Luo C, Maxson RT, Glasier CM, Kenney PJ, Robbins JM. Injured Children Receive Twice the Radiation Dose at Nonpediatric Trauma Centers Compared With Pediatric Trauma Centers. J Am Coll Radiol 2017; 15:58-64. [PMID: 28847467 DOI: 10.1016/j.jacr.2017.06.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Use of cranial CT scans in children has been increasing, in part due to increased awareness of sports-related concussions. CT is the largest contributor to medical radiation exposure, a risk factor for cancer. Long-term cancer risks of CT scans can be two to three times higher for children than for adults because children are more radiosensitive and have a longer lifetime in which to accumulate exposure from multiple scans. STUDY AIM To compare the radiation exposure injured children receive when imaged at nonpediatric hospitals (NPHs) versus pediatric hospitals. METHODS Injured children younger than 18 years who received a CT scan at a referring hospital during calendar years (CYs) 2010 and 2013 were included. Patient-level factors included demographics, mode of transportation, and Injury Severity Score, and hospital-level factors included region of state, radiology services, and hospital type and size. Our primary outcome of interest was the effective radiation dose. RESULTS Four hundred eighty-seven children were transferred to the pediatric trauma center during CYs 2010 and 2013, with a median age of 7.2 years (interquartile range 5-13). The median effective radiation dose received at NPHs was twice that received at the pediatric trauma center (3.8 versus 1.6 mSv, P < .001). Results were confirmed in independent and paired analyses, after controlling for mode of transportation, emergency department disposition, level of injury severity, and at the NPH trauma center level, hospital type, size, region, and radiology services location. CONCLUSION NPHs have the potential to substantially reduce the medical radiation received by injured children. Pediatric CT protocols should be considered.
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Affiliation(s)
- Rosemary Nabaweesi
- Department of Pediatrics, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas.
| | - Raghu H Ramakrishnaiah
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Mary E Aitken
- Department of Pediatrics, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Mallikarjuna R Rettiganti
- Arkansas Children's Research Institute, Little Rock, Arkansas; Department of Biostatistics, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Chunqiao Luo
- Arkansas Children's Research Institute, Little Rock, Arkansas; Department of Biostatistics, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Robert T Maxson
- Department of Pediatric Surgery, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Charles M Glasier
- Department of Pediatric Radiology, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Phillip J Kenney
- Department of Radiology, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - James M Robbins
- Department of Pediatrics, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas
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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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Imaging before transfer to designated pediatric trauma centers exposes children to excess radiation. J Trauma Acute Care Surg 2016; 81:229-35. [DOI: 10.1097/ta.0000000000001074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Emergency Department Use of Computed Tomography for Children with Ventricular Shunts. J Pediatr 2015; 167:1382-8.e2. [PMID: 26474707 DOI: 10.1016/j.jpeds.2015.09.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/16/2015] [Accepted: 09/04/2015] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To quantify rates and variation in emergency department (ED) cranial computed tomography (CT) utilization in children with ventricular shunts, estimate radiation exposure, and evaluate the association between CT utilization and shunt revision. STUDY DESIGN Retrospective longitudinal cohort study of ED visits from 2003-2013 in children 0-18 years old with initial shunt placement in 2003. Data were examined from 31 hospitals in the Pediatric Health Information System. Main outcomes were cranial CT performed during an ED visit, estimated cumulative effective radiation dose, and shunt revision within 7 days. Multivariable regression modeled the relationship between patient- and hospital-level covariates and CT utilization. RESULTS The 1319 children with initial shunt placed in 2003 experienced 6636 ED visits during the subsequent decade. A cranial CT was obtained in 49.4% of all ED visits; 19.9% of ED visits with CT were associated with a shunt revision. Approximately 6% of patients received ≥10 CTs, accounting for 37.2% of all ED visits with a CT. The mean number of CTs per patient varied nearly 20-fold across hospitals; the individual hospital accounted for the most variation in CT utilization. The median (IQR) cumulative effective radiation dose was 7.2 millisieverts (3.6-14.0) overall, and 33.4 millisieverts (27.2-43.8) among patients receiving ≥10 CTs. CONCLUSIONS A CT scan was obtained in half of ED visits for children with a ventricular shunt, with wide variability in utilization by hospitals. Strategies are needed to identify children at risk of shunt malfunction to reduce variability in CT utilization and radiation exposure in the ED.
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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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Kharbanda AB, Krause E, Lu Y, Blumberg K. Analysis of radiation dose to pediatric patients during computed tomography examinations. Acad Emerg Med 2015; 22:670-5. [PMID: 26010148 DOI: 10.1111/acem.12689] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/11/2014] [Accepted: 12/17/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Computed tomography (CT) utilization has increased rapidly over the past 15 years. CT is the most common source for radiation exposure. OBJECTIVES The objective was to measure the effective dose of radiation delivered during routine head and abdominal CT examinations at a children's hospital. METHODS This was a retrospective study of emergency department (ED) patients < 20 years of age who underwent head or abdominal CT scans in 2012 at a single children's hospital. The authors abstracted the dose-length product from the CT scanners and calculated the effective radiation dose delivered. Patient demographics were abstracted from the medical record. The relationship between effective dose and age, patient weight, and reason for examination were evaluated. RESULTS A total of 478 subjects were included: 255 underwent head CT, and 223 underwent abdominal CT. The median age was 8.1 years (interquartile range = 2.71 to 14.40 years) and 56.9% were male. The median effective dose for head CT was 2.68 mSv (95% confidence interval [CI] = 2.54 to 2.84 mSv) and decreased as age increased. For abdominal CT, the median effective dose was 5.06 mSv (95% CI = 4.58 to 6.03 mSv) and increased as age increased (3.67 to 11.12 mSv, p < 0.001). For abdominal CT, 8% of 5- to 10-year-olds, 28% of those 10 to 15 years, and 60% of patients over age 15 years received effective doses over 10 mSv. CONCLUSIONS The amount of radiation delivered to pediatric patients during routine CT examinations of the head and abdomen was low. Regardless, a large proportion of older patients were exposed to elevated effective doses of radiation during abdominal CT.
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Affiliation(s)
- Anupam B. Kharbanda
- The Department of Pediatric Emergency Medicine; Children's Hospitals and Clinics of Minnesota; Minneapolis MN
| | - Ernest Krause
- The Department of Research and Sponsored Programs; Children's Hospitals and Clinics of Minnesota; Minneapolis MN
| | - Yi Lu
- The Department of Research and Sponsored Programs; Children's Hospitals and Clinics of Minnesota; Minneapolis MN
| | - Karen Blumberg
- The Department of Radiology; Children's Hospitals and Clinics of Minnesota; Minneapolis MN
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Carnevale TJ, Meng D, Wang JJ, Littlewood M. Impact of an Emergency Medicine Decision Support and Risk Education System on Computed Tomography and Magnetic Resonance Imaging Use. J Emerg Med 2015; 48:53-7. [DOI: 10.1016/j.jemermed.2014.07.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 05/29/2014] [Accepted: 07/01/2014] [Indexed: 11/29/2022]
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Kuo W, Ciet P, Tiddens HAWM, Zhang W, Guillerman RP, van Straten M. Monitoring Cystic Fibrosis Lung Disease by Computed Tomography. Radiation Risk in Perspective. Am J Respir Crit Care Med 2014; 189:1328-36. [DOI: 10.1164/rccm.201311-2099ci] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Livingston MH, Igric A, Vogt K, Parry N, Merritt NH. Radiation from CT scans in paediatric trauma patients: Indications, effective dose, and impact on surgical decisions. Injury 2014; 45:164-9. [PMID: 23845570 DOI: 10.1016/j.injury.2013.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/28/2013] [Accepted: 06/09/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. PATIENTS AND METHODS We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient. RESULTS 157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12-75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0-16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. CONCLUSIONS CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.
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Affiliation(s)
- Michael H Livingston
- Division of General Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
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Fallon SC, Delemos D, Christopher D, Frost M, Wesson DE, Naik-Mathuria B. Trauma surgeon becomes consultant: evaluation of a protocol for management of intermediate-level trauma patients. J Pediatr Surg 2014; 49:178-82; discussion 182-3. [PMID: 24439605 DOI: 10.1016/j.jpedsurg.2013.09.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE At our level 1 pediatric trauma center, 9-54 intermediate-level ("level 2") trauma activations are received per month. Previously, the surgery team was required to respond to and assume responsibility for all patients who had "level 2" trauma activations. In 8/2011, we implemented a protocol where the emergency room (ER) physician primarily manages these patients with trauma consultation for surgical evaluation or admission. The purpose of this study was to prospectively evaluate the effects of the new protocol to ensure that patient safety and quality of care were maintained. METHODS We compared outcomes of patients treated PRE-implementation (10/2010-7/2011) and POST-implementation (9/2011-5/2012), including surgeon consultation rate, utilization of imaging and laboratory testing, ER length of stay, admission rate, and missed injuries or readmissions. Statistical analysis included chi-square and Student's t-test. RESULTS We identified 472 patients: 179 in the PRE and 293 in the POST period. The populations had similar baseline clinical characteristics. The surgical consultation rate in the POST period was only 42%, with no missed injuries or readmissions. The ER length of stay did not change. However, in the POST period there were significant decreases in the admission rate (73% to 44%) and the mean number of CT scans (1.4 to 1), radiographs (2.4 to 1.7), and laboratory tests (5.1 to 3.3) ordered in the emergency room (all p<0.001). CONCLUSION Intermediate-level pediatric trauma patients can be efficiently and safely managed by pediatric emergency room physicians, with surgical consultation only as needed. The protocol change improved resource utilization by decreasing testing and admissions and streamlining resident utilization in an era of reduced duty hours.
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Affiliation(s)
- Sara C Fallon
- Baylor College of Medicine Departments of Pediatric Surgery
| | - David Delemos
- Baylor College of Medicine Departments of Emergency Medicine
| | | | - Mary Frost
- Texas Children's Hospital Trauma Program
| | - David E Wesson
- Baylor College of Medicine Departments of Pediatric Surgery
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