Assessing the Pediatric Trauma Assessing the Pediatric Trauma Patient Patient – – What imaging is What imaging is enough enough Adela T. Casas Adela T. Casas - - Melley, MD, FACS, FAAP Melley, MD, FACS, FAAP Chief, Pediatric Surgery Chief, Pediatric Surgery Sanford Children Sanford Children ’ ’ s Hospital s Hospital Assistant Medical Director Trauma Service Assistant Medical Director Trauma Service SVP, Surgical and Cardiovascular services SVP, Surgical and Cardiovascular services
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Assessing the Pediatric Trauma Assessing the Pediatric Trauma
Patient Patient –– What imaging is What imaging is
enoughenough
Adela T. CasasAdela T. Casas--Melley, MD, FACS, FAAPMelley, MD, FACS, FAAP
Assistant Medical Director Trauma ServiceAssistant Medical Director Trauma Service
SVP, Surgical and Cardiovascular servicesSVP, Surgical and Cardiovascular services
ObjectivesObjectives
�� Describe the appropriate imaging of the Describe the appropriate imaging of the pediatric trauma patientpediatric trauma patient
�� Evaluate the risks of certain imaging Evaluate the risks of certain imaging modalities and establish criteria for imaging modalities and establish criteria for imaging decision makingdecision making
�� Discuss the likelihood of pediatric spine Discuss the likelihood of pediatric spine injuries and the need for imaginginjuries and the need for imaging
�� List different modalities for abdominal List different modalities for abdominal evaluation of the pediatric trauma patientevaluation of the pediatric trauma patient
Case #1Case #1
�� 11 YO female who was trying to go from one 11 YO female who was trying to go from one
fort to another via a zip line and her hand fort to another via a zip line and her hand
slipped and she fell 18 feet to the ground.slipped and she fell 18 feet to the ground.
�� She landed on her feet and crumpled to the She landed on her feet and crumpled to the
ground.ground.
�� She denies hitting her head, denies loss of She denies hitting her head, denies loss of
consciousness. Remembers the entire accidentconsciousness. Remembers the entire accident
�� Her only complaint is left ankle pain.Her only complaint is left ankle pain.
Case #1Case #1
�� She was evaluated at outside institution and hadShe was evaluated at outside institution and had
�� CT of head CT of head –– negativenegative
�� CT of CCT of C--spine spine –– negativenegative
�� CT of TCT of T--spine spine –– negativenegative
�� CT of LCT of L--spine spine –– negativenegative
�� CT of abdomen CT of abdomen –– negativenegative
�� No plain films obtainedNo plain films obtained
�� What are the consequences of all of these studies?What are the consequences of all of these studies?
Radiologyinfo.org
Radiation Exposure in XRadiation Exposure in X--raysrays
Study OrderedStudy Ordered Equivalent doseEquivalent dose
�� 53% of radiologist and 91% of ER physicians 53% of radiologist and 91% of ER physicians
did not believe CT increased lifetime risk of did not believe CT increased lifetime risk of
cancercancer
3 Ways to reduce exposure3 Ways to reduce exposure
�� Reduce the CT dose Reduce the CT dose –– We are lucky to have We are lucky to have
the first CT scanner with software to reduce the first CT scanner with software to reduce
radiation exposure by 45%radiation exposure by 45%
�� Replace CT when possible Replace CT when possible –– Ultrasound is a Ultrasound is a
very good viable alternative for trauma very good viable alternative for trauma
evaluation in childrenevaluation in children
�� Simply decrease the number of CTSimply decrease the number of CT’’s ordereds ordered
Do you really need that CT?Do you really need that CT?
�� Despite the fact that most CT scans are Despite the fact that most CT scans are associated with favorable ratios of benefit to associated with favorable ratios of benefit to risk there is strong evidence that too many are risk there is strong evidence that too many are being donebeing done
�� CT evaluation for blunt traumaCT evaluation for blunt trauma
�� Practice of defensive medicinePractice of defensive medicine
�� Repeat CTRepeat CT’’s (head injuries, solid organ s (head injuries, solid organ injuries)injuries)
�� Repeat because of lack of communicationRepeat because of lack of communication
AJR:169, October 1997
Impact of CT on patient management Impact of CT on patient management
in blunt traumain blunt trauma
�� Recent study evaluated 1500 consecutive Recent study evaluated 1500 consecutive
children with blunt abdominal traumachildren with blunt abdominal trauma
�� CT findings and decision for operative or non CT findings and decision for operative or non
operative management were recordedoperative management were recorded
�� 388 (26%) of CT scans had abnormal findings388 (26%) of CT scans had abnormal findings
Impact of CT on patient management Impact of CT on patient management
in blunt traumain blunt trauma
�� 20 of the 286 (7%) of solid organ injury and 25 of 30 20 of the 286 (7%) of solid organ injury and 25 of 30 (83%) of hollow viscous injury children underwent (83%) of hollow viscous injury children underwent surgerysurgery
�� Injury was confirmed in all children with solid organ Injury was confirmed in all children with solid organ injury and 24 of 25 children with hollow viscous injury and 24 of 25 children with hollow viscous injuryinjury
�� Decision for surgery was based on CT findings in Decision for surgery was based on CT findings in 25% of solid organ injury and 68% of hollow viscous 25% of solid organ injury and 68% of hollow viscous injuryinjury
�� But, 74% of children had negative CTBut, 74% of children had negative CT’’ss
AlternativesAlternatives
�� Focused assessment of sonography for trauma Focused assessment of sonography for trauma
(FAST) (FAST) –– Evaluates free fluid around the heart Evaluates free fluid around the heart
and three areas of the abdominaland three areas of the abdominal--pelvic cavitypelvic cavity
�� RUQ RUQ –– Between liver and kidney (MorrisonBetween liver and kidney (Morrison’’s s
pouch)pouch)
�� LUQ LUQ –– Between spleen and kidneyBetween spleen and kidney
�� Subxiphoid area Subxiphoid area –– pericardial sacpericardial sac
�� Suprapubic areas Suprapubic areas –– behind bladder in males, uterus behind bladder in males, uterus
in femalesin females
AlternativesAlternatives
�� Extended version of FAST (EExtended version of FAST (E--FAST) involves FAST) involves
evaluating anterior chest for pneumothoraxevaluating anterior chest for pneumothorax
�� Can determine if there is free fluid in abdomen Can determine if there is free fluid in abdomen
or pericardium in unstable patient to direct or pericardium in unstable patient to direct
intervention.intervention.
�� Does have limitations. Does not evaluate Does have limitations. Does not evaluate
retroperitoneum or hollow viscousretroperitoneum or hollow viscous
�� Convenient, portableConvenient, portable
AlternativesAlternatives
�� Use well documented in adults. Less clear in Use well documented in adults. Less clear in
pediatricspediatrics
�� Very specific to detect hemoperitoneum but Very specific to detect hemoperitoneum but
less sensitive to define less sensitive to define ““positivepositive”” studystudy
�� However, negative ultrasound and negative However, negative ultrasound and negative
Evaluation of the pediatric spineEvaluation of the pediatric spine
�� NEXUS has been validated multiple times and NEXUS has been validated multiple times and
compared to several other methods with good compared to several other methods with good
resultsresults
�� Sensitivity 99%Sensitivity 99%
�� Specificity 99%Specificity 99%
�� Is the NEXUS criteria valid in children?Is the NEXUS criteria valid in children?
Pediatrics:108:2, August 2001
Evaluation of the pediatric spineEvaluation of the pediatric spine
�� Prospective multicenter study done in pediatric Prospective multicenter study done in pediatric blunt trauma patients (<18 YO)blunt trauma patients (<18 YO)
�� Patient had NEXUS criteria applied during Patient had NEXUS criteria applied during evaluationevaluation
�� Decision to do films was at MDDecision to do films was at MD’’s discretion s discretion and not driven by NEXUS but NEXUS criteria and not driven by NEXUS but NEXUS criteria were documented were documented
�� Presence or absence of injury based on final Presence or absence of injury based on final interpretation of Xinterpretation of X--raysrays
Pediatrics:108:2, August 2001
Evaluation of the pediatric spineEvaluation of the pediatric spine
�� 3065 patients evaluated3065 patients evaluated
�� 30 patients (0.98%) had injury documented30 patients (0.98%) had injury documented
�� Study includedStudy included
�� 88 children under 288 children under 2
�� 817 between 2 and 8817 between 2 and 8
�� 2160 between 8 and 172160 between 8 and 17
Pediatrics:108:2, August 2001
Evaluation of the pediatric spineEvaluation of the pediatric spine
�� 45.9% of injuries were of the lower cervical 45.9% of injuries were of the lower cervical
spinespine
�� No cases of SCIWORANo cases of SCIWORA
�� Only 4 of 30 injured children were younger Only 4 of 30 injured children were younger
than 9than 9
�� None under 2None under 2
�� Most common finding were tenderness and Most common finding were tenderness and
distracting injurydistracting injury
Pediatrics:108:2, August 2001
Evaluation of the pediatric spineEvaluation of the pediatric spine
�� NEXUS correctly identified all pediatric NEXUS correctly identified all pediatric
patients with injurypatients with injury
�� Sensitivity 100%Sensitivity 100%
�� Correctly designated 603 patients as low riskCorrectly designated 603 patients as low risk
�� Negative predictive value 100%Negative predictive value 100%
Pediatrics:108:2, August 2001
Evaluation of the pediatric spineEvaluation of the pediatric spine
�� ConclusionsConclusions
�� Lower cervical spine most common site of injuryLower cervical spine most common site of injury
�� Injury very rare in children under 8Injury very rare in children under 8
�� NEXUS performed well and itNEXUS performed well and it’’s use could reduce s use could reduce 20% of c20% of c--spine filmsspine films
�� No single case in literature of occult injury in child No single case in literature of occult injury in child classified as low risk by NEXUSclassified as low risk by NEXUS
�� All patients with injury report pain, have All patients with injury report pain, have neurologic findings, or have altered mental status neurologic findings, or have altered mental status and get studiesand get studies
Emergency Radiology:10:4, February 2004
CT versus plain filmsCT versus plain films
�� Study to determine value of CT of spine in Study to determine value of CT of spine in
children under 5children under 5
�� 606 patients having cervical spine evaluation 606 patients having cervical spine evaluation
in the ERin the ER
�� Documented age and sex as well as exam Documented age and sex as well as exam
findings and presence of injury on plain films findings and presence of injury on plain films
and CTand CT
Emergency Radiology:10:4, February 2004
CT versus plain filmsCT versus plain films
�� Of the 606 patients studiesOf the 606 patients studies
�� 459 (75.7%) were cleared by combination of 459 (75.7%) were cleared by combination of
exam, and plain filmsexam, and plain films
�� 147 (24.3%) went on to CT imaging for clearing of 147 (24.3%) went on to CT imaging for clearing of
the cervical spinethe cervical spine
�� Of the 147 who had CTOf the 147 who had CT
�� 143 (97.3%) were negative143 (97.3%) were negative
�� 4 (2.7%) were positive. All of these patients had 4 (2.7%) were positive. All of these patients had
positive findings on plain filmspositive findings on plain films
Emergency Radiology:10:4, February 2004
CT versus plain filmsCT versus plain films
�� The yield of CT of the spine in children under The yield of CT of the spine in children under
5 was very low and all patients had the same 5 was very low and all patients had the same
finding of plain films.finding of plain films.
�� CT of the spine is equal to 60 CXR and 4 CCT of the spine is equal to 60 CXR and 4 C--
spine seriesspine series
�� Is it worth the risk?Is it worth the risk?
Pediatr Radiol:38:635-644, 2008
CT versus plain filmsCT versus plain films
�� A study to evaluate the radiation exposure of A study to evaluate the radiation exposure of
children who had CT of the cchildren who had CT of the c--spine was done spine was done
in Atlanta.in Atlanta.
�� Retrospective review of all children who had Retrospective review of all children who had
CT of the spine in the ER after traumaCT of the spine in the ER after trauma
�� 992 children were evaluated992 children were evaluated
�� Only 181 (18%) had prior COnly 181 (18%) had prior C--spine seriesspine series
Pediatr Radiol:38:635-644, 2008
CT versus plain filmsCT versus plain films
�� Divided the study into three groupsDivided the study into three groups
�� 00--4 YO4 YO
�� 55--8 YO8 YO
�� >8 YO>8 YO
�� They used anthropomorphic dosimetry They used anthropomorphic dosimetry
phantoms for group 1 and 2phantoms for group 1 and 2
Pediatr Radiol:38:635-644, 2008
CT versus plain filmsCT versus plain films
�� Evaluated exposure for CEvaluated exposure for C--spine seriesspine series
�� Series 1 Series 1 –– laterallateral
�� Series 2 Series 2 –– Four viewsFour views
�� Series 3 Series 3 -- Seven viewsSeven views
�� Evaluated exposure for CTEvaluated exposure for CT
�� CT headCT head
�� CT CCT C--spinespine
Pediatr Radiol:38:635-644, 2008
CT versus plain filmsCT versus plain films
�� They calculated radiation exposure of the They calculated radiation exposure of the
phantoms and then retrospectively calculated phantoms and then retrospectively calculated
the radiation exposure of the children in the the radiation exposure of the children in the
studystudy
�� They then calculated a relative risk of thyroid They then calculated a relative risk of thyroid
cancer based on comparison of previous study cancer based on comparison of previous study
of children exposed to radiation in the 50of children exposed to radiation in the 50’’s for s for
treatment of tinea capitistreatment of tinea capitis
Pediatr Radiol:38:635-644, 2008
CT versus plain filmsCT versus plain films
�� Results showed Results showed
�� 992 patients992 patients
�� 435 had C435 had C--spine xspine x--rays onlyrays only
�� 181 had C181 had C--spine and CTspine and CT
�� 376 had CT only376 had CT only
�� Radiation dose for CT of the CRadiation dose for CT of the C--spinespine
�� Group 1 Group 1 –– 200X more than from C200X more than from C--spine seriesspine series
�� Group 2 Group 2 –– 90X more than from C90X more than from C--spine seriesspine series
Pediatr Radiol:38:635-644, 2008
CT versus plain filmsCT versus plain films
�� Relative risk for developing thyroid cancerRelative risk for developing thyroid cancer
�� Group 1 Group 1 –– none from conventional Cnone from conventional C--spine seriesspine series
�� Group 1 Group 1 –– relative risk from CT head was 0.03 but relative risk from CT head was 0.03 but
relative risk of 2 for CT of Crelative risk of 2 for CT of C--spinespine
�� Group 2 Group 2 –– no increase from Cno increase from C--spine seriesspine series
�� Group 2 Group 2 –– relative risk from CT head 0.02 but relative risk from CT head 0.02 but
increased to 0.07 for CT Cincreased to 0.07 for CT C--spinespine
What alternatives do we haveWhat alternatives do we have
�� Evaluate the patient and determine if there is Evaluate the patient and determine if there is need for radiologic studiesneed for radiologic studies
�� Do not get studies because of a knee jerk Do not get studies because of a knee jerk decision of what is done on all trauma patientsdecision of what is done on all trauma patients
�� Evaluation of children can be very difficult. If Evaluation of children can be very difficult. If you think the child has significant injuries and you think the child has significant injuries and you are unable to get a good exam or feel you are unable to get a good exam or feel uncomfortable, send them to someone with uncomfortable, send them to someone with experienceexperience
What alternatives do we haveWhat alternatives do we have
�� Get baseline studies firstGet baseline studies first
�� Do not scan head to toe, rarely ever neededDo not scan head to toe, rarely ever needed
�� Use alternative studies when you canUse alternative studies when you can
�� Never delay transfer to another institution to Never delay transfer to another institution to
get scans. The accepting docs will determine get scans. The accepting docs will determine
what they need. Stabilize and sendwhat they need. Stabilize and send
�� If you do get CT, please use contrast so we can If you do get CT, please use contrast so we can
actually use dataactually use data
Trauma Reports:10:4, July 2009
What about CWhat about C--spinespine
�� Evaluate patient and determine NEXUS criteriaEvaluate patient and determine NEXUS criteria
�� Calm the child down and do a physical examCalm the child down and do a physical exam
�� Obtain plain films firstObtain plain films first
�� If you feel you need a CT by all means get it, but do If you feel you need a CT by all means get it, but do
not get it because it is a child and you feel not get it because it is a child and you feel
uncomfortable with the exam.uncomfortable with the exam.
�� You still need an exam before clearing the spine You still need an exam before clearing the spine
anyway. A negative CT does not clear the spineanyway. A negative CT does not clear the spine
Imaging of the pediatric trauma Imaging of the pediatric trauma
patientpatient
�� Hope this data has made you think about how Hope this data has made you think about how
many children we are exposing to risky doses many children we are exposing to risky doses
of radiationof radiation
�� This also applies to evaluation of the pediatric This also applies to evaluation of the pediatric
patient for abdominal painpatient for abdominal pain