Assessing the Pediatric Trauma Patient – What … the Pediatric Trauma Patient – What imaging is ... treatment of tinea capitis. Pediatr Radiol:38:635-644, ... decision of what

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

Chief, Pediatric SurgeryChief, Pediatric Surgery

Sanford ChildrenSanford Children’’s Hospitals Hospital

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

CT headCT head 20 CXR20 CXR

CT CCT C--SpineSpine 60 CXR60 CXR

CT ChestCT Chest 70 CXR70 CXR

CT Abdomen/PelvisCT Abdomen/Pelvis 100 CXR100 CXR

CC--Spine SeriesSpine Series 15 CXR15 CXR

Radiologyinfo.org

Background RadiationBackground Radiation

StudyStudy Background radiationBackground radiation

CXRCXR 10 days10 days

CT HeadCT Head 8 months8 months

CT CCT C--SpineSpine 2 years2 years

CT ChestCT Chest 2 years2 years

CT Abdomen/PelvisCT Abdomen/Pelvis 3 years3 years

CC--Spine seriesSpine series 6 months6 months

Exposure to this ChildExposure to this Child

�� Equivalent of 300 CXREquivalent of 300 CXR’’s in one days in one day

�� Equivalent to 8 years and 8 months of Equivalent to 8 years and 8 months of

background radiation exposurebackground radiation exposure

�� In a child with no complaints of injury.In a child with no complaints of injury.

Case #2Case #2

�� 2 YO Male who fell through a register 2 YO Male who fell through a register

approximately 9 to 10 feet on to a hard wood approximately 9 to 10 feet on to a hard wood

floor.floor.

�� Cried immediately, complained of headacheCried immediately, complained of headache

�� Became a little somnolent and ended up Became a little somnolent and ended up

intubatedintubated

�� Prior to transfer CT scans obtainedPrior to transfer CT scans obtained

Case #2Case #2

�� Following studies obtainedFollowing studies obtained

�� CT of head CT of head –– left occipital skull fractureleft occipital skull fracture

�� CT of CCT of C--spine spine –– negativenegative

�� CT chest CT chest –– negativenegative

�� CT abdomen and pelvis CT abdomen and pelvis –– negativenegative

�� No plain films obtainedNo plain films obtained

�� CT chest, abdomen and pelvis obtained CT chest, abdomen and pelvis obtained

without contrastwithout contrast

Radiation exposureRadiation exposure

�� Equivalent to 250 CXREquivalent to 250 CXR’’s in a 2 YO child that s in a 2 YO child that

is highly sensitiveis highly sensitive

�� CT of chest abdomen and pelvis obtained CT of chest abdomen and pelvis obtained

without contrast so they are truly useless.without contrast so they are truly useless.

�� Do not have anyone available that can respond Do not have anyone available that can respond

to data so why delay transfer to get itto data so why delay transfer to get it

�� Let the referring physician decide what studies Let the referring physician decide what studies

they needthey need

AJR:176,February 2001

CT CT –– An Increasing Source of An Increasing Source of

Radiation ExposureRadiation Exposure

�� Since 1970Since 1970’’s CT use had increased to about 62 s CT use had increased to about 62

million CTmillion CT’’s a years a year

�� 4 million CT4 million CT’’s in childrens in children

�� Major growth has been driven by decrease Major growth has been driven by decrease

time for CTtime for CT

�� CT contributes disproportionally to radiation CT contributes disproportionally to radiation

dose to populationdose to population

�� 4% of test = 40% of radiation4% of test = 40% of radiation

Radiation ExposureRadiation Exposure

�� Pediatrics represents small fraction of testsPediatrics represents small fraction of tests

�� But fraction is increasingBut fraction is increasing

�� Combination of higher radiation dose and Combination of higher radiation dose and

larger lifetime risk results in a significantly larger lifetime risk results in a significantly

higher lifetime cancer mortality risk.higher lifetime cancer mortality risk.

�� Lifetime risk attributable to single dose is Lifetime risk attributable to single dose is

larger in childrenlarger in children

NEJM:357:2277-2284,November 2007

Lifetime RadiationLifetime Radiation--Induced Risk of Induced Risk of

CancerCancer


Radiation RisksRadiation Risks

�� Calculated risk based on atomic bomb Calculated risk based on atomic bomb

radiation patientsradiation patients

�� Extrapolated data to determine organ exposure Extrapolated data to determine organ exposure

based on age at exposurebased on age at exposure

�� On basis of number of scans done and age On basis of number of scans done and age

distribution, the lifetime mortality risks are distribution, the lifetime mortality risks are

calculatedcalculated



�� Predicted total numbers of deaths attributable Predicted total numbers of deaths attributable

to 1 year of CT exams in the US areto 1 year of CT exams in the US are

�� 700 for head CT700 for head CT

�� 1800 for CT abdomen and pelvis1800 for CT abdomen and pelvis

�� Children account forChildren account for

�� 170 for head CT170 for head CT

�� 310 for CT abdomen and pelvis310 for CT abdomen and pelvis

AJR:176, February 2001


�� Childhood CT examinations contribute Childhood CT examinations contribute

significantly to overall estimatesignificantly to overall estimate

�� Pediatric CT exams make up only 4% of total Pediatric CT exams make up only 4% of total

test but contribute 20% of total deathstest but contribute 20% of total deaths

�� Lifetime cancer risk of a 1 year old from Lifetime cancer risk of a 1 year old from oneone

CT of abdomen and pelvis is 1 in 550CT of abdomen and pelvis is 1 in 550

�� 1 in 1500 for head CT1 in 1500 for head CT

AJR:176, February 2001

Radiation RiskRadiation Risk

�� If you take 600,000 as average number of CTIf you take 600,000 as average number of CT’’s s

done in children under 15done in children under 15

�� 500 children will ultimately die from the CT 500 children will ultimately die from the CT

scan they receivedscan they received

�� Weigh the risk benefit rationWeigh the risk benefit ration

�� Use alternatives when possibleUse alternatives when possible

NEJM:357:2277-2284, November 2007

Part of the problemPart of the problem

�� Physicians view CT studies in same light as Physicians view CT studies in same light as

other Xother X--raysrays

�� Recent survey of radiologist and ER Recent survey of radiologist and ER

physicians 75% underestimated radiation dose physicians 75% underestimated radiation dose

from CTfrom CT

�� 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

�� 286 solid organ286 solid organ

�� 103 other103 other

�� 30 hollow viscous injury30 hollow viscous injury

AJR:169, October 1997

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


�� 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


�� 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

exam virtually excludes injury.exam virtually excludes injury.

�� Can use FAST to guide need for CTCan use FAST to guide need for CT

Evaluation of the pediatric spineEvaluation of the pediatric spine

�� NEXUS criteria have been out for many years but NEXUS criteria have been out for many years but

have not been consistently used in pediatric patientshave not been consistently used in pediatric patients

�� Consist of deciding if patients need XConsist of deciding if patients need X--rays if they rays if they

show the followingshow the following

�� Midline cervical tendernessMidline cervical tenderness

�� Focal neurologic deficitsFocal neurologic deficits

�� Altered mental statusAltered mental status

�� Evidence of intoxicationEvidence of intoxication

�� Painful distracting injuryPainful distracting injury


�� 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


�� 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



�� 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



�� 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



�� 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%



�� 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



�� 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



�� 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


�� 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



�� 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



�� 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



�� 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



�� 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



�� 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

QuestionsQuestions

??

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Assessing the Pediatric Trauma Patient – What … the Pediatric Trauma Patient – What imaging is ... treatment of tinea capitis. Pediatr Radiol:38:635-644, ... decision of what