Reetta Kivisaari, pediatric radiologist, PhD

Children’s Hospital, University Hospital, Helsinki, Finland

FROM FAST TO SLOW, MAYBE CT

New Children’s Hospital

construction site,

gold?!

No, concrete

SWEETHEARTS ON THE ROAD

Sweethearts off the road

MOPED ACCIDENT

• Patient 1 driver

• diagnosis on the scene ; femur fracture

• => Pediatric trauma center

• radiographs

• chest

• pelvic

• femur

• abdominal ultrasound

• Patient 2

• no signs of trauma, only small scratchies

• => Local hospital

• cervical spine CT

• body CT

• radiographs

• elbow

• foot

• no findings

The use of whole body computed

tomography scans in pediatric trauma

patients: Are there differences among

adults and pediatric centers?

Pandit, Michailidou, Rhee, et al.Journal

of Pediatric Surgery 51 (2016) 649–653

PEDIATRIC TRAUMA PATIENT IN EMERGENCY

CT is a gold standard of abdominal injury,

but overuse of CT should be avoided!

How do we do that?

Careful clinical examination

Observation

Laboratory tests; blood and urine

FASTFOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA

• FAST is originally a tool for physicians

• haemodynamically unstable adult patients

• non-invasive test

• FAST adults => CT or straight to operation

• haemoperitonuem, haemothorax, pericardial effusion

• morrison pouch, splenorenal area

• extended FAST => inferior vena cava, pneumothorax

• in children approximately one third of the cases of intra-abdominal injuries are not associatedwith haemoperitoneum.

• majority of children with blunt abdominal injury are treated conservatively

FAST SENSITIVITY AND SPESIFITY IN CHILDREN

• sensitivity 66%, specificity 95% to detect intra-peritoneal fluid

• Holmes et al Performance of ultrasonography in pediatric blunt trauma patients: a meta-analysis. J

pediatr surg 2007 42:1588-94.

• sensitivity 50%, spesificity 88%

Focused abdominal sonograpfy for trauma in the clinical evaluatuion of children with blunt abdominal

trauma. Ben-Ishay et al world jour emerg surg 2015.

• sensitivity 52%, spesificity 96%

Test characteristics of focused assessment of sonography for clinically significant abdominal free fluid in

pediatric blunt abdominal trauma. Fox et al. Acad Emer Med 2011:18:477-482.

FAST

Positive

CT

Negative

CT if clinically suspected

adbominal trauma

Observation

Clinical status

Laboratory tests

Abdominal Ultrasound

Stable pediatric trauma patients

THE PECARN NETWORK RULE

TO FIND CHILDREN WHO HAVE A VERY LOW

RISK OF ABDOMINAL TRAUMA

Identifying Children at Very Low Risk of Clinically

Important

Blunt Abdominal Injuries

Holmes, Lillis, Monroe, et al. Ann Emerg

2013;62(2):107-116.

• No evidence of abdominal wall trauma or seat belt sign

• GCS >13

• No abdominal tenderness

• No evidence of thoracic wall trauma

• No complaint of abdominal pain

• No decreased breath sounds

• No vomiting

External validition of a clinical

prediction rule of very low risk

pediatric blunt abdominal trauma.

Springer, Frazier, Arnold et al. Amer

Jour Emer med. In Press

Vamman todennäköisyys < 1%

kliinisen arvion ja FASTin jälkeen,

näistä kuitenkin 49:lle vatsan-TT.

Näillä 173 ei todettuja vammoja .

USE OF FAST• The use of FAST in pediatric population with blunt abdominal trauma varies from center to

center (USA)

• In all centers FAST was done by a surgeon, emergency physician, pediatric emergency

physician, or pediatrician

• If used decreased the use of abd CT if consireded to be in risk of 1-10% for IAI before

FAST

Use of the focused assessment with sonography for trauma

(FAST) examination and its impact on abdominal computed

tomography use in hemodynamically stable children with blunt

torso trauma. Menaker, Blumberg, Wisner et al. J Trauma Acute Care

Surg,Volume 77, Number 3,2014.

Boy, 5 years old

Collision with a tree

No eyewitnesses

Parents took him to hospital

Drowsy

Slight abdominal tenderness

FAST + FAST -

liver 3 4

spleen 4 3

kidney 3

intestine 1

pelvis 1

2006-2008

276 patients

2016-2018

288 patients

SLOW- US

SECOND LOOK IF OTHERWISE WELL

• stable patient

• careful clinical observation

• no changes in clinical status

• laboratory test are insignificant

• abdominal ultrasound

ABDOMINAL ULTRASOUND

abdominal and pleural fluid

haemathomas

parenchymal changes are not allways

visible but sometimes are

intestinal wall ?

Doppler, contrast bubbles

tenderness (sonopalpation)

pneumothorax (more sensitive than chest x-ray)

CHILDREN’S HOSPITAL HELSINKI

• 2016-2018

• 30 patients (out of 288)

• FAST and later abdominal ultrasound

• suspision of spleen trauma in one patient

• control US 7 weeks later

• one liver contusion not seen in US

found with CT (clinical suspicion,

pain and lab-test)

moped 5

pedestrian motor vehicle 6

horse 3

fall 8

motor vehicle collision 6

all terrain vehicle collision 1

motocross 1

no findings 16

facial fracture 2

skull fracture 5

subdural haematoma 1

femur fracture 3

clavicular fracture 1

wrist fracture 1

liver contusion 1

spleen contusion 1

35 children with solid organ rupture diagnosed by abdominal ultrasound

2 immedete operations (spleen, kidney)

1 operation after CT (renal pelvis rupture and urinoma)

97% effective in surgical decision

2016-2018

CHILDREN’S HOSPITAL HELSINKI

ABBREVIATED INJURY SCORE, AIS 3+

• Severity codes as

• 1 minor

• 2 moderate

• 3 serious

• 4 severe

• 5 critical

• 6 maximum

• 93 patients out of 228

2016-2018 CHILDREN’S HOSPITAL HELSINKI

AIS 3+

• 93 patients

• 27 only abdominal ultrasound, no abdominal CT

• 11 did not have any abdominal ultrasound, only CT

• 9 FAST pos CT pos (3 spleen, 2 liver, 2 kidney, pelvic fracture, liver + kidney)

• 4 FAST neg CT pos (liver, liver and spleen and pelvic fracture, spleen, spleen and

intestine)

• 17 FAST neg body CT pos other than abdominal organs (lung contusion, fractures, etc)

MOST IMPORTANT POINTS

• team work ; clinical examination and observation

• be cautious if worrying trauma mechanism or patient is not alert

• lab test; is there a signs of bleeding or intra-abdominal trauma?

• FAST has low sensitivity but high specificity

• up to one third do not have haemoperitoneum

• FAST is not an abdominal ultrasound

• consider SLOW ultrasound

• nearly all abdominal injuries are treated conservatively

• use CT when it is needed

THANK YOU FOR YOUR ATTENTION!

• Paediatric trauma imaging:why do we need separate guidance? Negus, Fisher, Johnson et al. Clinical Radiology 69(2014)1209-1213.

• Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? Retzlaff, Hirsch, Till, Rolle. Journal of Pediatric Surgery (2010) 45,912-915.

• External validation of a clinical prediction rule for very low risk pediatric blunt abdominal trauma; Springer, Frazier, Arnold, Vukovic American Journal of Emergency Medicine xxx (xxxx) xxx, in press.

• Holmes et al Performance of ultrasonography in pediatric blunt trauma patients: a meta-analysis. J pediatr surg 2007 42:1588-94.

• Use of the focused assessment with sonography for trauma (FAST) examination and its impacton abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Menaker, Blumberg, Wisner et al. J Trauma Acute Care Surg,Volume 77, Number3,2014.

• The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers? Pandit, Michailidou, Rhee, et al.Journal of Pediatric Surgery 51 (2016) 649–653

2016-2018

CHILDREN’S HOSPITAL HELSINKI (OLD AND NEW)

• 228 trauma patients with possible blunt abdominal trauma

• 46 had head trauma (20,2%)

• 147 FAST (64%)

• 10 positive (6,8%)

• 90 abdominal CT (39%)

• 10 FAST and CT positive (100%)

• 6 FAST negative, CT positive for intra-abdominal injury (4,4% )

• 32 FAST neg, body CT pos (23,4%) (fractures, lung contusions etc)

• 180 any abdominal ultrasound (79 %)

• 103 only US (45%)

• 48 no US done (21%)

ALL BODY CT

FINDINGS 288 PATIENTS

• 9 liver injuries ( 4 FAST neg)

• 7 spleen injuries (3 FAST neg)

• 6 kidney injuries

• 1 intestine (FAST neg)

• 6 pelvic fractures

• 15 spine fractures

• 25 lung contusions or pneumothoraxes

• 46 had head trauma (20,2%)

• 5 deaths all because of brain trauma