Reetta Kivisaari, Pediatric radiologist, MD, PhDChildren’s Hospital, University Hospital,Helsinki, Finland

IMAGING STRATEGIES ANDRADIATION EXPOSURE IN PEDIATRIC MULTITRAUMA

First things first

▪ Clinical examination

▪ Chest x-ray

▪ FAST ultrasound

Focused assessment with sonography for trauma

▪ Stable or unstable?

▪ Stabilization before CT

Trauma CT▪ clinical decision rules can be used to predict which

child does not need imaging

▪ justification for all areas scanned

head

cervical spine radiographs, MRI

thorax chest x-ray and ultrasound

abdomen ultrasound

extremities radiographs

▪ Centers dedicated to children

Imaging protocols for different ages or bodyweights

dose reduction procedures

dual phase contrast media injection

Glasgow coma scale

Verbal response1. No verbal response2. Incomprehensible sounds. 3. Inappropriate words. 4. Confused. 5. Oriented.

Eye response1. No opening of the eye2. Eye opening in response to pain stimulus3. Eye opening to speech4. Eyes opening spontaneously

Motor response 1. No motor response2. Decerebrate posturing accentuated by pain (extensor response) 3. Decorticate posturing accentuated by pain (flexor response) 4. Withdrawal from pain 5. Localizes to pain 6. Obeys commands

Maximum 15 points = normal

Lancet 2017; 389: 2393–402Babl, Borland, Phillips et al.

Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study

20 137 aged < 18 years with head injuries (prospective)

The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules.

HEAD CTPECARN▪ Pediatric Emergency Care Applied Research

Network

▪ Identifies children at very low risk of clinicallyimportant brain injuries after head trauma

CHALICEChildren’s Head Injury Algorithm for the Prediction of Important Clinical Events

▪ witnessed LOC >5min or amnesia > 5 min▪ abnormal drowsiness▪ ≥ 3 vomits▪ suspicion of non-accidental injury▪ seizure▪ GCS <14 (if <1 year GCS <15)▪ suspision of skull or basal skull injury▪ positive neurological sign▪ bruise,swelling, laseration > 5cm▪ high-speed traffic accident (64km/h)▪ Fall of >3m

Dunning 2009, ChaliceRULE

CATCHCanadian Assessment of Tomography for Childhood Head injury

▪ GCS < 15 two hrs after injury

▪ suspected skull or basal skull fracture

▪ vorsening headache

▪ irritability on exam

▪ large scalp hematoma

▪ dangerous mechanism of injury

Cervical spine

▪ 1-2 % of pediatric trauma

▪ < 8 years of age =>motor vehicle collision

▪ >8 years of age => sports

▪ Sciwora spinal cord injury with out radiographic

abnormality

▪ MRI if definitive neurological signs

▪ radiography or CT

▪ before surgery, intubation

The NEXUS, cervical spine(National Emergency X-Ray Utilization Study)

▪ focal neurologic deficit (paresthesias on extremeties)

▪ midline spinal tenderness

▪ altered level of consciousness

▪ intoxication

▪ distracting injury

Canadian c-spine rule

Chest CT

▪ Blunt trauma

primary investigation is chest x-ray.

If x-ray and us for pneumothorax

are normal and conscious patent is clinically stableno need for ct

▪ Penetrating trauma

contrast enhanced CT is primary investigation

▪ thoracic spine is seen in chest CT

Abdomen CT

▪ if clinically indicated, history and examination

handle bar injuries

abdominal tenderness

laboratory tests (elevated amylases)

negative FAST doesn’t rule out intra-abdominaltrauma

lumbar spine and pelvis

The PECARN network

▪ 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 vomitingIdentifying Children at Very Low Risk of Clinically ImportantBlunt Abdominal InjuriesHolmes, Lillis, Monroe, et al. Ann Emerg 2013;62(2):107-116.

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.

▪ conclusion

supports the use of PECARN clinical predictionrule to decrease abdominal CT use

pelvic and spinal injuries can not be ruled out!

Extremities

▪ radiographs are primary investigation

▪ preoperative CT might be requested for complex fractures

▪ CT angiography if vascular trauma

▪ Current trends in pediatric imaging support the use of ultrasound (US) and (MRI) to decrease radiation exposure.

▪ Clinical decision rules can be used to predict which child does not need imaging.

▪ When CT is needed use pediatric protocols!

Emerging Concepts in PediatricEmergency RadiologyNicola Baker, MD*, Dale Woolridge, MD, PhD

▪ Thank you for your attention

▪ I hope you enjoy your stay in Helsinki!

The use of whole body computedtomography scans in pediatrictraumapatients: Are there differencesamong adults and pediatriccenters?Pandit, Michailidou, Rhee, et al.Journal of Pediatric Surgery 51 (2016) 649–653

▪ Centers investigating children

presettings for different ages or body weights

dose reduction procedures

▪ National guidelines to follow

STUK - Radiation and Nuclear Safety Authority

▪ Remember the value of radiographs !