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
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