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CITATION: Strait, L., Sussman, R., Ata, A., & Edwards, M. J. (2020). Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States.

Journal of Pediatric Surgery. https://doi- 10.1016/j.jpedsurg.2020.01.006

HOT TOPIC: Use of CT scanning in children with blunt trauma

Review: Roberta Miller RN MSN

Title: Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States

Authors: Lauren Strait, Rebecca Sussman, Ashar Ata, Mary J. Edwards

Author Affiliations: Department of Surgery, Albany Medical College, Albany, NY; Department of Surgery, Albany Medical College and Center

Downloaded From: www.sciencedirect.com

WHY THIS ARTICLE IS RELEVANT OR IMPORTANT: Discussed the implication of radiation exposure and cost. Explores the utility of whole-body CT in stable children without clinical evidence of significant injury.

VERY BRIEF REVIEW: Trauma is the most common cause of morbidity and mortality in children, with more than 10 million children in the United States presenting to the emergency department each year for treatment of traumatic injuries. Computed tomography (CT) scan is a widely used diagnostic modality in the evaluation of trauma patients. The speed, accessibility, and level of anatomic detail provided by computed tomography (CT) scans have made them an attractive diagnostic and screening tool since the 1970s. Over the past two decades, concern has risen about risk of future malignancy as a result of exposure to ionizing radiation in children, given the vulnerability of developing organs and the many remaining years of life in which cancer may develop. Prior studies have documented disparities in overall doses of radiation to which pediatric trauma patients are exposed in different practice settings, with a specific eye toward variability in the use of pediatric-specific parameters when scanning children. Clinical prediction rules and guidelines have been derived utilizing retrospective and prospective data to assist clinicians regarding appropriate utilization of CT in blunt trauma of the head, chest, abdomen and pelvis. While studies demonstrate that implementation of evidence-based imaging guidelines has the ability to decrease CT utilization for trauma, acceptance at individual centers is variable, even among pediatric trauma centers where some these guidelines have been developed. Analysis of rates of CT scans performed of the head, thorax, and abdomen was performed based on AIS by body region, and according to trauma center level designation. Multiple CT scans done on the same patient in the same body region were counted only once. Stand-alone adult or combined pediatric/adult trauma centers were treated similarly in this study and designated based on their highest overall adult level of accreditation. Only stand-alone pediatric trauma centers were analyzed separately as pediatric trauma centers.
Statistical significance for relationships was determined utilizing Pearson Chi2 test and Modified Poisson Regression was used to compare CT scan rates by injury type and trauma center level designation and risk ratios and 95% Confidence intervals were reported with statistical significance assessed at 0.05 level.

Background: Liberal use of CT scanning in children with blunt trauma risks unnecessary radiation exposure and cost. Recent literature questions the utility of whole-body CT in stable children without clinical evidence of significant injury, but this is often done based on injury mechanism. The purpose of this study is to quantify the utilization of CT scans of the head, chest, abdomen, and pelvis based on injury severity in these body regions and to assess the impact of American College of Surgeons (ACS) pediatric trauma center designation on CT utilization in children with minor or no injuries.

Methods: We queried the National Trauma Databank for 2014, 2015, and 2016 to identify all patients 14 years and younger. Using Abbreviated Injury Scale (AIS) score as a proxy for injury severity, we analyzed the number of head, thoracic, and abdominal CT scans done for patients at low levels of injury severity (AIS 02) in each of these body regions and according to trauma center level designation (ACS I, II, III, standalone pediatric I or II, and non ACS accredited).

Results: Of 257,661 children who were entered into the database for any reason, overall CT utilization was 20% for head, 5% for the chest and 9% for the abdomen and pelvis. Children with no injuries or minimal injury to the head were scanned 7% and 46% of the time, respectively, for the chest 3% and 13% and for the abdomen 6% and 30%. For all body regions and all levels of injury severity, level 1 stand-alone pediatric centers displayed significantly lower CT utilization rates than others.

Conclusion: CT scan rates for children with minimal or no injuries to the head, chest, abdomen and pelvis are significant. Level 1 stand-alone pediatric trauma centers are least likely to perform these studies. Widespread education and acceptance of clinical guidelines for imaging in stable patients throughout trauma systems could alleviate this disparity.

CITATION: Sathya, C., Alali, A. S., Wales, P. W., Langer, J. C., Kenney, B. D., Burd, R. S., Nance, M. L., & Nathens, A. B. (2019). Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury, 50(1), 142148. https://doi- 10.1016/j.injury.2018.09.036

HOT TOPIC: Radiation-associated cancer

Review: Roberta Miller

Title: Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types

Authors: Chethan Sathya, Aziz Alali, Paul Wales, Jacog Langer, Brian Kenney, Randall Burd, Michael Nance, Avery Nathens

Author Affiliations: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada

Downloaded From: www.sciencedirect.com

WHY THIS ARTICLE IS RELEVANT OR IMPORTANT: Computed tomography use among injured children is higher at adult and mixed trauma centers compared to pediatric trauma centers. Children with low injury severity, fall injury mechanism, and adolescent age are most vulnerable to differential imaging practices across centers. Quality improvement initiatives aimed at reducing heterogeneity in CT usage across trauma centers are required to mitigate pediatric radiation exposure and cancer risk.

VERY BRIEF REVIEW: Children are exposed to more radiation during fixed dose CT because of their relatively smaller cross sectional area when compared to adults. Further, they are at higher risk due to the increased radiosensitivity of their developing organs and the potential oncogenic effect of radiation is higher in children due to their longer life expectancy. These risks have prompted hospitals to develop strategies limiting the use of CT in children when possible. Pediatric CT protocols, such as the ALARA (as low as reasonably achievable) pediatric CT intelligent dose reduction protocol, have also been developed to minimize radiation exposure. To fill this knowledge gap, we evaluated how CT rates differ among ATC, MTC, and PTC. We also determined how CT rates across centers vary among children with differing ages, injury severity, and mechanism. By identifying differences in CT usage across trauma centers and among specific populations of injured children, our goal was to identify where potential quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children.

Background: Trauma is a common indication for computed tomography (CT) in children. However, children are particularly vulnerable to CT radiation and its associated cancer risk. Identifying differences in CT usage across trauma centers and among specific populations of injured children is needed to identify where quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children. We evaluated computed tomography (CT) rates among injured children treated at pediatric (PTC), mixed (MTC), or adult trauma centers (ATC) and estimated the resulting differential in potential cancer risk.

Methods: We identified children age ?18 years with blunt injury AIS ?2 treated from 2010 to 2013 at 130 U.S trauma centers participating in the Trauma Quality Improvement Program. CT rates were compared across center types using Chi-square analysis. Stratified analyses in children with varying injury severity, mechanism, and age were performed. We estimated the impact of differential rates of CT scans on cancer risk using published attributable risks.

Results: Among 59,010 children identified, CT rates were higher among injured children treated at ATC and MTC versus PTC. Findings were consistent after stratified analyses and were most striking in children with chest and abdomen/pelvis CT, adolescent age, low injury severity and fall injury mechanism. We estimated that for every 100,000 injured children, imaging practices in ATC and MTC would lead to an additional 17 and 16 lifetime cancers, respectively, when compared to PTC.

Conclusion: CT use among injured children is higher at ATC and MTC compared to PTC. Children with low injury severity, fall injury mechanism, and adolescent age are most vulnerable to differential imaging practices across centers. Quality improvement initiatives aimed at reducing heterogeneity in CT usage across trauma centers are required to mitigate pediatric radiation exposure and cancer risk

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