Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure

Purpose

We hypothesized that pediatric blunt trauma patients, initially evaluated at nontrauma centers with abdominal computed tomography (CT) scans, often undergo repeat scans after transfer. This study was designed to quantify this phenomenon, assess consequences, and elucidate possible causes.

Methods

This article is an institutional review board-approved, retrospective chart review of pediatric blunt abdominal trauma patients transferred to a level I trauma center from 2002 to 2007 and evaluated with abdominal CT at the trauma center or at a referring facility.

Results

A total of 388 patients met the study criteria, with 6 patients being excluded because of inability to verify outside records resulting in study group of 382 patients. Of those 382 patients, 199 (52%) underwent abdominal CT before transfer. Thirty-six (18%) of those 199 patients underwent repeat CT scanning at our level I trauma center. Of these 36 patients, 19 (53%) were transferred without their outside CT scans, with 10 (53%) of these 19 having significant abdominal injuries. Of the remaining 17, 6 (17%) had repeat scans to assess changes in vital signs, or patient condition, or because of inadequate outside imaging. The remaining 11 (30%) were repeated despite an acceptable outside CT and no change in patient condition. Only 2 of 11 resulted in changed management. Additional radiation delivered from these repeat scans totaled 180 mSv, and additional patient charges totaled more than $110,000. There was an apparent trend toward increased repeat scanning (from 6.7% in 2002 to 16.7% in 2007).

Conclusions

Abdominal CT scans, for evaluation of pediatric blunt trauma, are frequently repeated after transfer from outside hospitals. In many cases, repeat scans provide useful diagnostic information. However, more than 80% of repeat scanning is potentially preventable with better education of transport personnel (paramedics, emergency medical technicians, and nurses) and emergency department physicians.     

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

Introduction

Community hospitals commonly obtain computed tomographic (CT) imaging of pediatric trauma patients before triaging to a level I pediatric trauma center (PTC). This practice potentially increases radiation exposure when imaging must be duplicated after transfer.

Methods

A retrospective review of our level 1 PTC registry from January 1, 2004, to December 31, 2006, was conducted. Level I and II trauma patients were grouped based on whether they had undergone outside CT examination (head and/or abdomen) at a referring hospital (group 1) or received initial CT examination at our institution (group 2). Subgroups were analyzed based on whether duplicate CT examination was required at our PTC (Fischer's Exact test).

Results

A duplicate CT scan (within 4 hours of transfer) was required in 91% (30/33) of group 1 transfer patients, whereas no group 2 patient required a duplicate scan (0/55; P < .0001). There was no significant difference within the groups for weight, age, or intensive care unit length of stay.

Conclusion

A significant number of pediatric trauma patients who receive CT scans at referring hospitals before transfer to our level I PTC require duplicate scans of the same anatomical field(s) after transfer, exposing them to increase potential clinical risk and cost.     

Incidental findings in brain computed tomography scans of 3000 head trauma patients

BACKGROUND: Limited reports exist about intracranial incidental findings on computed tomography (CT) imaging. We studied the frequency of incidental findings on 3000 brain CT scans of trauma patients. METHODS: Three thousands standard brain CT scans of trauma patients were evaluated for some incidental findings. Cisterna magna was evaluated in 1500 CT scans. RESULTS: In this study we found 30 incidental abnormalities that include 8 cases of tumor: 3 meningioma, 2 craniopharyngioma, 1 oligodendroglioma, 1 low-grade astrocytoma, and 1 medulloblastoma. Suspect osteoma was found in 3 cases. In 3 cases, abnormal calcification was found in pineal region, basal ganglia, and temporal horn area. Three suspect lipomas were found in midline and near midline of the brain. Arachnoid cyst was found in 7 cases and hydrocephaly in 3 cases. Large cisterna magna (>10 cm(3)) was found in 11 cases. CONCLUSION: Cisterna magna enlargement was the most common incidental finding and brain tumor and arachnoid cyst were next in frequency.     

Peer assessment of pediatric surgeons for potential risks of radiation exposure from computed tomography scans

Purpose

Radiology literature reports potential cancer risk from radiation exposure from computed tomography (CT). We hypothesized that pediatric surgeons' knowledge of potential risks of radiation exposure from CT scan is limited.

Methods

We used an anonymous, Internet-based peer assessment survey for members of the American Pediatric Surgical Association (APSA). The survey assessed surgeon's knowledge based on potential risks of radiation exposure from CT as well as current practice patterns for use of CT. The χ² test of significance was used to detect any differences in responses based on years in training.

Results

Twenty percent (147/753) of the American Pediatric Surgical Association members completed the survey. About one half (54%) of surgeons believe that the lifetime risk of cancer was increased because of radiation from one abdominal/pelvic CT scan, although more than 75% of respondents underestimated the radiation dose from a CT scan compared to a chest radiograph. Most surgeons generally did not discuss the potential risks of CT scan with their patients. Surgeons demonstrated a range of responses for use of CT for select clinical scenarios.

Conclusions

Pediatric surgeon's knowledge of potential risks of radiation exposure from CT scan is limited. As the radiology literature indicates an increasing awareness for potential cancer risks from radiation exposure from CT, there is also a need for education of subspecialties outside of radiology.     

Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk

Introduction

A child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a “pan-scan,” is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management.

Methods

Pediatric (<15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales.

Results

Fifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P < 0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P < 0.001).

Conclusions

Clinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.     

Review of radiation risks from computed tomography: essentials for the pediatric surgeon

Background/Purpose

Over the past several years, increasing attention has been focused on the potential for radiation exposure from computed tomography (CT) for inducing the development of cancers. An understanding of these issues is important for the practice of pediatric surgery.

Methods

Medline based clinical review of current medical literature of the risks for the induction of cancers by CT. Data includes estimates of cancer risk from computer models, epidemiologic data from survivors of atomic bomb radiation exposure, and consensus opinions from expert panels.

Results

Review of scientific evidence demonstrates varied opinions, but consensus suggests there may be a potential for an increased risk of cancer from low level radiation exposure such as from CT. These calculations suggest that there may be as high as 1 fatal cancer for every 1000 CT scans performed in a young child.

Conclusions

Pediatric surgeons should be aware of the potential risks of CT. Minimizing the radiation risks of CT is a complex endeavor, and will require investments from pediatric surgeons as well as pediatric radiologists.     

Compliance with evidence-based guidelines for computed tomography of children with head and abdominal trauma

Introduction

Recently, two large prospective clinical trials developed and validated prediction rules for children at very low risk for clinically important traumatic brain injuries (ciTBI) or abdominal injury for whom CT is unnecessary. Specific criteria/guidelines were identified which if met would obviate the need for CT scanning. The purpose of this study was to assess compliance at a level one pediatric center with these guidelines as a tool for quality improvement.

Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma

Purpose

The finding of isolated free intraperitoneal fluid (FIPF) on computed tomography of the abdomen (CTA) in children after blunt trauma is of unclear clinical significance and raises suspicion for a solid or hollow viscus injury. In our institution, pediatric blunt trauma patients presenting with isolated FIPF on CTA who are hemodynamically stable and have no peritoneal signs on initial physical examination (iPE) have been historically approached nonoperatively. We reviewed our level 1 trauma center experience with this subset of the trauma population and sought to (1) justify an initial nonoperative approach and (2) identify early predictors of the eventual need for surgical exploration.

Methods

Data on all trauma patients less than 14 years of age admitted to our hospital from 2001 to 2006 after Blunt Abdominal Trauma (BAT) whose screening CTA showed FIPF and no other radiographic signs of solid or hollow viscus injury were retrieved from the local trauma registry. Clinical progress, operative findings, and follow-up were obtained by hospital and office chart review, as well as telephone contact. Mechanism of injury (MOI); Injury Severity Score (ISS); Revised Trauma Score; Pediatric Trauma Score (PTS); the presence of abdominal tenderness or external signs of injury on iPE; and quantity, location, and density of the FIPF were statistically analyzed as possible early predictors of the eventual need for surgical exploration.

Results

A total of 670 children admitted to our institution after blunt trauma were evaluated with CTA during the time of enrollment. Isolated FIPF was found in 94 individuals (14%). Mean age was 9.7 (±SD 3.2) years; 52% were males. Motor vehicle crash was the most common MOI. Mean PTS was 10.6 (±SD 1.8). Mean ISS was 10.2 (±SD 7.2). Free intraperitoneal fluid was most commonly found in only one intraperitoneal region (93%). Most patients (97%) were discharged home without undergoing a surgical procedure. Three other patients developed peritonitis on serial physical examination and were surgically explored. Hollow viscus injuries were found in 2 of these individuals and treated with primary repair or segmental bowel resection. All surgical patients enjoyed a full recovery, with no postoperative complications. The presence of abdominal tenderness on iPE and the quantity of FIPF on initial CTA were the only studied variables to reach statistical significance as predictors of the eventual need for operative intervention. Follow-up after hospital discharge was obtained in 46.8% (44/94) and averaged 124.9 weeks.

Conclusion

To the best of our knowledge, this is the largest series of pediatric blunt trauma patients with isolated FIPF on CTA ever reported. Our findings justify an initial nonoperative approach for the management of these individuals. Abdominal tenderness on iPE and the quantity of FIPF on initial CTA were predictors of the eventual need for operative intervention.     

Radiation exposure – how do CT scans for appendicitis compare between a free standing children’s hospital and non-dedicated pediatric facilities?

Background

We compare the amount of radiation children receive from CT scans performed at non-dedicated pediatric facilities (OH) versus those at a dedicated children’s hospital (CH).

Methods

Using a retrospective chart review, all children undergoing CT scanning for appendicitis at an OH were compared to children undergoing CT imaging for appendicitis at a CH between January 2011 and November 2012.

Results

One hundred sixty-three children underwent CT scans at 42 different OH. Body mass index was similar between the two groups (21.00 ± 6.49 kg/m², 19.58 ± 5.18 kg/m², P = 0.07). Dose length product (DLP) was 620 ± 540.3 at OH and 253.78 ± 211.08 at CH (P < 0.001). OH CT scans accurately diagnosed appendicitis in 81%, while CT scans at CH were accurate in 95% (P = 0.026). CTDI_vol was recorded in 65 patients with subset analysis showing CTDI_vol of 16.98 ± 15.58 and 4.89 ± 2.64, a DLP of 586.25 ± 521.59 and 143.54 ± 41.19, and size-specific dose estimate (SSDE) of 26.71 ± 23.1 and 3.81 ± 2.02 at OH and CH, respectively (P < 0.001).

Conclusion

Using SSDE as a marker for radiation exposure, children received 86% less radiation and had improved diagnostic accuracy when CT scans are performed at a CH.     

Plasma D-dimer safely reduces unnecessary CT scans obtained in the evaluation of pediatric head trauma

Purpose

Serum D-dimer has been proposed as a biomarker to aid in the diagnosis of pediatric traumatic brain injury (TBI). We investigated the accuracy of D-dimer in predicting the absence of TBI and evaluated the degree by which D-dimer could limit unnecessary computed tomography scans of the head (CTH).

Value of computed tomographic angiography in neck and extremity pediatric vascular trauma

Purpose

We sought to define the sensitivity and specificity of computed tomographic angiography (CTA) in pediatric vascular injuries.

Methods

All neck and extremity CTAs performed in pediatric patients at a level 1 trauma center were reviewed from 2001 to 2007.

Results

Overall, 78 patients were identified with an average age of 15.0 ± 4.0 (0-18 years). Males outnumbered females 3.6:1. CTA was performed for 41 penetrating and 37 blunt traumas. Most penetrating injuries were due to missile wounds (71%) or stab wounds (17%). Eleven major vascular injuries resulted from penetrating trauma. For penetrating trauma, CTA was 100% sensitive and 93% specific. CTA for penetrating trauma had a positive predictive value (PPV) of 85% and negative predictive value (NPV) of 100%. Most blunt injuries were due to motor vehicle accidents (57%), followed by pedestrian hit by car (27%). Eight major vascular injuries resulted from blunt trauma. For blunt trauma, CTA was 88% sensitive and 100% specific. CTA for blunt trauma had a PPV of 100% and an NPV of 97%. The accuracy for penetrating and blunt trauma was 95% and 97%, respectively.

Conclusions

CTA is highly sensitive, specific, and accurate for pediatric neck and extremity vascular trauma.     

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

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.

Radiation from CT scans in paediatric trauma patients: Indications,effective dose,and impact on surgical decisions

Objectives

The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans.

Patients and methods

We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specific for body region and age of the patient.

Results

157 paediatric trauma patients were identified during the 2-year study period. Mean Injury Severity Score was 22.5 (range 12–75). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 0–16). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5 mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, defined as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose.

Conclusions

CT is a significant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma.     

Impact of onlay fusion and cone beam computed tomography on radiation exposure and technical assessment of fenestrated-branched endovascular aortic repair

Objective

The objective of this study was to analyze the impact of advanced imaging applications and cone beam computed tomography (CBCT) on radiation exposure of the patient and operator and detection of technical problems during fenestrated-branched endovascular aortic repair (F-BEVAR) for treatment of pararenal aneurysms and thoracoabdominal aortic aneurysms (TAAAs).

Consequences of increased use of computed tomography imaging for trauma patients in rural referring hospitals prior to transfer to a regional trauma centre

Background

Computed tomography (CT) plays an integral role in the evaluation and management of trauma patients. As the number of referring hospital (RH)-based CT scanners increased, so has their utilization in trauma patients before transfer. We hypothesized that this has resulted in increased time at RH, image duplication, and radiation dose.

Methods

A retrospective chart review was completed for trauma activations transferred to an ACS-verified Level II Trauma Centre (TC) during two time periods: 2002–2004 (Group 1) and 2006–2008 (Group 2). 2005 data were excluded as this marked the transition period for acquisition of hospital-based CT scanners in RH. Statistical analysis included t test and χ² analysis. P < 0.05 was considered significant.

Results

1017 patients met study criteria: 503 in group 1 and 514 in group 2. Mean age was greater in group 2 compared to group 1 (40.3 versus 37.4, respectively; P = 0.028). There were 115 patients in group 1 versus 202 patients in group 2 who underwent CT imaging at RH (P < 0.001). Conversely, 326 patients in group 1 had CT scans performed at the TC versus 258 patients in group 2 (P < 0.001). Mean time at the RH was similar between the groups (117.1 and 112.3 min for group 1 and 2, respectively; P = 0.561). However, when comparing patients with and without a pretransfer CT at the RH, the median time at RH was 140 versus 67 min, respectively (P < 0.001). The number of patients with duplicate CT imaging (n = 34 in group 1 and n = 42 in group 2) was not significantly different between the two time periods (P = 0.392). Head CTs comprised the majority of duplicate CT imaging in both time periods (82.4% in group 1 and 90.5% in group 2). Mean total estimated radiation dose per patient was not significantly different between the two groups (group 1 = 8.4 mSv versus group 2 = 7.8 mSv; P = 0.192).

Conclusions

A significant increase in CT imaging at the RH prior to transfer to the TC was observed over the study periods. No associated increases in mean time at the RH, image duplication at TC, total estimated radiation dose per patient, and mortality rate were observed.     

The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries

BACKGROUND: The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies. METHODS: Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay. RESULTS: Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs. CONCLUSIONS: Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.     

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

IntroductionPatients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.MethodsFrom January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.ResultsIn our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p < 0.001), a Glasgow coma scale of 8 or less (p < 0.001), moderate or severe degrees of head injury severity scale (p < 0.001), positive physical examination findings (p < 0.001), and positive CT cranial abnormalities (p < 0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p < 0.001) and orbital fractures (p = 0.019).ConclusionsTBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.     

A single enhanced phase is sufficient for the initial computed tomography evaluation of retroperitoneal tumors in children

Purpose

The goal of this study was to evaluate the incremental value of unenhanced phase in the initial evaluation of retroperitoneal tumors in children by comparison with an enhanced phase alone using computed tomography (CT).

Metal artifact reduction for intracranial projectiles on post mortem computed tomography

PurposeTo compare the image quality of cranial post-mortem computed tomography (CT) obtained with and without projection-based single-energy metal artifact reduction (SEMAR) in cadavers with intracranial metallic ballistic projectiles.Materials and methodsFrom January 2017 to January 2018, cadavers with ballistic projectile head wounds with metal fragments and without massive head destruction were investigated using post-mortem CT. All subjects underwent CT using a conventional iterative reconstruction (IR) and SEMAR. To evaluate the impact of metallic artifacts, the total intracranial area (TA), non-interpretable zone (NIZ), disturbed interpretation zone (DZ), and artifact total surface (ATS) were delineated. Two independent readers identified extra-axial hemorrhage (EAH) and subarachnoid hemorrhage (SAH). Autopsy reports were used as the standard of reference.ResultsEleven corpses (10 males, 1 female; mean age, 62.8 ± 17.9 [SD] years) were evaluated. SEMAR showed a significant decrease in the ATS ratio with respect to conventional IR (72.1 ± 26.1 [SD] % [range: 26.8-99.1] vs. 86.4 ± 17.8 [SD] % [range: 37.2-100]; P < 0.001) and NIZ/TA ratios (11.6 ± 8.26% [range: 0.95–33.4] versus 42.5 ± 30.5% [range: 3.86–100]; P < 0.001). The interobserver reproducibility in diagnosing EAH and SAH was excellent with conventional IR (0.82) and good with SEMAR (0.75). SEMAR reduced uncertain diagnoses of EAH in 7 subjects for Reader 1 and in 6 for Reader 2, but did not influence the diagnosis of SAH for either reader.ConclusionSEMAR reduces the influence of metallic artifacts and increases the confidence with which the diagnosis of EAH can be made on post-mortem CT.     

Impact on trauma patient management of installing a computed tomography scanner in the emergency department

Background

Computed tomography (CT) plays a central diagnostic role for trauma patients. A 16-slice multi-detector CT scanner was installed in the emergency department (ED) of Prince of Wales Hospital in December 2004. The aims of this study were to evaluate the impact of the CT scanner within the ED on trauma management and to compare the utilisation patterns of trauma CT before and after the introduction of EDCT.

Methods

Analysis of prospectively collected trauma registry data. All consecutive trauma cases admitted through the ED that underwent CT between June 2004 and June 2005 (6 months before and after EDCT installation) were included. A positive CT was defined as the identification (by a specialist radiologist) of a significant finding which was consistent with injury.

Results

There were 226 and 202 trauma patients in the 6 months before and after EDCT installation, respectively. 111 (49.1%) patients underwent CT scanning before EDCT compared with 110 (54.5%) afterwards. 72 (65%) patients had CT scans performed before admission to definitive care compared with 99 (90%) after EDCT installed (p < 0.0001, χ² test). Mean time from arrival to first CT was shorter after EDCT (102 min vs. 197 min, p = 0.011). Mean trauma room length of stay increased after EDCT was implemented (106 min vs. 80 min; p < 0.001). Median time to urgent operation (<6 h) was less with EDCT (134 min before vs. 112 min after). No changes in median time to neurosurgical operation (138 min before vs. 148 min after); mean length of stay (12.8 days before vs. 12.5 days after); or mortality (8 patients before vs. 7 patients after). There were 203 scans (1.8/patient) done before EDCT compared with 226 scans (2.5/patient) after. There was no difference in the number of scans done by body region or the proportion of positive scans (32% before vs. 30% after). Logistic regression confirmed that after adjusting for injury severity and admission physiology, time to first CT was shorter (p = 0.0307) but ED length of stay was increased (p < 0.0001).

Conclusion

After the installation of EDCT, more trauma patients had CT scanning before definitive care, and scans were done sooner, with no significant increase in the number of unnecessary scans.