Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

Purpose

To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging.

Methods

A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry.

Results

A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score < 14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%).

Conclusion

The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging.     

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.     

CT scan and the pediatric trauma patient--are we overdoing it?

Background

Recent literature expresses concern for an increased risk of cancer in children exposed to low-dose radiation during computed tomography (CT). In response, children’s hospitals have implemented the ALARA (as low as reasonably achievable) concept, but this is not true at most adult referring institutions. The purpose of this study was to assess the diagnostic necessity of CT in the evaluation of pediatric trauma patients.

Methods

A retrospective review was conducted of the trauma database at a large, level I, freestanding children’s hospital with specific attention to the pattern of CT evaluations.

Results

From January 1999 to October 2003, 1,653 children with traumatic injuries were evaluated by the trauma team, with 1,422 patients undergoing 2,361 CT scans. Overall, 54% of obtained scans were interpreted as normal. Fifty percent of treated patients were transferred from referring hospitals. Approximately half arrived with previous CT scans with 9% of these requiring further imaging. Of the 897 patients that underwent abdominal CT imaging, only 2% were taken to the operating room for an exploratory laparotomy. In addition, of those patients who had abnormal findings on an abdominal CT scan, only 5% underwent surgical exploration.

Conclusions

CT scans are used with regularity in the initial evaluation of the pediatric trauma patient, and perhaps abdominal CT imaging is being used too frequently. A substantial number of these scans come from referral institutions that may not comply with ALARA. The purported risk of CT radiation questions whether a more selective approach to CT evaluation of the trauma patient should be considered.     

An analysis of proctoscopy vs computed tomography scanning in the diagnosis of rectal injuries in children: which is better?

Background

Current dogma suggests that the diagnosis of rectal injury can be made after physical examination and proctoscopy (PR). However, anecdotal evidence suggests that these modalities lack specificity when applied to children and that computed tomography (CT) scanning may be superior. A direct comparison between CT scanning and PR has not been performed. We therefore sought to compare CT with PR in the diagnosis of rectal injury by analyzing our large institutional experience.

Methods

To assess institutional outcome, the charts of all children younger than 18 years admitted to our level I trauma center (1999-2004) were prospectively collected and retrospectively assessed. Demographics, diagnostic accuracy (PR vs CT), and outcome (length of stay, days in the intensive care unit [ICU], Injury Severity Score, and missed injury) were assessed.

Results

There were 24 injuries (63% boys, 71% blunt, 100% survival), and diagnostic modality included the following: PR, 37.5%; CT, 37.5%; laparotomy alone, 8%. Length of stay (PR 5.7 ± 6.2 vs CT 13.7 ± 22.2, NS) were similar between groups. Of the missed rectal injuries, 66% of patients undergoing PR had missed injuries that were ultimately detected by CT whereas 33% of the patients undergoing CT scan had a missed injury.

Conclusion

CT is at least as accurate as PR in diagnosing pediatric rectal injury. Consideration of early scanning as opposed to PR may improve diagnosis and outcome in these patients.     

Resource utilization and its management in splenic trauma

Background

This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system.

Methods

Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities.

Results

Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled.

Conclusions

Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.     

Posttraumatic small bowel obstruction in children

Background

The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience.

Methods

Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied.

Results

All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative.

Conclusions

Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.     

Use of focused abdominal sonography for trauma at pediatric and adult trauma centers: a survey

Purpose

Focused abdominal sonography for trauma (FAST) has been popularized for the initial evaluation of trauma patients. We sought to understand the scope of practice on a national level with specific attention to its use in the pediatric age group.

Methods

An electronic survey was sent to all American College of Surgeons level I trauma centers and the National Association of Children's Hospitals and Related Institutions that were freestanding children's hospitals.

Results

The survey was emailed to 124 centers, and 98 (79%) completed the survey. Of the surveyed centers, 23% cared for adults only, 28% were freestanding children's hospitals, and 49% managed both. At adults-only institutions, 96% use FAST and at children's hospitals, only 15%; it is used at 85% of centers that care for both. For the centers that use FAST on children, 88% have no age limit. Of all the institutions that typically use FAST, the individual performing the examination could be a surgeon (73%), an emergency department doctor (48%), or a radiologist (3%). Of the centers that perform FAST, 51% bill for the FAST examination.

Conclusions

Adult hospitals are much more likely to perform FAST examinations in the trauma patient, and many adult centers routinely use FAST to examine pediatric patients.     

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.     

Presence of pneumomediastinum after blunt trauma in children: what does it really mean?

Background

Pneumomediastinum after blunt thoracic trauma is often considered a marker of serious aerodigestive injury that leads to invasive testing. However, the efficacy of such testing in otherwise stable children remains unknown. We hypothesize that pneumomediastinum after blunt trauma in clinically stable children is rarely associated with significant underlying injury.

Methods

We reviewed all patients in our pediatric trauma database (1997-2007) for pneumomediastinum after blunt injury. Patients were then subdivided into 2 groups: group I, isolated thoracic and group II, thoracic and additional injuries. Procedures and imaging were recorded, and outcomes were assessed.

Results

Thirty-two children with blunt thoracic trauma were included as follows: group I (n = 14) and group II (n = 18). In all patients, there were 28 diagnostic procedures performed resulting in only 1 positive test—a bronchial tear found on bronchoscopy in association with obvious respiratory distress. Group I was more than twice as likely to undergo invasive procedures as group II (P < .0001), resulting in significantly greater costs (?$13683 ± 2520 vs $5378 ± 1000; P < .002). Patients in group I also received more diagnostic imaging to assess pneumomediastinum (1.89 vs 1.08 studies/patient per day; P < .05). More than 28% of all patients were completely asymptomatic and had pneumomediastinum as their only marker of injury. Strikingly, these patients received more than 46% of the procedures.

Conclusions

Children with pneumomediastinum from blunt trauma often receive invasive and expensive testing with low yield, especially those with isolated thoracic trauma.     

If a picture is worth a thousand words, what is a trauma computerized tomography panel worth?

Background

There has been a progressive increase in the use of computerized tomography (CT) scans for evaluating trauma patients. The purpose of this study was to quantify that trend and consider the implications it holds for resource use.

Methods

Data were combined from the trauma registry and the radiology department’s administrative information system at a level I trauma center to define the radiographic use patterns applied to all trauma activations during a 3-month sampling period in each of 4 years.

Results

Trauma activations increased by 21% whereas total radiographic studies increased by 82%. The proportion of CT scans to total studies increased progressively from 18% to 27%. The average number of CT studies per patient increased from 2.68 ± 3.09 to 6.88 ± 7.50. CT use increased for patients presenting by primary or secondary transport, regardless of triage classification. In the final sampling period, CT scans alone generated an average of 3,726 images per day to be reviewed.

Conclusions

Increasing use of multi-image studies is facilitated by improvements in technology and medical-legal pressures. However, extensive imaging can stress overburdened trauma systems. Additional studies are needed to assess the implications of increasing radiographic use on trauma outcomes.     

Pediatric blunt and penetrating trauma deaths in Ontario: a population-based study

Purpose

The purpose of the study was to describe the mechanisms of injury and causes of death in children dying in a modern, integrated trauma system.

Method

Records of all children (<16 years of age) who died in Ontario from 2001 through 2003 after blunt or penetrating trauma were obtained from the Chief Coroner. Demographics and the nature and causes of injury and the causes of death were recorded. Estimates of the mortality rate were determined using census data.

Results

There were 234 injury deaths (222 blunt, 12 penetrating) over the 3 years. Thirty (13%) resulted from intentional injury. The median age was 10 (range, 0-15.9) years; 62% were male. Sixty-eight percent resulted from incidents involving motor vehicles (passenger, pedestrian, or cyclist). Most (74%) died at the scene; only 5% survived for more than 24 hours. Devastating craniocervical injury (Abbreviated Injury Scale 5 or 6) was present in 84% and was the only life-threatening injury in 40%. The annual mortality rate averaged 3.2 per 100,000 children.

Conclusions

In a modern, integrated trauma system, most pediatric injury deaths occur at the scene from severe head injuries. In this population, strategies to reduce the death rate from pediatric trauma must focus on primary and secondary injury prevention.     

Long-term outcome of nonoperative pediatric splenic injury management

Background

Nonoperative management (NOM) of blunt splenic trauma is the standard of care in hemodynamically stable children. The long-term risk of this strategy remains unknown. The object of this study was to investigate the incidence of long-term complications after NOM of pediatric splenic injury.

Methods

All children who underwent NOM for blunt splenic trauma over an 11-year period were identified. Patients were interviewed for any ailments that could be related to their splenic injury, and hospital data were analyzed.

Results

A total of 266 patients were identified, and 228 patients (86%) were interviewed. Mean follow-up time was 5 ± 3 years. One patient had a delayed complication, a splenic pseudocyst. Pain more than 4 weeks after injury was unusual. Time until return to full activity varied broadly.

Conclusion

The incidence of long-term complications after NOM of pediatric splenic injury was 1 (0.44%) in 228 patients. Nonoperative management of pediatric blunt splenic trauma in children is associated with a minimal risk of long-term complications.     

Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado

Background

The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries.

Method

Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries.

Results

For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.

Conclusion

The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma.     

Pediatric trauma care: a profitable enterprise?

Purpose

We set out to examine whether pediatric trauma care resulted in a financial burden.

Methods

We reviewed financial data for children with an International Classification of Diseases, Ninth Edition, injury diagnosis code over 2 years at an urban level I pediatric trauma center. We divided inpatients into length of stay categories, and profit or loss was calculated for each payor/length of stay category. These figures were then used to estimate revenue for each hospital based upon their patients payor/length of stay distribution that was obtained from the KID database. Our payor-based outpatient revenue figures were also applied to the other hospital-calculated outpatient visits to obtain an estimate of their outpatient revenues.

Results

We treated 49,437 injured children with a revenue balance of more than $8 million. Commercial insurance resulted in a positive revenue stream. Losses increased as length of stay increased for patients with Medicaid or self-pay. Outpatient encounters resulted in 59% of the revenue. Extrapolating our data, 84% of pediatric trauma centers in 27 states generate an average of $800,000 revenue.

Conclusions

Pediatric trauma care is a profitable enterprise. Inadequate reimbursement remains for Medicaid and self-pay patients, which could result in financial losses should this proportion of the patient mix be more than 55%.     

Risk factors for blunt thoracic aortic injury in children

Background/Purpose

Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children.

Methods

Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods.

Results

Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of ≥3) involving the head, thorax (other than aorta), abdomen, and lower extremities.

Conclusions

Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.     

Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons

Background/Purpose

The purpose of the study was to identify influential factors contributing to the variation with which antireflux procedures (ARPs) are performed at freestanding children's hospitals in the United States.

Methods

We conducted an online survey of pediatric surgeons working in Child Health Corporation of America (CHCA) member hospitals in which we examined decision making for ARPs.

Results

Thirty-six percent (n = 121) of contacted surgeons responded. Eighty percent reported requiring preoperative upper gastrointestinal series before ARPs, and 13% require a pH probe study. Although surgeons ranked their own opinion as the most important in preoperative decision making, parents and referring physicians played significant roles in hypothetical scenarios. In children with negative/equivocal objective studies, more than half of surgeons reported offering ARP when the referring specialist felt that ARP was indicated. Despite equivocal studies, 20% of the surgeons reported offering ARP when the parents were convinced that ARP would help. In a patient with both a positive pH probe and upper gastrointestinal series, 46% of surgeons reported declining ARP if parents were hesitant.

Conclusions

These data suggest that a surgeon's final decision to perform ARP may be just as influenced by nonobjective factors, such as referring physician and parental opinions, as it is by objective studies. Our survey reinforces the need for further examination of specific factors in preoperative decision making for ARPs in the pediatric population.     

Management of pediatric blunt splenic injuries in Canada—practices and opinions

Purpose

The aim of the study was to compare the self-reported practice patterns of Canadian general surgeons (GSs) and pediatric general surgeons (PGSs) in treating blunt splenic injuries (BSIs) in children.

Methods

Forty-five PGSs and 690 GSs were surveyed (internet and hard copy). χ² was used to compare groups; logistic regression was performed to determine independent factors influencing management variables.

Results

Thirty-three PGSs and 191 GSs completed the survey, for a response rate of 30%. Pediatric general surgeons are more likely than GSs to follow American Pediatric Surgical Association guidelines (52% vs 11%; P < .0001). In diagnosing BSIs, PGSs and GSs are equally likely to use computed tomography (CT) over ultrasound for initial imaging. Pediatric general surgeons are less likely to consider CT injury grade in deciding on nonoperative management (NOM) (odds ratio [OR], 0.2; confidence interval [CI], 0.07-0.5; P = .002) and are more likely to continue NOM for patients with contrast blush on CT (OR, 6.5; CI, 2.5-17; P = .0002). Pediatric general surgeons report more selective intensive care unit use, hospital stay, follow-up imaging, and activity restrictions. No differences were found in the management of splenic artery pseudoaneurysms.

Conclusion

Differences exist between PGSs and GSs in the management of pediatric BSIs, resulting in higher operative rates, use of resources, and radiation exposure. Further education of GSs in NOM and establishment of management guidelines are indicated.     

Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?

Background

Computerized tomography (CT) is considered as the imaging study of choice for blunt abdominal trauma in children. Nevertheless, recent investigations clearly indicate an increased risk of cancer in children exposed to radiation during abdominal spiral CT. Therefore, alternative strategies should be used for the diagnosis and surgical decision making in blunt abdominal trauma in children.

Methods

Retrospective analysis included all children with intraabdominal organ rupture after blunt abdominal trauma. Patients were diagnosed by a standardized emergency protocol that included primary clinical assessment and repeated ultrasound but not routine CT. Efficacy of abdominal ultrasound was evaluated in regard to safe diagnosis and appropriate surgical decision making.

Results

The study included 35 children with intraabdominal organ rupture diagnosed by ultrasound. One fifth (7/35) of the patients were polytraumatized, whereas 28 of 35 had an isolated blunt abdominal trauma. All patients underwent immediate ultrasound scanning of the abdomen and retroperitoneal space. Two patients were immediately operated because of hemodynamically instability. Four of 7 polytraumatized patients and 7 of 28 patients with isolated blunt abdominal trauma were additionally diagnosed by spiral CT. Only 1 patient underwent subsequent surgery because of the findings in the CT. Ultrasound was effective in more than 97% (34/35) of the patients for diagnosis and appropriate surgical decision making.

Conclusion

Ultrasound combined with clinical assessment presents an effective method for safe diagnosis and appropriate surgical decision making in pediatric blunt abdominal trauma. Selected cases with polytrauma and/or unequivocal findings in the ultrasound should undergo abdominal CT. Patients requiring abdominal CT should have an anticipated benefit that exceeds the radiation risk. The importance of repeated clinical assessment cannot be overstated.     

Electron beam CT scan is a valuable and safe imaging tool for the pediatric surgical patient

Purpose

Electron beam computed tomography (EBCT) is a relatively new technology that has been used primarily to detect coronary artery calcification in adult patients. EBCT has several potential advantages over traditional CT: (1) fast acquisition times resulting in less need for sedation, (2) decreased radiation exposure, and (3) robust software enabling real-time interactive 3-dimensional visualization of anatomic relationships. In this series of case reports, the authors describe their initial experience with the use of EBCT in pediatric noncardiac imaging.

Methods

Children with a variety of thoracic and abdominal disease processes were evaluated by EBCT.

Results

All patients underwent EBCT scanning without the need for sedation, and 3-dimensional images of the data sets were rendered in minutes after their acquisition. The diagnostic images provided equivalent spatial resolution to the multislice CT scanner but without motion artifacts and lower radiation exposure.

Conclusions

EBCT is a safe, effective, and user- and patient-friendly alternative to traditional CT in the care of pediatric surgical diseases. The diagnostic yield of EBCT will continue to improve with new technologic advances and clinical experience.     

The incidence and surgical management of paratubal cysts in a pediatric and adolescent population

Purpose

The aim of this study is to determine the incidence of paratubal cysts (PTCs) in a pediatric and adolescent population.

Methods

An institutional review board-approved retrospective chart review was performed between the years of 1998 and 2008 at a single children's hospital. Inclusion criteria were met if pathology reports demonstrated diagnosis of PTC, hydrosalpinx, or hydatid of morgagni.

Results

One hundred ten patients had confirmed diagnoses of hydatid of morgagni, hydrosalpinx, or PTC. The incidence of PTCs was 7.3%. Mean age of PTC diagnosis was 13.7 ± 2.82 years, with 12.6% diagnosed premenarchal. Mean age menarche was 11.7 ± 1.34 years among pubertal females. The age of menarche and diagnosis of PTC correlated (Pearson, 0.54) (P < .0001). There was a small correlation between body mass index and size of PTC (r = 0.36; P ≤ .001).

Conclusion

The incidence of PTCs was 7.3% in this pediatric and adolescent population. In addition, this is the first study to confirm presence of PTCs in prepubertal females. Surgeon should be aware of these benign cysts because they are frequently a source of abdominal pain in young girls. As nonphysiologic cysts, these will not resolve spontaneously and may increase in size and/or be at risk for adnexal torsion. Ultimately, surgical management is required for definitive resolution.