Anyone who reads this blog already knows I am a big believer in well-crafted and focused practice guidelines. And by focused I mean directed toward a clinical problem that typically sees a lot of variability between care providers. Use of imaging is one of these clinical problems. A surgeon may order a certain set of studies for a major blunt trauma patient, and their emergency medicine colleague might order a somewhat different set for someone with the exact same history, physical exam, and injury pattern. Who is right? Neither!
And the variability is even greater when we throw a pediatric patient into the mix. Trauma professionals tend to be even more “generous” when ordering studies on children because they are afraid they might miss something. Unfortunately, this has the potential for overuse of imaging and exposure to unnecessary radiation.
Avery Nathens and a consortium of pediatric trauma centers used the Trauma Quality Improvement Database (TQIP) to review CT imaging practices on children age < 18 over a four year period. Only blunt trauma patients were studied, and the Abbreviated Injury Scale had to be at least 2 for a minimum of one organ system. Transfer patients were excluded because there is no data on imaging for the referring hospital in the TQIP database for them. Comparisons were made between practices at adult trauma centers treating children (ATC), mixed adult/pediatric centers (MTC) and pediatric only trauma centers (PCT).
Here are the factoids:
- Over 59,000 pediatric trauma patients were identified in the data, and about half (31,081) received at least one CT scan
- The distribution among the three types of trauma centers was even, with roughly a third seen at each
- Of the study group 46% had a head CT, 17% a chest CT, and 26% underwent abdominal CT
- Injured children were more likely to undergo CT if they were older, had a higher ISS, lower motor GCS, were involved in a car crash, or had severe injuries to head or torso
- Overall CT rates were about the same across the three types of centers (56% ATC, 57% MTC, 43% PTC)
- Chest CT was performed 8x as much at ATC/MTC vs PTC (!)
- Abdominal CT was performed 2x as much at ATC/MTC vs PTC
- Lesser injured children received relatively more CT scans at ATC/MTC when compared to PTC
- Using standard estimates of cancer risk from all CT scans received, children treated at adult or mixed trauma centers received enough radiation to cause 17 additional lifetime cancers per 100,000 patients
- About 35 additional lifetime cancers per 100,000 would be caused by the chest and abdominal scans performed at the ATC/MTC centers when compared to pediatric-only centers
Bottom line: This is yet another reason to adopt a well-designed pediatric imaging guideline. Not only are adult centers using CT scanning much more that pediatric-only centers, but they are unnecessarily adding to the lifetime risk for cancer of our children!
As I always recommend, find a well-designed imaging guideline from an established pediatric center and “borrow” it. Sure, it may need a few minor tweaks to fit well with your hospital. That’s okay. Just get it done so your team can begin to order the initial imaging studies consistently and intelligently.
Reference: Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury 2018, in press. https://doi.org/10.1016/j.injury.2018.09.036