Here’s an interesting concept for a “speed bump.” Make it look like something you would want to slow down for!
The use of radiographic imaging in trauma patients has exploded over the past decade. A growing amount of research is looking at adult patients, but what about children?
Johns Hopkins did a one year retrospective review of radiographic imaging in kids age 14 and below. The studies performed and the estimated radiation dose was calculated for each child. A total of 719 children were studied and they underwent a total of 4603 studies:
- CT scans – 1457 (32%)
- Plain radiographs – 3097 (67%)
- Fluoroscopy – 49 (1%)
CT accounted for only 32% of studies but delivered 91% of the total radiation dose. Children involved in car crashes received the highest dose of radiation (18mSv) versus burned children, who had the lowest dose (1.2 mSv). Radiation exposure increased as the injury severity increased. The average age was 8 years, which means that these children have a long time until possible side-effects emerge.
What to do? First, seriously weigh the risks and benefits of every radiographic study before you order it. If CT is not essential, do something else. The ALARA concept is key (as low as reasonably achievable):
- Use weight-based CT protocols in order to deliver the minimum amount of radiation needed to get decent images
- Shield all sensitive areas that are not being imaged
- Use focused studies
- Avoid repeat exams
- Become knowledgeable about the effects of radiation exposure
- Ask yourself: “What if this were my child?”
Reference: Brown, et al. Diagnostic radiation exposure in pediatric trauma patients. J Trauma 2010, ahead of print.
Trauma professionals routinely worry about the thoracic aorta when evaluating adults after major blunt trauma. The question is, how much do we have to worry about blunt thoracic aortic injury in children?
Younger children are more elastic, and their organs tend to withstand more punishment than adults. After reviewing the literature, I’ve come to the conclusion that this injury is very rare in children in the single digit age range. It’s difficult to find a good paper that addresses this question. The majority include kids up to age 16 or 18, which really skews the results. These patients are most commonly involved in motor vehicle crashes, although a significant number are also pedestrians struck by cars.
The National Trauma Data Bank (NTDB) was queried for all children <18 years old sustaining blunt injury with at least 1 diagnosis code. There were nearly 27,000 records matching these criteria. Of these, only 34 had an injury to the thoracic aorta. And in the age range under 10, there were only 2! Both of these children were in very high energy car crashes.
The bottom line: Injury to the thoracic aorta practically never happens in children in the single digit age range. As they get closer to adolescence, they behave more like adults and become more susceptible. The diagnosis should be only be entertained in small children who are involved in very high-energy car crashes. Falls from the usual heights (2-3 stories) are probably not significant enough to cause it. A chest xray may show a full mediastinum, but this will most likely be due to a normal thymus. If investigation is warranted, the standard is to obtain a helical CT of the chest. This study would most likely be obtained anyway to evaluate the torso in a high-energy mechanism. Aortorgraphy is no longer used.
Reference: Trooskin, et al. Risk factors for blunt thoracic injury in children. J Pediatric Surg 40(1):98, 2005.
A contrast blush is occasionally seen on abdominal CT in patients with solid organ injury. This represents active arterial extravasation from the injured organ. In most institutions, this is grounds for call interventional radiology to evaluate and possibly embolize the problem. The image below shows a typical blush.
This thinking is fairly routine and supported by the literature in adults. However, it cannot be generalized to children!
Children have more elastic tissue in their spleen and tend to do better with nonoperative management than adults. The same holds true for contrast blushes. The vast majority of children will stop bleeding on their own, despite the appearance of a large blush. In fact, if children are taken to angiography, it is commonplace for no extravasation to be seen!
Angiography introduces the risk of local complications in the femoral artery as well as more proximal ones. That, coupled with the fact that embolization is rarely needed, should keep any prudent trauma surgeon from ordering the test. A recently released paper confirms these findings.
The only difficult questions is “when is a child no longer a child?” Is there an age cutoff at which the spleen starts acting like an adult and keeps on bleeding? Unfortunately, we don’t know. I recommend that you use the “eyeball test”, and reserve angiography for kids with contrast extravasation who look like adults (size and body habitus).
Reference: What is the significance of contrast “blush” in pediatric blunt splenic trauma? Davies et al. J Pediatric Surg 2010 May; 45(5):916-20.
There are only about 45 Pediatric Trauma centers in the United States. They are clustered in the Northeast, in the central Midwest, and along the west coast. This poses a problem for parents located in the rest of the country.
In contrast, there are nearly 500 adult trauma centers, scattered much more evenly across the country. All adult centers that treat more than 100 children per year are required to have basic pediatric trauma resources, such as a pediatric ICU and intensivists to man it.
A growing body of research shows that adults and children with major trauma do better if treated at an adult trauma center. Is there an advantage to having your child treated at a pediatric trauma center?
The answer is yes! A paper published in 2008 looked at children admitted to hospitals in Florida over a 10 year period. They found that children and young adults did better when admitted to a trauma center when compared to a non-trauma hospital, although the effect was less in younger children. The overall survival improvement was about 3%.
When treated at a pediatric trauma center, survival increased an additional 4%! The reasons are not entirely clear, because these studies do not have the ability to discern specifics. However, it appears that a combination of resource availability (present in all Level I and II trauma centers) and specialty capabilities (only present in hospitals with pediatric resources) is key.
Most children with injuries serious enough to require hospitalization can be treated at any trauma center. Those who have critical injuries that require considerable aftercare (severe brain injury, complex orthopedic/pelvic injuries) are best treated at a designated pediatric trauma center if one is available.
Reference: Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? Tepas, Flint et al. J Pediatric Surgery, 43, 212-221, 2008.