Elisha G Brownson MD FACS Trauma Medical Director Alaska Native Medical Center ANTHC Tribal Health Webinar Series October 22 2021 Radiation exposure from imaging increases risk of malignancy in pediatric patients ID: 1039695
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1. Imaging Decisions in Pediatric TraumaElisha G. Brownson, MD, FACSTrauma Medical DirectorAlaska Native Medical CenterANTHC Tribal Health Webinar SeriesOctober 22, 2021
2. Radiation exposure from imaging increases risk of malignancy in pediatric patientsRisk of development of malignancy is 1 in 500Risk greater for younger children (<2 years)CTs are often calibrated for adults higher dose than necessaryALARA: “As Low As Reasonably Achievable”Perform only necessary CT examinationsAdjust exposure parameters (dose and field)Use of validated prediction tools can reduce pediatric radiation exposure for low-risk patientsRadiation Exposure in Children
3. CT is standard of care in adult trauma careSome data suggests “pan-scan” in adults may improve survivalEfficiency of patient workupDesire (of provider or parent) to avoid missed injuryLack of data to indicate patients that can be managed safely without CTChallenges in Reducing CTs
4. Will review imaging decision making for:HeadNeckChestAbdomen/PelvisANMC is a combined Adult/Pediatric Level II Trauma CenterTrauma Imaging Decisions
5. Alaska state specific guidelinesSpecific to rural/remote situation in AlaskaHead Imaging Guidelines
6. Ad hoc committee of Alaska TSRC in 2017; revised in 201817 members: ED, surgery, neurosurgery, radiology, rural family medicine, intensive care, pre-hospital careChanges to address:Most acute care facilities now have CT scanning availableAdvances in telemedicinePrevious guidelines included children >5yoAdult Head Injury Guidelines Update
7. Challenge to create standard guidelines that translate to all regional areasLack of buy-in from stakeholder groupsNeed to divide out pediatrics ages 0-17Previously >5 yearsAdult Head Injury Guidelines Update
8. Ad hoc committee of Alaska TSRC in 2018; published in 201923 members: pediatrics, ED, surgery, neurosurgery, pediatric intensive care, pre-hospital careChanges to address:Previous guidelines included children >5yoPediatric Head Injury Guidelines
9. Scarcity of specialty care24-hour Neurosurgery: only in AnchoragePediatric intensive carePediatric trauma careTwo Level-II pediatric trauma centersANMC and ProvidencePediatric Care in Alaska
10. Scope of the Problem: PediatricAlaska 2011-2015: 364 Children ages 0-17 with isolated blunt head injuries entered into the trauma registry289 (80%) GCS 14,15 Mild 39 (11%) GCS 9-13 Moderate 23 (6%) GCS 3-8 Severe(13 GCS unknown)
11. 194 (53%) patients treated in Anchorage or Seattle5 mortalities: all with initial GCS 3-8Where are head injured patients cared for?
12. 105 patients with CT report in AK trauma registryMild GCS 14-15 Normal CT (28) 14% transferAbnormal CT (60) 65% transferModerate GCS 9-13 (12) 75% transferSevere GCS 3-8 (5) 80% transferNo Deaths of children kept at non-neurosurgical facilitiesRural Pediatric Transfer Rate
13. Pediatrics may be difficult to examineGCS scoreAnxiety without parents/at medical facilitySpecial Considerations
14. Pediatric GCS
15. AdolescentsAK State Guidelines cover 0-17 Due to PECARN recommendationsAmerican College of Surgeons age division at >14yoPuberty changes physiologyNon-accidental TraumaDoes not apply to these guidelines Special Considerations
16. Pediatric Emergency Care Applied Research Network (PECARN)Prospective cohort study with over 42,000 childrenPublished in 2009Identifies children who can safely forego head CT with very low risk of clinically significant head injuryDeathNeurosurgeryIntubation >24 hoursHospital Admission >2 daysPECARN
17. Younger than 2 yearsIncreased importance of reducing radiationMinimal ability of children to communicateDifference in trauma mechanismsAges 2-17Difference in trauma mechanismsPECARN Subgroups
18. PECARN: Ages <2
19. PECARN: Ages 2+
20. Pediatric Head Injury Guidelines
21. http://dhss.alaska.gov/dph/Emergency/Pages/traumaAK State Guidelines
22. In children over 3 years, clinical exam can rule out cervical spine injuryValidated predictive toolsNEXUS*Canadian C-spine Children differ in that CT is NOT the imaging modality of choiceCervical Spine Imaging
23. Pediatric C-Spine ImagingLow incidence of injury in children1st line is plain x-rays (no extension)2nd line is MRI
24. If CT Head is being obtained, may request C1-3 extension of fieldAvoids thyroid exposureHardest levels to imaging in plain filmsSpecial Considerations
25. Difficult to elicit physical examAAST Risk Score: GCS < 14 3pts GCS (eye) = 1 2pts MVC 2 pts Age > 2 years 1 ptA risk score <2 provides a negative predictive value of 99.93%Cervical Spine Imaging: 0-2
26. GCS < 14 or high mechanism consider imagingChildren who meet NEXUS and have low mechanism of injury do not need imagingIMAGING = 2-view c-spine films!!Cervical Spine Imaging: 0-2
27. Very rare in children, less than 1% (0.03 – 0.9)Screening with CTA Neck may be considered with:Altered mental statusCervical fracturesBasilar skull fracturesChest traumaIntracranial hemorrhageCervical seatbelt sign (more common in kids due to improper seatbelting)Blunt Cerebrovascular Injury
28. When CT is required, intravenous contrast is essentialIV contrast is safe in childrenDo not delay trauma scans for serum creatinineNon-contrast scans are difficult to interpret on childrenMay lead to repeat imagingConsiderations in Torso Imaging
29. The chest radiograph is the single most valuable radiographic study in traumaSystematic pattern for readingFor children with minor abnormalities on chest x-ray, chest CT is reported to have no impact on subsequent managementChest CT recommended for abnormal mediastinumChest Imaging
30. Physical exam is most importantAbdominal radiograph not recommendedFAST limited in childrenLab studies to include: LFTsPancreatic enzymesUrinalysisAbdominal Imaging
31.
32. Pediatric patients who are stable should have thoughtful imaging decisionsLess radiographic exposure to achieve diagnostic results is preferredIV contrast is safe and preferable for torso imagingSummary
33. Why is this important?We are all going to take care of seriously injured patients… the question is not IF but HOW we decide to deliver careIt makes a difference in patient outcomesIt’s the standard of care you want for your family and neighbors if they are seriously injuredWe want to do the best for our future generationsAlaska Trauma Care and You
34. Questions?Elisha Brownson: egbrownson@anthc.orgANMC Transfer Center: 907-729-2337