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The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers?
Journal of Pediatric Surgery xxx (2015) xxx–xxx
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The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers?☆,☆☆,☆☆☆ Viraj Pandit, Maria Michailidou, Peter Rhee, Bardiya Zangbar, Narong Kulvatunyou, Mazhar Khalil, Terence O'Keeffe, Ansab Haider, Lynn Gries, Bellal Joseph ⁎ Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona, USA
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Article history: Received 6 June 2015 Received in revised form 30 November 2015 Accepted 3 December 2015 Available online xxxx Key words: Whole body CT scan in pediatrics Scanning differences in adult and pediatric centers Radiation risk in pediatrics Scan utilization by trauma centers
a b s t r a c t Introduction: Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the management of pediatric trauma patients. Methods: We performed a two year (2011–2012) retrospective analysis of the National Trauma Data Bank. Pediatric (age ≤ 18 years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck, thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was performed. Results: A total of 30,667 pediatric trauma patients were included of which; 38.3% (n = 11,748) were managed in designated pediatric centers. 26.1% (n = 8013) patients received a WBCT. The use of WBCT scan was significantly higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p = 0.001). There was no difference in mortality rate between the two groups (2.2% vs. 2.1%, p = 0.37). After adjusting for all confounding factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3–2.1], p = 0.001). Conclusions: Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increasing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of WBCT across centers is warranted. © 2015 Elsevier Inc. All rights reserved.
Trauma remains the leading cause of mortality in patients less than 46 years [1]. In an effort to better identify injuries, the use of computed tomography (CT) has been widely accepted as a key element during their initial assessment. CT scans are widely available, provide fast and accurate diagnoses, and serve as a reliable guide for further management. Moreover, physicians often rely on their use while assessing pediatric trauma patients, since physical examination may be an unreliable tool in identifying injuries. ☆ Oral Presentation, Surgical Forum, American College of Surgeons, Clinical Congress, San Francisco, California, October 2014. ☆☆ There are no identifiable conflicts of interests to report. ☆☆☆ The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript. ⁎ Corresponding author at: University of Arizona, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA. Tel.: +1 520 626 5056; fax: +1 520 626 5016. E-mail address: [email protected] (B. Joseph).
Despite the advantages, the use of CT scan is associated with significant radiation risks [2], especially in the pediatric population [3–8]. Over the last decades, there has been a fivefold increase in the use of CT scans in pediatric patients who present to the emergency departments (ED), with head injury being one of the most frequent indications that prompts CT scan use [9]. Considering the alarming issue of radiation-induced malignancy, a nationwide trend toward limiting the use of CT scans and using alternative-imaging modalities instead has been observed since 2008 [10,11]. In addition, several dose reduction strategies have been developed, as well as algorithms that help identify the subset of patients who would benefit most from advanced imaging use [12–19]. Contrastingly on the other hand, recent evidence has suggested the survival advantage of utilizing whole body CT scan as a diagnostic procedure in trauma patients with severe blunt injury [20–22] and even in hemodynamically unstable patients or those who require emergency bleeding control. However, the use of whole body CT scan in pediatric patients remains unclear.
http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
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V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Variations in CT scan utilization exist between pediatric and adult trauma centers. Larson et al. observed an increased CT scan use in children who presented to nonpediatric facilities [9]. Similarly, pediatric trauma patients were twice as likely to undergo a CT scan of the cervical spine at level I adult trauma centers compared to those who presented to designated pediatric trauma centers [23]. Finally, children presenting to a level I trauma center were more likely to receive whole body CT (WBCT) compared to their adult peers [24]. The aim of this study was to compare the use of WBCT in pediatric patients among adult and designated pediatric trauma centers by utilizing the National Trauma Data Bank (NTDB). 1. Materials and methods We performed a two-year (2011–2012) retrospective analysis using the NTDB, version 7.3. The NTDB is the largest aggregation trauma registry data in the United States and contains more than 5 million patient records contributed by more than 900 trauma centers. It is maintained by the American College of Surgeons (Chicago, IL). In this study, we included patients aged less than 18 years, who underwent a head, chest, or abdominal and pelvic computed tomography, and were managed in a level I or level II trauma center. The trauma center designation (level I or level II) was determined based on the American College of Surgeons (ACS) list of verified trauma centers. Patients transferred from other institutions and patients dead on presentation were excluded from our study. We abstracted the following data points from the NTDB database: demographics (age, gender, race, and ethnicity), vitals on presentation (heart rate, systolic blood pressure, respiratory rate, and temperature), type of injury (blunt and penetrating), mechanism of injury (motor vehicle collision, falls, pedestrian struck, all-terrain vehicle accidents, stab wound, gun shout wound), Glasgow Coma Scale (GCS) score on presentation, intoxication details, CT scan utilization details (head, chest, abdomen and pelvis), ventilation days, hospital and intensive care unit length of stay, and in-hospital mortality. Patient's injury characteristics were abstracted utilizing the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) score. Patients were stratified into two groups based on the center in which they were managed: adult trauma centers (ATC) or designated pediatric trauma centers (PTC). Our primary outcome measure was WBCT utilization. CT scan utilization was abstracted from the NTDB utilizing the following ICD 9 procedure codes: head CT (87.03, 87.04), thoracic CT (87.41, 87.42) and abdominal CT (88.01). Patients with a combination of a head, chest, and abdominal CT scan were considered to have undergone a WBCT CT scan. WBCT scan use was compared between ATC and PTC. A subanalysis among adult centers was performed to compare for performance of WHCT between adult level I and level II centers. We also compared the head CT, thoracic CT, and abdominal CT utilization individually between ATC and PTC. Data are reported as mean ± standard deviation (SD) for continuous variables, median [range] for ordinal variables, and as proportions for categorical variables. We performed Mann–Whitney U and student t test to explore for differences in the two groups (ACT and PTC) for continuous variables, and chi-square test for categorical variables. Univariate analysis was performed to identify factors predicting WBCT use in pediatric patients. Factors with a p value ≤ 0.2 on univariate analysis were utilized in a multivariate regression analysis. A p value b 0.05 was considered statistically significant. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS, Version 21; IBM, Inc., Armonk, NY). 2. Results A total of 30,667 patients were included in the study of which, 38.3% (n = 11,748) were managed in designated pediatric centers. The mean age was 11.45 ± 6.2 years, 65.5% (n = 20,092) were male, mean systolic blood pressure was 124.9 ± 20.6 mm of Hg, median GCS was 14 [13–15], and median injury severity score was 10 [4–12]. The majority (89.8%,
Table 1 Patient Characteristic by Group. Characteristic Demographics Age, years (mean ± SD) ≤5 years, % 6–11 years, % ≥12 years, % Male, % Race Whites, % Blacks, % Hispanics, % Intoxication, % Vital Parameters GCS, Median [Range] GCS ≤ 8, % ED SBP, (mean ± SD) Hypotensive (SBP ≤ 90), % ED HR, (mean ± SD) Tachycardia (HR N 90), % ED RR, (mean ± SD) ED Temperature, (mean ± SD) Injury Parameters Blunt Mechanism of Injury MVC, % Falls, % Head AIS, Median [IQR] Head AIS ≥ 3, % Thorax AIS, Median [IQR] Thorax AIS ≥ 3, % Abdomen AIS, Median [IQR] Abdomen AIS ≥ 3, % ISS, Median [IQR] ISS ≥ 25, %
Adult Center (n = 18,919)
Pediatric Center (n = 11,748)
p
12.9 ± 5.8 17% 12% 71% 65.9%
9.13 ± 6.1 35% 21.4% 43.6% 64.9%
0.01 0.01 0.001 0.01 0.09
67.3% 14.4% 15.3% 8.1%
67% 13.9% 16% 7.6%
0.58 0.23 0.13 0.15
15 [13–15] 8.3% 127.8 ± 20.5 3.1% 102.1 ± 25.8 50.5% 20.16 ± 7.8 36.1 ± 0.3
15 [13–15] 7.9% 120.4 ± 19.9 5.9% 109.7 ± 29.3 50.1% 22.9 ± 9.1 36.2 ± 0.1
0.61 0.1 0.8 0.001 0.7 0.96 0.61 0.82
90%
89.5%
45% 17.6% 2 [2–3] 34.7% 1 [1–2] 18.3% 2 [2–3] 16.8% 10 [4–13] 9.8%
44.2% 18% 2 [2–3] 35.3% 1 [1–2] 18.1% 2 [2–3] 16.4% 9 [4–12] 9.8%
0.16 0.6 0.17 0.35 0.45 0.28 0.71 0.65 0.32 0.17 0.22 0.79
n = 27,541) had blunt injury and motor vehicle crash was the most common mechanism of injury (44.8%, n = 13,741). Table 1 compares the demographics and injury characteristics of the ATC and PTC groups. Patients managed in PTC were younger and more likely to be hypotensive on admission compared to patients managed in ATC. There was no difference in the admission GCS score, mechanism of injury, severity of head, thoracic, or abdominal injury and total injury severity score between patients managed in ATC and PTC. Table 2 demonstrates the CT scan performance in the study population. Head CT scans were performed in 88.3% (n = 27,069) of the patients, chest CT scans in 33% (n = 10,103), and abdominal CT scans in 49% (n = 15,043) of the patients. A total of 8008 (26.1%) received a WBCT. Patients managed in ATC were more likely to get a whole body CT scan compared to patients managed in PTC (p = 0.001). Table 3 demonstrates a subanalysis of the CT scan performance in level I and level II ATCs. There was no difference in head CT scan rate however level I adult trauma centers perform more thoracic and abdominal CT scans. Table 4 demonstrates the outcomes among the study population. Mean hospital length of stay was days 3.65 ± 2.5 days and a total of 30.5% (n = 9347) required ICU admission with a mean ICU length of stay of 1.1 ± 1.2 days. 67.7% (n = 20,763) patients were discharged home from the hospital. There was no difference in the hospital and ICU length of stay as well as the discharge disposition among the
Table 2 Computed Tomography Scans.
Whole Body CT Scan, % Head CT Scan, % Thorax CT Scan, % Abdomen CT Scan, %
Adult Center (n = 18,919)
Pediatric Center (n = 11,748)
p
31.4% 88% 39.8% 53%
17.6% 88.7% 21.9% 42.7%
0.001 0.09 0.01 0.01
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx Table 3 Computed Tomography Scans, Subanalysis of Adult Center.
Whole Body CT Scan, % Head CT Scan, % Thorax CT Scan, % Abdomen CT Scan, %
Adult Level I (n = 10,499)
Adult Level II (n = 8420)
p
33.2% 88.6% 41% 55%
29.2% 87.8% 38.4% 50.4%
0.001 0.08 0.003 0.001
Table 4 Outcomes.
Hospital LOS, (mean ± SD) ICU LOS, (mean ± SD) Vent Days, (mean ± SD) Discharge Disposition Home, % Rehabilitation center, % Skilled Nursing Facility, % Mortality, %
Adult Center (n = 18,919)
Pediatric Center (n = 11,748)
p
3.62 ± 2.6 1.1 ± 1.3 0.8 ± 0.4
3.73 ± 2.3 1.1 ± 1.2 0.7 ± 0.3
0.46 0.83 0.71
67.4% 7.15% 0.6% 2.2%
68.2% 6.8% 0.5% 2.1%
0.14 0.31 0.25 0.37
LOS, length of stay; ICU, intensive care unit; Vent, ventilation.
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patients in the study population (Fig. 1). The overall mortality rate was 2.1% (n = 663). The mortality rate was similar among patients managed in adult and pediatric trauma centers (p = 0.37). However patients receiving WBCT scan had a higher mortality rate compared to patients receiving selective scanning (3.6% vs. 1.6%, p b 0.001). 2.1. Factors associated with whole body CT scan utilization Table 5 demonstrates the univariate and multivariate analysis for factors associated with usage of a whole body CT scan. On univariate analysis, the following factors were linked to WBCT use: age ≥ 6 years, male gender, intoxication, GCS score ≤ 8, hypotension and tachycardia on presentation, blunt injury, motor cycle collision, head, thoracic or abdominal AIS ≥ 3, injury severity score ≥ 25 and management in an ATC. After adjusting for age, GCS score, admission vital parameters, mechanism, type and severity of injury, patients who presented in an ATC were 1.8 times more likely (OR: 1.8, CI: 1.3–2.1, p b 0.001) to undergo a WBCT scan. 2.2. Subanalysis for factors associated with usage of whole body CT scan in patients managed in adult trauma centers: Comparing level 1 vs. level 2 adult centers On assessing characteristics among patients between level 1 and level 2 adult centers we found there was no difference in patient's age
Fig. 1. Details of the Study Population.
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
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V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Table 5 Factors Associated with Need for Whole Body CT Scan.
Adult Center Demographics Age 6–11 years ≥12 years Male Whites Hispanics Intoxication Vital Parameters GCS score ≤ 8 Hypotension (SBP ≤ 90) Tachycardia (HR ≥ 100) Respiratory Rate Temperature Injury Parameters Blunt Injury Mechanism of Injury MVC Falls Head AIS ≥ 3 Thorax AIS ≥ 3 Abdomen AIS ≥ 3 ISS ≥ 25
Table 6 Subanalysis of Patients Managed in Adult Centers.
Univariate OR (95% CI)
p
Multivariate OR (95% CI)
p
2.1 (1.5–3.6)
0.001
1.8 (1.3–2.1)
0.001
1.2 (1.1–4.1) 1.1 (1.05–2.3) 1.2 (0.71–3.8) 1.3 (0.51–5.6) 1.1 (0.76–3.2) 1.5 (1.1–4.4)
0.02 0.04 0.18 0.36 0.41 0.04
1.1 (0.91–3.4) 1.1 (0.79–2.9) 1.1 (0.64–4.2) – – 1.4 (0.91–4.6)
0.12 0.19 0.41 – – 0.11
1.9 (1.4–6.2) 1.4 (1.2–3.5) 1.6 (1.1–4.7) 1.3 (0.75–2.3) 1.1 (0.39–3.7)
0.02 0.03 0.04 0.51 0.66
1.3 (1.2–3.9) 1.2 (1.1–2.6) 1.4 (0.94–3.1) – –
0.04 0.04 0.15 – –
1.4 (1.2–2.9)
0.03
1.2 (0.98–2.3)
0.09
1.4 (1.1–5.1) 1.1 (0.72–5.9) 1.3 (1.1–6.2) 1.8 (1.4–9.6) 1.4 (1.2–4.7) 2.6 (1.5–4.4)
0.04 0.61 0.02 0.04 0.03 0.01
1.1 (0.82–3.1) – 1.2 (1.1–5.4) 1.5 (0.94–8.2) 1.2 (1.1–3.1) 2.1 (1.3–5.8)
0.2 – 0.04 0.09 0.04 0.02
(p = 0.11), gender (p = 0.23), race (p = 0.45), GCS score (p = 0.51), hypotension (p = 0.31), mechanism of injury (p = 0.67), and severity of injury (p = 0.14). On performing univariate analysis, age group 6–11 years (p = 0.03), intoxication (p = 0.13), GCS score ≤ 8 (p = 0.01), hypotension (p = 0.02), tachycardia (p = 0.04), blunt injury (p = 0.02), head AIS ≥ 3 (p = 0.01), thorax AIS ≥ 3 (p = 0.02), abdomen AIS ≥ 3 (p = 0.02), injury severity score ≥ 25 (p = 0.01), and management in adult level I centers (p = 0.001) were associated with usage of a whole body CT scan. After controlling for all factors in a multivariate regression model, management in adult level I center was independently associated with usage of a whole body CT scan (p = 0.01). Table 6 demonstrates the univariate and multivariate analysis for subanalysis for factors associated with use of a whole body CT scan in patients managed only in adult level 1 and adult level 2 trauma centers. 3. Discussion Significant differences in CT scan utilization exist between adult and pediatric trauma centers that treat pediatric patients. Our study showed that children presenting in adult trauma centers were 1.8 times more likely to undergo a WBCT, compared to their peers who were treated in designated pediatric centers, even after adjusting for type and severity of injury. Specifically relative head CT rates did not differ among pediatric and adult trauma centers, thoracic and abdominal CT rates were significantly higher in adult trauma centers. Understating the causes for this variability in management and establishing protocols for minimizing the use of WBCT across centers will standardize care. In our study we found that WBCT scan utilization is different among trauma centers with different levels and particularly different referred population. Similarly, differences in imaging utilization among PTCs and ATCs have been described in several other studies. Mannix et al. observed more frequent utilization of cervical spine CT scans in children presenting at level I adult trauma centers compared to those being evaluated in pediatric trauma centers, as well as an increase in CT scan rates over their study period by non pediatric centers [23]. Similarly, the liberal use of CT scans in the ED facilities has been mainly adopted by nonpediatric centers [9]. Several factors may contribute to those observed differences. Most importantly, adult centers may lack pediatric
Adult Level I Center Demographics Age 6–11 years ≥12 years Male Whites Hispanics Intoxication Vital Parameters GCS Score ≤ 8 Hypotension (SBP ≤ 90) Tachycardia (HR ≥ 100) Respiratory Rate Temperature Injury Parameters Blunt Injury Mechanism of Injury MVC Falls Head AIS ≥ 3 Thorax AIS ≥ 3 Abdomen AIS ≥ 3 ISS ≥ 25
Univariate OR (95% CI)
p
Multivariate OR (95% CI)
p
1.9 (1.2–3.1)
0.001
1.3 (1.1–2.8)
0.01
1.4 (1.1–3.5) 1.2 (0.81–2.1) 1.1 (0.84–4.2) 1.3 (0.65–7.4) 1.2 (0.88–5.4) 1.4 (0.96–4.9)
0.03 0.3 0.41 0.62 0.39 0.13
1.2 (0.98–2.9) – – – – 1.2 (0.84–3.4)
0.09 – – – – 0.24
1.5 (1.2–6.9) 1.6 (1.4–5.8) 1.4 (1.2–3.4) 1.1 (0.62–2.9) 1.2 (0.55–2.3)
0.01 0.02 0.04 0.59 0.35
1.2 (1.1–5.5) 1.1 (1.05–4.2) 1.2 (0.98–2.7) – –
0.03 0.04 0.12 – –
1.5 (1.1–2.5)
0.02
1.1 (0.84–1.9)
0.13
1.3 (0.91–4.5) 1.2 (0.69–3.2) 1.6 (1.4–8.4) 1.4 (1.1–7.4) 1.5 (1.1–3.9) 2.1 (1.8–6.4)
0.31 0.46 0.01 0.02 0.02 0.01
– – 1.4 (1.2–9.5) 1.1 (1.06–10.3) 1.2 (1.1–4.5) 1.8 (1.4–7.2)
– – 0.03 0.04 0.04 0.01
CT protocols that adjust for patients' characteristics and limit radiation exposure [18]. Additionally, nondesignated pediatric centers may apply adult guidelines to presenting pediatric patients and may not be familiar with different patterns of injury in children. Strength of our study is that as a result of adjusting for confounding factors in analysis, we had similar cohort of patients to compare. Subsequently we found that the likelihood of performing a WBCT in ATC was higher, independent of injury severity or pattern. WBCT scan is advocated owing to survival benefit in adult trauma centers [20–22,25,26]. Caputo et al. in a metaanalysis showed that patients undergoing a WBCT, despite having significantly higher ISS at baseline compared with the group who received selective scanning, had a lower overall mortality rate and a more favorable pooled odds ratio [22]. However there is a lack of knowledge regarding the utility of WBCT in pediatric population and its relation to outcomes. In our study we could not find a survival advantage between PTC and ATC, However patients undergoing a WBCT compared to selective scanning had a higher mortality rate overall. This may be because of selective approach to only perform a WBCT scan in severely injured pediatric trauma patients. Several authors have examined the use of alternative imaging modalities such as x-rays or ultrasound for identification of injuries [16,27,17,28,29]. Although FAST has been proposed as an adjunct for the evaluation of a pediatric trauma patient by the ACS, its clinical usefulness remains debated [28,29]. Furthermore, chest x-rays should serve as the initial imaging modality in pediatric blunt trauma patients, with thoracic CT only to be used in certain circumstances [16,30]. The selective use of tube thoracostomy for the treatment of occult pneumothoraces further supports those findings [12]. In addition, xray is a reliable imaging study for identification of bone and soft tissue injuries [27]. We found that CT scan rates of the chest and abdomen were significantly higher in adult trauma centers. This finding is particularly important as a possible association with increased survival can alleviate the importance of perceived negative effect from excess radiation. In an effort to limit the CT use in pediatric trauma patients, several guidelines and prediction models for clinically important injuries have been developed that recommend selective imaging based on mechanism of injury, physical examination and laboratory data [13–15,19,31,32]. Holmes et al. created a prediction rule based solely on history and physical examination that would rule out a clinically significant abdominal injury
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
that would require surgical intervention, embolization or blood transfusion [19]. Further studies have added abnormal laboratory data such as hematuria and increased liver function tests to their models that would predict blunt abdominal trauma [15,31]. However, in our study we found no difference in survival between ATC and PTC in management of pediatric patients. Similarly, Jindal et al. reported higher rates of WBCT use in pediatric patients presenting with mild to moderate trauma compared to their adult peers, without any difference in outcomes [24]. The reported rise in CT scan use in the pediatric population has prompted several authors to emphasize the significant radiation exposure and malignancy risk associated with its use [2,3,5,6]. Egan et al. noted an important breast radiation exposure in female trauma patients who underwent thoracic CT for spine clearance, a radiation risk that was substantially higher in children compared to adolescents [7]. Additionally, pediatric trauma patients receiving more than two CT scans, including WBCT scans, are being exposed to significantly higher radiation compared to those undergoing less imaging [4]. Although we do not have data regarding the amount of radiation exposure in PTC compared to ATC, our data support reduction in use of CT scans in adult trauma centers as no survival benefit is observed in an adjusted analysis from a national database. In our study we defined pediatric patients with age ≤ 18 years as this is the most widely used definition across multiple studies to define pediatric patients. Furthermore, majority of the institutions reporting to the NTDB have defined pediatric patients as age ≤ 18 years. We understand that there remain variations across institutions for defining the age cutoff for pediatric patients however; as the NTDB does not provide institutional identifiers, we were not able to assess the age cutoff in each institution which is a potential limitation of the database. Our study has certain limitations. Although the NTDB represents the largest trauma registry, our results may not be generalizable given the retrospective nature of the database and missing data. Additionally, we were not able to detect CT scan rates of the cervical spine as they currently lack an ICD 9 procedure code. Moreover, the clinical significance of the CT scan utilization could not be captured in this study, i.e. we were not able to examine how the presence of the CT scan served as a guide for further management. We were unable to assess the pediatric training of providers managing patients across centers. We did not assess the causes for mortality in our patient population. Despite these limitations, our study presents the largest study that examines the WBCT utilization among pediatric and adult trauma centers. 4. Conclusion Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients who underwent a CT were more likely to be managed with WBCT in adult trauma centers were, increasing their risk for radiation without a difference in outcomes. Establishing protocols for minimizing the use of WBCT in pediatric population across adult trauma centers may standardize trauma care for the pediatric trauma patient. Acknowledgements No acknowledgements to make. References [1] Rhee P, Joseph B, Pandit V, et al. Increasing trauma deaths in the United States. Ann Surg 2014;260(1):13–21. [2] Brenner DJ, Hall EJ. Computed tomography — an increasing source of radiation exposure. N Engl J Med 2007;357(22):2277–84.
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Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013;62(2):107–16 e2. [20] Yeguiayan JM, Yap A, Freysz M, et al. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Crit Care 2012; 16(3):R101. [21] Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009; 373(9673):1455–61. [22] Caputo ND, Stahmer C, Lim G, et al. Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg 2014;77(4):534–9. [23] Mannix R, Nigrovic LE, Schutzman SA, et al. Factors associated with the use of cervical spine computed tomography imaging in pediatric trauma patients. Acad Emerg Med 2011;18(9):905–11. [24] Jindal A, Velmahos GC, Rofougaran R. Computed tomography for evaluation of mild to moderate pediatric trauma: are we overusing it? World J Surg 2002;26(1):13–6. [25] Huber-Wagner S, Biberthaler P, Haberle S, et al. Whole-body CT in haemodynamically unstable severely injured patients — a retrospective, multicentre study. PLoS One 2013;8(7), e68880. [26] Kimura A, Tanaka N. Whole-body computed tomography is associated with decreased mortality in blunt trauma patients with moderate-to-severe consciousness disturbance: a multicenter, retrospective study. J Trauma Acute Care Surg 2013; 75(2):202–6. [27] Nigrovic LE, Rogers AJ, Adelgais KM, et al. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care 2012; 28(5):426–32. [28] Retzlaff T, Hirsch W, Till H, et al. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma? J Pediatr Surg 2010;45(5):912–5. [29] Scaife ER, Rollins MD, Barnhart DC, et al. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg 2013;48(6): 1377–83. [30] Renton J, Kincaid S, Ehrlich PF. Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. J Pediatr Surg 2003;38(5):793–7. [31] Flood RG, Mooney DP. Rate and prediction of traumatic injuries detected by abdominal computed tomography scan in intubated children. J Trauma 2006;61(2):340–5. [32] Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med 2011;58(2):145–55.
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
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The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric centers?☆,☆☆,☆☆☆ Viraj Pandit, Maria Michailidou, Peter Rhee, Bardiya Zangbar, Narong Kulvatunyou, Mazhar Khalil, Terence O'Keeffe, Ansab Haider, Lynn Gries, Bellal Joseph ⁎ Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona, USA
a r t i c l e
i n f o
Article history: Received 6 June 2015 Received in revised form 30 November 2015 Accepted 3 December 2015 Available online xxxx Key words: Whole body CT scan in pediatrics Scanning differences in adult and pediatric centers Radiation risk in pediatrics Scan utilization by trauma centers
a b s t r a c t Introduction: Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the management of pediatric trauma patients. Methods: We performed a two year (2011–2012) retrospective analysis of the National Trauma Data Bank. Pediatric (age ≤ 18 years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck, thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was performed. Results: A total of 30,667 pediatric trauma patients were included of which; 38.3% (n = 11,748) were managed in designated pediatric centers. 26.1% (n = 8013) patients received a WBCT. The use of WBCT scan was significantly higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p = 0.001). There was no difference in mortality rate between the two groups (2.2% vs. 2.1%, p = 0.37). After adjusting for all confounding factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3–2.1], p = 0.001). Conclusions: Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increasing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of WBCT across centers is warranted. © 2015 Elsevier Inc. All rights reserved.
Trauma remains the leading cause of mortality in patients less than 46 years [1]. In an effort to better identify injuries, the use of computed tomography (CT) has been widely accepted as a key element during their initial assessment. CT scans are widely available, provide fast and accurate diagnoses, and serve as a reliable guide for further management. Moreover, physicians often rely on their use while assessing pediatric trauma patients, since physical examination may be an unreliable tool in identifying injuries. ☆ Oral Presentation, Surgical Forum, American College of Surgeons, Clinical Congress, San Francisco, California, October 2014. ☆☆ There are no identifiable conflicts of interests to report. ☆☆☆ The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript. ⁎ Corresponding author at: University of Arizona, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA. Tel.: +1 520 626 5056; fax: +1 520 626 5016. E-mail address: [email protected] (B. Joseph).
Despite the advantages, the use of CT scan is associated with significant radiation risks [2], especially in the pediatric population [3–8]. Over the last decades, there has been a fivefold increase in the use of CT scans in pediatric patients who present to the emergency departments (ED), with head injury being one of the most frequent indications that prompts CT scan use [9]. Considering the alarming issue of radiation-induced malignancy, a nationwide trend toward limiting the use of CT scans and using alternative-imaging modalities instead has been observed since 2008 [10,11]. In addition, several dose reduction strategies have been developed, as well as algorithms that help identify the subset of patients who would benefit most from advanced imaging use [12–19]. Contrastingly on the other hand, recent evidence has suggested the survival advantage of utilizing whole body CT scan as a diagnostic procedure in trauma patients with severe blunt injury [20–22] and even in hemodynamically unstable patients or those who require emergency bleeding control. However, the use of whole body CT scan in pediatric patients remains unclear.
http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
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V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Variations in CT scan utilization exist between pediatric and adult trauma centers. Larson et al. observed an increased CT scan use in children who presented to nonpediatric facilities [9]. Similarly, pediatric trauma patients were twice as likely to undergo a CT scan of the cervical spine at level I adult trauma centers compared to those who presented to designated pediatric trauma centers [23]. Finally, children presenting to a level I trauma center were more likely to receive whole body CT (WBCT) compared to their adult peers [24]. The aim of this study was to compare the use of WBCT in pediatric patients among adult and designated pediatric trauma centers by utilizing the National Trauma Data Bank (NTDB). 1. Materials and methods We performed a two-year (2011–2012) retrospective analysis using the NTDB, version 7.3. The NTDB is the largest aggregation trauma registry data in the United States and contains more than 5 million patient records contributed by more than 900 trauma centers. It is maintained by the American College of Surgeons (Chicago, IL). In this study, we included patients aged less than 18 years, who underwent a head, chest, or abdominal and pelvic computed tomography, and were managed in a level I or level II trauma center. The trauma center designation (level I or level II) was determined based on the American College of Surgeons (ACS) list of verified trauma centers. Patients transferred from other institutions and patients dead on presentation were excluded from our study. We abstracted the following data points from the NTDB database: demographics (age, gender, race, and ethnicity), vitals on presentation (heart rate, systolic blood pressure, respiratory rate, and temperature), type of injury (blunt and penetrating), mechanism of injury (motor vehicle collision, falls, pedestrian struck, all-terrain vehicle accidents, stab wound, gun shout wound), Glasgow Coma Scale (GCS) score on presentation, intoxication details, CT scan utilization details (head, chest, abdomen and pelvis), ventilation days, hospital and intensive care unit length of stay, and in-hospital mortality. Patient's injury characteristics were abstracted utilizing the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) score. Patients were stratified into two groups based on the center in which they were managed: adult trauma centers (ATC) or designated pediatric trauma centers (PTC). Our primary outcome measure was WBCT utilization. CT scan utilization was abstracted from the NTDB utilizing the following ICD 9 procedure codes: head CT (87.03, 87.04), thoracic CT (87.41, 87.42) and abdominal CT (88.01). Patients with a combination of a head, chest, and abdominal CT scan were considered to have undergone a WBCT CT scan. WBCT scan use was compared between ATC and PTC. A subanalysis among adult centers was performed to compare for performance of WHCT between adult level I and level II centers. We also compared the head CT, thoracic CT, and abdominal CT utilization individually between ATC and PTC. Data are reported as mean ± standard deviation (SD) for continuous variables, median [range] for ordinal variables, and as proportions for categorical variables. We performed Mann–Whitney U and student t test to explore for differences in the two groups (ACT and PTC) for continuous variables, and chi-square test for categorical variables. Univariate analysis was performed to identify factors predicting WBCT use in pediatric patients. Factors with a p value ≤ 0.2 on univariate analysis were utilized in a multivariate regression analysis. A p value b 0.05 was considered statistically significant. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS, Version 21; IBM, Inc., Armonk, NY). 2. Results A total of 30,667 patients were included in the study of which, 38.3% (n = 11,748) were managed in designated pediatric centers. The mean age was 11.45 ± 6.2 years, 65.5% (n = 20,092) were male, mean systolic blood pressure was 124.9 ± 20.6 mm of Hg, median GCS was 14 [13–15], and median injury severity score was 10 [4–12]. The majority (89.8%,
Table 1 Patient Characteristic by Group. Characteristic Demographics Age, years (mean ± SD) ≤5 years, % 6–11 years, % ≥12 years, % Male, % Race Whites, % Blacks, % Hispanics, % Intoxication, % Vital Parameters GCS, Median [Range] GCS ≤ 8, % ED SBP, (mean ± SD) Hypotensive (SBP ≤ 90), % ED HR, (mean ± SD) Tachycardia (HR N 90), % ED RR, (mean ± SD) ED Temperature, (mean ± SD) Injury Parameters Blunt Mechanism of Injury MVC, % Falls, % Head AIS, Median [IQR] Head AIS ≥ 3, % Thorax AIS, Median [IQR] Thorax AIS ≥ 3, % Abdomen AIS, Median [IQR] Abdomen AIS ≥ 3, % ISS, Median [IQR] ISS ≥ 25, %
Adult Center (n = 18,919)
Pediatric Center (n = 11,748)
p
12.9 ± 5.8 17% 12% 71% 65.9%
9.13 ± 6.1 35% 21.4% 43.6% 64.9%
0.01 0.01 0.001 0.01 0.09
67.3% 14.4% 15.3% 8.1%
67% 13.9% 16% 7.6%
0.58 0.23 0.13 0.15
15 [13–15] 8.3% 127.8 ± 20.5 3.1% 102.1 ± 25.8 50.5% 20.16 ± 7.8 36.1 ± 0.3
15 [13–15] 7.9% 120.4 ± 19.9 5.9% 109.7 ± 29.3 50.1% 22.9 ± 9.1 36.2 ± 0.1
0.61 0.1 0.8 0.001 0.7 0.96 0.61 0.82
90%
89.5%
45% 17.6% 2 [2–3] 34.7% 1 [1–2] 18.3% 2 [2–3] 16.8% 10 [4–13] 9.8%
44.2% 18% 2 [2–3] 35.3% 1 [1–2] 18.1% 2 [2–3] 16.4% 9 [4–12] 9.8%
0.16 0.6 0.17 0.35 0.45 0.28 0.71 0.65 0.32 0.17 0.22 0.79
n = 27,541) had blunt injury and motor vehicle crash was the most common mechanism of injury (44.8%, n = 13,741). Table 1 compares the demographics and injury characteristics of the ATC and PTC groups. Patients managed in PTC were younger and more likely to be hypotensive on admission compared to patients managed in ATC. There was no difference in the admission GCS score, mechanism of injury, severity of head, thoracic, or abdominal injury and total injury severity score between patients managed in ATC and PTC. Table 2 demonstrates the CT scan performance in the study population. Head CT scans were performed in 88.3% (n = 27,069) of the patients, chest CT scans in 33% (n = 10,103), and abdominal CT scans in 49% (n = 15,043) of the patients. A total of 8008 (26.1%) received a WBCT. Patients managed in ATC were more likely to get a whole body CT scan compared to patients managed in PTC (p = 0.001). Table 3 demonstrates a subanalysis of the CT scan performance in level I and level II ATCs. There was no difference in head CT scan rate however level I adult trauma centers perform more thoracic and abdominal CT scans. Table 4 demonstrates the outcomes among the study population. Mean hospital length of stay was days 3.65 ± 2.5 days and a total of 30.5% (n = 9347) required ICU admission with a mean ICU length of stay of 1.1 ± 1.2 days. 67.7% (n = 20,763) patients were discharged home from the hospital. There was no difference in the hospital and ICU length of stay as well as the discharge disposition among the
Table 2 Computed Tomography Scans.
Whole Body CT Scan, % Head CT Scan, % Thorax CT Scan, % Abdomen CT Scan, %
Adult Center (n = 18,919)
Pediatric Center (n = 11,748)
p
31.4% 88% 39.8% 53%
17.6% 88.7% 21.9% 42.7%
0.001 0.09 0.01 0.01
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx Table 3 Computed Tomography Scans, Subanalysis of Adult Center.
Whole Body CT Scan, % Head CT Scan, % Thorax CT Scan, % Abdomen CT Scan, %
Adult Level I (n = 10,499)
Adult Level II (n = 8420)
p
33.2% 88.6% 41% 55%
29.2% 87.8% 38.4% 50.4%
0.001 0.08 0.003 0.001
Table 4 Outcomes.
Hospital LOS, (mean ± SD) ICU LOS, (mean ± SD) Vent Days, (mean ± SD) Discharge Disposition Home, % Rehabilitation center, % Skilled Nursing Facility, % Mortality, %
Adult Center (n = 18,919)
Pediatric Center (n = 11,748)
p
3.62 ± 2.6 1.1 ± 1.3 0.8 ± 0.4
3.73 ± 2.3 1.1 ± 1.2 0.7 ± 0.3
0.46 0.83 0.71
67.4% 7.15% 0.6% 2.2%
68.2% 6.8% 0.5% 2.1%
0.14 0.31 0.25 0.37
LOS, length of stay; ICU, intensive care unit; Vent, ventilation.
3
patients in the study population (Fig. 1). The overall mortality rate was 2.1% (n = 663). The mortality rate was similar among patients managed in adult and pediatric trauma centers (p = 0.37). However patients receiving WBCT scan had a higher mortality rate compared to patients receiving selective scanning (3.6% vs. 1.6%, p b 0.001). 2.1. Factors associated with whole body CT scan utilization Table 5 demonstrates the univariate and multivariate analysis for factors associated with usage of a whole body CT scan. On univariate analysis, the following factors were linked to WBCT use: age ≥ 6 years, male gender, intoxication, GCS score ≤ 8, hypotension and tachycardia on presentation, blunt injury, motor cycle collision, head, thoracic or abdominal AIS ≥ 3, injury severity score ≥ 25 and management in an ATC. After adjusting for age, GCS score, admission vital parameters, mechanism, type and severity of injury, patients who presented in an ATC were 1.8 times more likely (OR: 1.8, CI: 1.3–2.1, p b 0.001) to undergo a WBCT scan. 2.2. Subanalysis for factors associated with usage of whole body CT scan in patients managed in adult trauma centers: Comparing level 1 vs. level 2 adult centers On assessing characteristics among patients between level 1 and level 2 adult centers we found there was no difference in patient's age
Fig. 1. Details of the Study Population.
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
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V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Table 5 Factors Associated with Need for Whole Body CT Scan.
Adult Center Demographics Age 6–11 years ≥12 years Male Whites Hispanics Intoxication Vital Parameters GCS score ≤ 8 Hypotension (SBP ≤ 90) Tachycardia (HR ≥ 100) Respiratory Rate Temperature Injury Parameters Blunt Injury Mechanism of Injury MVC Falls Head AIS ≥ 3 Thorax AIS ≥ 3 Abdomen AIS ≥ 3 ISS ≥ 25
Table 6 Subanalysis of Patients Managed in Adult Centers.
Univariate OR (95% CI)
p
Multivariate OR (95% CI)
p
2.1 (1.5–3.6)
0.001
1.8 (1.3–2.1)
0.001
1.2 (1.1–4.1) 1.1 (1.05–2.3) 1.2 (0.71–3.8) 1.3 (0.51–5.6) 1.1 (0.76–3.2) 1.5 (1.1–4.4)
0.02 0.04 0.18 0.36 0.41 0.04
1.1 (0.91–3.4) 1.1 (0.79–2.9) 1.1 (0.64–4.2) – – 1.4 (0.91–4.6)
0.12 0.19 0.41 – – 0.11
1.9 (1.4–6.2) 1.4 (1.2–3.5) 1.6 (1.1–4.7) 1.3 (0.75–2.3) 1.1 (0.39–3.7)
0.02 0.03 0.04 0.51 0.66
1.3 (1.2–3.9) 1.2 (1.1–2.6) 1.4 (0.94–3.1) – –
0.04 0.04 0.15 – –
1.4 (1.2–2.9)
0.03
1.2 (0.98–2.3)
0.09
1.4 (1.1–5.1) 1.1 (0.72–5.9) 1.3 (1.1–6.2) 1.8 (1.4–9.6) 1.4 (1.2–4.7) 2.6 (1.5–4.4)
0.04 0.61 0.02 0.04 0.03 0.01
1.1 (0.82–3.1) – 1.2 (1.1–5.4) 1.5 (0.94–8.2) 1.2 (1.1–3.1) 2.1 (1.3–5.8)
0.2 – 0.04 0.09 0.04 0.02
(p = 0.11), gender (p = 0.23), race (p = 0.45), GCS score (p = 0.51), hypotension (p = 0.31), mechanism of injury (p = 0.67), and severity of injury (p = 0.14). On performing univariate analysis, age group 6–11 years (p = 0.03), intoxication (p = 0.13), GCS score ≤ 8 (p = 0.01), hypotension (p = 0.02), tachycardia (p = 0.04), blunt injury (p = 0.02), head AIS ≥ 3 (p = 0.01), thorax AIS ≥ 3 (p = 0.02), abdomen AIS ≥ 3 (p = 0.02), injury severity score ≥ 25 (p = 0.01), and management in adult level I centers (p = 0.001) were associated with usage of a whole body CT scan. After controlling for all factors in a multivariate regression model, management in adult level I center was independently associated with usage of a whole body CT scan (p = 0.01). Table 6 demonstrates the univariate and multivariate analysis for subanalysis for factors associated with use of a whole body CT scan in patients managed only in adult level 1 and adult level 2 trauma centers. 3. Discussion Significant differences in CT scan utilization exist between adult and pediatric trauma centers that treat pediatric patients. Our study showed that children presenting in adult trauma centers were 1.8 times more likely to undergo a WBCT, compared to their peers who were treated in designated pediatric centers, even after adjusting for type and severity of injury. Specifically relative head CT rates did not differ among pediatric and adult trauma centers, thoracic and abdominal CT rates were significantly higher in adult trauma centers. Understating the causes for this variability in management and establishing protocols for minimizing the use of WBCT across centers will standardize care. In our study we found that WBCT scan utilization is different among trauma centers with different levels and particularly different referred population. Similarly, differences in imaging utilization among PTCs and ATCs have been described in several other studies. Mannix et al. observed more frequent utilization of cervical spine CT scans in children presenting at level I adult trauma centers compared to those being evaluated in pediatric trauma centers, as well as an increase in CT scan rates over their study period by non pediatric centers [23]. Similarly, the liberal use of CT scans in the ED facilities has been mainly adopted by nonpediatric centers [9]. Several factors may contribute to those observed differences. Most importantly, adult centers may lack pediatric
Adult Level I Center Demographics Age 6–11 years ≥12 years Male Whites Hispanics Intoxication Vital Parameters GCS Score ≤ 8 Hypotension (SBP ≤ 90) Tachycardia (HR ≥ 100) Respiratory Rate Temperature Injury Parameters Blunt Injury Mechanism of Injury MVC Falls Head AIS ≥ 3 Thorax AIS ≥ 3 Abdomen AIS ≥ 3 ISS ≥ 25
Univariate OR (95% CI)
p
Multivariate OR (95% CI)
p
1.9 (1.2–3.1)
0.001
1.3 (1.1–2.8)
0.01
1.4 (1.1–3.5) 1.2 (0.81–2.1) 1.1 (0.84–4.2) 1.3 (0.65–7.4) 1.2 (0.88–5.4) 1.4 (0.96–4.9)
0.03 0.3 0.41 0.62 0.39 0.13
1.2 (0.98–2.9) – – – – 1.2 (0.84–3.4)
0.09 – – – – 0.24
1.5 (1.2–6.9) 1.6 (1.4–5.8) 1.4 (1.2–3.4) 1.1 (0.62–2.9) 1.2 (0.55–2.3)
0.01 0.02 0.04 0.59 0.35
1.2 (1.1–5.5) 1.1 (1.05–4.2) 1.2 (0.98–2.7) – –
0.03 0.04 0.12 – –
1.5 (1.1–2.5)
0.02
1.1 (0.84–1.9)
0.13
1.3 (0.91–4.5) 1.2 (0.69–3.2) 1.6 (1.4–8.4) 1.4 (1.1–7.4) 1.5 (1.1–3.9) 2.1 (1.8–6.4)
0.31 0.46 0.01 0.02 0.02 0.01
– – 1.4 (1.2–9.5) 1.1 (1.06–10.3) 1.2 (1.1–4.5) 1.8 (1.4–7.2)
– – 0.03 0.04 0.04 0.01
CT protocols that adjust for patients' characteristics and limit radiation exposure [18]. Additionally, nondesignated pediatric centers may apply adult guidelines to presenting pediatric patients and may not be familiar with different patterns of injury in children. Strength of our study is that as a result of adjusting for confounding factors in analysis, we had similar cohort of patients to compare. Subsequently we found that the likelihood of performing a WBCT in ATC was higher, independent of injury severity or pattern. WBCT scan is advocated owing to survival benefit in adult trauma centers [20–22,25,26]. Caputo et al. in a metaanalysis showed that patients undergoing a WBCT, despite having significantly higher ISS at baseline compared with the group who received selective scanning, had a lower overall mortality rate and a more favorable pooled odds ratio [22]. However there is a lack of knowledge regarding the utility of WBCT in pediatric population and its relation to outcomes. In our study we could not find a survival advantage between PTC and ATC, However patients undergoing a WBCT compared to selective scanning had a higher mortality rate overall. This may be because of selective approach to only perform a WBCT scan in severely injured pediatric trauma patients. Several authors have examined the use of alternative imaging modalities such as x-rays or ultrasound for identification of injuries [16,27,17,28,29]. Although FAST has been proposed as an adjunct for the evaluation of a pediatric trauma patient by the ACS, its clinical usefulness remains debated [28,29]. Furthermore, chest x-rays should serve as the initial imaging modality in pediatric blunt trauma patients, with thoracic CT only to be used in certain circumstances [16,30]. The selective use of tube thoracostomy for the treatment of occult pneumothoraces further supports those findings [12]. In addition, xray is a reliable imaging study for identification of bone and soft tissue injuries [27]. We found that CT scan rates of the chest and abdomen were significantly higher in adult trauma centers. This finding is particularly important as a possible association with increased survival can alleviate the importance of perceived negative effect from excess radiation. In an effort to limit the CT use in pediatric trauma patients, several guidelines and prediction models for clinically important injuries have been developed that recommend selective imaging based on mechanism of injury, physical examination and laboratory data [13–15,19,31,32]. Holmes et al. created a prediction rule based solely on history and physical examination that would rule out a clinically significant abdominal injury
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
that would require surgical intervention, embolization or blood transfusion [19]. Further studies have added abnormal laboratory data such as hematuria and increased liver function tests to their models that would predict blunt abdominal trauma [15,31]. However, in our study we found no difference in survival between ATC and PTC in management of pediatric patients. Similarly, Jindal et al. reported higher rates of WBCT use in pediatric patients presenting with mild to moderate trauma compared to their adult peers, without any difference in outcomes [24]. The reported rise in CT scan use in the pediatric population has prompted several authors to emphasize the significant radiation exposure and malignancy risk associated with its use [2,3,5,6]. Egan et al. noted an important breast radiation exposure in female trauma patients who underwent thoracic CT for spine clearance, a radiation risk that was substantially higher in children compared to adolescents [7]. Additionally, pediatric trauma patients receiving more than two CT scans, including WBCT scans, are being exposed to significantly higher radiation compared to those undergoing less imaging [4]. Although we do not have data regarding the amount of radiation exposure in PTC compared to ATC, our data support reduction in use of CT scans in adult trauma centers as no survival benefit is observed in an adjusted analysis from a national database. In our study we defined pediatric patients with age ≤ 18 years as this is the most widely used definition across multiple studies to define pediatric patients. Furthermore, majority of the institutions reporting to the NTDB have defined pediatric patients as age ≤ 18 years. We understand that there remain variations across institutions for defining the age cutoff for pediatric patients however; as the NTDB does not provide institutional identifiers, we were not able to assess the age cutoff in each institution which is a potential limitation of the database. Our study has certain limitations. Although the NTDB represents the largest trauma registry, our results may not be generalizable given the retrospective nature of the database and missing data. Additionally, we were not able to detect CT scan rates of the cervical spine as they currently lack an ICD 9 procedure code. Moreover, the clinical significance of the CT scan utilization could not be captured in this study, i.e. we were not able to examine how the presence of the CT scan served as a guide for further management. We were unable to assess the pediatric training of providers managing patients across centers. We did not assess the causes for mortality in our patient population. Despite these limitations, our study presents the largest study that examines the WBCT utilization among pediatric and adult trauma centers. 4. Conclusion Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients who underwent a CT were more likely to be managed with WBCT in adult trauma centers were, increasing their risk for radiation without a difference in outcomes. Establishing protocols for minimizing the use of WBCT in pediatric population across adult trauma centers may standardize trauma care for the pediatric trauma patient. Acknowledgements No acknowledgements to make. References [1] Rhee P, Joseph B, Pandit V, et al. Increasing trauma deaths in the United States. Ann Surg 2014;260(1):13–21. [2] Brenner DJ, Hall EJ. Computed tomography — an increasing source of radiation exposure. N Engl J Med 2007;357(22):2277–84.
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Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002