Clinical Radiology 69 (2014) 1209e1213
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Review
Paediatric trauma imaging: Why do we need separate guidance? S. Negus a, *, J. Danin b, R. Fisher c, K. Johnson d, C. Landes e, J. Somers g, C. Fitzsimmons h, N. Ashford f, h, i, J. Foster j a
Department of Radiology, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK Department of Radiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK c Department of Paediatric Surgery, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK d Department of Radiology, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK e Department of Radiology, Alder Hey Children’s Hospital, Eaton Rd, Liverpool, Merseyside L12 2AP, UK f Department of Radiology, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK g Department of Paediatric Emergency Medicine, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK h Department of Radiology, St Richards Hospital, Spitalfields Lane, Chichester, West Sussex PO19 6SE, UK i The Royal College of Radiologists, 63 Lincoln’s Inn Fields, London WC2A 3JW, UK j Department of Radiology, Derriford Hospital, Derriford Rd, Plymouth, Devon PL6 8DH, UK b
art icl e i nformat ion Article history: Received 28 April 2014 Received in revised form 16 June 2014 Accepted 1 July 2014
It is often assumed that the pattern of injury in children mirrors that of the adult population, but children have different anatomical proportions and the relative elasticity of their tissues results in different injury patterns. The authors of this review are members of the British Society of Paediatric Radiologists subgroup and developed the recently published47 paediatric trauma protocols for imaging children involved in major blunt trauma. The following article has been written to bring these guidelines to the attention of the wider community of UK radiologists, and explain the rationale behind the recommendations. Ó 2014 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.
Introduction The majority of clinicians from all disciplines are understandably anxious when faced with a child presenting to the emergency department (ED) following an episode of major blunt trauma.1 Despite the use of both pre-hospital * Guarantor and correspondent: S. Negus, Department of Radiology, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 8ER, UK. Tel.: þ44 0 20 8725 1481; fax: þ44 0 20 8725 2936. E-mail address: [email protected] (S. Negus).
triage tools, and clinical prediction rules, it is notoriously difficult to accurately identify those children who do not have a major internal injury despite a significant mechanism.2e4 It is often assumed that the pattern of injury in children mirrors that of the adult population, and that definitive trauma care should be initiated within the first “golden hour”, requiring rapid and sensitive radiological investigation within this 60 min window. Obviously imaging must be done in a timely fashion, but the relationship between time and outcome is unclear for trauma cases. For example, a
http://dx.doi.org/10.1016/j.crad.2014.07.001 0009-9260/Ó 2014 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.
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S. Negus et al. / Clinical Radiology 69 (2014) 1209e1213
recent multicentre North American study, carried out to investigate emergency service intervals and survival in trauma, failed to find a relationship between out-ofhospital time and mortality. The patients were subdivided into several groups including level of first emergency responder, mode of transport, age, injury type, and “physiological stability”, with 3656 adults and 460 children recruited into the study. Despite the multiple variables and different age groups, the lack of a relationship between outof-hospital time and mortality led the authors to conclude that it was acceptable to take a little extra time to transport patients to a specialized trauma centre.5 Many will view this as a contentious issue, but perhaps imaging should not be prioritized at the expense of careful examination, observation, and stabilization, particularly for the paediatric population. Guidelines for imaging the severely injured patient of any age6e8 stress the need for sensitive and specific imaging, and the Royal College of Radiologists (RCR) guidelines for the severely injured patient (2010) states that (appendix 2) “paediatric trauma patients should be referred to a paediatric radiologist” for an appropriate imaging protocol. What these “appropriate imaging protocols” are is not discussed, and because paediatric radiologists are not available at all times, it is not always possible to discuss these cases thoroughly. Thus, for children presenting to a general ED, whole-body CT is often seen as the safe, default examination by the attending clinicians and radiologists with more experience in imaging major blunt trauma in adults, where it is recognized that early whole-body CT, with documentation of the full extent of all injuries, can increase the probability of survival.9e12 But is this truly the “safe” option? Although this is considered the case for adults, children have different anatomical proportions and the relative elasticity of their tissues results in different injury patterns.13 What may be the “safe” option in adults cannot be automatically said for children, who are more sensitive to the effects of ionizing radiation (IR), and have longer to live and develop radiation-induced cancers.14 Several recent high-profile studies have highlighted the relationship between exposure to IR and an increase in the absolute lifetime risk of developing a malignancy.15 Specifically the positive association between developing leukaemia and brain tumours were assessed in patients who underwent a CT head scan when they were younger than 22 years of age.16 The risk was found to increase threefold for both malignancies, which due to their relative rarity would result in one extra case of each per 10,000 head CT examinations. For cervical spine imaging, Jimenez et al.17 demonstrated that the IR dose to the thyroid, where there is a linear association between IR dose and the development of cancer, was 90e200 times that of the conventional two or three plain film radiographs. This translated to twice the excess risk of developing thyroid cancer for children aged up to 4 years old. It is acknowledged that low-dose techniques are being developed, with improvement in CT technology and software development, but the associated IR dose is still
substantially higher than that of conventional plain film radiographs.18,19 The RCR has responded to these studies by saying that this “confirms what we knew”, and that it remains “important that these long-term risks are set against the benefit of being able to reach a diagnosis quickly and determine the right course of treatment”.20 In other words, if the examination is “justified”, it becomes the appropriate imaging method. There are already NICE (National Institute for Health and Care Excellence) guidelines for head injury (triage, assessment, investigation, and early management of head injury in infants, children, and adults) that were originally published in 2003, and have been revised in 2007 and 2014.21 With regards to head injury, small children (particularly those
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Review
Paediatric trauma imaging: Why do we need separate guidance? S. Negus a, *, J. Danin b, R. Fisher c, K. Johnson d, C. Landes e, J. Somers g, C. Fitzsimmons h, N. Ashford f, h, i, J. Foster j a
Department of Radiology, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK Department of Radiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London W2 1NY, UK c Department of Paediatric Surgery, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK d Department of Radiology, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK e Department of Radiology, Alder Hey Children’s Hospital, Eaton Rd, Liverpool, Merseyside L12 2AP, UK f Department of Radiology, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK g Department of Paediatric Emergency Medicine, Sheffield Children’s NHS Foundation Trust, Western Bank, Sheffield S10 2TH, UK h Department of Radiology, St Richards Hospital, Spitalfields Lane, Chichester, West Sussex PO19 6SE, UK i The Royal College of Radiologists, 63 Lincoln’s Inn Fields, London WC2A 3JW, UK j Department of Radiology, Derriford Hospital, Derriford Rd, Plymouth, Devon PL6 8DH, UK b
art icl e i nformat ion Article history: Received 28 April 2014 Received in revised form 16 June 2014 Accepted 1 July 2014
It is often assumed that the pattern of injury in children mirrors that of the adult population, but children have different anatomical proportions and the relative elasticity of their tissues results in different injury patterns. The authors of this review are members of the British Society of Paediatric Radiologists subgroup and developed the recently published47 paediatric trauma protocols for imaging children involved in major blunt trauma. The following article has been written to bring these guidelines to the attention of the wider community of UK radiologists, and explain the rationale behind the recommendations. Ó 2014 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.
Introduction The majority of clinicians from all disciplines are understandably anxious when faced with a child presenting to the emergency department (ED) following an episode of major blunt trauma.1 Despite the use of both pre-hospital * Guarantor and correspondent: S. Negus, Department of Radiology, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 8ER, UK. Tel.: þ44 0 20 8725 1481; fax: þ44 0 20 8725 2936. E-mail address: [email protected] (S. Negus).
triage tools, and clinical prediction rules, it is notoriously difficult to accurately identify those children who do not have a major internal injury despite a significant mechanism.2e4 It is often assumed that the pattern of injury in children mirrors that of the adult population, and that definitive trauma care should be initiated within the first “golden hour”, requiring rapid and sensitive radiological investigation within this 60 min window. Obviously imaging must be done in a timely fashion, but the relationship between time and outcome is unclear for trauma cases. For example, a
http://dx.doi.org/10.1016/j.crad.2014.07.001 0009-9260/Ó 2014 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.
1210
S. Negus et al. / Clinical Radiology 69 (2014) 1209e1213
recent multicentre North American study, carried out to investigate emergency service intervals and survival in trauma, failed to find a relationship between out-ofhospital time and mortality. The patients were subdivided into several groups including level of first emergency responder, mode of transport, age, injury type, and “physiological stability”, with 3656 adults and 460 children recruited into the study. Despite the multiple variables and different age groups, the lack of a relationship between outof-hospital time and mortality led the authors to conclude that it was acceptable to take a little extra time to transport patients to a specialized trauma centre.5 Many will view this as a contentious issue, but perhaps imaging should not be prioritized at the expense of careful examination, observation, and stabilization, particularly for the paediatric population. Guidelines for imaging the severely injured patient of any age6e8 stress the need for sensitive and specific imaging, and the Royal College of Radiologists (RCR) guidelines for the severely injured patient (2010) states that (appendix 2) “paediatric trauma patients should be referred to a paediatric radiologist” for an appropriate imaging protocol. What these “appropriate imaging protocols” are is not discussed, and because paediatric radiologists are not available at all times, it is not always possible to discuss these cases thoroughly. Thus, for children presenting to a general ED, whole-body CT is often seen as the safe, default examination by the attending clinicians and radiologists with more experience in imaging major blunt trauma in adults, where it is recognized that early whole-body CT, with documentation of the full extent of all injuries, can increase the probability of survival.9e12 But is this truly the “safe” option? Although this is considered the case for adults, children have different anatomical proportions and the relative elasticity of their tissues results in different injury patterns.13 What may be the “safe” option in adults cannot be automatically said for children, who are more sensitive to the effects of ionizing radiation (IR), and have longer to live and develop radiation-induced cancers.14 Several recent high-profile studies have highlighted the relationship between exposure to IR and an increase in the absolute lifetime risk of developing a malignancy.15 Specifically the positive association between developing leukaemia and brain tumours were assessed in patients who underwent a CT head scan when they were younger than 22 years of age.16 The risk was found to increase threefold for both malignancies, which due to their relative rarity would result in one extra case of each per 10,000 head CT examinations. For cervical spine imaging, Jimenez et al.17 demonstrated that the IR dose to the thyroid, where there is a linear association between IR dose and the development of cancer, was 90e200 times that of the conventional two or three plain film radiographs. This translated to twice the excess risk of developing thyroid cancer for children aged up to 4 years old. It is acknowledged that low-dose techniques are being developed, with improvement in CT technology and software development, but the associated IR dose is still
substantially higher than that of conventional plain film radiographs.18,19 The RCR has responded to these studies by saying that this “confirms what we knew”, and that it remains “important that these long-term risks are set against the benefit of being able to reach a diagnosis quickly and determine the right course of treatment”.20 In other words, if the examination is “justified”, it becomes the appropriate imaging method. There are already NICE (National Institute for Health and Care Excellence) guidelines for head injury (triage, assessment, investigation, and early management of head injury in infants, children, and adults) that were originally published in 2003, and have been revised in 2007 and 2014.21 With regards to head injury, small children (particularly those
