Article, Traumatology

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury

a b s t r a c t

Objective: Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury.

Methods: Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were Neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation.

Results: Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention.

Conclusion: The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified.

(C) 2014

  1. Introduction

A normal physical examination by itself has been shown to be unreliable for excluding intraAbdominal injury in multi-trauma adult patients [1-6].

Since the 1970s, computed tomography (CT) imaging has become the mainstay diagnostic evaluation of blunt trauma patients [1,2,4,7-9]. It is generally accepted that Hemodynamically stable patients with abnormal physical examination undergo CT imaging, as well as patients with a depressed level of consciousness [3,10]. Controversy exists regarding awake, clinically evaluable patients with no obvious signs of internal organ injury. In the last years, a number of studies have assessed the role of CT scans in the evaluation of asymptomatic trauma patients with a high suspicion for internal organ injury according to the mechanism of trauma [4,11,12]. It was

? Disclosure: The authors declare that they have no commercial associations, financial disclosures, or other competing interests with regard to this article. There are no sources of funding.

* Corresponding author at: Division of Surgery, Assaf Harofeh Medical Center, Zerifin 70300, Israel. Tel.: +972 8 9778276; fax: +972 8 9778399.

E-mail address: [email protected] (I. Jeroukhimov).

shown that in 10% to 20% of such patients, the management plan changed because of the CT results [3,4,12,13]. Thus, liberal use of CT scans was recommended [3,6,8,9].

Exposure to ionizing radiation is considered the major disadvantage of CT imaging. The risk of radiation induced malignancy has been shown by many authors [4,5,7,8,13,14]. An inverse relationship has been reported between the risk of radiation and the age of the exposed patient. Children are up to 10 times more sensitive to ionizing radiation than adults [5,11,14-16], and the risk of radiation induced mortality ranges from 1/1000 to 1/2000 [5,11].

The purpose of this study was to evaluate the role of abdominal and chest CT imaging in pediatric patients with a suspicious mechanism of injury, who are hemodynamically stable and have no obvious signs of chest or abdominal trauma.

  1. Patients and methods

A prospective observational study was performed at a high volume level II trauma center located in central Israel from January 1, 2007, to June 30, 2009. This study was conducted with institutional review board approval. Only patients whose legal guardian signed an inform consent were enrolled.

0735-6757/(C) 2014

698 Y. Hershkovitz et al. / American Journal of Emergency Medicine 32 (2014) 697699

All pediatric patients up to the age of 15 years with a blunt mechanism of multisystem trauma were eligible for enrollment to

Table 2

Computed tomography findings

the study.

Inclusion criteria were based on the mechanism of injury (a high

Age (Y)

Gender Computed tomography management changes

speed [N 55 km/h] motor vehicle accident, a pedestrian struck by a car, or a fall from a height of greater than 3 meters). All the study patients were neurologically intact and hemodynamically stable, had no visible chest or abdominal injury, or had no signs of chest or abdominal trauma on initial examination.

Patients underwent CT imaging of the chest, abdomen and pelvis as part of their evaluation. The CT scan was performed in the emergency department shortly after admission and clinical examina- tion. Based on the CT findings, patients were admitted either to the surgical ward or to the intensive care unit (ICU) or were discharged to the other services. Each CT was interpreted by the on-call attending radiologist. In-hospital routine protocol recommends ICU admittance for every pediatric trauma patient with parenchymal organ injury.

An abnormal CT scan was defined as one exhibiting any traumatic abnormality. Patient treatment plan changes were defined as an alteration in management based solely on the CT findings. These changes included early discharge to other services, admission for observation, requirements for additional diagnostic studies, and immediate surgical intervention.

All the decisions regarding patient management were made by the on-call attending trauma surgeon.

Data regarding patient demographics, mechanism of injury, physical examination findings, Glasgow Coma Scale score on admission, Injury Severity Score, radiologic interpretation of chest and pelvic roentgenograms results, Focus Assisted Sonography for Trauma (FAST) and CT findings, surgical procedures required, and changes in manage- ment plan were recorded.

  1. Results

Forty-two patients were included in the study and underwent CT of the chest and abdomen. Patient data is specified in Table 1. Clinical examination and radiography of chest and pelvis were normal in all patients as well as FAST results. Thirty-one (74%) patients had normal chest and abdomen CT scans. Twelve abnormalities in 11 (26%) patients were revealed on CT scan (Table 2). Chest CT diagnosed mild pulmonary contusion in 2 patients, and 1 had a minimal pneumothorax. None of these 2 patients had signs of respiratory distress and were discharged after 24 hours of observation. One patient had grade I Liver lacerations and a second had grade I splenic laceration. They were admitted to ICU for observation. Four patients had a small amount of intraperitoneal fluid. None of these patients required additional intervention. One patient had a rib fracture and a minor pubic rami fracture was diagnosed in 2 patients (1 of whom had splenic laceration). These fractures did not prevent patient mobilization. Both (rib and pelvic fractures) were missed on initial radiographs.

Two patients were admitted for observation in the ICU based exclusively on CT results. Seven additional patients had different

Table 1

Patient characteristics

8 Male lung contusion None
  • 11 Male Pelvic fracture, minor splenic laceration Observation in ICU
  • 11 Male Minor liver laceration Observation in ICU
  • 8 Male Pneumothorax None
  • 10 Male Intraperitoneal fluid None
  • 15 Male Intraperitoneal fluid None
  • 4 Female Pelvic fracture None
  • 8 Male Intraperitoneal fluid None
  • 15 Male Rib fracture None
  • 9 Female Intraperitoneal fluid None
  • 1.5 Female Lung contusion None
  • extremity fractures and were transferred to the Orthopedic service right after the CT scan.

    Due to lack of significant findings in these 42 patients, we decided that it would be unethical to continue exposing the patients to unnecessary radiation, and the study was discontinued.

    1. Discussion

    Management of asymptomatic pediatric patients presenting with a suspicious mechanism of blunt trauma is controversial.

    Physical examination alone is unreliable in ruling out intra-abdominal injury [1-6]. Laboratory tests are not sensitive enough and lack specificity for intra-abdominal injury [1]. The sensitivity of chest x-ray and Pelvic radiography is considered to be low [1,3,4]. It has also been shown that FAST is less sensitive in the pediatric population when compared to adults [8], and its role is still unclear [15].

    CT imaging is the gold standard Diagnostic modality in hemodynamically stable adult blunt trauma patients [4,6-9]. The main concern in performing CT in children is exposure to ionized radiation. The concept of radiation induced malignancy has been discussed by many authors [4,5,7,8,11,13,14]. Children are 10 times more susceptible to radiation in terms of cancer morbidity and mortality [5,11,15,16]. There is an inverse relation between the patient’s age and the degree of exposure to radiation [14]. Radiation- induced mortality can reach 1/1250 in the pediatric population, where the risk of deadly malignancy can be as high as 1/1000 [5,11].

    Anatomic factors such as a relatively thin abdominal wall and smaller antero-posterior diameter make children more susceptible to abdominal injuries after blunt abdominal trauma [6,17]. Serial abdom- inal examination is the most sensitive indicator of occult bowel injury, but at the expense of delayed diagnosis [18,19]. There is no consensus on the consequences of delayed diagnosis of Intra-abdominal injuries. While some argue that there is an increased rate of complications in cases of delayed management [20], others have shown no adverse consequences in terms of length of stay or postoperative infection complications [21,22].

    More than 70% of the scans done for trauma in adults are normal [2,5,12]. Studies have shown that CT imaging has led to a change in management in 10% to 20% of the patients [3,4,16]. Performing abdominal or chest CT based only on the mechanism of injury has not

    Patient characteristic Normal CT

    (n = 31)


    7.5 +- 4.1

    9.1 +- 4.1

    7.2 +- 4.1

    Gender (male/female)




    Abnormal CT

    (n = 11)


    (n = 42)

    been proven to be cost effective [2].

    While most of the studies that emphasized the role of CT in asymptomatic trauma patients were performed on adult patients, our study focused on the pediatric population. In this study, 31 (74%) out

    Mechanism of injury Pedestrian hit by car

    19 (61.1%)

    6 (54.6%)

    25 (59.6%)

    of the 42 CT scans performed based on the mechanism of injury, were

    Motor vehicle accident

    5 (16.1%)

    2 (18.1%)

    7 (16.6%)

    in the normal range. None of the CT findings required intervention.


    7 (22.8%)

    3 (27.3%)

    10 (23.8%)

    The management of 2 patients was changed (4.7%) according to CT

    results. Both had low grade parenchymal organ injury and were admitted to the ICU for Close monitoring.

    Injury severity score (mean)

    4.1 +- 3.6

    10.0 +- 8.3

    5.6 +- 5.7

    Length of hospital stay (mean)

    1.45 +- 1.4

    1.72 +- 0.8

    1.52 +- 1.3

    Y. Hershkovitz et al. / American Journal of Emergency Medicine 32 (2014) 697699 699

    There is a consensus regarding conservative management of solid Organ injuries [6] and the main indications for surgical intervention based on clinical parameters, mainly hemodynamic instability [9]. Minimal findings on CT, such as intraperitoneal fluid or low-grade parenchymal organ injury, which have no correlation with physical examination or laboratory changes, usually have no effect on patient management [10,23].

    Considering the fact that serial physical examinations are more reliable in the diagnosis of intra-abdominal injury, one might question the role of routine CT based solely on the mechanism of trauma. Christiano et al [24] showed that findings of intraperitoneal fluid in hemodynamically stable pediatric patients does not mandate operative treatment.

    1. Limitations

    The current study has several limitations. The study sample was small and so universal conclusions cannot be reached based on this study. It is also possible that because our center is a level 2 trauma center, more Severe trauma patients were transferred to other hospitals.

    1. Conclusion

    In our study, the majority of the CT scans performed based solely on mechanism of injury were normal. Even those CT scans that demonstrated pathology did not affect the management of the patient in most of the cases. Given the radiation induced morbidity and mortality attributed to CT, we conclude that the routine use of CT in asymptomatic blunt trauma pediatric patients with a suspected mechanism of injury is not justified. CT imaging should be performed selectively and should be based on clinical and laboratory parameters along with the mechanism of injury.


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