Author: Nikki Abela / Codes: CC4, CC5, PMP4 / Published: 23/07/2016
Trauma is such a sexy topic. Add children and well feelings can change.
But why? I hear you ask. What is so different?
Paediatric trauma is different. If you have not heard that phrase before, then you obviously have not heard the talk Ross Fisher gave at the RCEM conference in Manchester, because if you did, you would have remembered it. I know that this blog will not be able to do it justice, so I really urge you to listen to it on our website.
While running an adult through a pan-CT is relatively easy, when you consider this in children, people do tend to worry about radiation dose.
This is because when you weigh up the 85-year risk of cancer in say a 50-year old man (who would be very lucky to reach that age), against that of a 2-year old boy (whose odds of reaching that age are likely and whose maturing tissues are more radiosensitive), the problem becomes a real one. A Swedish study even found a correlation between low doses of ionising radiation in infancy and lower IQs later in life.
So we really need to turn to the evidence when ordering paediatric imaging. The problem is, with kids, this can sometimes be scarce.
Lets start with the easy stuff, head injury- NICE has covered this nicely already.
Now, lets get one thing out of the way, as a fair few young children fall downstairs and it causes quite a bit of anguish with some doctors. Most paediatricians/senior EM colleagues have passed on this pearl of knowledge to me, which I found to be mainly true:
Children around 2 years of age do not fall down stairs in the same way as adults, in that they dont fall down in one projectile movement, but tumble downstairs, meaning they have a collection of small falls, reducing the MOI.
If youre “CTing” the head and have a c-spine worry, go ahead and continue imaging the neck. You should also start with CT if there is:
- A GCS less than 13 or patient is intubated
- Focal neurological signs.
- Definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
- Another body area scanned
- There is strong clinical suspicion of injury despite normal X-rays.
- Plain X-rays are technically difficult or inadequate.
Otherwise, do start with a plain xray BEFORE MOVING THE NECK if there is neck pain or there is a dangerous MOI (NICE define this differently for necks as a fall from a height of greater than 1m or 5 stairs; axial load to the head; accident involving motorised recreational vehicles; bicycle collision).
To be fair, I personally think that the adult version of Canadian c-spine and nexus could be applied here and I really like canadiems take on it.
Worried about the rest of the spine? Then the RCR guidance advises to use good old clinical judgment, but do call a friend (radiologist) for advice as MRI would be ideal if there is a high index of suspicion after x-ray.
You should also consider only imaging the upper C-spine with your CT as this is where these uncommon injuries often hide and they’re poorly visualised on plain film. A CT upper c-spine and plain lateral of the rest of the spine might get you where you need to get to. I haven’t seen this studied anywhere so if you’re aware of any let us know in the comments box below.
Do not forget that the spine will be included in CT for other body parts, but for blunt chest trauma, XR remains the primary imaging modality, and CT should be the first go-to only in penetrating trauma (due to the risk of vascular injury).
Further imaging in blunt chest trauma depends on the MOI, the clinical condition of the child and findings on x-ray.
If the patient is conscious, stable and initial x-ray is normal, then it is likely they can do away with CT.
Things arent so clear with abdominal trauma.
FAST? Might as well flip a coin (as Ross says), as the negative predictive value is around 50%. However, a good paediatric radiologist advised me that you may find radiology experts who can confidently perform a formal US abdomen instead of CT and the sensitivity for injury increases, so it is worthwhile having a discussion with them. There is no rigid guidance for CT abdomen, and again you are going to have to rely on your medical knowledge and clinical judgment, but if you are still doing x-rays, please stop.
Pelvis injuries are rare in children, but the exception really defines the rule, so do image according to clinical findings. X-ray is a good place to start with bony tenderness, but contrast CT is really needed if positive due to visceral/vascular injuries associated with pelvic fractures.
Do not forget speaking to those friendly radiologists for interventional radiology procedures if there are positive findings.
- Dont fret, children do really well even with the most exceptional injuries.
- There is robust guidance for head and c-spine injury, but all other injuries need good clinical judgment and good old plain x-rays (except in abdominal trauma), before jumping to CT.
- Do phone a friend before knee-jerk ordering more imaging.
- Do it right, if only for the kids!
- NICE: Major trauma: Assessment and initial management
- RCR: Paediatric trauma protocols
- HEFTEM: NICE guidance on Major trauma
- NICE: Head injury guidance
- Candiem: Canadien C-spine rule mnemonic
- St Emlyns summary of the RCR guidelines by Natalie May
- EM Lit of Note on the PECARN Abdo trauma decision instrument, PEM Morsels on the same paper
- ER Cast with Andy Sloas and Rob Orman on Paeds C Spine Imaging
Special thanks to my super brother-in-law Andre Gatt, Paediatric Radiology Consultant, for adding his pearls of knowledge to this blog.