USE OF CT SCAN IN A CHILD WITH MTBI

Transcription

1 TO SCAN OR NOT TO SCAN USE OF CT SCAN IN A CHILD WITH MTBI LISA AYOUB-RODRIGUEZ MD PEDIATRIC HOSPITALIST MIKE LEE MD PEDIATRIC RESIDENT BERT JOHANSSON MD PEDIATRIC HOSPITALIST

2 DISCLOSURES I M NOT A SURGEON OTHERWISE NO FINANCIAL DISCLOSURES OR CONFLICTS OF INTEREST

3 OBJECTIVES Understanding epidemiology of minor head injuries Review radiation risk of Head CT Reviewing clinical decision rules for head injury - How they are unique - Sensitivity and specificity How family plays a role in care and management Case reviews

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5 HEAD INJURY STATS Of the million annual emergency department visits for TBI, almost half a million (473, ,000) are made by children aged 0 to 14 years. CDC Lots of money involved - $2,713,992,000. (CDC Cost of Injury Module) 2, 76 billion according to CDC in Most head injuries in childhood are mild. There are a small number who will have serious injuries. We need to be able to identify injuries that are potentially life threatening or require neurosurgical intervention.

6 WHY IT S IMPORTANT TBI is the leading cause of death and disability in children worldwide. Kuppermann2009 Most patients seen are GCS Approximately 50% of head injured children in ED receive a head CT. However, Less than 10% of CT scans show traumatic brain injuries. citbi are uncommon in pts with GCS Head CT rates in North America have doubled since 1990s, Blackwell 2007 despite a large amount of results being normal. CT comes with risks associated with radiation and potentially additional costs.

7 EVALUATION OPTIONS

8 OBSERVATION DECREASES CT USENIGROVIC 2011 Subanalysis of prospective multicenter observational study of children with minor blunt head trauma.

9 OBSERVATION DECREASE CT USE SCHOFELD2013 Prospective cohort study, GCS >14 1,381 patients enrolled, 49% observed in ED, 20% had CT.

10 THE DIRT ON RADIATION CXR 2V msv, two days of background radiation Head CT 2 msv, 243 days of background radiation Abdominal CT - 3 msv, 20 months of background radiation (Assumption of average effective dose from CXR of 0.02mSv, assumption of average effective dose from natural background radation of 3mSv per year in US) Target organ dose is amplified i.e. lens in HeadCT Institutional variance: 1/10 pediatric radiation dose at UMC/EPCH vs some nearby outside facilities

11 RADIATION RISKS IN CHILDREN: NO DEBATE Kids are extra-vunerable. Tissues are more radiosensitive. Longer lifetime to manifest radiation-induced injury (cancer, cataracts) Each exam (therefore dose) is cumulative. Increased risk for developing cancer (induction of stochastic effects of carcinogenesis)

12 BIOLOGIC EFFECTS OF RADIATION Damage to DNA Reactions are rapid The damage to DNA may lead to genomic instability Induction of cancer takes many years Lifetime risk for death from cancer related to Head CT done at age Brenner yrs ~0.03%, newborn period ~0.08%. **Controversial as this is extrapolated from radioactive disasters. **Also note it usually involved α and β waves, radiologic procedures use γ waves.

13 ESTIMATED RATE OF LETHAL MALIGNANCIES FROM CT IS BETWEEN 1:1000 TO 1:5000 IN PEDIATRIC CRANIAL CT. BRENNER 2002 CLEAR DATA FOR CT USE, HOWEVER UNAVAILABLE AND THERE IS PRACTICE VARIATION.

14 LIFETIME CANCER MORTALITY RISK Breakdown by cancer type of estimated lifetime CTattributable cancer mortality risks as a function of age. BRENNER 2001

15 Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated. Minor head injuries occur commonly in children and adolescents. Approximately 50% of children who visit hospital emergency departments with a head injury are given a CT scan, many of which may be unnecessary. Unnecessary exposure to x-rays poses considerable danger to children, including increasing the lifetime risk of cancer because a child s brain tissue is more sensitive to ionizing radiation. Unnecessary CT scans also impose undue costs to the health care system. Clinical observation prior to CT decision-making for children with minor head injuries is an effective approach.

16 WE NEED BALANCE

17 CLINICAL DECISION RULES FOR HEAD INJURY Clinical Decision Rules use elements of history and physical exam to help make medical decisions. Help balance identifying significant head injury and risk of CT scan. PECARN Pediatric Emergency Care Applied Research Network CHALICE Children s head injury algorithm for the prediction of important clincial events CATCH Canadian assessmen of tomography for childhood head injury

18 WHO ARE CDRS FOR? - Not patients who clearly need imaging. Clinical judgment still wins. - For patients who present diagnostic difficulty. - For use by clinicians who apply them with careful attention. - With flowcharts alone, CDR is applied to a wider population than intended. Lyttle2013

19 PECARN STUDY KUPPERMANN 2009 Involved > 42,000 patients younger than 18 years with head trauma in 25 emergency departments in US Focused on children with minor head injury and GCS (CT use in GCS <14 is not controversial) Described need for separate CDR for different age groups as younger children are more difficult to assess and more sensitive to radiation Aim was to derive and validate prediction rules for citbi to identify children at very low risk of citbi after blunt head trauma for whom CT might be unnecessary.

20 PECARN KUPPERMANN It states if no predictor variables are present than CT is not necessary. -Gives risk of intracranial injury with predictor variable, still doesn t say to scan. **Remember does not state to scan all who don t meet low risk criteria.

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22 ACCURACY OF PECARN -Prediction: 50 CT scans to identify 1 clinically significant injury, and more than 200 to identify a neurosurgical injury. ** Medwid Excluded those who had so minor injury no one would consider Head CT or so severe Head CT is obviously necessary.

23 CHALICE DUNNING 2006 Involved 22,772 children < 16 years old who presented with head injury in 10 EDs in England Included children with all severity of HI in whom there is a low prevalence of life threatening complications Aim was to conduct a prospective multicenter diagnostic cohort study to provide a rule for selection of highrisk children with head injury for CT scanning

24 CHALICE DUNNING st CDR for managing pediatric head injury. CT scan for the following: History -Witnessed LOC > 5 min -Hx of amnesia > 5 min -Abnormal drowsiness - 3 vomits after head injury -Suspicion of non-accidental trauma -Seizure after head injury without hx of epilepsy Examination -GCS < 14, or GCS <15 if < 1yr old -Suspicion of penetrating or depressed skull injury or tense fontanelle -Sign of basaliar skull fracture -Focal neuro findings -Presence of bruise, swelling or laceration >5cm if <1yr old

25 CHALICE DUNNING 2006 Mechanism -High speed road traffic accident either as pedestrian, cyclist or occupant (speed >40 mph) -Fall >3 meters (9ft) If none of the History, Examination or Mechanism variables are present then patient is at low risk for intracranial pathology. CHALICE would increased CT rates by 240% in retrospective study, none of which required neurosurgical intervention. Crowe 2010

26 THE CATCH CLINICAL DECISION RULE OSMOND 2010 Involved 3866 patients with blunt head trauma with GCS who presented to 10 Emergency depts in Canada Decision based on 4 high risk factors and 3 medium risk factors for neurological intervention Focused on children with minor head injuries and GCS Aim was to prospectively derive an accurate and reliable clinical decision rule for the use of CT in children with minor head injury (WHO TO SCAN)

27 CATCH OSMOND 2010 CT head children with 1 of the following: High risk 1. GCS <15 at 2h after injury 2. Suspected open or depressed skull fracture 3. Hx of worsening headache 4. Irritability on examination Medium risk 1. Sign of basalar skull fracture 2. Large, boggy hematoma of the scalp 3. Dangerous mechanism of injury

28 CDR COMPARISON PECARN CHALICE CATCH Study population <2, 2-18 yo Under 16 yo Under 17 yo Sample size 33,875 22,772 3,866 Outcome No CT Requiring CT Requiring CT Validated Yes No In Progress Impact analysis Sensitivity <2 yo, 98.6% >2 yo, 96.7% Specificity <2 yo, 53.7% >2 yo, 58.5% NPV <2 yo, 99.9% >2 yo, 99.95% PPV <2 yo, 99.95% >2 yo, 2% 97.6% 98.1% 87.3% 50.1% 99.9% 99.8% 5.4% 7.8%

29 PROJECTED CT RATES AFTER CDR APPLIED LYTTLE2012

30 You are called to the ED to evaluate a 10 year old M who fell off the trampoline and struck his head on a metal bar 2 days prior to arrival. The accident was witnessed by friends. No LOC reported and patient cried immediately afterwards. Since his fall, the patient has been complaining of increasing headaches, neck pain and had episodes of emesis. Vital signs are stable and within normal limits, GCS of 15. Patient is tearful but not in acute distress. He is alert and oriented, complains of a headache. He has tenderness to palpation over R upper occiput but no noticeable depression. He also has tenderness to palpation of C- spine. CN II-XII intact, no neurological abnormality on PE. Of the following, the MOST appropriate next step in the management of this child is to A. Observation in the ED B. Discharge the child home with head injury precautions C. Obtain CT of the head and C-spine

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32 Based on the 3 CDRs, the patient fulfilled the criteria for CT of head based on >2 episodes of vomiting, worsening headache and severe mechanism of injury. CT of head was negative for intracranial pathologies. CT of C-spine was also unremarkable. The patient was admitted to EPCH for observation due to persistent neck pain. A tertiary survey done the following day did not reveal additional injuries. No nausea or vomiting reported overnight and patient reported improvement of his headache and neck pain and was discharged home in stable condition

33 You are called to the ED to evaluate a 12 year old M who struck his head while playing tug of war. There was brief LOC. Per EMS, he initially had a GCS of 3 and improved to 13 en route and did not require emergent intubation. Vital signs are stable and within normal limits, GCS of 15. Patient is alert and oriented, complains of a headache. He has tenderness to palpation and ecchymosis over his R eyelid as well as multiple abrasions over the frontal scalp. CN II-XII intact, no neurological abnormality on PE. Of the following, the MOST appropriate next step in the management of this child is to A. Observation in the ED B. Discharge the child home with head injury precautions C. Obtain CT of the head

34 CT of face, brain and neck did not reveal any pathology. Patient was admitted for observation at EPCH. No nausea or vomiting reported overnight and patient reported improvement of his headache and neck pain and was discharged home in stable condition.

35 You are called to the ED to evaluate a 14 month old M with history of hemophilia s/p fall. Patient fell while standing and landed on his back today. Mother unsure if patient struck his head. Since the fall, the patient has developed bruising/hematoma of his L buttocks as well as R shin, L shin and R cheek. No history of vomiting, seizures or irritability noted by patient. Vital signs are stable and within normal limits, GCS of 15. Patient is acting appropriately for age, no signs of distress noted. He has a large hematoma on his L buttock. Bruising noted on R/L shin as well as R cheek. CN II-XII intact, no neurological abnormalities on physical examination H/H 10/29, PLT 482, PT 13, PTT 83, INR 1 Of the following, the MOST appropriate next step in the management of this child is to A. Observation in the ED B. Discharge the child home with head injury precautions C. Obtain CT of the head

36 Patients with hemophilia can develop spontaneously or following mild head trauma Determining the appropriate evaluation for a patient with hemophilia and head trauma is challenging with no neuroimaging guidelines and limited clinical evidence Due to the elevated risk of ICH, most children with hemophilia and CHI receive factors and undergo CT scanning despite having normal neurological exams. CT scan was negative for intracranial pathology. Patient was observed in the ED and was discharged home with immediate followup with Hem-Onc

37 FAMILY CENTERED CARE

38 WHAT DO PARENT PREFER? KARPAS parents of head-injuried kids >2 yo surveyed after given educational material reagarding the risks, benefits of immediate CT scanning and observation. 40% preferred immediate CT, 57% preferred observation, 3% no indication of preference. Most common reason to prefer CT, I need to be 100% sure there is no bleeding in my child s brain. Most common reason for observation preference, I don t want my child to have a test unless he/she absolutely has to and I m concerned about the possibility of radiation causing a brain tumor

39 FAMILY CENTERED CARE Involve families in health care decisions. Discuss management options. Risks and benefits.

40 REFERENCES 1. Center for Disease Control, National Center for Injury Preventions and Control. Traumatic brain injury in the United States: assessing outcomes in children. CDC,2006. Available at: Accessed October 21, Center for Disease Control, National Center for Injury Preventions and Control. Data & Statistics (WISQARS): Cost of Injury Reports Schronfeld, D. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma. Annuals of Emergency Medicine : Nigrovic LE. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics. 2011;127: Blackwell, CD. Pediatric head trauma: changes in use of CT in emergency departments in the US over time. Ann Emerg Med Mar;49(3): Brenner D. Estimated Risks of Radiation-Induced Fatal Cancer from Pediatric CT. AJR 2001;176: Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002; 32: Brenner DJ, Hall EJ. Computed tomography An increasing source of radiation exposure. N Engl J Med 2007; 357: Choosing Wisely. American academy of pediatrics: five things physicians and patients hould question. Available at: Accessed December 1, Kuppermann, N. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. 2009;374: Lyttle M, Crowe L, Oakley E, et al. Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J 2012;29: Lumba A. Evidence-Based Assessment and Management of Pediatric Mild Traumatic Brain Injury. Pediatric Emergency Medicine Practice 2011; 8(11): Dunning J. Derivation of the chilren s head injury algorith for the predicion of important clincal events decision rule for head injury in chldren. Arch Dis Child 2006;91: Osmond M. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010;182(4): Karpas, A. Which management strategy do parents prefer for their head-injured child: Immediate computed tomography scan or observation? Pediatric Emergency Care. 2013;29,1: Schunk J. Pediatric Head Injury. Pediatrics in Review 2012;33;

41 PICTURES high-dose-pediatric-ct-scans-could-cut-associated-cancers- 62-percen