Imaging for Pediatric Trauma and the Acute Patient What to Order When

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Sherilyn Watts
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1 Imaging for Pediatric Trauma and the Acute Patient What to Order When Paula Shultz, MD Pediatric Radiologist Central Oregon Radiology Associates November 8, yr old male involved in multicar accident, thrown from car, arrives combative, confused, with multiple head and lower body abrasions Imaging Ordered: Head, Chest, Abdomen and Pelvis CT Approximately how much radiation exposure will these CT scans represent? a. 3 msv b. 10 msv c. 15 msv d. What is a msv? What dose of radiation is considered safe for a person to receive each year? a. 2 msv b. 5 msv c. 10 msv d. 50 msv e. I still don t know what a msv is Who does not receive radiation on a daily basis? a. Physician in OR b. OR patient c. Radiology Tech d. OR Tech e. Volunteer in gift shop f. A person in this audience

Learning Objectives: List considerations of radiation exposure unique to the pediatric patient Discuss CT as a diagnostic tool in the

imaging algorithm in the pediatric patient Historical Perspective 1972 CT scanner was invented Diagnostic radiation exposure was not

has increased nearly 700% in the last 10 years, with approximately 11% of all CT scans being performed in children Historical

15% of the ionizing radiation exposure to the US population In 2006, medical imaging accounted for almost 50% Historical Perspective-

2 Learning Objectives: List considerations of radiation exposure unique to the pediatric patient Discuss CT as a diagnostic tool in the trauma and acute pediatric patient and the individual risk-benefit over MRI and Ultrasound Using case examples, discuss an appropriate imaging algorithm in the pediatric patient Historical Perspective 1972 CT scanner was invented Diagnostic radiation exposure was not considered a problem Technological advances have allowed detailed images to be obtained in a rapid, almost effortless manner Use of CT has increased nearly 700% in the last 10 years, with approximately 11% of all CT scans being performed in children Historical Perspective- cont. In the early 1980 s, medical imaging accounted for approx. 15% of the ionizing radiation exposure to the US population In 2006, medical imaging accounted for almost 50% Historical Perspective- cont. Radiation-related cancer risk at low doses among atomic bomb survivors, Pierce and Preston, Radiation Research Estimated risks of radiation-induced fatal cancer from pediatric CT, Brenner DJ, et. al. AJR. 2001

3 Attitude Change No amount of radiation is truly safe ; lowlevel radiation exposure (10-20 msv)can result in a small risk of cancer later in life Attitude Change Several organizations now classify ionized radiation as a carcinogen WHO s International Agency for Research in Cancer the National Institute of Environmental Health Sciences the Agency for Toxic Substances and Disease Registry of the Centers for Disease Control and Prevention Pediatric Population Unique because have longer period of time to manifest a neoplasm related to radiation exposure Radiation exposure is cumulative Children are more sensitive than adults to the potentially damaging effects of ionizing radiation Source Typical radiation doses Est. dose (msv) Natural background msv/yr Airport security x-ray scanner msv 7 hour airplane flight 0.03 msv Single view CXR 0.01 msv Head CT up to 2 msv Abdomen/pelvis CT 5-10 msv CT pulmonary angiogram msv Relative Radiation Doses Radiation Source Natural Background Airport security scanner 7 hr airplane flight Chest X-ray (single) Head CT Abdominal CT CT pulmonary angio Days Background Radiation 1 day Less than 1 hour Less than 1 day 1 day up to 8 months up to 2-3 years up to 7-12 years What dose of radiation is considered safe for a person to receive each year? a. 2 msv b. 5 msv c. 10 msv d. 50 msv e. I don t know what a msv is

4 Who does not receive radiation on a daily basis? a. Physician in OR b. OR patient c. Radiology Tech d. OR Tech e. Volunteer in gift shop f. A person in this audience Efforts to decrease radiation exposure ALARA (as low as reasonably achievable) Image Gently, Image Wisely CT imaging protocols adjusted to decrease patient (both pediatric and adult) radiation dose CMI participates in the national CT dose registry; results used to further adjust protocols Approximately how much radiation exposure will these CT scans represent? (Head, Chest, Abdomen and Pelvis) a. 3 msv b. 10 msv c. 15 msv d. 25 msv CT use in pediatric trauma Traumatic Brain Injury Major head trauma CT emergently, MRI f/u Minor head trauma (Glasgow Coma Score 14-15) Less than 10% of CT scans demonstrate a traumatic brain injury Kuppermann N et al. Identification of children at very low risk of clinically important brain injuries after head trauma; a prospective cohort study. Lancet 2009;374; CT use in pediatric trauma Cervical spine injuries Much less common than in the adult population; if present, often involve the cord or spinal ligaments and NOT a fracture CT less valuable as a screening tool for cervical spine injuries Clinical cervical spine clearance for blunt trauma victims (J. Trauma 2009; 67:543-9, J. Neurosurg Pediatr 2010;5:292-6) If clinical suspicion high, consider MRI (nonemergent) -sedation will be needed in the young, uncooperative patient CT use in pediatric trauma Significant blunt abdominal trauma CT is the gold standard In the hemodynamically stable child, US combined with physical examination and lab studies as well as a secondary US may help refine the use of CT scanning J. Pediatr Surg 2001;36:565-9 Am Surg 2004;70:164-7,167-8 J. Surg Res 2009;157:103-7 J. Trauma 2004;57:934-8

CT use in pediatric trauma CT is the most important imaging modality in the setting of significant trauma Clinicians need to be aware of the risks of radiation and make responsible decisions

Ultrasound IF imaging warranted (any question- consult your radiologist) Abdominal Pain Vomiting Bloody stools Abdominal mass 9 yr old female presents with 1 wk history of RLQ pain Elevated WBC

5 CT use in pediatric trauma CT is the most important imaging modality in the setting of significant trauma Clinicians need to be aware of the risks of radiation and make responsible decisions regarding use of medical imaging In any circumstance in which there is clinical question for how best to image, consult your radiologists Pediatric Imaging in the Acute Patient In general, use Ultrasound IF imaging warranted (any question- consult your radiologist) Abdominal Pain Vomiting Bloody stools Abdominal mass 9 yr old female presents with 1 wk history of RLQ pain Elevated WBC (20.2) US appropriately ordered What imaging study is most appropriate? Single view of the abdomen Upper GI Abdominal US Abdominal CT Impression: Constellation of findings consistent with appendicitis

6 CT Abdomen/pelvis then ordered? What results will/could alter the clinical plan Pt was taken to surgery for appendectomy Path confirmed acute appendicitis, with extravasated mucin limited to submucosa and muscularis propria 2 month old male with projectile nonbilious vomiting and poor weight gain. What imaging study is most appropriate? Single view of the abdomen Upper GI Abdominal US Abdominal CT 19 month old with intermittent crampy abdominal pain and bloody stools What imaging study is most appropriate? Single view of the abdomen Upper GI Abdominal US Abdominal CT Summary In the setting of significant trauma, CT is the gold standard If possible, tailor the exams to include ONLY the areas of clinical concern Ultrasound combined with physical examination and labs can be used in the hemodynamically stable blunt abdominal trauma patient MRI not used emergently in the trauma setting Summary In the acute setting, use Ultrasound initially whenever possible Consult radiologist if non-diagnostic or uncertain of appropriate additional imaging MRI useful for: Cooperative patient when US non-diagnostic Appendicitis Sheer injury for traumatic brain injury (but not emergent) In the uncooperative patient, will need sedation Summary The pediatric patient is more sensitive to radiation exposure and has a longer time to manifest a neoplasm related to radiation exposure Be aware of the risks of radiation exposure and make responsible decisions regarding the use of medical imaging Consult radiologist to determine appropriate medical imaging

7 Learning Objectives: Traci Clautice Engle, MD Central Oregon Radiology Associates Understand the appropriate use of MRI in patients with trauma Review indications for utilizing MRI in the emergency evaluation of patients with abdominal/pelvic pathology. Discuss the limitations of MRI in the acutely ill patient. Body MRI Body MRI:Limitations No ionizing radiation Higher tissue contrast Greater tissue characterization High Resolution: specialized coils Body Coil: Enterography Abdominal Liver lesion, MRCP, Renal mass, pancreatitis Pelvic Appendix, mass, fistula, abscess, tumor Contraindications Magnetically susceptible devices and clips in brain, eye, spine Electrical implant devices, pacemaker, neurostimulator Availability Time scan times can take min for one region Body MRI:Limitations MRI: Trauma Patient Patients cooperative, pain controlled Breathe hold sequences Cost Regional evaluation, contrast Artifact Motion (including cardiac/bowel) related artifacts can make the exam nondiagnostic Assessment of occult fractures on plain films Acute vs chronic vertebral fracture Bone marrow edema Occult bone fracture hip/pelvis Modality of choice for osteoporotic patients If CT is negative and concern is high, MRI is recommended Bone marrow edema, fracture line, soft tissue injury Improve delay of diagnosis Conservative vs surgical management

Occult Hip Fracture Pelvic Fracture Abdominal

the acute evaluation of emergent A/P trauma

Follow up of known parenchymal lacerations:

15 year old with liver hematoma Embolization

Liver Hematoma Indications for MRI in the

8 Occult Hip Fracture Pelvic Fracture Abdominal Trauma: Use of MRI No indication for MRI in the acute evaluation of emergent A/P trauma Parenchymal laceration nonemergent patient Follow up of known parenchymal lacerations: conservative management Trauma: Liver Hematoma 15 year old with liver hematoma Embolization Drain follow up CT exams (multiphase, A/P) Liver Hematoma Indications for MRI in the Acutely Ill Patient Emergent Pregnant patients with acute abdominal/pelvic pain and nondiagnostic US Differentiate between immediate surgical vs. conservative treatment Nonemergent MRCP, pancreatitis, renal/liver mass (abscess), complications of IBD (fistula)

Safety of MR Imaging in Obstetrics: Theoretical Risks Exposure to Electromagnetic radiation No studies have demonstrated harmful effects on human or animal

Obstetrics The risk of exposure to the fetus from any radiological procedure with ionizing radiation is greater than the theoretical risk of MR ACR approves the

diagnosis Recommendation for Advanced Imaging of Pregnant Patients Acute abdominal or pelvic pain If US nondiagnostic proceed to MRI Renal colic US followed by

abscess, bowel obstruction, intussusceptions, Chron s disease Biliary: choledocolithiasis, gallstones Pancreatitis Renal: ureteral colic GYN: adenexal masses,

9 Safety of MR Imaging in Obstetrics: Theoretical Risks Exposure to Electromagnetic radiation No studies have demonstrated harmful effects on human or animal embryos Heat production by the RF magnetic field Tissue heating approaches zero near body center secondary to maternal tissue absorption Safety of MR Imaging in Obstetrics The risk of exposure to the fetus from any radiological procedure with ionizing radiation is greater than the theoretical risk of MR ACR approves the use of MRI in any trimester of pregnancy although referring physician and radiologist should be prudent Gadolinium is not recommended unless necessary for diagnosis Recommendation for Advanced Imaging of Pregnant Patients Acute abdominal or pelvic pain If US nondiagnostic proceed to MRI Renal colic US followed by MRI Acute PE CTPA or perfusion only VQ Trauma US followed by CT if severe trauma Acute Abdominal or Pelvic Pain in the Pregnant Patient GI: acute appendicitis, abscess, bowel obstruction, intussusceptions, Chron s disease Biliary: choledocolithiasis, gallstones Pancreatitis Renal: ureteral colic GYN: adenexal masses, torsion, acute or red degeneration or torsion of fibroid Limitations of Motion Appendix Normal Appendix Diameter <6mm Wall <2mm Lumen T2 low SI No periappendiceal inflammation Normal Appendix

Appendix Alternative Diagnoses Acute Appendicitis Diameter >7mm Wall >2mm Lumen T2 High SI Periappendiceal Inflammation Indeterminant Appendix Diameter 6 7mm Wall <2mm Lumen T2 high Signal

interpretation of bowel wall Goal: Distend bowel, separate bowel loops, distinguish fluid filled bowel from intraperitoneal fluid collections Oral contrast may be positive or negative density

10 Appendix Alternative Diagnoses Acute Appendicitis Diameter >7mm Wall >2mm Lumen T2 High SI Periappendiceal Inflammation Indeterminant Appendix Diameter 6 7mm Wall <2mm Lumen T2 high Signal Acute Cholecystitis Acute Pancreatitis CT A/P: Indications for Oral Contrast Absence of oral contrast limits evaluation of bowel, appendix Delay in diagnosis and 10% repeat CT rate Inaccurate interpretation of bowel wall Goal: Distend bowel, separate bowel loops, distinguish fluid filled bowel from intraperitoneal fluid collections Oral contrast may be positive or negative density CT A/P: Indications for Oral Contrast Non obstructive GI pathology Non Trauma CT in a child: acute appendicitis Intra peritoneal abscess Very thin patients Triple Contrast for penetrating trauma

William H Wheir M.D. Central Oregon Radiology Associates Review appropriateness criteria for ordering MRI examinations in the setting of acute neurological patient presentations.

11 William H Wheir M.D. Central Oregon Radiology Associates Review appropriateness criteria for ordering MRI examinations in the setting of acute neurological patient presentations. Discuss advantages and limitations of MRI in the acute setting. Discuss utilization of Gadolinium contrast. If you have any question or concern regarding appropriate imaging please call one of us and we ll be happy to help protocol the the exam! Many times CT and MRI are complementary exams and both are needed to provide complete diagnostic, prognostic and surgical planning information. Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with limited glomerular filtration rate (<30), and almost never in other patients. There is growing literature regarding NSF. Some controversy and lack of clarity remains There is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit type and amount in patients with estimated GFR rates <30 Rating Scale 1, 2, 3 Usually not appropriate, 5, 6 May be appropriate, 8, 9 Usually appropriate

Ataxia Cerebrovascular Disease Cranial Neuropathy Dementia and Movement Disorders Focal Neurologic Deficit Head Trauma Headache Low Back Pain

Suspected Spine Trauma Vertigo and Hearing Loss STROKE MRA Head & Neck CTA Head & Neck CT Head (perfusion less accurate in posterior fossa) 8

12 Ataxia Cerebrovascular Disease Cranial Neuropathy Dementia and Movement Disorders Focal Neurologic Deficit Head Trauma Headache Low Back Pain Myelopathy Neck Mass/Adenopathy Neuroendocrine Imaging Orbits, Vision and Visual Loss Plexopathy Seizures and Epilepsy Sinonasal Disease Suspected Spine Trauma Vertigo and Hearing Loss STROKE MRA Head & Neck CTA Head & Neck CT Head (perfusion less accurate in posterior fossa) TRAUMA (LESS THAN 24H) CT Temporal Bone wo (if skull base or middle ear disease is suspected) INFECTION MRI Cervical Spine CT Head w CT Head

NEW FOCAL NEUROLOGIC DEFICIT <3HRS Initial

TX FOCAL NEUROLOGIC DEFICIT >3HRS MRA Head

13 NEW FOCAL NEUROLOGIC DEFICIT <3HRS Initial eval prior to rtpa Should not delay TX Should not delay TX MRA Head and neck Should not delay TX CT Head w perfusion Should not delay TX FOCAL NEUROLOGIC DEFICIT >3HRS MRA Head and Neck CT perfusion NORMAL PRESSURE HYDROCEPHALUS

14 UNEXPLAINED ACUTE CONFUSION OR ALTERED LEVEL OF CONSCIOUSNESS MINOR OR MILD ACUTE (GCS >13) Ct Head wo MRA Head & Neck wo MRA Head & Neck 3 3 MINOR OR MILD ACUTE CLOSED HEAD INJURY WITH FOCAL NEUROLOGIC DEFICIT MODERATE OR SEVERE ACUTE CLOSED HEAD INJURY MRA Head & Neck wo MRA Head & Neck MRA Head & Neck wo MRA Head & Neck MILD OR MODERATE ACUTE CLOSED HEAD INJURY, CHILD < 2YO SUBACUTE OR CHRONIC CLOSED HEAD INJURY WITH COGNITIVE OR NEUROLOGIC DEFICIT MRA Head & Neck wo MRA Head & Neck MRA Head & Neck wo MRA Head & Neck

15 CLOSED HEAD INJURY, RULE OUT ARTERIAL DISSECTION CTA Head & Neck MRA Head & Neck wo MRA Head & Neck SKULL FRACTURE CTA Head & Neck X-ray CHRONIC HA, NO NEW FEATURES CHRONIC HA WITH NEW FEATURES CT head MRA Head CT Head

SYNDROME CTA Head & Neck MRA Head & Neck NEW HA, HIV+ OR

16 SUDDEN ONSET OF SEVERE HA CTA Head MRA Head SUDDEN ONSET UNILATERAL HA, OR SUSPECTED DISSECTION, OR HORNER S SYNDROME CTA Head & Neck MRA Head & Neck NEW HA, HIV+ OR IMMUNOCOMPROMISED PATIENT NEW HA, SUSPECT MENINGITIS/ENCEPHALITIS CT Head

$>50yo, especially women, or men with osteoporosis/compres sion fracture Unexplained Fever Immunosuppression History of Cancer Intravenous Drug Use Prolonged use of Corticosteroids, osteoporosis Age >$

17 UNCOMPLICATED ACUTE (<6WKS) AND/OR RADICULOPATHY MRI L-spine wo X-ray 2 2 POSSIBLE CANCER OR INFECTION MRI L-spine MRI L-spine wo CT L-spine w CT L-spine wo X-ray Trauma Unexplained Weight Loss Age >50yo, especially women, or men with osteoporosis/compres sion fracture Unexplained Fever Immunosuppression History of Cancer Intravenous Drug Use Prolonged use of Corticosteroids, osteoporosis Age > 70yo Focal Neurologic Deficits with progressive or disabling symptoms Duration longer than 6 weeks Prior Surgery LOW BACK PAIN WITH RED FLAG CAUDAEQUINA SYNDROME MRI L-spine wo MRI L-spine CT L-spine wo MRI L-spine wo MRI L-spine CT L-spine w CT L-spine wo X-ray

ADULT NONPULSATILEAFEBRIL E CT Neck w MRI Neck MRI Neck wo CT Neck wo ADULT NONPULSATILE FEBRILE ADULT PULSATILE MASS CT Neck w MRI Neck CT Neck wo MRI Neck wo CT

18 ADULT NONPULSATILEAFEBRIL E CT Neck w MRI Neck MRI Neck wo CT Neck wo ADULT NONPULSATILE FEBRILE ADULT PULSATILE MASS CT Neck w MRI Neck CT Neck wo MRI Neck wo CT Neck w CTA Neck MRI Neck MRA Neck US Neck ADULT MULTIPLE MASSES CHILD (UP TO 14YO) CT Neck w MRI Neck MRI Neck wo CT Neck wo US Neck CT Neck w MRI Neck MRI Neck wo

ONSET TRAUMATIC CT Head w ACUTE/SUBACUTERHINOS INUSITIS

19 PITUITARY APOPLEXY (HEMORRHAGE) MRI Head pituitary MRI Head pituitary wo CT Head NEW ONSET NON-TRAUMA OR NON-ALCOHOL NEW ONSET TRAUMATIC CT Head w ACUTE/SUBACUTERHINOS INUSITIS SINONASAL OBSTRUCTION CT Sinuses wo MRI Face MRI Sinuses CT Maxillofacial wo

SUSPECT C-SPINE TRAUMA WITH MYELOPATHY SUSPECTED C-SPINE TRAUMA, PATIENT NOT ABLE TO BE EVALUATED >48H CT C-spine wo CT C-spine wo MRI C-spine wo MRI C-spine wo SUSPECT C-SPINE TRAUMA, CONCERN FOR

20 SUSPECT C-SPINE TRAUMA WITH MYELOPATHY SUSPECTED C-SPINE TRAUMA, PATIENT NOT ABLE TO BE EVALUATED >48H CT C-spine wo CT C-spine wo MRI C-spine wo MRI C-spine wo SUSPECT C-SPINE TRAUMA, CONCERN FOR ARTERIAL INJURY CT C-spine and CTA Neck MRA Neck SUSPECTED C-SPINE TRAUMA, CONCERN FOR LIGAMENTOUS INJURY OR BLUNT TRAUMA WITH NEUROLOGIC ABNORMALITY CT C-spine wo MRI C-spine wo If you have any question or concern regarding appropriate imaging please call one of us and we ll be happy to help protocol the the exam! Many times CT and MRI are complementary exams and both are needed to provide complete diagnostic, prognostic and surgical planning information.

n Make tremendous difference in patients lives: n Diagnosing or excluding disease and injury n Evaluating response to therapy

n Make tremendous difference in patients lives: n Diagnosing or excluding disease and injury n Evaluating response to therapy Imaging: Choosing the Appropriate Exam Rob Milman, MD Austin Radiological Association What is a Radiologist? A physician who specializes in diagnosing and treating disease and injury by using medical imaging