Sasha Dubrovsky, MSc MD FRCPC Pediatric Emergency Medicine Montreal Children s Hospital - MUHC October 2010
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1 Sasha Dubrovsky, MSc MD FRCPC Pediatric Emergency Medicine Montreal Children s Hospital - MUHC October 2010
2 Learning objectives 1. Discuss diagnostic goals in pediatric trauma Diagnose All vs. Severe Injuries Risks vs. benefit of CT Scan 2. Recognize which blunt torso trauma patients are at high risk for injuries 3. Role of bedside U/S in pediatric trauma
3 Trauma # 1 killer children > 1 years old 20% ED visits trauma related Predominant mechanism BLUNT MVC Auto vs. Pedestrian Bicycle-related Fall
4 Major Trauma Head Most common injury Responsible for 80% trauma deaths Thorax Account for ~15% trauma related deaths Abdomen Common cause of initially missed fatal injuries
5 Pediatric ED s Trauma Paradigm: Assess all trauma patients Minor Major Diagnose and manage Clinically apparent injuries Occult injuries Do no harm Both at risk of occult injury Ex. CT radiation Ex. Missed serious injuries
6 Overview Case Radiation Risks of computer tomography Common injuries Intra-abdominal Injury (IAI) Role of screening tests Pediatric Bedside Ultrasound
7 Computed tomography Imaging gold standard Cost Sedation and transport considerations Severe injuries less common than in adults Most injuries managed conservatively Radiation Risks
8 Radiation imparts an increased lifetime risk of cancer MORTALITY 1 per 1000 pediatric CT 1 per 3000 adult CT
9 1/550 1/1000 Brenner et al. NEJM 2001 Lifetime attributable cancer mortality risk as a function of age for a single typical CT examination
10 ALARA As Low As Reasonably Achievable Principle Limiting number of CT scans ordered (Physician) Size-based adjustments of scanning parameters (Radiology Department)
11
12 Who should get CT? Is there a way to stratify those at higher risk of serious injury and need for intervention? Ex: Head Injury CATCH, PECARN, Canadian CT Ex: C-Spine NEXUS, Canadian c/spine
13 Who should get CT? How to select out those blunt trauma patients at highest risk of severe injury to the abdomen?
14 Intra-Abdominal Injuries (IAI) Seen in 10-30% pediatric multisystem traumas Common cause of initially unrecognized fatal injuries Mechanism MVC (especially lateral impact MVC, seat belt use, ejected) Pedestrian Falls (especially >10 feet) Abuse/Assault
15 Intra Abdominal Injury Most common injuries Liver Spleen Kidney Less common include Hollow viscus Pancreas Bladder
16 Spleen
17 Stable Patient with IAI: Non-operative Management American Pediatric Surgical Association Guideline 2000
18 Non-operative Management McVay et al Throw out the grade book for stable patients Admit x 24 hours NPO and bedrest Serial exam Serial 6, 12, 24 hours (HCT>0.21) Clinic in 1 month with U/S
19 Regardless of conservative strategy, >95% managed successfully with no intervention Of those who fail, become apparent clinically Mainly high grade injuries (Grades 4+) Clear discharge instruction Ex. Delayed Splenic Bleed rate 0.33%-1.4% (Davies et al 2009, Zarzour et al. 2009)
20 So what to do Risk vs. benefit Trauma center philosophy Identify ALL Then need to scan ALL Identify Severe Need to identify strategy to identify those at high risk
21 Risk Stratification based on investigations To dip or not to dip? That is the question
22 Risk Stratification via investigations Taylor et al children with CT Abdomen Hematuria in 68% Hematuria risk (1.6 fold) of any IAI liver (33%) spleen (37%) renal (27%) However, only Symptomatic Hematuria at risk
23 Risk Stratification via investigations Holmes et al Prospective observational study, age < patients enrolled, trauma team activation Goal: identify elements of physical exam and laboratory data predictive of IAI Identification of children with intra-abdominal injuries after blunt trauma. Annals of Emergency Medicine 2002, 39:
24 Imaging or Look inside in 664/1095 (64%) 36% not investigated NO apparent cases of missed IAI (1 week phone f/u + rechecked registry at end of study)
25 10% intra-abdominal injury Mean age 8.4 ± 4.8 years 73% had free fluid Organs injured: Liver 41% Spleen 38% GI tract 23% Urinary tract 15% Multiple Injury 22%
26 85% patients with IAI had physical exam findings suggestive Abdominal tenderness BP Femur Fracture GCS 13 ( unreliable exam )
27 15% OCCULT intra-abdominal injury
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29
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31 Validation Study: Holmes et al Pediatric Validation Study 1119 patients, 14% IAI 68% Positive rule 20% IAI 32% Negative rule 2% IAI Sensitivity 95% 7/8 missed observation alone 1/8 Non-therapeutic laparotomy (seatbelt)
32
33 Focused Assessment with Sonography in Trauma (aka FAST)
34 FAST Morison s Pouch (RUQ)
35 FAST Left Upper Quadrant
36 FAST Pelvic
37 Adult FAST SOAP RCT Trial by Melinker et al Decreased time to operative care (57 vs 166 min) Shorter hospital lengths of stay (6 vs 10 days) Less likely to have CT Torso Lower hospital charges Fewer complication rates
38 Pediatric FAST No clear role Conservative management for most FAST less sensitive Not well studied
39 Why is literature so confusing? U/S Performer: Trauma Team Leader (TTL) vs. Radiology Diverse training/experience U/S Goal: Free fluid: Population: Outcome: Free fluid vs. Parenchymal vs. both Absent in up to 30% pediatric IAI Severe trauma vs. All trauma CT vs. Clinical Course
40 FAST Performer When looking for free fluid Radiology = TTL (surgical or ED)
41 U/S Goal Free fluid vs. parenchymal Radiology based studies Ex. Richards et al Liver Injury CT Grade Sensitivity Free Fluid Sensitivity Free Fluid ± Parenchymal 1 17 % 26 % 2 74 % 80 % 3 97 % 97 % % 100 % % 100 %
42 Free Fluid Emery et al Observational study in children Outcome: any IAI on CT Sensitivity 45%, Specificity 88%, NPV 81% Most of false negative low grade
43 Population Holmes et al Normotensive Sensitivity 82%, Specificity 95%, NPV 97% BP 100% Sensitivity Hypotensive (n=13) Sensitivity 100%, Specificity 100%, NPV 100% 98% (n=187) negative FAST conservatively managed 2 GI tract injury \ 2 liver ( LFTs )
44 Outcome Soudack et al (radiology) 313 pediatric patients Outcome: + CT/OR or Normal follow-up Sensitivity 93% specificity 97% PPV 95% NPV 96% 65% FAST negative No IAI \ nor late complications Since introduction of FAST, use of CT
45 FAST by Pediatric TTL Thourani et al patients <15 years old by PGY 3 + Sensitivity 80% Specificity 100% NPV 96% 2 false negative 2 yo Trace fluid no IAI 11 yo Pedestrian with repeat FAST + and splenic injury
46 FAST by pediatric TTL Patrick et al children with BAT Sensitivity 71% Specificity 100% NPV 93% Sensitivity 100% for Significant free fluid
47 Meta-analysis Pediatric FAST Holmes et al studies, all cohort, 3838 children U/S Protocol FAST FAST FAST (free fluid) (free fluid) (free fluid and solid organs) Outcome of interest Hemoperitoneum Any IAI Any IAI Sensitivity 80% 66% 82% Specificity 96% 93% 97% Likelihood ratio % Likelihood ratio
48
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50 Physical Exam with FAST Suthers et al Prospective observational study <17 yo 180 children screened 120 had FAST/ P/E / CT Mean age 10, ISS 13, mostly blunt trauma Sensitivity Specificity PPV NPV Physical Exam 81% 73% 47% 93% FAST 70% 100% 100% 92% P/E + FAST 100% 75% 54% 100%
51 LFTs and FAST Sola et al (Jackson Memorial, Miami) Retrospective review 400 patients Mean age 9, Mean ISS 16 Any injury on CT (including injuries with no free fluid) FAST alone: FN=67, >2/3 low grade liver/spleen If take out low grade, FAST sensitivity >80% Sensitivity Specificity PPV NPV FAST 50% 91% 68% 83% FAST + LFTs 88% 98% 94% 96%
52 Serial FAST Blackbourne et al Serial FAST within 24 hours by TTL (on-call residents) Mean age 39 [1-90], mean time to 2 nd FAST 4 hours Outcome: clinical course Sensitivity Specificity PPV NPV Initial U/S 31% 99.8% 95% 92% Second U/S 72% 99.8% 98% 97%
53 Serial FAST Blackbourne et al % FAST negative had CT/OR 2/501 (0.4%) Neg-Neg OR (hollow-viscus) 10/26 (35 %) Neg-Pos OR
54 Advanced trauma application Pneumothorax Bedside u/s more sensitive than supine CXR Sensitivity 98% vs. 75%
55 Bedside Ultrasound Clear role in pediatric BAT screens for those at high risk severe IAI (i.e. high grade injury)
56 Proposed Algorithm
57 Potential Algorithm FAST + Serial FAST +
58 Summary Occult abdominal injuries up to 10% Most injuries managed conservatively CT-SCAN ALL NOT INDICATED select those at high risk of severe injuries Serial Exams Serial Bedside U/S CXR Screening HCT, LFT, U/A
59 Conclusion As pediatric trauma experts Need to diagnose severe injuries Need to ensure no harm Educate / Primary prevention
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