PEDIATRIC BLUNT TRAUMA WHAT S DIFFERENT? NORDIC TRAUMA COURSE 2016

Transcription

1 PEDIATRIC BLUNT TRAUMA WHAT S DIFFERENT? NORDIC TRAUMA COURSE 2016 Ken F. Linnau, MD, MS Emergency Radiology Harborview Medical Center University of Washington Seattle, WA

2 Thanks to Nupur Verma, MD University of Florida, Gainesville, FL

3 OUTLINE Epidemiology Radio-sensitivity Ways to save dose Head Cervical spine Aorta and thorax Abdomen Liver Kidneys

4 EPIDEMIOLOGY Trauma is leading cause of death in children 5000 deaths/ year MVC, ped vs car, bicycle 47% Drowning 10-15% Homicide 13% Burns 5-10% Avarello-JT, Cantor RM. Emerg Med Clin N Am 25 (2007) 803.

5 EPIDEMIOLOGY NORDIC Gothenburg, Sweden, children admitted to PICU (0-16 years) with multiple injuries. 2/ MVC 64% Falls 24% Most common injuries were thoracic and abdominal 3/45 died, 7%. Franzen L et al. Eur J Surg Suppl Jul; (588): 3

6 ANATOMIC DIFFERENCES Head-to-body ratio is greater. More serious head injury Cervical spine injury patterns differ Liver, spleen Less protected by ST, muscle Kidneys Less protected More mobile Multiple trauma More common Smaller body size: greater distribution of injury Avarello-JT, Cantor RM. Emerg Med Clin N Am 25 (2007) 803.

7 RADIO-SENSITIVITY Brenner DJ et al. AJR 176 (2001): 289

8 RADIO-SENSITIVITY Brenner DJ et al. AJR 176 (2001): 289

9 IMAGING BLUNT PEDS TRAUMA Judicious use of radiography and computer tomography Clinical decision rule (CDRs) Mechanism of injury Plausibility of the history (child abuse) Clinical exam Cardiovascular hemodynamic stability of the patient, Laboratory findings Verma N et al. ECR 2016

10 HEAD TRAUMA Most common cause of death Incidence: >1100/ >80% minor head injury CATCH, CHALICE and PECARN Clinical Decision Rules (CDRs) CT head non-contrast Helical acquisition: reformations MR Brain No radiation, but fractures may be difficult to see Axial T2 only, 5-10 minutes In Singapore CDRs would have increased CT scanning at least 4-fold. Lyttle MD, et al. Emerg Med J 2012; 29: 785 Thiam DW, Yap SH, Chong SL. Ann Acad Med Singapore 2015; 44: 335

11 4 YO BOY, MVC

12 2 YO BOY, 4.5 METER FALL

13 2 YOM 4.5 M FALL

14 3 YOM, 3 METER FALL

15 CERVICAL SPINE Prevalence of injury is 1-2%. International recommendations based on CDRs NEXUS Canadian Cspine Rule Start with radiographs (almost always) AP and lateral view Odontoid view only if older child (> 5-8 years) CT if xrays are equiviocal or suggest injury MRI if xrays and CT are equivocal Slaar A, et al. Eur J Rad 2015; 85: 57 Hannon M et al. Ann Emerg Med 2015 March; 65(3): 239

16 XRAYS VS CT -- DOSE DR total All CT DECT (FORCE) x60 (msv) (msv) (msv) x30 C SPINE T SPINE (Chest WO) Jeffrey M. Moriano, MS, Medical Physics Division UW, unpublished data 2015.

17 HOW TO IMAGE CSPINE? Children (0-13): Start with radiographs If head CT is done in young children: extend it through C2 Adults (11-64): It depends. Elderly (> 65) CT imaging modality of choice HMC C-spine evaluation protocol 2012

18 4 YO BOY, MVC

19 4YO BOY, MVC

20 PROFESSIONALS/EDUCATION/RADIOLOGY/CERVICAL- SPINE/DOWNLOAD/

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22 4YO BOY, MVC

23 HEAD TO BODY RATIO

24 C-SPINE INJURY DISTRIBUTION Leonard JR for PECARN. Pediatrics 2014 May; 133 (5); 1179

25 5 YOM, MVC

26 5 YOM, MVC Verma N, et al, Emergency Radiology 2015 Dec; 22 (6): 705.

27 » Next step? 10 YOF HIT BY CAR

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30 Sag STIR Ax MPGR Ax STIR

31 CLINICAL OUTCOME: EYE BLINK ONLY LIFE-LONG RESPIRATOR DEPENDENCY DUE TO SPINAL CORD INJURY

32 TORSO INJURY

33 VASCULAR INJURY Barmparas G, et al, J Ped Surg 2010; 45: 1404.

34 BLUNT TRAUMATIC AORTIC INJURY Very uncommon in children Many reported cases are in teenagers Adults have 7-fold higher prevalence Almost never in children < 5 years of age Lower mortality than adults No consensus on treatment Anderson SA et al. J Ped Surg (2008) 43: 1077 Barmparas G et al. J Ped Surg (2010) 45: 1404

35 12 YOF MVC

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37 6 YO GIRL MVC Courtesy N Verma, MD University of Florida

38 12 YOM DROWNED

39 12 YOM DROWNED

40 ABDOMEN INJURY Accounts for 8% of trauma admissions CT scanning is modality of choice If radiation concern and low probability of injury: Consider serial physical exams with serial US Injury patterns and detection are similar to adults Avarello-JT, Cantor RM. Emerg Med Clin N Am 25 (2007) 803.

41 13 YOF MVC

42 7 YOF MVC Courtesy N Verma, MD University of Florida

43 4 YOM MVC

44 PEDIATRIC BLUNT TRAUMA Kidney is most commonly injured organ in blunt abdominal trauma In adults 3 rd most common [1] Renal injury in 10% of pts presenting with BAT [2] [1] Anh JH, et al. Emerg Med Clin North Am [2] Brown SL. J Urol 160(1): , 1998.

45 PEDIATRIC KIDNEY AT GREATER RISK OF INJURY Proportionally greater size Limited thoracic protection less well ossified ribs Limited perirenal fat protection Weaker abdominal muscles May retain fetal lobulations permits easier parenchymal disruption Brown SL referring to Miller RC, Kuzmarov I.

46 6 YOF KICKED BY HORSE» Next step?

47 SUMMARY PEDS TRAUMA Clinical decision rules may be useful SR 3D bone for head CT (sutures) Cspine: start with xrays Aorta: very uncommon in children Kidneys: use low dose technique for urinoma

48 Thank you.