Imaging In Paediatric Trauma SOP-BSUH-Paed-001€¦ · FAST scanning and Abdominal Radiography have no role in paediatric abdominal major trauma . Imaging In Paediatric Trauma SOP-BSUH-Paed-001

Imaging In Paediatric Trauma SOP-BSUH-Paed-001

Author: Miki Lazner, Ima Moorthy, Kyriakos Iliadis, Lakidzani Tambula. Issue Date: July 2017 Review Date: July 2019 Location: Imaging Shared Drive, Paediatrics Page 1 of 19

Consensus Document for the Imaging of Trauma in the Under 17 Year Age Group

Children’s Emergency Department, Paediatric Radiology, Paediatric Surgery



Contents

1. Introduction- rationale underlying Imaging choices………………………… Pg. 3

2. BSUH Major Trauma Team Members and Responsibilities……………….... Pg. 4

3. How is Imaging to be agreed, performed and reported?............................... Pg. 5

4. Cranial imaging protocol………………………………………………………........ Pg. 6

5. Cervical spine imaging protocol………………………………………………...... Pg. 7

6. Imaging the Thoracolumbar Spine……………………………………………..... Pg. 9

7. Imaging the Chest………………………………………………………………....... Pg. 10

8. Imaging the Abdomen and pelvis………………………………………………… Pg. 11

9. Notes and Evidence……………………………………………………………......... Pg. 13

10. References…………………………………………………………………………...... Pg. 14

11. Appendix One - Paediatric contrast Guidelines………………………………… Pg. 15

12.

Appendix Two - Acute primary assessment report for Paediatric CT with major trauma Pg. 17

13. Summary of changes………………………………………………………………... Pg. 18

14. Document History……………………………………………………………………. Pg. 19



1. Introduction

“The child is not a small adult”

This local BSUH Guideline for the management of Paediatric Trauma is based on 2014 Royal College of Radiologists’ Paediatric trauma protocols (1) and NICE Clinical Guideline 176 (2). Rationale underlying Imaging choices According to 2012-2013 Trauma Audit and Research network (TARN) data:

The incidence of major trauma in the under-16 year age group in the UK was 7% that in

the over-16 year age group.

In a major trauma setting, most paediatric injuries involved the extremities, and to a

lesser extent, the head and cervical spine.

The injury pattern in children is typically localised to an isolated anatomical area, rather

than to multiple sites.

The ALARA principle (the radiation dose must be ‘as low as reasonably achievable’)

must be strictly adhered to, because children are more radiosensitive than adults, and

have a longer life-span in which they might develop radiation-related side-effects,

notably cancer.

Imaging choices must, therefore, be guided by

– Careful and competent clinical evaluation on a case- by- case basis by senior ED /

Paediatric Surgical doctors - at ST3 level or above.

– Knowledge of injury patterns in children of various ages.

– Plain radiographs where possible

– Targeted use of CT following relevant paediatric protocols.

– “Traumagrams” (i.e. whole body scans), will rarely be necessary in children presenting to

BSUH, and MUST be used judiciously in adolescents (although they are accepted practice

in adult trauma).

Use of CT scans in children which delivers cumulative doses of about 50 mGy might almost triple the risk of leukaemia and doses of about 60 mGy might triple the risk of brain cancer.

We do not provide interventional radiology for children in BSUH.



2. BSUH Major Trauma Team Members and Responsibilities

Members of the Paediatric major trauma team Role Responsibilities

RACH CED or RSCH ED Consultant Trauma Team Leader (after discussion between the two Clinicians)

RSCH ED Middle Grade Primary survey doctor

RSCH ED Nurse Nurse team leader

RACH CED Nurse As directed by Nurse team leader

Nurse 3 Ideally RACH CED Nurse. Paediatric nursing input. Liaison with family.

RACH CED Registrar / SHO Circulation doctor

Senior Anaesthetist Airway and anaesthetic management of the child. Escorting of ventilated child to CT scanner / theatre / definitive care if required.

Airway assistant (usually ODP) Assisting the senior anaesthetist

Paediatric Surgical Registrar / Consultant

Paediatric Surgical input / definitive non-Orthopaedic treatment. Surgical team in conjunction with CED team have responsibility for child once they leave resuscitation area.

Orthopaedic Registrar / Consultant Management of bony injuries including spine

Radiographer Primary trauma imaging +/- facilitating CT

Scribe Documentation

Major trauma team activated by 2222 call

Team immediately assemble in the designated resuscitation bay of the RSCH or RACH Emergency Department.



3. How is Imaging to be agreed, performed and reported?



4. Cranial Imaging Protocol (Algorithm below, courtesy of NICE CG 176)



5. Cervical Spine Imaging Protocol



5.1 General Considerations

Paediatric cervical spine injury is uncommon.

Clinical evaluation must be done by senior Registrar or Consultant before

imaging is performed, as it is an anatomical area that is relatively

radiosensitive.

the presence of head injury alone is not an indication for imaging the

cervical spine; there must be suspicion of cervical spinal injury

If arm pull needed, this can be done by doctor or Paediatric Emergency

Nurse Practitioner.



6. Imaging the Thoracolumbar Spine

If there are definitive neurological signs, the primary imaging modality should

be MRI.

In hours – discuss paediatric MRI with duty paediatric radiologist

(extension 3152 or 2585).

Out of hours – paediatric MRI to be discussed on a case-by-case basis

between CED consultant / paediatric surgical consultant / paediatric

radiology consultant

Plain X-rays should be done first

Targeted CT may be necessary

Thoracic spine is automatically imaged with CT chest

Lumbosacral spine is automatically imaged with CT

abdomen and pelvis



7. Imaging the Chest

A well, asymptomatic child does not need chest imaging See appendix one regarding information on cannula size, contrast amounts and pump vs hand injection.

7.1 Blunt Chest Trauma

7.2 Penetrating Chest trauma



8. Imaging the abdomen and pelvis

8.1 Imaging the abdomen

Abdominal injury should be suspected only in the presence of a relevant history,

and abdominal symptoms and signs.

- Lap belt or handlebar injuries

- Abdominal wall ecchymoses

- Persistent abdominal tenderness

- Abdominal distension

- Clinical evidence of hypovolaemia e.g. persistent unexplained tachycardia

- Blood from rectum / frank haematuria

A reduced GCS or neurological impairment, with no abdominal symptoms or

signs is not an indication for abdominal CT.

Suspicion of

abdominal

injury

Severe

multisystem

trauma or isolated

abdominal injury

CT abdomen

and pelvis

Using split bolus

contrast infusion

1. Abdomen and pelvic ultrasound may

be considered in stable patients, after

discussion between clinicians and

radiologists.

2. Close clinical monitoring is essential

FAST scanning and Abdominal Radiography have no role in

paediatric abdominal major trauma



8.2. Imaging the pelvis

Pelvic fractures are rare in children.

The presence of a SAM splint is not an indication for imaging

8.3 Method

Where clinically indicated, single volume dual-contrast CT of the abdomen and

pelvis, (e.g. following the Camp Bastion protocol), is the imaging modality of

choice.

See appendix one regarding information on cannula size, contrast amounts

and pump vs hand injection

All dual phase CT of the abdomen/pelvis must be pump injection only.

If only a yellow cannula is available, hand injection of contrast only.

Requesting Doctor to hand inject the contrast, scan to begin 70 seconds after

the start of the injection. If it takes longer than 70 seconds to inject the

contrast, start the scan as soon as the doctor has injected all the contrast and

is able to leave the scan room.

Suspicion

of pelvic

injury

Do not do

1. Pelvic x-rays

2. FAST scan

CT abdomen

and pelvis

Using split bolus

contrast infusion



9. Notes and evidence Clinical decision rule for CXR (3) (98% NPV) Increased respiratory rate, abnormal chest

examination, low systolic blood pressure, low GCS

Common chest injuries in children

Lung contusions, pneumothorax, haemothorax, rib fractures.

Usually associated with RTC or falls from height

Very uncommon injuries

Vascular and mediastinal injuries

CXR will miss some thoracic injuries, but patients rarely require intervention based on CT findings.

Most findings following chest trauma are located within 1cm of dome of liver and would be visible

on CT abdomen (4).

A normal abdominal CT strongly predicts lack of future clinical deterioration. Common injuries

Liver lacerations, spleen lacerations, kidney – parenchymal contusion or haematoma

Usually managed conservatively in children

Uncommon injuries

Bowel, pancreas, bladder

Certain paediatric patient groups have a high rate of intra-abdominal injuries (5)

Intubated patients (27%)

Severely head injured patients (23%)

High ISS, (injury Severity Score)

Clinical decision rule for abdominal CT for blunt trauma (6)

Low systolic blood pressure

Abdominal or low thoracic pain or tenderness

Femur fracture

Abnormal: initial HCT125, microscopic haematuria



PECARN rule 2013 (7) – intra-abdominal injury requiring intervention:

1. Abdominal wall trauma or seat belt sign 2. GCS ≤ 13 3. Abdominal tenderness 4. Thoracic wall trauma 5. c/o abdominal pain 6. Decreased breath sounds 7. Vomiting

If seat belt sign is present and child c/o abdominal pain or tenderness, do CT abdomen. If seat belt sign and no pain or tenderness, consider prolonged observation only.

10. References

1. The Royal College of Radiologists. Paediatric trauma protocols. London: The Royal College of Radiologists. 2014

2. www.nice.org.uk/guidance/CG176 3. Holmes JF et al. Identification of children with intra-abdominal injuries after blunt trauma.

Ann Emerg Med. 2002;39:500-509 4. Patel RP, Hemanz- Schulman M, Hilmes MA, et al. Pediatric chest CT after trauma- impact

on surgical and clinical management. Pediatr Radiol 2010; 40(7) 1246-53 5. Flood R. et al. Rate and Prediction of Traumatic Injuries Detected by Abdominal Computed

Tomography Scan in Intubated Children. J Trauma 2006;61:340 –345 6. Holmes J. et al. Validation of a prediction rule for the identification of children with

intraabdominal injuries after blunt torso trauma. Ann Emerg Med 2009; 54:528–533 7. Holmes J et al, for the Paediatric Emergency Care Applied Research Network (PECARN).

Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med 2013;62:107-116

8. Leung VJ, Grima M, Khan N, Jones HR. Early experience with a split-bolus single-pass CT protocol in paediatric trauma. Clinical Radiology 2017;72(6):497-501

http://www.nice.org.uk/guidance/CG176



11. Appendix 1 Paediatric Trauma CT Contrast Scans

Any patient under the age of 18 must be cannulated, flushed and connected by a Doctor only. The Doctor must sign the contrast/cannulation checklist. If the child has any known contra-indication to contrast the referring clinician must discuss these with the Radiologist

The timings of the arterial and portal venous phase for children should be the same as adults when using the pump (please use the guidance under ‘hand injections’ for alterations)

Contrast Dose

Continue to administer 2mls per kg for children up to 90mls (45kg) for all body scans. The

only exception being a dual phase scan on a child larger than 45kg

Pump Injection in Children

The pump can be used for children as long as they have a BLUE 22g (minimum) cannula.

Do not pump inject contrast through a cannula smaller than 22g. (Blue).

Do not use a flow rate higher than 2mls per second

The pump will provide a steady bolus but try to avoid using it on very young/small children,

a hand injection is safer.

The cannula site must be observed throughout the entire injection where the scanning

protocol allows, looking for signs of extravasation. If there are signs of this the injection

should be ceased immediately and the Radiologist contacted.

Hand injection in children

Hand injection to be used for children where a cannula smaller than 22g is in situ, (yellow).

For an arterial CT chest the requesting Doctor to hand inject the contrast as quick as reasonably achievable. Scan to start as soon as Dr leaves scan room, (as close to 30 seconds as possible).

For an abdo/pelvis CT, requesting Doctor to hand inject the contrast, scan to start at 70

seconds. If it takes longer than 70 seconds to inject the contrast, start the scan as soon as

the doctor has injected all the contrast and has left the scan room.

This will work well for the majority of cases but is subject to variation at the discretion of the Radiologist.



Dual Phase Abdo/Pelvis CT Contrast Calculator

Please use the following contrast calculator as a guide to the bolus requirements for a dual

phase abdo/pelvis scan. The flow rate will increase above the preferred 2mls/s at the point

of a 40kg child. This is acceptable for these trauma scans however a larger pink 20g

cannula would be preferred for these patients.

Dual Phase Chest Abdomen and Pelvis CT Contrast Calculator

Very rarely used in paediatric trauma, same contrast details as below.

Patient size Contrast amount

Flow rate 1 Flow rate 2 Cannula size

20 kg patient 40mls 26mls @ 0.5 ml/sec 14mls @ 1.0 ml/sec Blue 22g

25kg patient 50mls 34mls @ 0.6 ml/sec 16mls @ 1.2 ml/sec Blue 22g



40kg patient 80mls 54mls @ 1.0 ml/sec 26mls @ 2.1 ml/sec Pink 20g

45kg patient 90mls 60mls @ 1.1 ml/sec 30mls @ 2.2 ml/sec Pink 20g

50 – 59kg patient

100mls 66mls @ 1.2 ml/sec 34mls @ 2.4 ml/sec Pink 20g

60 – 69kg patient

120mls 80mls @ 1.4 ml/sec 40mls @ 3.0 ml/sec Pink 20g

70kg + patient

ADULT FLOW RATE PROTOCOL Pink 20g

Always round down the patient’s weight. For example if a child weights 23KG apply the 20KG patient size, 38KG apply the 35KG patient size.



12. Appendix 2

Acute Primary Assessment Report for Paediatric CT with Major Trauma (courtesy RCR Paediatric trauma protocols)



13. Summary of Changes 13.1 Plain Film

PEG views to be done on all ages of children as long as they are able to cooperate and

open their mouths.

Pelvis X rays not routinely carried out in Resus as part of a trauma call

Arm pulls can be carried out either by a Doctor or Paediatric Emergency Nurse Practitioner

13.2 CT

Whole body traumogram scans not routinely carried out, instead targeted CT more

appropriate

Chest CT in trauma not routinely carried out, CXR is usually sufficient

CT abdomen and pelvis in trauma should be carried out using dual phase split bolus

technique, (unless they have yellow cannula)

Pump to be used for all patients with blue or pink cannula

Hand injection for all patients with yellow cannula



DOCUMENT HISTORY Document Name Imaging in Paediatric Trauma

Current Filename

sop-bsuh-paed-001 - imaging in paediatric

trauma - July 17

Issue Date Review Details

1 October 2014

2 November 2014

Transferred onto new template

3 January 2015 updated

4 July 2017 updated

5

6

Documents

Imaging In Paediatric Trauma SOP-BSUH-Paed-001€¦ · FAST scanning and Abdominal Radiography have no role in paediatric abdominal major trauma . Imaging In Paediatric Trauma SOP-BSUH-Paed-001