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The Use of CT Scan in Hemodynamically Stable Children with Blunt Abdominal Trauma: Look before You Leap

We set out to determine the diagnostic value of computed tomographic (CT) scans in relation to the radiation dose, tumor incidence, and tumor mortality by radiation for hemodynamically stable pediatric patients with blunt abdominal injury. We focused on the changes in management because of new information obtained by CT. CT scans for suspected pediatric abdominal injury performed in our accident and emergency department were retrieved from the radiology registry and analyzed for: injury and hemodynamic parameters, changes in therapy, and radiological interventions. The dose length product (DLP) was used to calculate the effective dose (ED) and with the BEIR VII report we calculated the estimated induced lifetime tumor and mortality risk. Seventy-two patients underwent abdominal CT scanning for suspicion of abdominal injury and eight patients were excluded for hemodynamic instability, leaving 64 hemodynamically stable patients. Four patients died (6%). On the remaining 60 patients, only one laparotomy was performed for suspicion of duodenal perforation. Only in three out of the 64 hemodynamically stable cases (5%), a CT scan brought forward an indication for intervention or change in management. One patient was suspected of a duodenal perforation and underwent a laparotomy. A grade II hepatic laceration, but no duodenal, injury was found. Two patients underwent embolization of the splenic artery. One for an arterial blush caused by splenic laceration as was observed on the contrast enhanced-CT. Patient remained stable and during the angiogram the blush had disappeared. The second patient underwent (prophylactic) selective arterial embolization for having sustained a grade V splenic injury. The median radiation dosage was 11.43 mSv (range 1.19-23.76 mSv) in our patients. The use of the BEIR VII methodology results in an estimated increase in the lifetime tumor incidence of 0.17% (range, 0.05-0.67%) and an estimated increase in lifetime tumor incidence of 0.08% (0.02-0.28%). The results of our data suggest that the use of CT scans can largely be avoided in hemodynamically stable children with blunt abdominal injury

Only Moderate Intra- and Inter-observer Agreement between Radiologists and Surgeons when Grading Blunt Paediatric Hepatic Injury on CT Scan

Introduction: The American Pediatric Surgical Association developed guidelines for the management of haemodynamically stable children with hepatic or splenic injury, based on grade of injury on CF scan. This study investigated the intra- and inter-observer agreement of radiologists, paediatric surgeons, trauma surgeons and hepatobiliary surgeons when scoring liver injury based on CT scan findings. Patients and Methods: CT scans of patients with blunt abdominal trauma were independently assessed twice by a fellow and a consultant radiologist, paediatric surgeon, trauma surgeon and one consultant hepatobiliary surgeon. Reviewers were unaware of the clinical course. All scans were multislice CTs with a slice thickness of 3 mm, and both the arterial and venous phase were assessed. Injury was scored using the American Association for the Surgery of Trauma (AAST) liver injury scale. Intra-observer agreement was tested using Cohen's kappa coefficient. Inter-observer agreement was tested using Cohen's kappa for the second reading of individual observers and Spearman's rank correlation for the mean of both readings from each observer. Results: CT scans of 27 patients (11 girls and 16 boys, median age 11.7 +/- 5.2 years) were reviewed. Mean AAST grade of liver injury was 3.3 +/- 1.1 for radiologists, 2.9 +/- 1.0 for paediatric surgeons, 3.0 +/- 0.9 for trauma surgeons and 3.2 +/- 0.8 for the hepatobiliary surgeon (p=0.30) Intra-observer agreement was moderate, with kappa below 0.7 for all observers except for one of the radiologists. Inter-observer correlation using Cohen's kappa coefficient was also moderate, with kappa below 0.5. In contrast, inter-observer correlation using Spearman's test was good, suggesting that there is agreement on the general severity of injury but not on the exact grading of injury using the AAST scoring system. Conclusion: Intra-observer agreement is only moderate when assessing liver injury using the AAST grading system. Only the most experienced radiologist demonstrated good intra-observer agreement which might indicate the necessity of the presence of a senior trauma radiologist at all times. However, this is not possible in most centres. Although there was agreement concerning the general severity of injury, inter-observer agreement is also moderate. These data cast doubt on the use of the AAST liver injury score alone as a decision-making tool when assessing haemodynamically stable children with blunt hepatic injury

Paediatric Blunt Liver Trauma in a Dutch Level 1 Trauma Center

Introduction: Paediatric blunt hepatic trauma treatment is changing from operative treatment (OT) to non-operative treatment (NOT). In 2000 the American Pediatric Surgical Association has published guidelines for NOT of these injuries. Little is known about the treatment of paediatric liver trauma in the Netherlands. Patients and methods: Data of all patients aged 18 years and younger admitted to our hospital for blunt hepatic trauma in the past 18 years were retrospectively analysed using a prospective trauma registry. The mechanism Of injury, treatment, ICU admission time, total admission time, morbidity and mortality were assessed. Subsequently the group was divided into patients treated before and after 2000. Results: Eighty patients were identified: 52M, 28F with a mean age of 12 years (range 2-18). Thirty patients sustained isolated liver injury. Concomitant injuries were fractures of long bones (28), abdominal (25), chest (24) and head injuries (18). Mean ISS score was 18 (range 4-57). Mortality was 8%. Mechanisms of injury consisted of bicycle (25%), car (20%), and motorcycle accidents (15%), pedestrian hit by vehicle (15%), fall from height (14%) and accidents associated with animals (11%). Haemodynamically stable patients underwent NOT (55). 25 patients (31%) underwent a laparotomy, which in 20 cases (80%) was related to hepatic injury. Although the groups treated before and after 2000 did not differ haemodynamically on admission to hospital, a shift to NOT is evident: 24/37 (63%) patients underwent NOT before 2000 versus 38/45 (84%) after 2000 (p=0.04). Complications following NOT were rare. Late onset bleeding did not occur. Two patients developed an infected biloma, requiring a laparotomy. Mean ICU stay before 2000 was 4.2 days (range 0-25 days) and 2.6 days (range 0-17 days) after 2000. Total hospital time did not decrease: 14 days (range 1-39 days) before 2000 and 14 days (range 1-60 days) after 2000. The overall mortality was 8%. All deaths occurred in the operative group and were spread evenly over both periods. Conclusion: In blunt paediatric liver trauma, the incidence and trauma mechanism seem age-related. A shift to NOT is found in the treatment of paediatric blunt hepatic trauma. NOT is the preferred treatment for the haemodynamically stable patient. Complications are rare and the success rate is 96%. The mean ICU stay has decreased but the total admission time could possibly be shortened