Imaging in Pediatric Abdominal Trauma: What Test, and Why?
Imaging in Pediatric Abdominal Trauma: What Test, and Why?
Authors: Laleh Gharahbaghian, MD, Clinical Instructor of Surgery/Emergency Medicine, Associate Director Emergency Ultrasound, Stanford University School of Medicine, Stanford, CA; Valerie Vigil, MD, Resident, Stanford/Kaiser Emergency Medicine Program, Stanford, CA; Sarah Williams, MD, Clinical Assistant Professor of Surgery/Emergency Medicine, Director Emergency Ultrasound, Stanford University School of Medicine, Assistant Residency Director, Stanford/Kaiser Emergency Medicine Residency Program, Stanford; Ewen Wang, MD, Assistant Professor of Surgery/Emergency Medicine, Associate Director Pediatric Emergency Medicine, Stanford University School of Medicine.
Peer Reviewers: Eric Legome, MD, Chairman, Department of Emergency Medicine, St. Vincent's Hospital, Manhattan, New York, NY; Leroy Nickles, MD, Attending Physician, Department of Emergency Medicine, St. Vincent's Hospital, Manhattan, New York, NY.
With trauma as the leading cause of death in children nationwide, pediatric abdominal trauma is a commonly encountered clinical situation in the emergency department (ED). The majority of trauma in this age group involves blunt trauma inflicted by events such as traffic collisions and falls, making evaluation and diagnosis of intra-abdominal injury a key component of pediatric trauma management. In this article, the authors discuss the evaluation of pediatric abdominal trauma, the differences between pediatric and adult trauma victims, and the various imaging modalities used, with an emphasis on the pediatric focused assessment of sonography for trauma (FAST) scan.
Background Epidemiology
Children younger than age 15 comprise 21.7% of ED visits each year.1 Unintentional injuries are the leading cause of mortality in children age 1 to 19 years and account for more than 43% of deaths in this age group.2-5 Traffic collisions (automobile versus automobile, automobile versus pedestrian, and automobile versus bicycle) and falls comprise the majority of pediatric unintentional injuries.6 Since a significant percentage of injuries result in a blunt force injury to the abdomen, these injuries are classified as blunt abdominal trauma (BAT).7,8 The imaging modality used for evaluating BAT deserves careful consideration.3,4,7
In the setting of BAT, the management of the pediatric patient differs from the management of the adult trauma patient. A retrospective study of 2,011 adults and children treated over a 10-year period for BAT noted that children were less likely than adults to have chest or spine injuries.7 Another study of 411 trauma victims showed that children are less likely to sustain pelvic fractures following trauma, as compared to adults.9 Additionally, blunt splenic trauma in pediatric patients is more likely to be managed non-surgically than in adult patients.10 This may be due to differences in body size, proportional anatomy, and splenic and hepatic capsular integrity.3,4,7,9 It is clear that one cannot simply treat children as "small adults" when developing a management and treatment plan following traumatic injury. This is also the case when deciding on imaging modality for trauma evaluation.
Imaging of the pediatric patient should take into consideration differences as compared with adults in terms of usual body habitus, abdominal organ size and position, and physiology. One should consider the potential cumulative effects of radiation exposure from plain films and computed tomography (CT) scans. Choice of imaging study also depends on the patient's physical exam findings, hemodynamic stability, availability of that imaging modality and its appropriate interpretation, and the ability of the institution to intervene based on the findings of that imaging study.
Clinical Cases
The following clinical scenarios are presented for consideration while reviewing the evidence regarding each imaging modality. At the end of the article we will discuss the appropriate imaging modality that is best for each case.
Case 1: A 6-year-old, previously healthy male brought in by ambulance was an appropriately restrained backseat passenger of a rollover motor vehicle collision noted to be going 35 mph. He complained of neck pain. He had no loss of consciousness, was alert and oriented on scene, and was found walking upon arrival by ambulance, and was moving all extremities without difficulty breathing, chest pain, abdominal pain, or back pain. He remained asymptomatic throughout transport. He arrived to the ED of a Level 1 trauma center in a cervical collar and backboard with stable vital signs throughout transport and in the ED. Upon evaluation you note a well-appearing child holding a teddy bear that the medics had given him while en route. Using Advanced Trauma Life Support (ATLS), you note that the primary exam is unremarkable; the secondary exam is only notable for mild tenderness to palpation in the lateral cervical neck musculature without midline tenderness.
Case 2: A 10-year-old, previously healthy female was brought in by parents for a fall down a three-foot embankment; she went over the handlebars while riding her bicycle with a helmet at a slow speed. She walked home, where her parents noted her to be crying and saying her arms and stomach hurt. She is taken to the urgent care of a local hospital. She is complaining of pain at the sites, where she has abrasions on her hands and forearms. She said she had abdominal pain immediately after the fall, described as mild, but the pain has since resolved. She has stable vital signs, and is noted to have an unremarkable primary ATLS exam. Her secondary exam is notable for multiple abrasions over her hand and forearms without bony tenderness or deformity, and she has no abdominal tenderness.
Case 3: A 1-year-old, previously healthy female was brought in by ambulance to the ED of a Level 1 trauma center for a fall from a second-story window. She had no loss of consciousness. Medics found her lying on her right side where she had fallen. She is alert, with notable difficulty breathing as well as right-sided pain from her chest wall to her hip. She is moving all extremities. She was crying, tachycardic and tachypneic, with stable blood pressure and normal oxygen saturation. She arrives with a secured cervical spine and backboard to the ED with unchanged vital signs, appearing scared and crying. The primary ATLS exam is unremarkable. The secondary exam is notable for tenderness to palpation on the lower lateral chest wall in the anterior axillary line without crepitance, a soft abdomen with tenderness in the right upper quadrant and epigastric areas, with guarding during palpation.
Case 4: An 8-year-old, previously healthy male is brought in by ambulance to the ED of a Level 1 trauma center after being hit by a car going 30 mph. He is noted to have been unconscious upon paramedic arrival, with tachycardia (rate 130), tachypnea (rate 30), and hypoxia (90% room air), and normal blood pressure. He began to wake up en route with a mild cry, and is noted to be moving all extremities. Upon arrival in a cervical collar and backboard, he has unchanged vital signs, and is conscious but somnolent and difficult to arouse. His primary ATLS exam is remarkable for diminished breath sounds on the right. After endotracheal intubation and right chest tube placement, his vital signs are noted to improve. His secondary exam is notable for a moderate cephalohematoma in the right temporal area, with step off of the scalp in the associated area, crepitance over the right chest wall, step off noted of lateral ribs 5-7, a soft abdomen with bruising noted from lateral chest wall to lateral hip, a stable pelvis, and multiple areas of abrasions, with deformity of the right femur.
Case 5: A 3-year-old, previously healthy female was brought in by her parents to the ED of a Level 2 trauma center after a 50-inch television fell on her. The parents stated that the child immediately cried, but has since become more somnolent. The triage nurse immediately brings the child back and informs the ED doctor of the patient's vital signs, which included a heart rate of 200, respiratory rate of 40, five-second capillary refill, and oxygen saturation of 90% on room air. The ED doctor notes a pale and ill-appearing child. The primary ATLS exam is remarkable for tachypnea and weak pulses. The secondary exam is only notable for bruising over chest wall extending to the firm, tender, and protuberant abdomen evident on exam.
Plain Films
X-rays of the chest, pelvis, and cervical spine are the traditional set of plain films obtained for immediate trauma evaluation. Portable bedside imaging allows for early identification of significant, life-threatening injuries such as pneumothorax, hemothorax, pulmonary contusions, perforated viscus, pelvic fractures causing significant hemodynamic instability, and dangerous cervical spine injuries without the patient leaving the trauma suite. The plain films often allow for immediate correlation with physical exam, aiding in prompt intervention in the trauma suite. However, plain radiographs do not provide definitive imaging for BAT; missed intra-abdominal injury is an important cause of morbidity in children. Holmes and colleagues identify six clinical predictors of intra-abdominal injury: low systolic blood pressure, abdominal tenderness, femur fracture, increased serum hepatic transaminase concentration, a low initial hematocrit, and hematuria.11 Abdominal tenderness was present in 58% of children with injuries; children with a decreased level of consciousness may have an unreliable abdominal exam. Seventy-seven percent (77%) of children with GCS > 13 had abdominal tenderness. Both seatbelt marks and handlebar bruises should be considered potential indicators of serious underlying injury.
Plain films provide varying amounts of radiation, depending on the number of films needed. Overall, radiation from plain films is orders of magnitude less than CT. Depending on body habitus and size, one "bodygram" may be sufficient to minimize radiation exposure. Interpretation involves an experienced radiology technician to obtain adequate images and an experienced physician to read those images. Plain films also diagnose bony injuries, but rarely are these causes of significant mortality (excluding pelvic and femur fractures). Therefore, the use of plain films alone is not a sufficient means to diagnosing significant injuries, and does not evaluate intra-abdominal injuries to the extent that is needed.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) has yet to become part of the acute trauma evaluation outside of evaluating spinal cord injuries.12-14 It plays no role in ED evaluation of blunt abdominal trauma.
Computed Tomography
CT is the current standard of imaging in the United States for the evaluation of pediatric patients who have suffered BAT.15-17 (See Figures 1 and 2.) Approximately 4 million CT examinations are performed annually on children in the United States. The use of CT in adults and children has increased about seven-fold in the last decade. Multidetector (or multislice) CT, now common in hospitals around the country, provides even greater imaging ability than the older generation single slice helical CT scanners. It allows an appropriate evaluation of abdominal trauma in the stable trauma victim, locating site of injury (see Figure 3), and identifying free air and free fluid (FF) in the peritoneal cavity. In the setting of trauma, any amount of FF on CT is suspicious for injury. This is usually evaluated with serial abdominal exams, repeat CT scans, or exploratory laparotomy. While CT is a very sensitive and accurate diagnostic tool in the evaluation of BAT victims, there are also some injury patterns in which CT has lower accuracy. This includes intestinal (hollow viscus), diaphragmatic, and pancreatic injury. With the increased use of higher resolution multi-slice CT scans, the evaluation of these intra-abdominal injuries may improve. Last but not least, CT is inappropriate for the unstable patient due to the lack of resuscitation equipment in the scanner and the time delay caused by transporting the patient and performing the scan.15,18
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Recently, there has been increased awareness of dose-based radiation-induced malignancy.19-22 This is especially important in children; their organs are more susceptible to radiation damage, and they have more years of life during which a cancer induced by radiation could develop. The evidence from atomic bomb survivors as well as nuclear plant workers demonstrates that there is an increased risk of cancer from low-level radiation exposure such as from CT.23 Although CT scans comprise about 10% of diagnostic radiological procedures in large U.S. hospitals, it is estimated that CT scans contribute approximately 65% of the effective radiation dose from all medical x-ray examinations to the population.19,24 A recent review of the literature showed a risk of one fatal cancer per 1,000 CT scans done in the pediatric population. Given that 1.5% to 2% of all cancers in the United States may be attributable to the radiation from CT scans, and that the largest increase in CT use has been in the pediatric population, the risk of radiation exposure should be minimized and alternative imaging modalities should be considered in pediatric populations.23,25
ALARA, an acronym for "as low as reasonably achievable," is a philosophy of radiation dose management set forth by the Society for Pediatric Radiology, which continues to promote lower dose radiation exposure in pediatric CT. This goal can be accomplished by several mechanisms. The first is to decrease the radiation dosage for children who receive CT imaging. The dose parameters of CT scanners, especially new generation scanners, can be set to decrease radiation dosage for children. However, sometimes this may affect the perceived quality of the image.26 Table 1 illustrates the amount of radiation exposure to pediatric patients comparing unadjusted settings and settings adjusted for body weight, according to the National Cancer Institute.27
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Other methods to decrease radiation exposure include replacing CT with other imaging modalities such as ultrasound for the primary study in the appropriate patient. Serial ultrasound exams in the stable trauma patient without abdominal pain, as well as repeated physical exams and overnight observation, can also reduce pediatric radiation exposure.
Ultrasound
In the 1980s, cheaper, smaller, and more portable ultrasound machines were developed. This allowed use in the ED, particularly during evaluation of blunt trauma victims.28,29 The focused assessment of sonography for trauma (FAST) scan, which evaluates for free fluid (FF) around the heart and three areas of the abdominal-pelvic cavity, continues to be used as a goal-directed study during the evaluation of trauma patients.30,31
The technique for performing the FAST scan involves evaluating for FF in the right upper quadrant between the liver and kidney (also known as Morison's pouch) (Figures 4 and 5), left upper quadrant (between the spleen and kidney) (Figure 6), subxiphoid area (to see FF collection within pericardial sac) (Figure 7), and suprapubic areas (behind the bladder in males or behind the uterus in females) (Figure 8). FF appears black on ultrasound and is found using either a curved or phased-array low-frequency probe.
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Hemothorax is detected if black fluid is detected above the diaphragm (just cephalad to the liver or spleen on ultrasound). An extended version of the FAST scan (E-FAST) involves evaluating the anterior chest for pneumothorax using the linear (high-frequency) probe. Lung sliding at the pleural line (representing the interface of the parietal and visceral pleura) with comet tail rays emanating down from the pleural line exclude pneumothorax. (See Figure 9.) This has been incorporated as an extension of the FAST exam in many institutions in adults, and though there is no dedicated literature on pediatric patients, this application may also translate into the pediatric population.32,33
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Since the majority of preventable deaths occur early and are due to injuries or physiologic derangements of the airway, thoracoabdominal cavities, or brain, the FAST scan can aid in determining whether there is FF in the peritoneal cavity or within the pericardium, which can direct operative intervention in the unstable patient. In the trauma setting, FF seen on ultrasound is interpreted as blood, although the specific organ or structure injured cannot reliably be determined by FAST scan.30
Ultrasound does have limitations in the evaluation of traumatic injury. Ultrasound does not reliably evaluate injuries of the retroperitoneum and hollow viscus unless they produce FF in the peritoneal cavity.34-36 Ultrasound also is less likely to depict intra-abdominal injuries that result in minimal or no hemoperitoneum. The injuries most likely to be missed by ultrasonography include retroperitoneal hematoma, kidney or adrenal injury, or hollow viscus injury.37 Ultrasound also is inadequate for identifying the existence of bleeding from a pelvic fracture, despite confirmed FF in the pelvis by CT or laparotomy.38,39 Ultrasound also is highly operator-dependent, and the initial investment for equipment can be expensive.
For the emergency physician or trauma surgeon, a FAST scan has many advantages. It is attractive because of its convenience and portability; it can be used as an extension of the physical exam in the trauma setting.40 Additionally, it can be used on an unstable patient, even during resuscitation, and it does not pose the radiation risk associated with CT.25,41 Like CT, FAST has the ability to detect intraperitoneal FF and thus, the presence of intra-abdominal injury. It has also been suggested that the FAST exam may be sufficient to obviate a CT exam in a child with a normal presentation and low risk of intra-abdominal injury.42,43
While the use of FAST is well documented for the adult population, with high sensitivities and specificities ranging between 80% to 95%, the data concerning the pediatric population is less clear.44-46 It is well supported that pediatric FAST is very specific in detecting hemoperitoneum; however, its sensitivity is not consistently demonstrated, with values between 30% and 100% being reported.40,47-50 Prior studies have suggested that FAST scans are less sensitive than CT, more sensitive than diagnostic peritoneal lavage (DPL), and not a useful screening tool in pediatric blunt trauma.40,47,48 However, the previously published studies vary widely among their positive diagnostic end-points, definition of a true positive FAST scan, methods, and study design. Most studies included patients who went to surgery as true positives, but some also included patients with any injury, including solid-organ injury detected by CT scan, and others included only patients with intraperitoneal FF.40,47,49,50 It is worth noting, however, that the recent literature has shown that the combination of a negative ultrasound evaluation and a negative repeated clinical assessment in a patient observed for at least 12-24 hours virtually excludes abdominal injury.37
Figure 10 shows an algorithm for the evaluation of blunt abdominal trauma and summarizes the clinical disposition of pediatric patients after abdominal trauma.51 As illustrated in the algorithm, the most important factors involved include FAST scan interpretation and vital signs. With a positive FAST scan and unstable vitals, the patient should be explored in the operating room. However, in stable patients with a significant mechanism, a concerning physical exam, and/or abnormal labs, a CT scan to evaluate injury is indicated and the patient requires admission. With a negative FAST scan and unstable vitals, operative exploration must be considered, but, more importantly, other causes of hemodynamic instability must be considered, including neurogenic and cardiogenic shock. Lastly, the patient can be observed if the mechanism was not significant, the physical exam is unremarkable, and the FAST is negative.
Other Imaging Modalities for Pediatric Patients
Various other imaging modalities, though still available, are not nearly as useful as ultrasound, x-rays, and CT for the evaluation of the pediatric trauma patient. Barium swallow or an upper gastrointestinal (GI) series could possibly be used as a diagnostic adjunct for trauma-related esophageal foreign bodies, obstruction, or suspected perforation in such a setting; however, it is very rare that such an exam would be used acutely in a pediatric abdominal trauma evaluation.
Clinical Cases Overview
Case 1: The appropriate strategy for evaluating this patient includes serial physical exams at the least, and incorporating serial FAST scans at the most. Since the patient had the mechanism for having blunt trauma to the abdomen but did not have abdominal pain, the suspicion for abdominal injury is low, especially with stable vital signs.
Case 2: The appropriate strategy for evaluating this patient includes serial physical exams and serial FAST scans. This patient initially had abdominal pain, which was described as mild, but it had since resolved, with stable vital signs, and normal initial physical exam. The suspicion for abdominal injury is low. The patient should have appropriate follow up with the child's pediatrician.
Case 3: The appropriate strategy for evaluating this patient includes the screening E-FAST and confirmatory CT scan to evaluate for abdominal injury. Given the patient's mechanism of injury and initial exam findings of tenderness over chest wall and right upper quadrant of abdomen with guarding, the suspicion for intra-abdominal injury is high. The vitals signs are not normal but are stable; further evaluation is necessary using CT.
Case 4: The appropriate strategy for evaluating this patient includes the screening E-FAST and confirmatory CT. The physical exam is unreliable in a patient with abnormal mental status. Given that this patient has abnormal vital signs and a mechanism to have intra-abdominal injury, the suspicion is high and a CT is necessary if stable vital signs are present.
Case 5: The appropriate strategy for evaluating this patient includes the screening E-FAST followed by immediate transport to the operating room (OR) for exploratory laparotomy. This patient has an obvious abnormality on exam and high probability of injury within the abdomen and should be transported to the OR for further evaluation, especially if the FAST scan is positive. In this case, the FAST scan is the best screening tool for evaluation of the abdomen since the patient is too unstable for CT and has a deteriorating clinical status.
Conclusion
The evaluation of the pediatric trauma victim is distinctly different from the adult workup due to differences in injury type, trauma management, body habitus, organ size, and physiology. The decision of which imaging modality will best evaluate and manage the pediatric trauma patient remains a controversial topic. It is generally accepted in the pediatric literature that the physical exam in pediatric abdominal trauma is not considered reliable, and imaging for children at high risk of injury will be performed often.49,50 Given the current literature, all unstable patients should obtain a bedside FAST scan and operative intervention if positive. Stable patients should obtain serial bedside FAST scans with confirmatory CT scans in the setting of a concerning mechanism, worrisome physical exam, and/or abnormal labs. With a positive FAST scan in a stable patient, a follow-up CT scan is also useful as it will delineate location and severity of injury. Plain films and MRI should be used as indicated by injury type, and other less common types of imaging only in very specific circumstances (i.e., barium swallow for trauma-related foreign body). Minimizing radiation exposure should always be considered, and the risks and benefits weighed - the risks of potential delayed or missed diagnosis from not performing a CT scan weighed against the increased risk for radiation-induced cancer over a lifetime in a child versus an adult, and the increased radiosensitivity of children.26,52
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With trauma as the leading cause of death in children nationwide, pediatric abdominal trauma is a commonly encountered clinical situation in the emergency department (ED).Subscribe Now for Access
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