Delayed diagnosis of injuries in pediatric trauma: the role of radiographic ordering practices

Willner, Emily L.; Jackson, Hollie A.; Nager, Alan L.

doi:10.1016/j.ajem.2010.10.033

Cited by 7 publications

(9 citation statements)

References 23 publications

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“…Physicians may have had a lower threshold to CT scan or operatively explore patients with penetrating mechanism, which may decrease the risk of missed injuries. Most of our missed injuries were extremity fractures, again commonly seen in pediatric[15] and adult trauma patients. [5]…”

Section: Discussionmentioning

confidence: 99%

Missed injuries and unplanned readmissions in pediatric trauma patients

Choi

Keller

2017

Journal of Pediatric Surgery

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Background We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. Methods We conducted a retrospective review of all trauma patients who presented to our ACS-Verified Level-1 pediatric trauma center from 2009–2014. Results Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5 days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5 days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p <0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed non-accidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. Conclusions Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk.

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Section: Discussionmentioning

confidence: 99%

Missed injuries and unplanned readmissions in pediatric trauma patients

Choi

Keller

2017

Journal of Pediatric Surgery

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“…While physical examination, laboratory testing and non-invasive, non-radiating imaging are integral components of the diagnosis and management of traumatically injured children, CT scan remains the most sensitive and specific radiologic test to identify injury and is thus included in the work-up in most emergency rooms 5,9-13 . Prior studies have investigated the risk of radiation exposure risk and strategies for managing this risk as well as the need for repeat imaging once transferred to a pediatric trauma center 3,5,9,12,14-17 .…”

Section: Introductionmentioning

confidence: 99%

Computed tomography–related radiation exposure in children transferred to a Level I pediatric trauma center

Brinkman¹,

Gill

Leys³

et al. 2015

Journal of Trauma and Acute Care Surgery

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Purpose Pediatric trauma patients presenting to Referring Facilities (RF) often undergo computed tomography scans (CT) to identify injuries before transfer to a Level 1 Pediatric Trauma Center (PTC). The purpose of our study was to evaluate RF compliance with the American College of Radiology (ACR) guidelines to minimize ionizing radiation exposure in pediatric trauma patients and to determine the frequency of additional or repeat CT imaging after transfer to a PTC. Methods After IRB approval, a retrospective review of all pediatric trauma admissions from January 2010-December 2011 at our American College of Surgeons (ACS) Level 1 PTC was performed. Patient demographics, means of arrival, injury severity score and disposition were analyzed. Patients who underwent CT were grouped by means of arrival: those that were transferred from a RF versus those that presented primarily to the PTC. Compliance with ACR guidelines and need for additional or repeat CT scans were assessed for both groups. Results 697 children (<18yo) were identified with a mean age of 10.6 years. 321 (46%) patients presented primarily to the PTC. 376 (54%) were transferred from a RF, of which 90 (24%) patients underwent CT imaging prior to transfer. CT radiation dosing information was available for 79/90 patients (88%). After transfer, 8/90 (9%) of children imaged at a RF required additional CT scans. In comparison, 314/321 (98%) of patients who presented primarily to the PTC and underwent CT received appropriate pediatric radiation dosing. Mean radiation dose at PTC was approximately half of that at RF for CT scans of the head, chest and abdomen/pelvis (p<0.01). Conclusions Pediatric trauma patients transferred from RF often undergo CT scanning with higher than recommended radiation doses, potentially placing them at increased carcinogenic risk. Fortunately, few RF patients required additional CT scans after PTC transfer. Finally, compliance with ACR radiation dose limit guidelines is better achieved at a PTC.

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“…[7] The immediate performing of total body imaging permits evaluation of the extent of injuries and provides direction for emergency management, and is of particular importance in children, since medical history may be unreliable, particularly in those who cannot yet talk, are sleepy, or are comatose and/or intubated. [6] Reasons for delay in management following arrival in the Trauma Unit were numerous, including delay in registration and issuing a hospital folder, and lack of available and appropriately trained radiographic staff to undertake body imaging and scanning. (During after-hours and weekends, only 1 radiographer is on call for the entire hospital, frequently leading to delays in imaging.)…”

Section: Discussionmentioning

confidence: 99%

“…[5] Imaging is crucial in the evaluation of children presenting after polytrauma because clinical examination tends to be unreliable. [6] It is estimated that 30% of children with severe trauma die because of inadequate evaluation on arrival in hospital. [5] Accurate evaluation, early initiation of critical care measures and early radiographic imaging have the potential to prevent these deaths.…”

mentioning

confidence: 99%