Paediatric trauma (test layout)

• Incidence of paediatric trauma is low compared with adults.
• The growing child has different physiological and anatomical considerations which require a different approach to imaging.
• There is increased risk of ionising radiation in children. The ALARP (as low as reasonably practicable) principle should be adhered to.
• Decision making in imaging injured patients should always be underpinned by clinical discussions between senior level clinicians and radiologists.
• CT is helpful in the paediatric trauma setting but is not mandatory and should be tailored to the patient
• The use of FAST and unenhanced ultrasound are not appropriate and can provide false reassurance.
• In penetrating trauma contrast enhanced imaging is the modality of choice.
• Blast injuries demand adjustments to major trauma protocols. CT is the most effective imaging modality. 

• There is no safe lower level of radiation exposure        
• There is an increased risk from ionising radiation in children from factors such as cumulative radiation risk over a lifetime, longer lifetime to express relative risk and a growing child has more radiosensitive tissues.          
• The ALARP (as low as reasonably practicable) principle should be adhered to.
• Using the ALARP principle in a trauma setting, the initial clinical question needs to be: ‘Does this child need imaging at all?’ 
• If imaging is required, further questions should be asked in regard to which anatomical areas need to be covered, and whether primary imaging should be plain radiographs or an alternative modality such as CT.

• The modality, extent and timing of imaging is not mandatory and should be tailored to the patient after appropriate senior level of discussion between the referring physician and the radiologist.

• Contrast-enhanced CT can be helpful in the paediatric trauma setting but should be applied judiciously.      

• FAST (Focused Abdominal Sonography in Trauma) and unenhanced ultrasound are not appropriate in the assessment of blunt abdominal trauma and can provide false reassurance.    

• Contrast enhanced ultrasound is widely used in Europe and may be used in expert hands in appropriate cases after discussion.     

• MR imaging is primarily reserved for potential spinal cord injury, though it is acknowledged that access to MR imaging may be difficult.

• The value of a normal radiograph for specific areas must not be underestimated. 

• All imaging pathways for suspected injury must rely on clinical history, examination and observation as their starting point. The patient’s likely onward journey may also need to be considered. 

• If CT is deemed the most appropriate investigation, suitable dose reduction procedures must be in place.    

• All CT manufacturers have dose reduction software and these should be used to their full extent. If possible, the use of more advanced iterative reconstruction software applications should be made available. However these reconstructive algorithms may add considerable delay in producing the definitive image and should be taken into account, balanced with the clinical situation.

• Significant dose reduction can be achieved in paediatric patients without any loss of diagnostic information by the use of judicious kilovolt and milliampere reduction. 

3.1 Imaging recommendations by anatomical area

Head 

• It is recommended to follow the imaging algorithm for selecting people under 16 for a CT head scan (see algorithm 2) in the NICE guidance : Head Injury: assessment and early management 
  3D CT reconstructions of the skull vault have the capability of increasing sensitivity for the detection of linear fractures and is highly recommended  

Cervical Spine

• It is recommended to follow the imaging algorithm for selecting people under 16 for a cervical spine scan (algorithm 4) in the NICE guidance: Head Injury: assessment and early management 23
• Thoracic and Lumbar Spine   
  •    Potential spinal injuries should be assessed on a case-by-case basis with appropriate imaging guided by discussion with the radiologist where clinical condition allows.
  •    Clinical assessment should underpin investigations
  •    Plain radiographs of the injured region will generally be the primary investigation.
  •    Targeted CT of an area may be required for further assessment.
  •    CT of the lumbar spine is included in CT of the abdomen and pelvis.
  •    Where there are definitive neurological signs, the primary imaging modality should be MR where possible.

Chest

•    The primary investigation for blunt chest trauma is the chest X-ray. This will detect significant pneumothorax, haemothorax, displaced rib fractures, gross mediastinal abnormalities and gross diaphragmatic injuries.      
•    Further imaging in blunt chest trauma should be dictated by the nature of the trauma, the clinical condition of the child and the initial radiographic findings. 
•    Penetrating trauma is an indication for contrast-enhanced chest CT due to the incidence of occult vascular injury.
•    Contrast-enhanced CT should also be considered in cases where there has been a rapid deceleration (defined as fall > 6 metres) or high impact motor vehicle crash (>40miles/hour), intoxication, reduced GCS or distracting painful injury.      - as per Nexus chest criteria 
•    CT can be omitted in patients with normal chest film and clinical examination as it is unlikely to lead to a change in management .
Abdomen 

•    Where clinically indicated contrast-enhanced CT of the abdomen and pelvis is the modality of choice for the assessment of acute traumatic intra-abdominal injury.       
•    Single-volume dual-contrast CT is advised to minimise radiation burden.
•    An example of a suitable contrast and timings calculator is included (see the Camp Bastion contrast wheel, Appendix 1).
•    A hand injection of contrast is appropriate in very small children and babies.
•    Decisions to perform abdominopelvic CT should be made on the basis of the clinical history and examination.  
•    Where there is an isolated head injury, a reduced Glasgow Coma Scale (GCS) score should not be the only justification for abdominal CT. The decision to perform abdominal CT should be made on the basis of the clinical history and examination. The following clinical variables have been found to be associated with intra-abdominal injury and may indicate the need for abdominopelvic CT.    
o    Lap belt or handle bar injuries
o    Abdominal wall ecchymosis
o    Abdominal tenderness in a conscious patient
o    Abdominal distension
o    Clinical evidence of persistent hypovolaemia; for example, persistent unexplained tachycardia
o    Blood from the urethra, rectum or nasogastric tube.

•    Abdominal injuries are rare where there is neurological impairment in the absence of abdominal signs and symptoms. 
•    Abdominopelvic CT findings have been documented to influence patient monitoring and management plans. 
•    A normal CT strongly predicts the lack of subsequent deterioration of a patient’s condition.  

Pelvis 
•    Pelvic fractures are rare in children. 
•    A screening pelvic radiograph is not indicated in all cases.        
•    Pelvic imaging should only be considered if there are concerns after clinical assessment.
•    The presence of a pelvic binder is not an indication in isolation for imaging without prior clinical assessment.
•    Pelvic fractures can be associated with multi-organ injuries. The bony pelvis will be included on CT evaluation of the abdomen and pelvis. Where clinically indicated, contrast-enhanced CT of the abdomen and pelvis is the modality of choice.
•    When there are high clinical concerns or a radiologically proven pelvic fractures, imaging post removal of the pelvic binder is sometimes required. When this is the case both the orthopaedic team and wider team should be in attendance when the binder is removed in case the patient deteriorates. 

Limbs

•    Using the clinical history and examination, clinicians should request plain radiographs of the injured region as the primary investigation.
•    This will usually be anteroposterior and lateral views including the adjacent joints.
•    CT may be required for complex fractures or concern of vascular injury. 

3.2    Delayed presentation of injury 

•    Imaging evaluation in delayed presentations of blunt trauma is difficult given the heterogeneity of the aetiology and subsequent clinical presentation. 
•    Consideration should be given to contrast-enhanced imaging, given the limitations in non-enhanced imaging although the initial aetiology and clinical evolution of the patient remain important factors in determining onward imaging.
3.3    Special considerations

•    The use of radiological imaging to exclude injury should be considered in situations where history and/or clinical examination is compromised.
•    This includes the following:
o    Children with decreased level of consciousness including intubated patients
o    Unwitnessed injury in the non-verbal child
o    Children in situations with limited clinical observation such as awaiting hospital transfers or needing immediate operative intervention
o    Clinical concerns regarding suspected physical abuse. Suspected physical abuse (SPA) is a major cause of trauma in infants. Radiological investigation of SPA should follow RCR guidance: The radiological investigation of suspected physical abuse in children .