Evaluation and Necessity of  Imaging Modalities in Pediatric Thoracic Trauma: Balancing Clinical Benefits and Radiation Risks

doi:10.21203/rs.3.rs-5173203/v1

Purpose: Thoracic trauma in pediatric patients presents unique challenges in diagnosis and management. This study aimed to evaluate the frequency and impact of CXR and CT scans on the management of pediatric thoracic trauma.

Methods:This study analyzed data on 819 thoracic trauma patients from 11,532 pediatric trauma patients admitted to a single trauma center. Patient demographics, trauma mechanisms, imaging results, and interventions were assessed. Cohort and and non-intervention group compared on positive findings.Statistical analyses were performed to assess the significance of imaging findings and their impact on management decisions.

Results:The study included predominantly male patients (70.5%) with a mean age of 10.59 years. Blunt trauma accounted for 85.2% of cases. CXR was performed in 79% of cases, with 68% normal results. Conversely, CT scans detected a higher percentage of pathological findings, notably pulmonary contusions (54%) and pneumothoraces (45%). However, the increased diagnostic yield of CT did not significantly alter patient management or necessitate intervention..

Conclusion:Our findings highlight the overuse of imaging modalities in pediatric thoracic trauma with limited impact on management decisions. While CT scans offered greater sensitivity for detecting minor injuries, their routine use did not substantially influence clinical outcomes or therapy decisions.

Pediatric thoracic trauma

radiation

imaging modality

trauma intervention

Thoracic injuries account for 5–25% of the total number of trauma cases in children. Trauma is the leading cause of death in children, and chest trauma being the second most common cause [1]. Patients with chest injuries have a significantly increased mortality rate, up to 20 times higher than normal [2]. While current ATLS guidelines recommend the evaluation of blunt chest injuries with a chest x-ray (CXR) following a physical examination, there is no consensus on the use of computed tomography (CT) in the evaluation of chest trauma. Conventional chest X-rays have long been the mainstay imaging modality for evaluating pediatric thoracic trauma due to their wide availability, relatively low cost, and rapid acquisition time. However, chest X-rays can be limited in their sensitivity, particularly for detecting occult or subtle injuries. In recent years, CT scans have emerged as a more sensitive diagnostic tool for thoracic trauma. However, their use in pediatric patients has sparked debate due to concerns about radiation exposure and potential long-term health risks [3, 4]. It is generally accepted that one fatal malignancy occurs for every thousand CT scans performed in children [5]. There has been limited data examining the rationale for the use of computed tomography (CT) scans in the diagnosis and management of pediatric chest trauma. We conducted a retrospective analysis to determine how often chest x-ray (CXR) and chest computed tomography (CCT) scans were used and how they influenced management decisions in pediatric patients with chest trauma.

This retrospective study was conducted at a single pediatric trauma center, focusing on patients under 18 years of age admitted between January 2015 and December 2018. Approval for the study was obtained from the institution’s local ethics committee (reference number: 2018/007). A total of 11,532 pediatric trauma patients were initially evaluated within the specified timeframe. Data was collected from the hospital's computer system, patients' follow-up charts, and medical records. After excluding 358 cases due to insufficient data, a cohort of 819 patients meeting the criteria for thoracic trauma was included for analysis. In the evaluation process, all pediatric trauma cases were evaluated and categorized as part of the "thoracic trauma group" based on specific criteria.

Criteria for inclusion

Patients were included based on the following criteria:

a. Manifestation of physical signs indicative of chest trauma.

b. Presence of discernible injuries on chest radiographs (CXR).

c. Identification of trauma-related symptoms on chest computed tomography (CT) scans.

d. Underwent tube thoracostomy.

e. Received treatment with Velpeau bandage.

f. Underwent thoracic surgery.

g. Pediatric fatalities attributed to chest trauma.

Criteria for Exclusion

Exclusion criteria comprised:

a. Patients transferred to another facility after admission due to chest trauma.

b. Lack of adequate medical documentation

c. Patients whose families declined medical treatment and left against medical advice.

Clinical Assessments

Demographic information, trauma mechanism, trauma causes, trauma scores, imaging results, and therapy approaches were documented. Patients underwent a comprehensive physical examination, which included vital signs, laboratory testing, and imaging scans. Signs and symptoms connected to trauma were evaluated. Standard blood tests conducted upon admission consisted of a full blood count and serum biochemistry. Patients were assessed based on the Glasgow Coma Scale. Imaging necessity and medical therapy options were assessed for each patient. Patients who had chest X-rays (CXR) and/or computed tomography scans when suspicion remained were documented.

Following a physical examination, treatment outcomes were assessed based on the findings from the planned imaging techniques. Evaluation of follow-up and treatment outcomes was based on the findings of chest X-ray (CXR) and chest computed tomography (CCT). The thoracic trauma cohort was divided into two primary groups based on whether they required interventional procedures. To differentiate follow-up patients who did not require any intervention, regardless of whether imaging was performed or what modality was used, from other trauma patients, we created a subgroup of patients who did not require any intervention.

Cohort group consisting of 819 patients with chest trauma (n = 819).
Non-intervention group; consisted of patients who did not need treatment with Velpeau bandage, tube thoracostomy, or thoracic surgery and were discharged alive (n = 581).

The cohort group's CXR and CCT imaging findings, along with the signs of physical examination and demographic details, were compared to those of the non-intervention group. Furthermore, the CXR and CCT outcomes of patients undergoing thoracic surgery and tube thoracostomy were assessed.

Statistical Analyses

Data were analyzed using SPSS 25.00 (Statistical Package for Social Sciences, Inc., Chicago, IL). Continuous variables were presented as mean ± standard deviation (SD) and percentage (%). Categorical variables were presented as numbers and percentages. Chi-Square test aplied for cathegorical variables. The Mann-Whitney U test and Kruskal-Wallis Test was used to analyze for non-parametric variables, p values less than 0.05 (p < 0.05) were considered statistically significant.

A total of 819 pediatric chest trauma patients were evaluated and found that 70.5% of the cases involved male patients. The mean age was 10.5 ± 5.1 years with a statistical insignificance of the age distribution (p < 0.01). Moreover, the proportion of injuries due to blunt trauma was far more prevalent at 85.2%, with the majority of penetrating trauma cases being male-centric, accounting for 90.9% (p < 0.05).

Out of the patients, 53.1% (n = 435) had normal physical examination findings, whereas 41.1% (n = 337) displayed evidence of swelling, ecchymosis, or laceration, and 5.7% (n = 47) had either gunshot or intrathoracic wounds. Assessment at the initial examination showed that 87.7% had a Glasgow Coma Score (GCS) between 13 and 15, whereas 10% had a GCS between 3 and 8. Likewise, 77.8% had a Pediatric Trauma Score between 9 and 12.

Traffic accidents were the predominant type of trauma (47.6%, n = 390), followed by falls (21.9%, n = 109) and gunshot or stab wounds (13.8%, n = 110). A total of 16.3% (n = 134) of patients received Velpeau bandage, 6.7% (n = 55) required tube thoracostomy, and 1.3% received thoracic surgery (n = 11). No deaths were reported among patients with only chest injuries. The mortality rate was 5.9% (n = 48). The findings also indicated significant P values for male gender, blunt trauma types, the mechanism of motor vehicle crush, normal thoracic physical examination findings, Glasgow coma score, and pediatric trauma score (Table 1).

Tablo 1: Summary of the cases

Characteristic Mean ± or n (%) p value

N:819

Age, mean 11 (10,59±5,19) <0.01

0-4 140 (17,1)

5-9 195 (23,8)

10-14 219 (26,7)

15-18 265 (32,4) <0.05

Male 577 (70,5) <0.05

Mechanism of injury

Blunt 698 (85,2) <0.05

Male 467 (66,9)

Female 231 (33,1)

Penetrating 121 (14,8)

Male 110 (90,9)

Female 11 (9,1) <0.001

Physical examination findings

Normal 435 (53,1) <0.05

Swelling, ecchymosis, laceration 337 (41,1)

Gunshot or intrathoracic wound 47 (5,7)

GCS

13-15 718 (87,7) <0.05

9-12 19 (2,3)

3-8 82 (10)

PTS

9-12 637 (77,8) <0.05

<9 182 (22,2)

Injury types

MVC 390 (47,6) <0.05

Fall 109 (21,9)

Motorcycle or bicycle 32 (3,9)

Gunshot or stab 110 (13,8)

Other * 108 (13,2)

Treatment intervantion

Velpeau bandage** 134 (16,3)

Tube thoracostomy 55 (6,7)

Thoracic surgery 11 (1,3)

Mortality rate 48 (5,9)

*Unclassified trauma mechanism which contain blunt or penetrating trauma

** Although the Velpeau bandage is not a true intrathoracic intervention, it is a frequently used method of stabilizing clavicle fracture because of trauma related to the thorax.

The summary of the chest x-ray (CXR) and chest computed tomography (CCT) outcomes revealed that a total of 819 pediatric chest trauma patients were evaluated for imaging. The overall findings detected by CXR and CCT imaging are summarized in Table 2. CXR was performed in 650 patients. Intriguingly, CXR identified 444 (68%) normal results, distinguishing several clavicle fractures and limited severe pathological findings. In addition, pneumothorax (n = 25), pulmonary contusion (n = 11), pleural effusion or hemothorax (n = 2), rib fracture (n = 4), and multiple lesions (n = 25) were detected in 67 patients.

CCT examinations were performed in 492 patients, and 96 (20%) had normal findings. In contrast, CCT examination portrayed a higher percentage of pathologic results, with 96 (20%) normal findings and a prominent detection of pulmonary contusion (n = 265, 54%) and pneumothorax (n = 219, 45%). Moreover, an insightful comparison of normal and pathologic results of CXR and CCT imaging uncovered that a significant number of patients with normal CXR findings displayed pathologic results on CCT. Conversely, patients with positive CXR results exhibited similar pathologic results on CCT at a convincing rate, suggesting high diagnostic equivalence.

Tablo 2:Finding on CXR and CCT

Findings	CXR n ,(%) (N = 650)	CCT n,( %) (N = 492)
Normal	444 (68)	96 (20)
Pulmonary contusion	11 (2)	265 (54)
Pneumothorax	25 (4)	219 (45)
Pleural effusion or hemothorax	2 (0)	44 (9)
Rib fracture	4 (1)	65 (13)
Clavicle fracture	139 (21)	35 (7)
Other/multiple lesions*	25 (3)	NA
Sternum fracture	-	5 (1)

Comparison of normal and pathologic results of CXR and CCT imaging are summarized in Table 3. Of the 288 patients with normal CXR, 234 (81.2%) patients had pathologic results on CCT. Of 86 patients with positive CXR results, 70 (81.2%) patients had positive CCT findings. The comparison of CXR and CCT results was not statistically significant (p = 0.976).

Tablo 3: Comparison results of CCT and CXR

					P value
	CCT normal findings		CCT positive findings		P value
	n	%	n	%	0.976*
CXR Normal findings (288)	54	18,8	234	81,2
CXR Positive findings (86)	16	18,6	70	81,4
* Pearson Chi-Square or Yates chi-square

All patients who underwent intervention, regardless of the imaging modality used, are summarized in Fig. 1. In the group where CXR was not performed, 22 of 169 patients underwent an intervention. 14 of them underwent tube thoracostomy. Of these 14 patients, 12 had CCT imaging and 6 died. According to CXR findings, the highest interventional procedure was Velpeau bandage for clavicle fractures in 126 out of 156 patients. Of these, 444 patients had normal findings on CXR and 20 of them underwent interventional procedure. Of 492 patients who underwent CCT scan, 396 patients had positive results while 91 patients had interventions. 91 patients who had normal CCT findings did not require any intervention like chest tube insertion or thoracic surgery (Fig. 1).

Table 4

CXR and CCT results for cohort and non-intervention group, tube thoracostomy, thoracic surgery interventions
Result of CXR and CCT for General group and Redesigned group.	CRX		Not Performed n(%)	Normal n (%)	Positive n (%)	P value
		Cohort group	169 (57.9%)	444 (52.2%)	206¹(80.2%)	p < 0.05¹
		Non-intervention group	123(42.1%)	407 (47.8%)	51¹ (19.8%)	p < 0.05¹
	CCT
		Cohort group	327 (60.3%)	96 (54.2%)	396 (58.1%)	p = 0.35
		Non-intervention group	215 (39.7%)	81 (45.8%)	285 (41.9%)	p = 0.35
Tube thoracostomy and thoraci surgery intevrventin
	CXR
		Tube thoracostomy+	non	15 (%3.4)	26 (%12.6)	< 0.001
		Tube thoracostomy-	non	429 (%96.6)	180 (%87.4)
		Thoracic surgery+	non	1⁴ (%0.2)	6 (%2.9)	< 0.05
		Thoracic surgery-	non	443 (99.8%)	200 (%97.1)
	CCT
		Tube thoracostomy+	non	0 (%0)	50 (%12.6)	< 0.001²
		Tube thoracostomy-	non	96 (%100)	346 (%87.4)
		Thoracic surgery+	non	0 (%0)	10 (%2.5)	= 0.22³
		Thoracic surgery-	non	96 (%100)	386 (%97.5)
P value has significant difference according to positive results 2..Yates Chi-Square, 3..Fisher Exact Test, 4. Gunshot, ventricular repair .

Table 4 summarizes the comparison of CXR and CCT between the cohort group and the non-intervention group. There was a statistically significant difference for positive/pathological results for CXR (p<0.05) compared to CCT (p=0.35). Tube thoracostomy was not required in 96.6% of patients with normal CXR and 87.4% of patients with pathologic/positive CXR findings. Thoracic interventional procedure was not required in 99.8% of patients with normal CXR and 97.1% of patients with pathologic/positive CXR. Conversely, tube thoracostomy was not required in 100% of patients with normal CCT and 87.4% of patients with pathologic/positive CCT findings. Thoracic surgery was not required in 100% of patients with normal CCT and in 97.5% of patients with pathologic/positive CCT.

When determining if chest radiography and/or computed tomography are necessary for pediatric thoracic trauma, it is important to assess the role of these imaging techniques in diagnosing and selecting appropriate treatment. Our study is one of the largest pediatric trauma series. An essential finding of this study is that it demonstrated the widespread utilization of CCT at emergency department for trauma. Furthermore, the study revealed that the increased utilization of CCT did not have a significant impact on trauma treatment or the decision-making process for interventional procedures. And we found that in patients with stable pulmonary status, CXR detected a few lung injuries such as contusion or pneumothorax. CCT had a high sensitivity for pulmonary contusions, but an increase in diagnosed pulmonary contusions did not lead to a change in management. Given the growing concern about the established health risks associated with radiation exposure in pediatric cases, it is important to carefully balance clinical benefits and radiation risks when deciding on the appropriate imaging modality.

Out of the 11,532 pediatric trauma patients in our data, 819 (7.1%) were thoracic trauma cases. Among these, 79% had chest radiography (CXR), and 60% of those who had CXR also had computed tomography (CCT) as an initial evaluation. 81.2% of chest X-ray (CXR) images, which were first assessed as normal on CXR, were later found to have abnormality on computed tomography (CCT) scans. Nevertheless, the requirement for interventional procedures was comparatively minimal in this group, encompassing Velpeau bandages, tube thoracostomy, and thoracic surgery (16.3%, 6.7%, and 1.3%, respectively). The fatality rate in our series was 5.9% (n:48) and, similar to other trauma studies, was associated with central nervous system injuries[6–8]. Ugalde et al. determined that the rate of requiring supplementary therapy remained constant, regardless of the presence of a higher proportion of favorable results in chest X-rays (CXR)[1]. In a recent study, patients who had abnormal chest X-rays (CXR) and subsequently had computed tomography (CCT) showed a positive result rate of 71%, which was comparable with our study[3]. And, among patients who underwent both CXR and CCT imaging, the increased rate of positive findings by CCT was similar for cases where the CXR imaging showed normal results or positive findings. This was believed to be a consequence of the heightened sensitivity of CCT, without any change in patient care. Notably, chest X-rays may reveal certain positive results that were not identified on computed tomography scans [1, 3]. Our research revealed that the most prevalent pathological findings in chest X-rays (CXR) were clavicle fractures, while in CCT scans, the most common abnormalities were pulmonary contusion and pneumothorax. Figure 1 demonstrates a significant occurrence of scans using radiation for both imaging modalities. However, it is worth noting that most of these studies were performed on patients who had perfomed Velpeau bandages and tube thoracostomy. These therapies could be decided according to patients’ physical exam, as suggested by prior studies [9]. However, in our study, we found that the physical examination finding on the anterior chest wall did not predict a relationship with intrathoracic injury that may require further imaging. Because, even the most diagnosed pathology of our series, lung contusion, was not a life-threatening condition, and the higher rate of diagnosis did not affect the ongoing treatment [10].

Upon comparing the results of CXR and CCT between the group of patients with thoracic trauma and the groups without any medical intervention, it was discovered that the higher number of positive findings on CXR were specifically attributed to patients with clavicle fractures, as indicated in Table 4. As seen in the comparison between the cohort and the non-intervention group, it has also been observed that there is a high incidence of positive intrathoracic damage in the imaging results of patients in the non-intervention group, which does not require intervention. Given that lung contusion, which we can identify through imaging methods, heals without sequelae within 7 days, and asymptomatic pneumothorax also spontaneously resolves [11, 12]. Additionally, rib fractures heal within 6 weeks [13]. This situation indicates that patients not requiring intervention were also exposed to unnecessary radiation. Indeed, while evaluating the status of tube thoracostomy in patients with positive CXR and CCT results, it was determined that excessive radiologic imaging was conducted. The CCT scanning just verified the pathology observed on the chest CXR and did not result in any alteration in trauma care[14].

Another study, known as CCT, found even more pathological findings than CXR. However, the therapy of trauma only changed a minor fraction, despite the increased radiation exposure [4]. The study conducted by Aneta et al. found that emergency physicians had a higher frequency of requesting computed tomography for pediatric trauma compared to pediatric emergency physicians In our analysis, the primary cause for the elevated frequency of computed tomography scans was predominantly the evaluation of trauma patients by emergency physicians, who determined the necessity of employing this imaging modality. Another study [15], found that excessive tomography was performed due to the lack of an algorithm in pediatric trauma cases. Similarly, our study also lacked an approach for radiological imaging. Mhanna et al. observed that thoracic trauma cases requiring immediate attention can also be detected on chest X-rays (CXR). They also stated that computed tomography (CCT) increases the amount of radiation exposure [16]. Kharbanda et al. said that radiation exposure in pediatric trauma was primarily caused by computed tomography and was believed to have long-term detrimental effects [17]. More than half of the series in our sample utilized CXR and CCT scan. Due to the presence of emergency physicians in our trauma center, there was a lack of a systematic procedure or clinical rationale for determining which imaging techniques to use. Furthermore, the majority of the trauma patients exhibited cranial computed tomography (CCT), which is a component of panCT. We suggest that the evaluation of pediatric thoracic trauma should prioritize identifying urgent clinical conditions that require immediate intervention without the need for imaging scans. Once these conditions have been addressed, patients with thoracic trauma should be stabilized to ensure proper pulmonary function. If there is suspicion of intrathoracic injury, a chest X-ray should be performed as the initial diagnostic test. However, if there is no suspicion of thoracic injury, it is advisable to avoid performing a chest X-ray. The decision should be determined by the patient's clinical severity.

Our series of patients was evaluated using Glasgow Coma Scores, Pediatric Trauma Scores, physical examinations, and analysis of trauma causes. The majority of patients were determined to be in a stable condition. The findings also revealed that the patients with thoracic trauma were generally stable according to the standard trauma score systems [1, 3, 7, 18]. Proportion of male gender with penetrating mechanism was reached to 90.9% in our series. Predominancy of male gender and of mechanism blunt trauma was as similar [6].

There were limitations of this study. The retrospective study design is constrained by limitations such as the challenge of establishing causation and the incorporation of a lengthy time frame. The involvement of multiple clinicians in the treatment plan resulted in heterogeneity in decision making, leading to a range of imaging approaches. The evaluation of the decision makers' choice of imaging technology was not conducted. Moreover, the extraction of information from hospital records may have resulted in inadequate data. Therefore, it is crucial to consider these limitations while examining the results of the study.

Our study provides insights into the use of imaging techniques, notably chest radiography (CXR) and computed tomography (CT), in cases of thoracic trauma in children. Our findings indicate that CCT scans are more effective at detecting minor injuries, but their regular use may not have a major impact on decision-making on patient care. Although CT scans were able to detect additional pathology, such as pulmonary contusions and pneumothoraces, this did not significantly impact patient care or necessitate interventional therapies.

In addition, our study emphasizes the possible hazards linked to radiation exposure in children who receive imaging examinations. To reduce the amount of radiation exposure in situations of thoracic trauma in children, it is recommended that emergency physicians avoid utilizing computed tomography (CT) scans as the first diagnostic tool. They should also refrain from using chest X-rays (CXR) unless the patient's condition is stable. We recommend the implementation of an algorithm for children thoracic trauma to reduce both the radiation dose and cost.

Funding : This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interests: None

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The authors declare no competing interests.

Evaluation and Necessity of Imaging Modalities in Pediatric Thoracic Trauma: Balancing Clinical Benefits and Radiation Risks

Status:

Version 1

Abstract

Figures

Introduction

Methods

Criteria for Exclusion

Clinical Assessments

Statistical Analyses

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1