Pediatric CT Guidelines

Pediatric CT Guidelines After Blunt Trauma

David Ray Velez, MD

Table of Contents

CT Head
CT Cervical-Spine
CT Chest
CT Abdomen/Pelvis

*CT Utilization in Pediatric Blunt Trauma Remains an Evolving and Often Debated Topic

Imaging Decisions Should Be Guided by Institutional Protocols, History/Exam, and Clinical Judgment

The PECARN Guidelines are Generally the Most Well Validated and Widely Adopted Among Available Pediatric Clinical Decision-Making Tools

Children are more susceptible to ionizing radiation than adults because of greater tissue radiosensitivity and longer life expectancy. CT should therefore be obtained only when the expected diagnostic benefit outweighs the potential radiation risk, following the ALARA (As Low As Reasonably Achievable) principle.

CT Head

PECARN (Pediatric Emergency Care Applied Research Network)

Age < 2 Years Old

High Risk Factors (4.4% Risk of Injury) – CT Recommended:

  • Altered Mental Status
  • GCS < 15
  • Palpable Skull Fracture

Intermediate Risk Factors (0.9% Risk of Injury) – Consider Observation vs CT:

  • Loss of Consciousness ≥ 5 Seconds
  • Non-Frontal Hematoma – Scalp Hematoma Anywhere Except the Forehead
  • Not Acting Normally
  • Severe Mechanism
    • Fall > 3 ft
    • MVC with Ejection, Death of Passenger, or Rollover
    • Unhelmeted Pedestrian or Bicyclist Struck by Vehicle
    • Head Struck by High Impact Object

Very Low Risk (< 0.02% Risk of Injury) – Avoid CT:

  • No Risk Factors Above

PECARN (Pediatric Emergency Care Applied Research Network)

Age ≥ 2 Years Old

High Risk Factors (4.3% Risk of Injury) – CT Recommended:

  • Altered Mental Status
  • GCS < 15
  • Signs of Basilar Skull Fracture

Intermediate Risk Factors (0.9% Risk of Injury) – Consider Observation vs CT:

  • History of Loss of Consciousness
  • History of Vomiting
  • Severe Headache
  • Severe Mechanism
    • Fall > 5 ft
    • MVC with Ejection, Death of Passenger, or Rollover
    • Unhelmeted Pedestrian or Bicyclist Struck by Vehicle
    • Head Struck by High Impact Object

Very Low Risk (< 0.05% Risk of Injury) – Avoid CT:

  • No Risk Factors Above

Other Algorithms/Guidelines

  • CATCH (Canadian Assessment of Tomography for Childhood Head Injury)
  • CHALICE (Children’s Head Injury Algorithm for the Prediction of Important Clinical Events)
  • Palchak Clinical Prediction Rule

Additional Factors Used in Other Imaging Guidelines

  • Some Emphasize Progressive Symptoms Rather than Single Events
  • GCS < 15 at 2 Hours After Injury
  • Amnesia > 5 Minutes
  • Tense Fontanelle
  • Clinical Suspicion for Non-Accidental Trauma (NAT)

CT Cervical-Spine

PECARN (Pediatric Emergency Care Applied Research Network)

High Risk Factors (12% Risk of Injury) – Consider CT:

  • GCS 3-8 or APVU = U (Unresponsive)
  • Abnormal Airway, Breathing, or Circulation
  • Focal Neurologic Deficits

Non-Negligible Risk Factors (3.6% Risk of Injury) – Consider X-Rays:

  • GCS 9-14, APVU = V (Verbally Responsive) or P (Painfully Responsive), or Other Sign of Altered Mental Status
  • Self-Reported Posterior Midline Neck Pain or Neck Tenderness on Examination
  • Substantial Head or Torso Injury (Defined as Warranting Inpatient Observation or Surgical Intervention – Such as Skull Fracture, PTX, Solid Organ Injury, T/L-Spine Fracture, or Sacral/Pelvic Fracture)

Negligible Risk (0.2% Risk of Injury) – Clinically Clear without Any Cervical Spine Imaging:

  • No Risk Factors Above

Other Algorithms/Guidelines

  • NEXUS (National Emergency X-Radiography Utilization Study) – Primarily Used in Adults and Not Well Validated in Pediatrics
  • Canadian C-Spine Rule – Primarily Used in Adults and Not Validated in Pediatrics
  • PCSCWG (Pediatric C-Spine Clearance Working Group)
  • TAC (Trauma Association of Canada)
  • PEDSPINE
  • AANS/CNS Guideline
  • Leonard Clinical Prediction Model

Additional Factors Used in Other Imaging Guidelines

  • Torticollis/Abnormal Head Position
  • Limited Cervical Range of Motion
  • Distracting Injuries
  • Intoxication

Imaging Options

  • CT
    • The Gold Standard Radiographic Test for High-Risk Patients
  • X-Ray
    • Preferred Series: Three-Views (Lateral, Anterior-Posterior [AP], and Open-Mouth Odontoid [When Able])
    • Flexion-Extension Views Generally Add Little, But May Be Used if CT and Traditional X-Ray Series are Negative
  • MRI
    • Generally Not Used as the Initial Imaging
    • Preferred if Evaluating for Ligamentous Injury or if Clinically Indicated Despite Normal X-Rays and/or CT

CT Chest

There Are No Widely Accepted or Validated Pediatric CT Chest Algorithms

Most Centers Perform an Initial Chest X-Ray and Reserve CT for Stable Patients with Abnormal X-Ray, Concerning Clinical Findings, or Suspected Major Thoracic Injury Based Upon Institutional Protocols and Clinical Judgment

General Indications

  • Abnormal Chest X-Ray Suggesting Significant Thoracic Injury
  • Persistent Hypoxia or Respiratory Distress Not Explained by Chest X-Ray
  • High Suspicion of Major Thoracic Injury
  • High-Energy Mechanism with Concerning Exam Findings

General Management Guidelines (Not CT Decision Making Specific Protocols)

  • ATLS (Advanced Trauma Life Support)
  • EAST (Eastern Association for the Surgery of Trauma) Guidelines
  • NEXUS (National Emergency X-Radiography Utilization Study) Chest
  • ACR (American College of Radiology) Appropriateness Criteria

CT Abdomen/Pelvis

Abdomen/Pelvis is More Complex

  • PECARN Has an Excellent Negative Predictive Value (NPV) for Identifying Intraabdominal Injury Requiring Acute Intervention (IAI-I)
  • PECARN May Miss Minor Intraabdominal Injuries (IAI) – Most Commonly Low-Grade Solid Organ Injuries

Institutional Protocols Often Include PECARN Risk Factors, Labs, UA, FAST, and Plain Films

General Indications

  • History/Exam:
    • Altered Mental Status or Unreliable Examination with History Suggestive of Intraabdominal Injury (IAI)
    • Abdominal Pain or Tenderness
    • Abdominal Wall Bruising/Seatbelt Sign
    • Vomiting
  • Labs:
    • AST > 200 IU/L
    • ALT > 125 IU/L
    • Lipase/Amylase – Elevated Above Upper Limit of Normal
    • Urinalysis – Showing Hematuria
  • Additional Imaging:
    • Positive or Equivocal FAST
    • CXR
  • Associated Major Injuries:
    • Significant Thoracic Injury
    • PTX/HTX
    • Pulmonary Contusions
    • Long Bone Fractures

PECARN (Pediatric Emergency Care Applied Research Network)

  • Risk Factors:
    • Evidence of Abdominal Wall Trauma or Seatbelt Sign
    • GCS < 14
    • Abdominal Tenderness
    • Abdominal Pain
    • Vomiting
    • Thoracic Wall Trauma
    • Absent or Decreased Breath Sounds
  • Patients Without Any Risk Factors are at Very Low Risk for an Intraabdominal Injury (IAI) Requiring Acute Intervention (IAI-I) – Defined as Laparotomy, Embolization, Blood Transfusion for Abdominal Hemorrhage, Hospital Admission ≥ 2 Nights, or Death Due to Abdominal Injury

Other Algorithms/Guidelines

  • Holmes Model – Early Derivation Study Formed the Basis of the PECARN Rule
  • Streck Model – Includes Exam, and Labs, and CXR but Not Widely Validated
  • BATiC (Blunt Abdominal Trauma in Children Score) – European Score Including Exam, Labs, and FAST but Limited External Validation and Minimal Adoption Outside of Europe

Additional Management Guidelines (Not CT Decision Making Specific Protocols)

  • ATOMAC (Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium) Consensus
  • EAST (Eastern Association for the Surgery of Trauma) Guideline
  • APSA (American Pediatric Surgical Association) Guidelines