Injury, Int. J.

Care Injured 45 (2014) 164169

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Injury
journal homepage: www.elsevier.com/locate/injury

Radiation from CT scans in paediatric trauma patients: Indications, effective dose, and impact on surgical decisions
Michael H. Livingston a, Ana Igric a,c, Kelly Vogt a,b, Neil Parry a,c,d, Neil H. Merritt a,d,e,*
a

Division of General Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada b Acute Care Surgery and Surgical Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA c Division of Critical Care, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada d Trauma Program, London Health Sciences Centre, London, Ontario, Canada e Division of Paediatric Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 9 June 2013 Keywords: Paediatric Trauma Radiation Computed tomography Effective dose

Objectives: The purpose of this study was to determine the effective dose of radiation due to computed tomography (CT) scans in paediatric trauma patients at a level 1 Canadian paediatric trauma centre. We also explored the indications and actions taken as a result of these scans. Patients and methods: We performed a retrospective review of paediatric trauma patients presenting to our centre from January 1, 2007 to December 31, 2008. All CT scans performed during the initial trauma resuscitation, hospital stay, and 6 months afterwards were included. Effective dose was calculated using the reported dose length product for each scan and conversion factors specic for body region and age of the patient. Results: 157 paediatric trauma patients were identied during the 2-year study period. Mean Injury Severity Score was 22.5 (range 1275). 133 patients received at least one CT scan. The mean number of scans per patient was 2.6 (range 016). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common. The average dose per patient was 13.5 mSv, which is 4.5 times the background radiation compared to the general population. CT head was the most commonly performed type of scan and was most likely to be repeated. CT body, dened as a scan of the chest, abdomen, and/or pelvis, was associated with the highest effective dose. Conclusions: CT is a signicant source of radiation in paediatric trauma patients. Clinicians should carefully consider the indications for each scan, especially when performing non-resuscitation scans. There is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for patients with severe multisystem trauma. 2013 Elsevier Ltd. All rights reserved.

Introduction Computed tomography (CT) has become a fundamental part of the workup for patients with traumatic injuries. Some studies have advocated the use of pan-scanning in order to avoid missing injuries in severely injured patients [1]. In some centres, this practice has become routine for adult patients, and often carries over to the management of paediatric trauma patients. There is evidence that paediatric trauma patients are scanned even more

* Corresponding author at: London Health Sciences Centre, Victoria Hospital, Childrens Hospital of Western Ontario, 800 Commissioners Road East, London, Ontario, Canada N6A 5W9. Tel.: +1 519 685 8454; fax: +1 519 685 8465. E-mail address: neil.merritt@lhsc.on.ca (N.H. Merritt). 00201383/$ see front matter 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.06.009

liberally than adults, perhaps because of issues with communication or confusion over the typical pattern of injuries in children [2]. Over the last decade, there has been growing concern regarding the risk of malignancy due to the ionizing radiation associated with CT [35]. In 2001, Brenner et al. [4] used historical data from survivors of the atomic bomb to estimate the risk of fatal cancer to be approximately 1 in 1000 for children undergoing CT scans. The values reported varied signicantly with age, such that the risk of cancer in an infant was approximately 24 times as high as that of an adolescent, and up to 10 times as high as that of an adult. The attributable risk from a CT in a 1 year-old child was as high as 0.18% for scans of the abdomen and 0.07% for scans of the head. While this represents a very small increase over the background rate of malignancy, it is important to note that there are 7 million CT scans performed on children each year in the United States alone [6].

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Assuming a 1 in 1000 risk of malignancy, the number of future excess cancers due to CT scans may be as high as 7000 per year. There are several reasons for the higher risk of malignancy in children [6]. First, tissues that are growing tend to be more sensitive to ionizing radiation compared to those that are in a steady state and mature. Second, children have a lifetime ahead of them to manifest the oncogenic effects of ionizing radiation, whereas an older adult may die from other causes before the dose has a clinically signicant effect. Finally, if CT scan parameters are not appropriately adjusted for paediatric patients, the smallercross sectional area of a child results in a dose of radiation that is concentrated in smaller amount of tissue. This can result in a higher effective dose compared to the same scan in adults. The most useful means of assessing the radiation risk to a particular body area is the effective dose, expressed in millisieverts (mSv). The effective dose has been dened by the International Commission on Radiologic Protection as the single dose quantity reecting the overall risk to a reference person from any radiation exposure, where the risk is averaged over all ages and both sexes [7]. The effective dose from a single CT scan can be derived from scan parameters including scan length, pitch, tube current, and tube voltage [8,9]. The dose length product (DLP) is a scan-specic measure reecting the total dose delivered over a particular scan length, and can be used to estimate effective dose through the use of conversion factors for body region and age of the patient [1012]. The goal of this study was to quantify the total amount of radiation from CT scans received by severely injured paediatric trauma patients at our institution. Our institution is a Level I paediatric and adult trauma centre, which treats 7080 paediatric trauma patients with severe injuries per year (Injury Severity Score greater than or equal to 12). We hypothesized that paediatric trauma patients are receiving signicant doses of radiation, secondary to multiple scans, at the time of resuscitation, during their hospital stay, and an outpatient. We also explored reasons for each scan and determined, as accurately as possible, any follow-up action taken as a result of these investigations. Patients and methods This study received approval from the Research Ethics Board at our institution (Study Number 16522E). All patients were identied through our centres prospectively collected trauma database. We included all patients with: (1) age less than 18 years and (2) Injury Severity Score (ISS) greater than or equal to 12. Data were retrieved from both the trauma database and each patients electronic medical record. We included all CT scans that patients received at our centre during the initial resuscitation (dened as rst 4 h after admission), the remainder of the hospital stay, and 6 months following the trauma. Only scans performed at our centre were included in the analysis. The dose report accompanying each CT scan was used to identify the DLP. Published conversion factors were used to convert the DLP to effective dose (in mSv) [1315]. The reason for each CT was recorded as well as any action taken as a result of the scan. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 20. Results 157 paediatric trauma patients were identied during the 2year period. Our patient population was predominantly male (73%) with a mean age of 9 years 7 months (range 1 month to 17 years 11 months). Mechanisms of injury included blunt trauma (98%), penetrating trauma (1%), and burns (1%). The majority of our

Table 1 Summary of patient characteristics. CT Total Gender Male Female Age Mean Standard deviation Mechanism Blunt Penetrating Burn Presentation Direct Referred Injury Severity Score Mean Standard deviation Mortality Survivor Non-survivor 133 100 33 10y 7mo 5y 9mo 131 2 0 43 90 22.2 8.5 121 12 No CT 24 15 9 3y 10mo 4y 8mo 22 0 2 5 19 24.1 9.5 21 3 Total 157 115 42 9y 7mo 6y 1mo 153 2 2 48 109 22.5 9.6 142 15

patients were referred from other institutions (69%) rather than direct presentations (31%). Mean ISS was 22.5 (standard deviation 9.6) with an in-hospital mortality of approximately 10% (Table 1). Length of stay at our centre among the 142 survivors ranged from 1 to 111 days (mean 10 days). Only one patient was observed in the emergency department for 6 h and was not admitted to hospital. 133 patients received at least one CT scan. The number of scans per patient ranged from 0 to 16 with an average of 2.6 (Fig. 1). Excluding patients who were not scanned (n = 24), the average number of scans was 3.1. The most common type of scan was a CT head (104/133 patients, 78%), followed closely by scans of the body (73/133 patients, 55%). Body scans were dened as CT of the chest, abdomen, and/or pelvis. Other types of scans included CT spine (59/133, 44%), CT face (9/133, 7%), and CT of the extremities (3/133, 2%). In our study, CT of the extremities included scans of the elbow, shoulder, and knee. Total effective dose for all 157 patients ranged from 0 to 61 mSv (Fig. 2). The average radiation dose per patient scanned (n = 133) was 13.5 mSv (indicated by the black line in Fig. 2). Although the scan most frequently repeated scan was a CT head, the most signicant source of radiation was CT body (Table 2). Indications for scans included initial resuscitation (56%), reassessment of injury without change in clinical status (30%), and change in clinical status (13%) (Table 3). Most scans resulted in no further action (56%) or additional imaging (32%). A decision to

Fig. 1. Number of CT scans per patient.

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Fig. 2. Total effective dose per patient in millisiverts (mSv). Solid black line indicates the maximum recommended annual dose of 3.0 mSv.

perform a procedure (2%), surgery (8%), or withdrawal of life support (2%) was less common (Table 4a and b). Procedures included the placement or adjustment of an external ventricular drain (n = 8), placement of a subdural drain (n = 1), and splenic artery embolization (n = 1). Discussion Our study demonstrated that paediatric trauma patients are being exposed to signicant radiation as a result of CT scans. As shown in Fig. 2, the majority of patients included in this study received more radiation than what a typical person living in the United States is exposed to in an entire year (3.0 mSv) [16]. Some patients were exposed to a dose up to twenty times this amount. Among the 133 patients who had at least one CT scan, the average effective dose due to CT was 13.5 mSv. This is 4.5 times the background level.
Table 2 Number of CT scans and average dose per patient. Number of patients with resuscitation scans Heada Faceb Spinec Bodyd Extremitiese All scans
a b c d e

Recent studies of paediatric trauma patients have revealed similar levels of radiation [1721]. Kim et al. found a mean effective dose of 14.9 mSv in their study of 506 paediatric trauma patients [17]. Their study considered a variety of radiologic studies, including plain lm, uoroscopy, angiography, nuclear medicine, and CT. Interestingly, 97.5% of the total effective dose was due to CT. Similarly, Brunetti et al. found mean effective dose of 12.8 mSv, of which 91% was due to CT [18]. In a study of 75 paediatric trauma patients, Tepper et al. reported a mean effective dose of 11.4 mSv for CT scans done in the rst 24 h as part of the resuscitation [19]. On average, there was an additional 4 mSv of radiation for repeat CT scans done in the rst 6 days following admission for a mean total of 15.4 mSv. Mueller et al. reported a mean effective dose of 17.4 mSv for scans performed during the initial evaluation [20]. This study used dosimeters placed on the each patient to determine the effective dose, and may account for the higher reported estimate. More recently, Kharbanda et al. [21] used the National Trauma Data Bank to report a mean effective dose of 12.0 mSv among 26,360 paediatric trauma patients who underwent CT. The mean or median ISS in these ve studies ranged from 5.1 to 16 whereas ours was 22.5. We should also note that these studies considered scans from different time intervals. Some studies included scans from the rst 24 h [20,21], some from the rst 7 days [19], and others considered scans from the entire admission to hospital [17,18]. As mentioned previously, our study included CT scans from the initial resuscitation, hospital admission, and as an outpatient up to 6 months after the initial injury. Despite these differences, the values reported for effective dose were similar, ranging from 11.4 to 17.4. This is likely because the majority of the effective dose from CT is delivered in the rst 24 h following injury [19]. To the best of our knowledge, our study is the rst to describe the indications and actions taken as result of all types of scans. Cook et al. looked at reasons for repeat CT scans of the abdomen after transfer of paediatric trauma patients from other hospitals

Number of patients with non-resuscitation scans 43 2 2 20 1 58

Mean number of scans 2.1 1.6 1.1 1.4 1.3 3.1

Average dose per scan 3.1 1.6 1.7 9.8 4.2 4.7

Average total dose per patient 5.8 2.2 1.8 13.8 5.7 13.5

104 9 59 73 3 133

Head, head/face, CT angiogram head/neck, head/cervical-spine. Face. Cervical-spine, thoracic/lumbar-spine. Abdomen, pelvis, abdomen/pelvis, chest, chest/abdomen/pelvis. Elbow, shoulder, knee.

Table 3 Indications for CT scans. Resuscitation Heada Faceb Spinec Bodyd Extremitiese All scans
a b c d e

Reassess injury 79 11 4 22 3 119 (36%) (65%) (7%) (23%) (75%) (30%)

Change in clinical status 44 1 0 7 0 52 (20%) (6%) (0%) (7%) (0%) (13%)

Total 219 17 60 95 4 395

96 5 56 66 1 224

(44%) (29%) (93%) (70%) (25%) (56%)

Head, head/face, CT angiogram head/neck, head/cervical-spine. Face. Cervical-spine, thoracic/lumbar-spine. Abdomen, pelvis, abdomen/pelvis, chest, chest/abdomen/pelvis. Elbow, shoulder, knee.

M.H. Livingston et al. / Injury, Int. J. Care Injured 45 (2014) 164169 Table 4 (a) Action taken as a result of resuscitation scans. (b) Action taken as a result of non-resuscitation scans. No Intervention (a) Heada Faceb Spinec Bodyd Extremitiese All scans (b) Heada Faceb Spinec Bodyd Extremitiese All scans
a b c d e f g h

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Further imaging 34 1 2 21 0 57 (35%) (20%) (4%) (31%) (0%) (25%)

Surgery 12 1 0 3 0 16 (13%) (20%) (0%) (5%) (0%) (7%)

Procedure 4 0 0 1 0 6 (4%)f (0%) (0%) (2%)g (0%) (3%) (4%)h (0%) (0%) (0%) (0%) (4%)

Withdrawal of life support 6 0 0 0 0 6 (5%) (0%) (0%) (0%) (0%) (3%)

Total 96 5 56 66 1 224

41 3 54 41 1 139

(43%) (60%) (96%) (62%) (100%) (62%)

52 7 3 20 1 83

(42%) (58%) (75%) (69%) (33%) (49%)

53 5 1 7 0 66

(43%) (42%) (25%) (32%) (0%) (39%)

11 0 0 2 2 15

(9%) (0%) (0%) (3%) (67%) (9%)

5 0 0 0 0 5

2 0 0 0 0 2

(2%) (0%) (0%) (0%) (0%) (1%)

123 12 4 29 3 171

Head, head/face, CT angiogram head/neck, head/cervical-spine. Face. Cervical-spine, thoracic/lumbar-spine. Abdomen, pelvis, abdomen/pelvis, chest, chest/abdomen/pelvis. Elbow, shoulder, knee. Placement of external ventricular drain. Splenic artery embolization. Placement or adjustment of external ventricular drain, placement of subdural drain.

and found that 80% of these scans were unnecessary or preventable [22]. In our study, we were concerned to discover that many CT scans were repeated to reassess injury, rather than because of a change in clinical status. This happened most frequently in scans of the head. We were also concerned how frequently CT scans resulted in no further action or additional imaging (87% total). A decision to perform a procedure, surgery, or withdrawal of life support was much less common (13% total), even though these scans were performed on patients with severe injuries. There were no apparent differences in this trend when comparing imaging performed during the course of resuscitation (Table 4a) and in hospital or as an outpatient (Table 4b). One of the strengths of this study is that we considered CT scans up to 6 months after the traumatic event. As mentioned previously, other studies only considered CT scans performed during the rst week of admission [19] or during the initial evaluation [20,21]. Patients with severe injuries may have long and complicated stays in hospital as well as an outpatient. We therefore thought it would be important to extend our collection period to include scans performed during the initial resuscitation, hospital stay, and as an outpatient. Another strength of our design is the relatively short time period of 2 years. Practise patterns are unlikely to have changed in such a short period of time and our ndings likely give an accurate estimate of true practice at our centre. Finally, we should note that the effective dose was calculated using the DLP for each scan and applying age-adjusted factors. This more accurately captures the dose of each scan, rather than using a standard estimated dose and applying it to all patients who had this type of scan. For example, we did not assume an effective dose of 3.1 mSv for all CT scans of the head and apply it to all patients who had this investigation. We calculated a unique effective dose for all 395 scans included in our review. This is the same approach used by in similar studies by Kim et al. [17] and Tepper et al. [19]. There are several limitations to our study. First, we only considered radiation from CT. As mentioned previously, CT has been reported to contribute over 90% of the effective dose due to imaging in paediatric trauma patients [17,18,21], so our focus on CT is appropriate. Second, since our study did not capture CT scans performed outside our centre, the cumulative dose of radiation that these children were exposed to may be even higher than that

reported here. This is important for the reader to consider, since only 31% of our patients were direct presentations. Finally, and most importantly, we were unable to determine how many surgeries were prevented because of negative ndings on these scans. This is probably impossible to tell because there is no way of knowing how many patients who would have been considered for an exploratory laparotomy or some other invasive procedure in the absence of a negative CT scan. We also did not assess the degree to which scans with positive ndings may have impacted medical management. For example, we did not determine whether a CT scan of the head showing increased intracranial pressure resulted in the administration of mannitol or hypertonic saline. Up until recently, the evidence for CT scans leading to cancer was based mainly on data from survivors of the atomic bombs in Hiroshima and Nagasaki [4]. The validity of this methodology has been debated extensively in the medical literature [23]. One of the chief criticisms is that: Cancer risks at very low doses are uncertain and depend on extrapolating risks from atomic-bomb survivors who were exposed to high doses. The authors of the survivor study agree that estimating the risk of cancer from very low doses of radiation (less than 5 mSv) is uncertain, but have provided direct evidence that low doses (5100 mSv) are associated with a small but statistically signicant increase in the risk of cancer [4,23]. Despite this positive nding, other concerns remain: (1) the dose estimates from the atomic bomb itself are uncertain; (2) survivors of the atomic bomb were exposed to mainly gamma rays rather than x-radiation; and (3) there are different background rates of cancer in Japan compared to other parts of the world. These issues are discussed in detail elsewhere [24]. There is emerging epidemiological evidence that should also be considered. In 2012, Pearce et al. reported an excess risk of leukaemia and brain tumour in a cohort of 178,604 children who underwent CT scans in the United Kingdom between 1985 and 2002 [25]. This was the rst human epidemiological study to demonstrate that CT scans increase the risk of cancer. In the 10year follow-up, there was one excess case of leukaemia and one excess case of brain tumour per 10,000 CT scans of the head. Thus, the risk of developing a fatal cancer was estimated to be approximately 1 in 5000. This is comparable to the estimate of 1 in 1000 obtained from the atomic bomb data, which involved a

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longer follow-up (approximately 50 years instead of 10) and all types of malignancies (not just leukaemia and brain tumour). More recently, Matthews et al. reported increased rates of cancer in 680,211 people in Australia who underwent a CT scan during childhood and adolescence between 1985 and 2005 [26]. The risk of malignancy was compared to the general population of over 10 million people. Interestingly, there were not only higher rates leukaemia and brain tumour, but also melanoma, lymphoma, and tumours of the soft tissue, gastrointestinal system, urinary tract, thyroid, and female reproductive system. The excess risk was estimated to be approximately 1 in 2000. As expected, the reported risk is higher than that from the study from the United Kingdom because more cancers were considered. In light of these recent studies, there is now denitive evidence that CT scans cause a small but signicant increase in cancer. This is also suggests that the estimates provided by the atomic bomb survivor data are accurate. There are several ways to reduce the radiation associated with CT scans. First, clinicians and radiologists should be aware of the principles of the Image Gently campaign [27]. These include decreasing the voltage and current to a child-size dose, performing a single phase scan whenever possible, and scanning only the indicated area. They should also strive to keep radiation doses as low as reasonably achievable (ALARA) [28]. Strategies include developing weight-based protocols, improve shielding, performing focused or limited-view studies, discouraging repeat studies, and considering imaging modalities with less or no radiation, such as ultrasound and magnetic resonance imaging. Future research should focus on developing treatment algorithms to guide decision making for determining which scans should be performed. The Paediatric Emergency Care Applied Research Network (PECARN) performed a prospective cohort study of over 42,000 children to develop prediction rule for identifying children at very low risk of intracranial injury [29]. For those younger than 2 years, negative predictive value and sensitivity were 100%. In patients 218 years old, negative predictive value was 99.95% and sensitivity was 96.8%. Similar decision rules are available for cervical spine injuries [30,31]. The National Emergency X-ray Utilization Study (NEXUS) decision rule for cervical spinal injuries has a sensitivity of 100% in children greater than 8 years old [30]. Anderson et al. [31] developed a protocol to rule out cervical spine injuries in children aged 03 years. This approach uses CT and MRI selectively and did not miss any injuries in a sample of 575 young children with traumatic injuries. A rule for identifying intra-abdominal injuries has also been developed [32]. The sensitivity approached 95% and showed encouraging results. Unfortunately, these rules are not always applicable to paediatric patients with severe multisystem injuries. Consequently, clinicians are forced to use the adult-style pan scan (which results in increased radiation) or revert to an ad hoc approach of selective scanning (which may result in missed injuries). There is clearly a need for an all-encompassing screening tool to guide clinicians through these challenging decisions. Several studies have advocated for increased use of ultrasound, especially for the workup of abdominal injuries [3235]. This imaging modality has no radiation and can be brought into the trauma bay to at the time of the patients presentation. When combined with evidencebased clinical decision tools and laboratory investigations, ultrasound has great potential to decrease our reliance on CT in a way that is safe and evidence-based. Conclusions CT scans are a signicant source of radiation exposure in paediatric trauma patients. Clinicians should carefully consider the

indications for each scan, especially in cases of repeat imaging. They should also think carefully about how the results of these investigations may or may not impact patient management, since the majority of scans in this study resulted in no further action or further imaging. Finally, there is a need for evidence-based treatment algorithms to assist clinicians in selecting appropriate imaging for paediatric patients with severe multisystem injuries.

Conict of interest Each author certies that he or she has no commercial associations that might pose a conict of interest in connection with the article. Acknowledgements This work was supported by the Trauma Program at London Health Sciences Centre and by the Division of General Surgery at the University of Western Ontario. We dedicate this project to the memory of Dr. Murray Girrotti, who was an incredible teacher, an inspiring leader, and will be greatly missed by his friends and colleagues. References
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