Limiting thoracic CT: a rule for use during initial pediatric trauma evaluation

Despite increases in imaging guidelines for other body-regions during initial trauma assessment and the demonstrated utility of chest radiographs (CXR), guidelines for use of thoracic computed-tomography (TCT) are lacking. We hypothesized that TCT utilization had not decreased relative to other protocolized CTs, and mechanism and CXR could together predict significant injury independent of TCT.

We performed a retrospective review of blunt trauma patients ≤18 y.o. (2007-2015) at two level-1 trauma centers who received chest imaging. Baseline characteristics and incidences of body region-specific CT were compared. Injury mechanism, intrathoracic pathology, and interventions among other data were examined (significance: p<0.05).

Although other body-region CT incidence decreased (p<0.05), TCT incidence did not change (p=0.65). Of the 2951 patients, 567 had both CXR and TCT, 933 received TCT-only, and 1451 had CXR-only. TCT altered management in 17 patients: 2 operations, 1 stent-placement, 1 medical management, 9 thoracostomy tube placements, and 4 negative diagnostic workups. All clinically significant changes were predicted by vehicle-related mechanism and abnormal CXR findings.

TCT utilization has not decreased over time. All meaningful interventions were predicted by CXR and mechanism of injury. We propose a rule, for prospective validation, reserving TCT for patients with abnormal CXR findings and severe vehicle-related trauma.

Diagnostic study, Level III.