Pediatric IEP Newsletter article

1. The use of whole body computed tomography scans in pediatric trauma
patients: Are there differences among adults and
pediatric centers?☆,☆☆,☆☆☆
Viraj Pandit, Maria Michailidou, Peter Rhee, Bardiya Zangbar, Narong Kulvatunyou, Mazhar Khalil,
Terence O'Keeffe, Ansab Haider, Lynn Gries, Bellal Joseph ⁎
Division of Trauma, Emergency Surgery, Critical Care, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona, USA
a b s t r a c ta r t i c l e i n f o
Article history:
Received 6 June 2015
Received in revised form 30 November 2015
Accepted 3 December 2015
Available online xxxx
Key words:
Whole body CT scan in pediatrics
Scanning differences in adult and pediatric centers
Radiation risk in pediatrics
Scan utilization by trauma centers
Introduction: Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in
pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the
management of pediatric trauma patients.
Methods: We performed a two year (2011–2012) retrospective analysis of the National Trauma Data Bank. Pedi-
atric (age ≤ 18 years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck,
thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and
abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in
designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was
performed.
Results: A total of 30,667 pediatric trauma patients were included of which; 38.3% (n = 11,748) were managed in
designated pediatric centers. 26.1% (n = 8013) patients received a WBCT. The use of WBCT scan was significantly
higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p = 0.001). There was no dif-
ference in mortality rate between the two groups (2.2% vs. 2.1%, p = 0.37). After adjusting for all confounding
factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to
patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3–2.1], p = 0.001).
Conclusions: Variability exists in the use of WBCT scan across trauma centers with no difference in patient out-
comes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increas-
ing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of
WBCT across centers is warranted.
© 2015 Elsevier Inc. All rights reserved.
Trauma remains the leading cause of mortality in patients less than
46 years [1]. In an effort to better identify injuries, the use of computed
tomography (CT) has been widely accepted as a key element during
their initial assessment. CT scans are widely available, provide fast and
accurate diagnoses, and serve as a reliable guide for further manage-
ment. Moreover, physicians often rely on their use while assessing pedi-
atric trauma patients, since physical examination may be an unreliable
tool in identifying injuries.
Despite the advantages, the use of CT scan is associated with signif-
icant radiation risks [2], especially in the pediatric population [3–8].
Over the last decades, there has been a fivefold increase in the use of
CT scans in pediatric patients who present to the emergency depart-
ments (ED), with head injury being one of the most frequent indications
that prompts CT scan use [9]. Considering the alarming issue of
radiation-induced malignancy, a nationwide trend toward limiting the
use of CT scans and using alternative-imaging modalities instead has
been observed since 2008 [10,11]. In addition, several dose reduction
strategies have been developed, as well as algorithms that help identify
the subset of patients who would benefit most from advanced imaging
use [12–19]. Contrastingly on the other hand, recent evidence has sug-
gested the survival advantage of utilizing whole body CT scan as a diag-
nostic procedure in trauma patients with severe blunt injury [20–22]
and even in hemodynamically unstable patients or those who require
emergency bleeding control. However, the use of whole body CT scan
in pediatric patients remains unclear.
Journal of Pediatric Surgery xxx (2015) xxx–xxx
☆ Oral Presentation, Surgical Forum, American College of Surgeons, Clinical Con-
gress, San Francisco, California, October 2014.
☆☆ There are no identifiable conflicts of interests to report.
☆☆☆ The authors have no financial or proprietary interest in the subject matter or ma-
terials discussed in the manuscript.
⁎ Corresponding author at: University of Arizona, Department of Surgery, Division
of Trauma, Critical Care and Emergency Surgery, 1501 N. Campbell Ave, Room 5411, P.O.
Box 245063, Tucson, AZ, 85724, USA. Tel.: +1 520 626 5056; fax: +1 520 626 5016.
E-mail address: bjoseph@surgery.arizona.edu (B. Joseph).
http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002
0022-3468/© 2015 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery
journal homepage: www.elsevier.com/locate/jpedsurg
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences
among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002

2. Variations in CT scan utilization exist between pediatric and adult
trauma centers. Larson et al. observed an increased CT scan use in chil-
dren who presented to nonpediatric facilities [9]. Similarly, pediatric
trauma patients were twice as likely to undergo a CT scan of the cervical
spine at level I adult trauma centers compared to those who presented
to designated pediatric trauma centers [23]. Finally, children presenting
to a level I trauma center were more likely to receive whole body CT
(WBCT) compared to their adult peers [24].
The aim of this study was to compare the use of WBCT in pediatric
patients among adult and designated pediatric trauma centers by utiliz-
ing the National Trauma Data Bank (NTDB).
1. Materials and methods
We performed a two-year (2011–2012) retrospective analysis using
the NTDB, version 7.3. The NTDB is the largest aggregation trauma registry
data in the United States and contains more than 5 million patient records
contributed by more than 900 trauma centers. It is maintained by the
American College of Surgeons (Chicago, IL). In this study, we included pa-
tients aged less than 18 years, who underwent a head, chest, or abdominal
and pelvic computed tomography, and were managed in a level I or level
II trauma center. The trauma center designation (level I or level II) was de-
termined based on the American College of Surgeons (ACS) list of verified
trauma centers. Patients transferred from other institutions and patients
dead on presentation were excluded from our study.
We abstracted the following data points from the NTDB database:
demographics (age, gender, race, and ethnicity), vitals on presentation
(heart rate, systolic blood pressure, respiratory rate, and temperature),
type of injury (blunt and penetrating), mechanism of injury (motor ve-
hicle collision, falls, pedestrian struck, all-terrain vehicle accidents, stab
wound, gun shout wound), Glasgow Coma Scale (GCS) score on presen-
tation, intoxication details, CT scan utilization details (head, chest, abdo-
men and pelvis), ventilation days, hospital and intensive care unit
length of stay, and in-hospital mortality. Patient's injury characteristics
were abstracted utilizing the Injury Severity Score (ISS) and the Abbre-
viated Injury Scale (AIS) score. Patients were stratified into two groups
based on the center in which they were managed: adult trauma centers
(ATC) or designated pediatric trauma centers (PTC).
Our primary outcome measure was WBCT utilization. CT scan utiliza-
tion was abstracted from the NTDB utilizing the following ICD 9 procedure
codes: head CT (87.03, 87.04), thoracic CT (87.41, 87.42) and abdominal CT
(88.01). Patients with a combination of a head, chest, and abdominal CT
scan were considered to have undergone a WBCT CT scan. WBCT scan
use was compared between ATC and PTC. A subanalysis among adult cen-
ters was performed to compare for performance of WHCT between adult
level I and level II centers. We also compared the head CT, thoracic CT,
and abdominal CT utilization individually between ATC and PTC.
Data are reported as mean ± standard deviation (SD) for continuous
variables, median [range] for ordinal variables, and as proportions for
categorical variables. We performed Mann–Whitney U and student t
test to explore for differences in the two groups (ACT and PTC) for con-
tinuous variables, and chi-square test for categorical variables. Univari-
ate analysis was performed to identify factors predicting WBCT use in
pediatric patients. Factors with a p value ≤0.2 on univariate analysis
were utilized in a multivariate regression analysis. A p value b0.05
was considered statistically significant. All statistical analyses were per-
formed using Statistical Package for Social Sciences (SPSS, Version 21;
IBM, Inc., Armonk, NY).
2. Results
A total of 30,667 patients were included in the study of which, 38.3%
(n = 11,748) were managed in designated pediatric centers. The mean
age was 11.45 ± 6.2 years, 65.5% (n = 20,092) were male, mean systolic
blood pressure was 124.9 ± 20.6 mm of Hg, median GCS was 14 [13–15],
and median injury severity score was 10 [4–12]. The majority (89.8%,
n = 27,541) had blunt injury and motor vehicle crash was the most
common mechanism of injury (44.8%, n = 13,741). Table 1 compares
the demographics and injury characteristics of the ATC and PTC groups.
Patients managed in PTC were younger and more likely to be hypoten-
sive on admission compared to patients managed in ATC. There was no
difference in the admission GCS score, mechanism of injury, severity of
head, thoracic, or abdominal injury and total injury severity score be-
tween patients managed in ATC and PTC.
Table 2 demonstrates the CT scan performance in the study popula-
tion. Head CT scans were performed in 88.3% (n = 27,069) of the patients,
chest CT scans in 33% (n = 10,103), and abdominal CT scans in 49% (n =
15,043) of the patients. A total of 8008 (26.1%) received a WBCT. Patients
managed in ATC were more likely to get a whole body CT scan compared
to patients managed in PTC (p = 0.001). Table 3 demonstrates a
subanalysis of the CT scan performance in level I and level II ATCs. There
was no difference in head CT scan rate however level I adult trauma cen-
ters perform more thoracic and abdominal CT scans.
Table 4 demonstrates the outcomes among the study population.
Mean hospital length of stay was days 3.65 ± 2.5 days and a total of
30.5% (n = 9347) required ICU admission with a mean ICU length of
stay of 1.1 ± 1.2 days. 67.7% (n = 20,763) patients were discharged
home from the hospital. There was no difference in the hospital and
ICU length of stay as well as the discharge disposition among the
Table 1
Patient Characteristic by Group.
Characteristic Adult Center
(n = 18,919)
Pediatric Center
(n = 11,748)
p
Demographics
Age, years (mean ± SD) 12.9 ± 5.8 9.13 ± 6.1 0.01
≤5 years, % 17% 35% 0.01
6–11 years, % 12% 21.4% 0.001
≥12 years, % 71% 43.6% 0.01
Male, % 65.9% 64.9% 0.09
Race
Whites, % 67.3% 67% 0.58
Blacks, % 14.4% 13.9% 0.23
Hispanics, % 15.3% 16% 0.13
Intoxication, % 8.1% 7.6% 0.15
Vital Parameters
GCS, Median [Range] 15 [13–15] 15 [13–15] 0.61
GCS ≤ 8, % 8.3% 7.9% 0.1
ED SBP, (mean ± SD) 127.8 ± 20.5 120.4 ± 19.9 0.8
Hypotensive (SBP ≤ 90), % 3.1% 5.9% 0.001
ED HR, (mean ± SD) 102.1 ± 25.8 109.7 ± 29.3 0.7
Tachycardia (HR N 90), % 50.5% 50.1% 0.96
ED RR, (mean ± SD) 20.16 ± 7.8 22.9 ± 9.1 0.61
ED Temperature, (mean ± SD) 36.1 ± 0.3 36.2 ± 0.1 0.82
Injury Parameters
Blunt 90% 89.5% 0.16
Mechanism of Injury 0.6
MVC, % 45% 44.2% 0.17
Falls, % 17.6% 18% 0.35
Head AIS, Median [IQR] 2 [2–3] 2 [2–3] 0.45
Head AIS ≥ 3, % 34.7% 35.3% 0.28
Thorax AIS, Median [IQR] 1 [1–2] 1 [1–2] 0.71
Thorax AIS ≥ 3, % 18.3% 18.1% 0.65
Abdomen AIS, Median [IQR] 2 [2–3] 2 [2–3] 0.32
Abdomen AIS ≥ 3, % 16.8% 16.4% 0.17
ISS, Median [IQR] 10 [4–13] 9 [4–12] 0.22
ISS ≥ 25, % 9.8% 9.8% 0.79
Table 2
Computed Tomography Scans.
Adult Center
(n = 18,919)
Pediatric Center
(n = 11,748)
p
Whole Body CT Scan, % 31.4% 17.6% 0.001
Head CT Scan, % 88% 88.7% 0.09
Thorax CT Scan, % 39.8% 21.9% 0.01
Abdomen CT Scan, % 53% 42.7% 0.01
2 V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences
among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002

3. patients in the study population (Fig. 1). The overall mortality rate was
2.1% (n = 663). The mortality rate was similar among patients managed
in adult and pediatric trauma centers (p = 0.37). However patients re-
ceiving WBCT scan had a higher mortality rate compared to patients re-
ceiving selective scanning (3.6% vs. 1.6%, p b 0.001).
2.1. Factors associated with whole body CT scan utilization
Table 5 demonstrates the univariate and multivariate analysis for fac-
tors associated with usage of a whole body CT scan. On univariate analy-
sis, the following factors were linked to WBCT use: age ≥ 6 years, male
gender, intoxication, GCS score ≤ 8, hypotension and tachycardia on pre-
sentation, blunt injury, motor cycle collision, head, thoracic or abdominal
AIS ≥ 3, injury severity score ≥ 25 and management in an ATC. After
adjusting for age, GCS score, admission vital parameters, mechanism,
type and severity of injury, patients who presented in an ATC were 1.8
times more likely (OR: 1.8, CI: 1.3–2.1, p b 0.001) to undergo a WBCT scan.
2.2. Subanalysis for factors associated with usage of whole body CT scan in
patients managed in adult trauma centers: Comparing level 1 vs. level 2
adult centers
On assessing characteristics among patients between level 1 and
level 2 adult centers we found there was no difference in patient's age
Table 3
Computed Tomography Scans, Subanalysis of Adult Center.
Adult Level I
(n = 10,499)
Adult Level II
(n = 8420)
p
Whole Body CT Scan, % 33.2% 29.2% 0.001
Head CT Scan, % 88.6% 87.8% 0.08
Thorax CT Scan, % 41% 38.4% 0.003
Abdomen CT Scan, % 55% 50.4% 0.001
Table 4
Outcomes.
Adult Center
(n = 18,919)
Pediatric Center
(n = 11,748)
p
Hospital LOS, (mean ± SD) 3.62 ± 2.6 3.73 ± 2.3 0.46
ICU LOS, (mean ± SD) 1.1 ± 1.3 1.1 ± 1.2 0.83
Vent Days, (mean ± SD) 0.8 ± 0.4 0.7 ± 0.3 0.71
Discharge Disposition
Home, % 67.4% 68.2% 0.14
Rehabilitation center, % 7.15% 6.8% 0.31
Skilled Nursing Facility, % 0.6% 0.5% 0.25
Mortality, % 2.2% 2.1% 0.37
LOS, length of stay; ICU, intensive care unit; Vent, ventilation.
Fig. 1. Details of the Study Population.
3V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences
among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002

4. (p = 0.11), gender (p = 0.23), race (p = 0.45), GCS score (p = 0.51),
hypotension (p = 0.31), mechanism of injury (p = 0.67), and severity
of injury (p = 0.14).
On performing univariate analysis, age group 6–11 years (p = 0.03),
intoxication (p = 0.13), GCS score ≤ 8 (p = 0.01), hypotension (p =
0.02), tachycardia (p = 0.04), blunt injury (p = 0.02), head AIS ≥ 3
(p = 0.01), thorax AIS ≥ 3 (p = 0.02), abdomen AIS ≥ 3 (p = 0.02), in-
jury severity score ≥ 25 (p = 0.01), and management in adult level I cen-
ters (p = 0.001) were associated with usage of a whole body CT scan.
After controlling for all factors in a multivariate regression model, man-
agement in adult level I center was independently associated with
usage of a whole body CT scan (p = 0.01). Table 6 demonstrates the uni-
variate and multivariate analysis for subanalysis for factors associated
with use of a whole body CT scan in patients managed only in adult
level 1 and adult level 2 trauma centers.
3. Discussion
Significant differences in CT scan utilization exist between adult and
pediatric trauma centers that treat pediatric patients. Our study showed
that children presenting in adult trauma centers were 1.8 times more
likely to undergo a WBCT, compared to their peers who were treated
in designated pediatric centers, even after adjusting for type and sever-
ity of injury. Specifically relative head CT rates did not differ among pe-
diatric and adult trauma centers, thoracic and abdominal CT rates were
significantly higher in adult trauma centers.
Understating the causes for this variability in management and es-
tablishing protocols for minimizing the use of WBCT across centers
will standardize care.
In our study we found that WBCT scan utilization is different among
trauma centers with different levels and particularly different referred
population. Similarly, differences in imaging utilization among PTCs
and ATCs have been described in several other studies. Mannix et al. ob-
served more frequent utilization of cervical spine CT scans in children
presenting at level I adult trauma centers compared to those being eval-
uated in pediatric trauma centers, as well as an increase in CT scan rates
over their study period by non pediatric centers [23]. Similarly, the lib-
eral use of CT scans in the ED facilities has been mainly adopted by
nonpediatric centers [9]. Several factors may contribute to those ob-
served differences. Most importantly, adult centers may lack pediatric
CT protocols that adjust for patients' characteristics and limit radiation
exposure [18]. Additionally, nondesignated pediatric centers may
apply adult guidelines to presenting pediatric patients and may not be
familiar with different patterns of injury in children. Strength of our
study is that as a result of adjusting for confounding factors in analysis,
we had similar cohort of patients to compare. Subsequently we found
that the likelihood of performing a WBCT in ATC was higher, indepen-
dent of injury severity or pattern.
WBCT scan is advocated owing to survival benefit in adult trauma cen-
ters [20–22,25,26]. Caputo et al. in a metaanalysis showed that patients
undergoing a WBCT, despite having significantly higher ISS at baseline
compared with the group who received selective scanning, had a lower
overall mortality rate and a more favorable pooled odds ratio [22]. How-
ever there is a lack of knowledge regarding the utility of WBCT in pediatric
population and its relation to outcomes. In our study we could not find a
survival advantage between PTC and ATC, However patients undergoing a
WBCT compared to selective scanning had a higher mortality rate overall.
This may be because of selective approach to only perform a WBCT scan in
severely injured pediatric trauma patients.
Several authors have examined the use of alternative imaging mo-
dalities such as x-rays or ultrasound for identification of injuries
[16,27,17,28,29]. Although FAST has been proposed as an adjunct for
the evaluation of a pediatric trauma patient by the ACS, its clinical use-
fulness remains debated [28,29]. Furthermore, chest x-rays should serve
as the initial imaging modality in pediatric blunt trauma patients,
with thoracic CT only to be used in certain circumstances [16,30]. The
selective use of tube thoracostomy for the treatment of occult
pneumothoraces further supports those findings [12]. In addition, x-
ray is a reliable imaging study for identification of bone and soft tissue
injuries [27].
We found that CT scan rates of the chest and abdomen were signifi-
cantly higher in adult trauma centers. This finding is particularly impor-
tant as a possible association with increased survival can alleviate the
importance of perceived negative effect from excess radiation. In an ef-
fort to limit the CT use in pediatric trauma patients, several guidelines
and prediction models for clinically important injuries have been devel-
oped that recommend selective imaging based on mechanism of injury,
physical examination and laboratory data [13–15,19,31,32]. Holmes
et al. created a prediction rule based solely on history and physical ex-
amination that would rule out a clinically significant abdominal injury
Table 5
Factors Associated with Need for Whole Body CT Scan.
Univariate OR
(95% CI)
p Multivariate OR
(95% CI)
p
Adult Center 2.1 (1.5–3.6) 0.001 1.8 (1.3–2.1) 0.001
Demographics
Age
6–11 years 1.2 (1.1–4.1) 0.02 1.1 (0.91–3.4) 0.12
≥12 years 1.1 (1.05–2.3) 0.04 1.1 (0.79–2.9) 0.19
Male 1.2 (0.71–3.8) 0.18 1.1 (0.64–4.2) 0.41
Whites 1.3 (0.51–5.6) 0.36 – –
Hispanics 1.1 (0.76–3.2) 0.41 – –
Intoxication 1.5 (1.1–4.4) 0.04 1.4 (0.91–4.6) 0.11
Vital Parameters
GCS score ≤ 8 1.9 (1.4–6.2) 0.02 1.3 (1.2–3.9) 0.04
Hypotension (SBP ≤ 90) 1.4 (1.2–3.5) 0.03 1.2 (1.1–2.6) 0.04
Tachycardia (HR ≥ 100) 1.6 (1.1–4.7) 0.04 1.4 (0.94–3.1) 0.15
Respiratory Rate 1.3 (0.75–2.3) 0.51 – –
Temperature 1.1 (0.39–3.7) 0.66 – –
Injury Parameters
Blunt Injury 1.4 (1.2–2.9) 0.03 1.2 (0.98–2.3) 0.09
Mechanism of Injury
MVC 1.4 (1.1–5.1) 0.04 1.1 (0.82–3.1) 0.2
Falls 1.1 (0.72–5.9) 0.61 – –
Head AIS ≥ 3 1.3 (1.1–6.2) 0.02 1.2 (1.1–5.4) 0.04
Thorax AIS ≥ 3 1.8 (1.4–9.6) 0.04 1.5 (0.94–8.2) 0.09
Abdomen AIS ≥ 3 1.4 (1.2–4.7) 0.03 1.2 (1.1–3.1) 0.04
ISS ≥ 25 2.6 (1.5–4.4) 0.01 2.1 (1.3–5.8) 0.02
Table 6
Subanalysis of Patients Managed in Adult Centers.
Univariate OR
(95% CI)
p Multivariate OR
(95% CI)
p
Adult Level I Center 1.9 (1.2–3.1) 0.001 1.3 (1.1–2.8) 0.01
Demographics
Age
6–11 years 1.4 (1.1–3.5) 0.03 1.2 (0.98–2.9) 0.09
≥12 years 1.2 (0.81–2.1) 0.3 – –
Male 1.1 (0.84–4.2) 0.41 – –
Whites 1.3 (0.65–7.4) 0.62 – –
Hispanics 1.2 (0.88–5.4) 0.39 – –
Intoxication 1.4 (0.96–4.9) 0.13 1.2 (0.84–3.4) 0.24
Vital Parameters
GCS Score ≤ 8 1.5 (1.2–6.9) 0.01 1.2 (1.1–5.5) 0.03
Hypotension (SBP ≤ 90) 1.6 (1.4–5.8) 0.02 1.1 (1.05–4.2) 0.04
Tachycardia (HR ≥ 100) 1.4 (1.2–3.4) 0.04 1.2 (0.98–2.7) 0.12
Respiratory Rate 1.1 (0.62–2.9) 0.59 – –
Temperature 1.2 (0.55–2.3) 0.35 – –
Injury Parameters
Blunt Injury 1.5 (1.1–2.5) 0.02 1.1 (0.84–1.9) 0.13
Mechanism of Injury
MVC 1.3 (0.91–4.5) 0.31 – –
Falls 1.2 (0.69–3.2) 0.46 – –
Head AIS ≥ 3 1.6 (1.4–8.4) 0.01 1.4 (1.2–9.5) 0.03
Thorax AIS ≥ 3 1.4 (1.1–7.4) 0.02 1.1 (1.06–10.3) 0.04
Abdomen AIS ≥ 3 1.5 (1.1–3.9) 0.02 1.2 (1.1–4.5) 0.04
ISS ≥ 25 2.1 (1.8–6.4) 0.01 1.8 (1.4–7.2) 0.01
4 V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences
among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002

5. that would require surgical intervention, embolization or blood transfu-
sion [19]. Further studies have added abnormal laboratory data such as
hematuria and increased liver function tests to their models that would
predict blunt abdominal trauma [15,31]. However, in our study we
found no difference in survival between ATC and PTC in management of
pediatric patients. Similarly, Jindal et al. reported higher rates of WBCT
use in pediatric patients presenting with mild to moderate trauma com-
pared to their adult peers, without any difference in outcomes [24].
The reported rise in CT scan use in the pediatric population has
prompted several authors to emphasize the significant radiation exposure
and malignancy risk associated with its use [2,3,5,6]. Egan et al. noted an
important breast radiation exposure in female trauma patients who
underwent thoracic CT for spine clearance, a radiation risk that was sub-
stantially higher in children compared to adolescents [7]. Additionally, pe-
diatric trauma patients receiving more than two CT scans, including WBCT
scans, are being exposed to significantly higher radiation compared to
those undergoing less imaging [4]. Although we do not have data regard-
ing the amount of radiation exposure in PTC compared to ATC, our data
support reduction in use of CT scans in adult trauma centers as no survival
benefit is observed in an adjusted analysis from a national database.
In our study we defined pediatric patients with age ≤ 18 years as this
is the most widely used definition across multiple studies to define pe-
diatric patients. Furthermore, majority of the institutions reporting to
the NTDB have defined pediatric patients as age ≤ 18 years. We under-
stand that there remain variations across institutions for defining the
age cutoff for pediatric patients however; as the NTDB does not provide
institutional identifiers, we were not able to assess the age cutoff in each
institution which is a potential limitation of the database.
Ourstudyhas certainlimitations.AlthoughtheNTDB representsthelarg-
est trauma registry, our results maynot begeneralizablegiventhe retrospec-
tive nature of the database and missing data. Additionally, we were not able
to detect CT scan rates of the cervical spine as they currently lack an ICD 9
procedure code. Moreover, the clinical significance of the CT scan utilization
could not becaptured inthis study, i.e. we were not ableto examine how the
presence of the CT scan served as a guide for further management. We were
unable to assess the pediatric training of providers managing patients across
centers. We did not assess the causes for mortality in our patient population.
Despite these limitations, our study presents the largest study that examines
the WBCT utilization among pediatric and adult trauma centers.
4. Conclusion
Variability exists in the use of WBCT scan across trauma centers with
no difference in patient outcomes. Pediatric patients who underwent a
CT were more likely to be managed with WBCT in adult trauma centers
were, increasing their risk for radiation without a difference in out-
comes. Establishing protocols for minimizing the use of WBCT in pediat-
ric population across adult trauma centers may standardize trauma care
for the pediatric trauma patient.
Acknowledgements
No acknowledgements to make.
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5V. Pandit et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Please cite this article as: Pandit V, et al, The use of whole body computed tomography scans in pediatric trauma patients: Are there differences
among adults and pediatric cen..., J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.002