Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, CA 90027, USA.
Am J Emerg Med. 2012 Jan;30(1):115-23. doi: 10.1016/j.ajem.2010.10.033. Epub 2011 Feb 5.
We sought to describe the use of radiographic studies in pediatric major trauma patients and determine the extent to which a selective, clinically guided use of imaging contributes to delayed diagnosis of injury (DDI).
We conducted a retrospective chart review of 324 consecutive pediatric major trauma patients at our level 1 trauma center. One radiologist reviewed all imaging. Delayed diagnosis of injury was defined as detection after more than 12 hours. Equivalency testing was performed to compare radiology use in patients with and without DDI.
Twenty-six (8%) of 324 patients had 36 DDI; 27 (75%) of 36 were orthopedic injuries. Median time to DDI detection was 20.5 hours (interquartile range, 15-60.5). During initial evaluation, DDI patients had similar numbers of plain radiographs (3.5 vs 3, P = .54) but more computed tomographic (CT) scans (4 vs 3, P = .03) compared with patients without DDI. Sixteen percent of all patients received CT thorax; 55%, CT cervical spine; and 56%, CT abdomen. Only 1 clinically important DDI was detected solely on the basis of a later CT scan (0.3%; 95% confidence interval, 0-1.5). No cervical spine, intrathoracic, or intraabdominal DDI was attributable to failure to obtain a CT during initial evaluation. Patients with DDI had higher injury severity scores, intubation rates, and pediatric intensive care unit admission rates than those without DDI.
Patients with DDI had similar initial plain x-ray evaluations to patients without DDI, despite DDI patients being more severely injured. Delayed diagnosis of injury was not attributable to inadequate CT use. Most DDIs were orthopedic, highlighting the importance of a tertiary survey and a low threshold for skeletal radiographs.
本研究旨在描述小儿严重创伤患者的影像学检查使用情况，并确定有选择地、临床指导下使用影像学检查是否会导致创伤后延迟诊断（DDI）。
我们对我院 1 级创伤中心连续收治的 324 例小儿严重创伤患者进行了回顾性病历分析。一位放射科医生对所有影像学检查结果进行了审核。DDI 定义为在超过 12 小时后才发现的损伤。采用等价检验比较了 DDI 患者和无 DDI 患者的影像学使用情况。
324 例患者中有 26 例（8%）发生了 36 例 DDI；36 例中 27 例（75%）为骨科损伤。DDI 检测的中位时间为 20.5 小时（四分位间距，15-60.5）。在初始评估中，DDI 患者的平片数量相似（3.5 与 3，P=0.54），但 CT 扫描数量更多（4 与 3，P=0.03）。所有患者中，16%接受了胸部 CT 检查，55%接受了颈椎 CT 检查，56%接受了腹部 CT 检查。仅 1 例具有临床意义的 DDI 是仅基于后期 CT 扫描发现的（0.3%；95%置信区间，0-1.5）。初始评估时未行 CT 检查，并未导致颈椎、胸内或腹内 DDI 的漏诊。与无 DDI 患者相比，DDI 患者的损伤严重程度评分、插管率和儿科重症监护病房收治率更高。
尽管 DDI 患者的损伤更严重，但 DDI 患者的初始平片评估与无 DDI 患者相似。DDI 的发生并不是因为 CT 检查使用不足。大多数 DDI 为骨科损伤，这突出了进行三级检查和对骨骼 X 线检查持低阈值的重要性。
