单纯的损伤机制不能作为在钝性小儿创伤中进行计算机断层扫描成像的唯一指征。
Mechanism of injury alone is not justified as the sole indication for computed tomographic imaging in blunt pediatric trauma.
机构信息
From the Department of Surgery, Denver Health Medical Center, University of Colorado, Denver School of Medicine, Denver, Colorado.
出版信息
J Trauma Acute Care Surg. 2013 Dec;75(6):995-1001. doi: 10.1097/TA.0b013e3182ab065b.
BACKGROUND
The liberal use of computed tomographic (CT) scanning during the evaluation of injured children has increased their exposure to the risks of ionizing radiation. We hypothesized that CT imaging performed for mechanism of injury alone is unnecessary and that serious or life-threatening injury is rarely identified.
METHODS
All pediatric blunt trauma team evaluations (age < 15 years) at a pediatric Level 2 trauma center over 72 months were reviewed. CT findings in patients with normal Glasgow Coma Scale (GCS) score, vital signs (VS), and physical examination (PE) (Group I) were compared with Group II (GCS score < 15), Group III (abnormal VS/PE), and Group IV (abnormal GCS score, VS/PE). Variables associated with any positive finding were entered into a multiple logistic regression model to assess for independent contributions. Each patient's total effective radiation dose from CT scans in millisieverts was calculated using an age-adjusted scale.
RESULTS
A total 174 children met trauma team activation criteria (mean [SD] age, 7 [5] years; 63% male; mean [SD] Injury Severity Score [ISS], 10 [10]). A total of 153 (88%) were imaged by CT (I, 54 of 66; II, 25 of 25; III, 49 of 57; IV, 25 of 26). No patient in Group I had a serious finding on CT compared with Group II (17 of 77), III (25 of 111), and IV (18 of 72). Mortality was 4%. Radiation dose (mSv) from CT was not different among the groups (I, 17 [14]; II, 29 [13]; III, 21 [16]; IV, 27 [17]). By univariate analysis, GCS score of less than 15 (p < 0.01) and respiratory rate of greater than 30 (p = 0.09) were associated with a positive CT finding. By logistic regression analysis, GCS score of less than 15 remained the only variable associated significantly with a positive finding (odds ratio, 6.7; 95% confidence interval, 3-14; p < 0.01).
CONCLUSION
In children imaged based only on mechanism, no patient had a serious positive finding but was subjected to radiation doses associated with an increased risk of future malignancy. The use of CT imaging in injured children in the absence of a physiologic or anatomic abnormality does not seem to be justified.
LEVEL OF EVIDENCE
Care management study, level IV.
背景
在评估受伤儿童时，计算机断层扫描（CT）的广泛应用增加了他们接触电离辐射风险。我们假设，仅为了明确受伤机制而进行 CT 成像没有必要，且很少能发现严重或危及生命的损伤。
方法
回顾了在小儿 2 级创伤中心 72 个月内所有接受小儿创伤团队评估（年龄＜15 岁）的患者。比较格拉斯哥昏迷量表（GCS）评分正常、生命体征（VS）和体格检查（PE）正常的患者（I 组）与 GCS 评分＜15（II 组）、VS/PE 异常（III 组）和 GCS 评分、VS/PE 异常（IV 组）患者的 CT 检查结果。将与任何阳性发现相关的变量输入多元逻辑回归模型，以评估独立贡献。使用年龄调整量表计算每位患者 CT 扫描的总有效辐射剂量（以毫西弗表示）。
结果
共有 174 名儿童符合创伤团队激活标准（平均年龄 7[5]岁，63%为男性，损伤严重程度评分[ISS]平均为 10[10]）。共有 153 名（88%）进行了 CT 成像（I 组 66 例中有 54 例，II 组 25 例中有 25 例，III 组 57 例中有 49 例，IV 组 26 例中有 25 例）。与 II 组（77 例中有 17 例）、III 组（111 例中有 25 例）和 IV 组（72 例中有 18 例）相比，I 组无一例患者 CT 检查有严重发现。死亡率为 4%。各组 CT 扫描的辐射剂量（mSv）无差异（I 组 17[14]，II 组 29[13]，III 组 21[16]，IV 组 27[17]）。单变量分析显示，GCS 评分＜15（p＜0.01）和呼吸频率＞30（p=0.09）与 CT 阳性发现相关。通过逻辑回归分析，GCS 评分＜15 仍然是与阳性发现显著相关的唯一变量（比值比，6.7；95%置信区间，3-14；p＜0.01）。
结论
在仅根据机制进行成像的儿童中，无一例患者有严重的阳性发现，但却接受了与未来发生恶性肿瘤风险增加相关的辐射剂量。在没有生理或解剖异常的情况下，对受伤儿童进行 CT 成像似乎没有理由。
证据水平
护理管理研究，IV 级。
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