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Risk Factors in Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign

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Risk Factors in Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign ORIGINAL RESEARCH Risk Factors in Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign Irma T. Ugalde, MD* *McGovern Medical School at The University of Texas Health Sciences Mary K. Claiborne, MD¶ Center, Department of Emergency Medicine, Houston, Texas Marylou Cardenas-Turanzas, MD, DrPH* †McGovern Medical School at The University of Texas Health Sciences Center, Manish N. Shah, MD§ Department of Diagnostic and Interventional Radiology, Houston, Texas James R. Langabeer II, PhD, MBA*‡ ‡McGovern Medical School at The University of Texas Health Sciences Rajan Patel, MD† Center, The University of Texas Health Sciences Center School of Biomedical Informatics, Houston, Texas §McGovern Medical School at The University of Texas Health Sciences Center, Department of Pediatric Surgery and Neurosurgery, Houston, Texas ¶Phoenix Children’s Hospital, Department of Pediatric Emergency Medicine, Phoenix, Arizona Section Editor: Paul Walsh, MD, MSc Submission history: Submitted June 19, 2018; Revision received September 5, 2018; Accepted September 22, 2018 Electronically published October 18, 2018 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2018.9.39429 Introduction: Computed tomography angiography (CTA) is used to screen patients for cerebrovascular injury after blunt trauma, but risk factors are not clearly defined in children.This modality has inherent radiation exposure. We set out to better delineate the risk factors associated with blunt cervical vascular injury (BCVI) in children with attention to the predictive value of seatbelt sign of the neck. Methods: We collected demographic, clinical and radiographic data from the electronic medical record and a trauma registry for patients less than age 18 years who underwent CTA of the neck in their evaluation at a Level I trauma center from November 2002 to December 2014 (12 years). The primary outcome was BCVI. Results: We identified 11,446 pediatric blunt trauma patients of whom 375 (2.7%) underwent CTA imaging. Fifty-three patients (0.4%) were diagnosed with cerebrovascular injuries. The average age of patients was 12.6 years and included 66% males. Nearly half of the population was white (52%). Of those patients who received CTA, 53 (14%) were diagnosed with arterial injury of various grades (I-V). We created models to evaluate factors independently associated with BCVI. The independent predictors associated with BCVI were Injury Severity Score >/= 16 (odds ratio [OR] [2.35]; 95% confidence interval [CI] [1.11-4.99%]), infarct on head imaging (OR [3.85]; 95% CI [1.49-9.93%]), hanging mechanism (OR [8.71]; 95% CI [1.52-49.89%]), cervical spine fracture (OR [3.84]; 95% CI [1.94-7.61%]) and basilar skull fracture (OR [2.21]; 95% CI [1.13-4.36%]). The same independent predictors remained associated with BCVI when excluding hanging mechanism from the multivariate regression analysis. Seatbelt sign of the neck was not associated with BCVI (p=0.68). Conclusion: We have found independent predictors of BCVI in pediatric patients. These may help in identifying children that may benefit from screening with CTA of the neck. [West J Emerg Med. 2018;19(6)961–969.] Volume 19, NO. 6: November 2018 961 Western Journal of Emergency Medicine Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign Ugalde et al. INTRODUCTION The incidence of head or neck vascular injury after Population Health Research Capsule blunt trauma ranges from 0.03-0.9% of pediatric injured 1-4 patients. Our focus is on blunt cervical vascular injury What do we already know about this issue? (BCVI). Without recognition and treatment, BCVI can result Computed tomography angiography (CTA) 4-6 in neurologic morbidity or death. A challenge in diagnosing can screen patients for blunt cervical BCVI is that symptoms may not initially present with focal, vascular injury (BCVI), but pediatric risk neurologic findings. Studies show there is often a delay in factors are not clear. Judicious CTA use is neurologic symptoms up to 10-72 hours after trauma in adults necessary in children. and children alike.7,8 Screening criteria for adults are well 9 established as described by the Denver and Memphis criteria. What was the research question? There are no clearly delineated risk factors for pediatric BCVI What are the risk factors for BCVI in children 10 nor standardized treatments. The current recommendations and is the seatbelt sign a reliable predictor? of the Eastern Association for the Surgery of Trauma (EAST) recommends that pediatric patients should be screened using What was the major finding of the study? 11 the same criteria as those in adult populations. Some but not all of the risk factors of Due to the often-occult presentation of these injuries pediatric BCVI are similar to those in adults. and paucity of research until recently, the true incidence, risk Seatbelt sign is not a predictor. factors and treatment regimens in pediatric BCVI are not certain. Yet a more generous screening regimen following the How does this improve population health? recommendations in adults may be problematic. Children are Findings contribute to evidence to clarify more susceptible to carcinogenic effects of ionizing radiation appropriate CTA screening with its inherent and they have a longer life expectancy during which cancer radiation exposure, for BCVI in children, 12,13 risk accumulates and can manifest. The standard radiation limiting the exposure to those at highest risk. dose of a brain and neck computed tomography angiogram (CTA) is about 16.400 millisieverts (mSv) while that of CT of the head is about 2.00 mSv.14 A goal in pediatric radiology and trauma is to use dose-reduction strategies to reduce the number of radiation-induced cancers.15 To comply with these goals and avoid radiation exposure when not warranted, a good screening adjunct radiographic studies for injuries including cerebral algorithm is needed to determine those at high risk of BCVI. hemorrhage, infarct on head imaging, facial fracture, cervical There is evidence that decision rules have helped decrease the spine fracture or ligamentous injury, basilar skull fracture, number of imaging studies in pediatric head trauma.16-18 clavicle fracture, thoracic spine fracture, rib fracture, and The purpose of our study was to determine the incidence scapula fracture. of BCVI along with risk factors and treatment regimens While ISS is not available in the trauma bay during an observed in the pediatric trauma patients at our Level I trauma evaluation we are using it here as a surrogate for degree center. We also set out to determine the significance of the of severity of trauma, which may be used along with other seatbelt sign in BCVI. factors to influence the decision to perform imaging on a patient (See Appendix A for data extraction form). These METHODS clinical and radiographic covariates were largely extrapolated The study was a hospital-based cohort, retrospective from those included in the Memphis, Denver and EAST review of patients less than 18 years of age in our trauma criteria to assess their significance in children. Data were registry with blunt trauma who had a CTA of the neck extracted from the trauma registry and the electronic medical performed from November 2002 to December 2014 in our record (EMR) and recorded in a secure database (See Level I trauma center. We grouped the patients into age Appendix B for trauma registry data abstraction methods). groups of less than 15 years and 15 years and older, as well Seatbelt sign represented blunt injury to the neck including as less than 2 years of age, 2-5 years, 6-14 years, and 15- deeper abrasions, hematoma, “seatbelt sign” or deep bruising 17 years of age. Among the patients who underwent a CTA of the neck. We separated mechanisms of injury into three of the neck, individual and clinical markers were recorded groups: motor vehicle collisions, other motorized vehicles, including age, sex, race, Glasgow Coma Scale Score (GCS), and other blunt injury. Two physicians each extracted data on mechanism of injury, Injury Severity Score (ISS), presence of all patients independently. Any inconsistencies were reviewed cervical bruit, seatbelt sign of neck, hanging mechanism, focal by both and reexamined in the EHR and a conclusion made. neurologic exam and presence of laceration. We reviewed Our outcome of interest was arterial injury of the neck. Western Journal of Emergency Medicine 962 Volume 19, NO. 6: November 2018 Ugalde et al. Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign The images and electronic medical record of the patients found A p-value <.05 (two-tailed) was considered statistically to have BCVI in our cohort were queried for type of vessel significant in all tests. We performed all analyses with IBM damaged and mode of treatment in addition to the parameters SPSS software (version 23). mentioned prior. Vascular injuries were characterized as the following: internal carotid artery, common carotid artery, and RESULTS vertebral artery. Mode of treatment included observation, aspirin, During the study period, 13,735 pediatric trauma patients anticoagulation, and surgical intervention, including endovascular less than 18 years of age were evaluated in the emergency stenting and ligation. The observation group included those who department and entered into the trauma registry. Of these, had collaterals negating need for intervention, those for whom the 11,446 suffered blunt injuries (83.3%). The 375 (3.3%) positive radiological report was felt to be artifact by the treating children who experienced blunt trauma and underwent physician, or patients for whom observation was the dominant screening with neck CTA were included in this study. Fifty- management strategy. This group also included the patients who three patients were diagnosed with cervical vascular injuries died within 48 hours of presentation for devastating head injury. (0.5% of all pediatric blunt trauma patients evaluated in the Each patient was assigned to the highest grade of injury when study period; 14% of all blunt trauma patients screened with more than one lesion was present and to the most aggressive CTA).
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