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ืืืืฉืื ืืืืืง ืืืขืืื.9ืชืื ืืง ืื ืืืื ืืงืื ืคืขืืืื ืืจื ืืืขืชื ืืืืื ืืืขืช ืืื
ืืืื ืืื ืขืจื ื ืืืืื ื.
ืืื ?GCS ืืขืจืืช ื-ืืฉืืจืจ ืืืืชื ?
? CTืืืืืื ืืืฉืืื ืืืืื ืืกืคืจ ืฉืขืืช ?
ืฉืขืืช ?24ืืืฉืคื ื-
ืื ืืกืืืื ืืืืื ืชืื ืืืืืืืชืืช?
ืืื ืื ืจืคืืืืืื ืื ืจืคืืื
ืืืื ืช ืืฉืจืื - ืืฉืจื ืืืืืื ืืขื ืืื ื ืืืจืืืืช
ืืจืืืืช
ืื ืืื: ืื ืืืืช ืงืืื ืืืช ืืืืคืื ืื ืคืืขื ืืืืช ืจืืฉ ืงืื ืืืขืืืข ืืื
1999 ืืืืงืืืืจ 25
????
ืืื ืืืื ืืืืืื ืืงืืืฆื ื ืคืจืืช
2001 >>> 2005We now have more evidenceโฆ
Schutzman SA et al. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines.
Pediatrics. 2001;107:983-993Simon B et al. Pediatric minor head trauma: indications for computed
tomographic scanning revisited .J Trauma. 2001;51:231-238
Palchak MJ et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma .
Ann Emerg Med. 2003;42(4):495-506Dunning J et al. A meta-analysis of variables that predict significant
intracranial injury in minor head trauma. Arch Dis Child. 2004;89:653-659
2001 >>> 2005We now have more evidenceโฆ
Palchak MJ et al. Does an Isolated History of Loss of Consciousness or
Amnesia Predict Brain Injuries in Children After Blunt Head Trauma?
Pediatrics. 2004;113:507-513
Reed MJ et al. Can we abolish skull x rays for head injury?
Arch Dis Child. 2005;90:859-864
Macgregor DM et al. CT or not CT- that is the question. Whether it is better to evaluate clinically and x ray than to undertake a CT head scan.
Emerg Med J. 2005;22:541-543
Pediatric MHI โ Adult MHI
?Occult ICIืืื ืฆืขืืจ ืืืืื ืืืจื ืกืืืื ืืฉืืขืืชื.๏ฟฝ๏ฟฝ
ืื ืื ืื ื ืคืืื ืฉืื ื: ืืืชืจ ื ืคืืืืช ืืืืจืืืช, ื ืคืืื ืืืื ืืืืจื, ื ืคืืื ืืขืืื/ืืืกื
ืืื ืืื ืืื ื ืชืื ืื ืจืืืื ืื ืืชืื ืืงืืช
ืืืืช ืจืืฉ ืืืืื ืช )ืืชืขืืืืช( ืืื ื ืกืืื ืืคืฉืจืืช ืืืืืช ืจืืฉ ืืชืื ืืงืืช
ืืงืจืื ืืืืืืื - ืืืื' ืืืืื ืขื ืืืืืช ืืจืื ืืืช ืืืื ืฉืืชืืง ืืืืื, ืืืืื ืขื ืคืืืืจ ืืืื,
ืืืืื ืขื ืฉืื ื ืืืจื-ืคืจืืชืื ืืื
Pediatric Minor head injury
ืืกืืื ืื ืืืกืืืคืืืืื ืฉื ืคืืืขื ืชืื ืืืืืืืชืืช ืืืื ืืฆืขืืจ ืื ืืขืืชืื ืขืืื ืื
ืืื ืงืืื ืืืืื ื. ืืืืืงื ืืืืคื ืืช )ืืืคืจื ืืืืืงื
ืื ืืืจืืืืืืช( ืฉื ืืชืื ืืง ืฉืื ื ืืื ืฉื ืืืืืืจ ืืืื ืชืืืื ืืืื ืืืกืืืืืก
ืืืชืคืชืืืชื ืฉืื
Occult ICI ?
Clinical Indicators of Intracranial Injury in Head-injured InfantsGreenes and Schutzman
Pediatrics 1999;104:861-867
A 1-year prospective study of all infants younger than 2 years of age presenting to a pediatric ED with head trauma
Occult ICI ?
Only 16/30 (52%) subjects with ICI had at least one of the following clinical symptoms or signs of brain injury: loss of consciousness, history of behavior
change, seizures, emesis, depressed mental status, irritability, bulging fontanel, focal neurologic findings, or vital signs indicating increased
intracranial pressure. 14/30 were asymptomatic
Of the 14 asymptomatic subjects with ICI, 13 (93%) had significant scalp hematoma
Occult ICI ?
Clinical signs of brain injury are insensitive indicators of ICI in young infants
A substantial fraction of infants with ICI will be detected through radiographic imaging of otherwise asymptomatic infants with
significant scalp hematomas
Asymptomatic infants older than 3 months of age who have no significant scalp hematoma may be safely managed without
radiographic imaging
ืจืืคืืื ืฉืืื ื ืืืืื ืื ืืืืืงืช ืชืื ืืงืืช: )ืืคืจื ืืื' ืื ืืืจืืืืืืช(
โ ืขืืืืื ืืืขืืช ืืืืืื ืืืืช ืจืืฉ ืืฉืืขืืชืืช ืื
ืืืืชืจืืชCTืืืจืืืช ืืืืฆืืข ืืืืงืืช โ
ืืืื ืืคืืืืืจื:CTืืืืงืช โ ื ืืฉืืช ืืืืจื ืกืืืื ืงืจืฆืื ืืื ื ืขืชืืื
)ืืื ื ื ืืืืช ืกืืืื ืื. ืืื ืืืชืจ?( ืืืจืฉืช ืกืืฆืื โ
Whatโs the problemโฆ. Lets CT them all โฆ
Paterson A, Frush DP, Donnelly LF. Helical CT of the body: are settings adjusted for pediatric patients?
AJR Am J Roentgenol.2001; 176 :297 โ301
Brenner DJ, Elliston CD, Hall EJ, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT.
AJR Am J Roentgenol.2001; 176 :289 โ296
Donnelly LF, Emery KH, Brody AS, et al. Minimizing radiation dose for pediatric body applications of single-detector helical CT.
AJR Am J Roentgenol.2001; 176 :303 โ306
Derived from 50-year follow-up of atomic bomb survivors, medical exposures )especially radiation oncology( and occupational exposures
Whatโs the problemโฆ. Lets CT them all โฆ
Estimated risks of radiation-induced fatal cancer from pediatric CT. Brenner D, Elliston C, Hall E, Berdon W
Am J Roentgenol 2001; 176:289-96
โAssessment of the lifetime cancer mortality risks attributable to radiation from pediatric CTโ
In the United States, of approximately 600,000 abdominal and head CT examinations annually performed in children under the age of 15 years, a
rough estimate is that 500 of these individuals will ultimately die from cancer attributable to the CT radiation
Radiation Risks and Pediatric Computed Tomography )CT(: A Guide for Health Care Providers )20/08/2002(
Radiation exposure is a concern in both adults and children. However, there are two unique considerations in children:
1. Children are considerably more sensitive to radiation than adults, as demonstrated in epidemiologic studies of exposed populations.
2. Children also have a longer life expectancy, resulting in a larger window of opportunity for expressing radiation damage.
Radiation Risks from CT in Children is a Public Health Issue
EXAM TYPE RELEVANTORGAN
APPROXIMATEEQUIVALENT DOSE TORELEVANT ORGAN (mSv)*
Pediatric Head CT ScanUnadjusted Settings**)200 mAs, neonate(
Brain 60
Pediatric Head CT ScanAdjusted Settings**)100 mAs, neonate(
Brain 30
Pediatric Abdominal CT ScanUnadjusted Settings)200 mAs, neonate(
Stomach 25
Pediatric Abdominal CT ScanAdjusted Settings)50 mAs, neonate(
Stomach 6
Chest X-ray )PA/lateral( Lung 0.01 / 0.15
Screening Mammogram Breast 3
* The lowest equivalent doses for which increased cancer risks were observed in A-bomb survivors were in the range of 50 to 200 mSv (5 to 20 rem).
** "Unadjusted" refers to using the same settings as for adults. "Adjusted" refers to settings adjusted for body weight.
โฆ. All physicians who prescribe pediatric CT should continually assess its use on a case-by-case basisโ
โโฆ.. it is important to limit CT radiation by following the ALARA )as low as reasonably achievable( principle. There is a variety of
strategies to limit radiation dose, including performing only necessary examinations, limiting the region of coverage, and adjusting individual CT settings based on indication, region
imaged, and size of the childโฆโ P. Frush, L. F. Donnelly, and N. S. Rosen. Computed Tomography and Radiation Risks: What Pediatric Health Care Providers Should Know. Pediatrics, October 1, 2003; 112(4): 951 - 957
the Radiologist:
The ER doc:
Risk Minimizers vs. Test Minimizers
"ืื ื ืคืงืฉืฉ ืืืื"- "ื ืืฉื ืืื ืืืืื" -ืกืื ืช ืงืจืื ื ืืืืื ืืืจืื - ืืขืืืช ืกืืฆืื - ืืื- ืขืืืช-
- ืคืืืช ืงืจืื ื ืืื ืฆืืจื ืืกืืฆืื- ืืื- ืืื ืขืืืช ืืืื"ื- ืกืืืื ืืืชืจ ืืืื ืืืขืืช-
ืืืจืื, ืขืืจืื ืืื, ืื ืืืช ืืืืช ืืืืื ...
ืืขืฉืืช ""ืกืืื
"ืื ืืขืฉืืช ืกืืื"
Factors Associated with Intracranial Injury
Historical of Exam Finding Comment
LOC Marginal PPV for detecting ICI
Emesis Marginal PPV for detecting ICI
Scalp Hematoma (< 2y/o) Good PPV for ICI
Facial Injury Marginal PPV for detecting ICI
Decreased GCS (from 15) Good PPV for detecting ICI
Headache Marginal PPV for detecting ICI
Focal neurologic deficit High PPV for ICI
Amnesia Marginal PPV for detecting ICI
*
Factors Associated with Intracranial Injury Historical of Exam Finding Comment
Irritability Marginal PPV for detecting ICI
Bulging fontanelle High PPV for detecting ICI (not common)
Clinical signs of skull Fx
) depressed or basilar(
High PPV for ICI
Age > 1 y/o Increased risk for ICI (expert consensus)
Age > 3 months High risk for ICI (expert consensus)
Progressively worsening vomiting Increased risk for ICI (expert consensus)
High energy mechanism of injury
)fall from height, MVC(
High risk for ICI (expert consensus)
LOC > 1 minute Increased risk for ICI (expert consensus)
ืืืืฉื ืืืืจ"ื ืืืืืืช ืจืืฉ ืืื ืืจืืืช ืืืืืื
( - ืืืืฆืืช ืืื ืจืื"ื ืืืืกืคืช ืคืจืง 99ืืื ืื ืจืคืืื ืื ืืฉื ืืืืืช ืจืืฉ ืงืืืช )ืฉื ืช *ืคืืืืืจื
ืืชืืืืืช ืงืืื ืืืช - ืชืจืฉืื ืืจืืื โ ืืืืฉื ืืืืจ"ื ืืืืืืช ืจืืฉ ืืื ืืจืืืช ืืืืืื -
ืกืจืื ืืืืืืื ืืืชืื ืืื - - ืืฃ ืื ืืืืช ืืืืจืื )ืืคื ื ืฉืืจืืจ(
:ืืืืืฆืืช ื ืืชืื ืขื ืืื ืืขืื ืืืืืืช ืฉืืืงืื ืืฆืืจื ืืืกืคืช ืืคืจืง ืืคืืืืืจื. ืืืขืื ืืืื ืืช *.ื"ืจ ืืื ืืืกืื, ืื"ืจ ืืื ืืจืื"ื, ืืืจ"ื ืืจืื ืจืคืืื "ืฉื ืืืืจ" ืืืืืื, ืคืชื ืชืงืื
ืืจืื ืจืคืืื "ืืืืคืกืื", ืืืืื, ื"ืจ ืืืจื ืื ืืืืื, ืืื' ืืจืคืืื ืืืืคื ืืืืื ..ื"ืจ ืืืกื ืืืืจ, ืืืจ"ื ืืจืื ืจืคืืื "ืฉื ืืืืจ" ืืืืืื, ืคืชื ืชืงืื
ืืจืื ืจืคืืื "ืืกืฃ ืืจืืคื", ืจืืฉื"ืฆ, ื"ืจ ืขืจื ืงืืฆืจ, ืืื' ืืจืคืืื ืืืืคื ืืืืื .ื"ืจ ืขืจื ืื ืืืจ, ืื' ืืืจืืืื, ืืจืื ืจืคืืื "ืจืื"ื", ืืืคื
.ื"ืจ ืืื ืคืืืื, ืืื' ืื ืืืจืืืืจืืจืืื ืืืืื, ืืจืื ืจืคืืื "ืฉืืื" ืชื ืืฉืืืจ .ื"ืจ ืืืกื ืื ืืจื, ืืืืืื ืืืืคืื ื ืืจืฅ ืืืืื ืืืืจ"ื ืืืืื, ืืจืื ืจืคืืื "ืื ื", ืชื ืืืื.ื"ืจ ืืืชื ืฉืืื, ืืื' ืืจืคืืื ืืืืคื, ืื"ื "ืืืืืจ" ืืืืืื, ืืจืื ืจืคืืื "ืจืื"ื", ืืืคื
ืคืจืืค' ืืฉื ืจืืื, ืื"ืจ ืืืืขืฆื ืืืืืืืช ืืืจืืืื, ืืืืืืฆืืช ืืืขืื ื ืฉืืื ืื"ืจ ืืฆืืง ืืจืืืืืฅ, ืืฉื ื ืืื ื"ื ืืฉืจื ืืืจืืืืช
ืืืืจ ืืืืงืช ืืืื/ืชื ืืืืจ ืืืืื ื ืืฆื ืื ืืกืืืจืืช ืืืืื ืืืืืช ืืื ืงืื ื ืืืืชืจ ืืืื ื .ืืฆืืืงื ืืฉืคืื, ืืืื ืืื/ืืื ืฉืืืจืจ/ื ืืืืชื
ืืขืืชืื ื ืืืจืืช ืืืืชืจ
ืกืืื ื ืืืื ืื ืืืคืืขืื ืืืืืืจ ืืืฉ ืืืืืช ืขืจื ื ืืืชืคืชืืืืืช ืื ืืฉืื ืืืื ืืืฆื. ืืืฉื ืขืฉืจืื : ืืืจืืข ืืฉืขืืช ืืจืืฉืื ืืช ืืืืจ ืืืืื ืืฉ ืืฉืื ืื ืืืืคืขืช ืืกืืื ืื ืืืืื
ืืงืืืช ืืืืจืชืฉืื ืื ืืืชื ืืืืช )ืืืื ืืืืื ืื ืืฉื ืื ืืืช( ืื ืฉืื ืื ืืืฆื ืืืืจื
ืืืคืขืช ืคืจืืืกืื )ืืชืืืืฆืืืืช(ืืืคืขื ืคืชืืืืืช ืฉื ืืืืื ืื ืขืืืื ืื ืืฆืืื
ืืืืื ืืืืฃ ืื ืืืืืืืืืฉืช ืื ืื ืจืื
ืืืคืขื ืคืชืืืืืช ืฉื ืืืื ืจืืฉ ืขืืื ืื ืืฉืืืฉ ืจืืื
.ืืื ืืืช ืืืชืคืชืืืืืช ืืื ืืฉ ืืืืืจ ืืืืืืช ืืืืืงื ืืืืจืช ืืืืจ ืืืืื:ืืืืื ืืืชืขืืจืจืืช ืฉืืืืช ื ืืชื ืืคื ืืช ื
'ืืืจ ืืืื ืืืจืื ืืจืคืืื, ืื. ืฉืขืืช ืืืฉืืจืืจ48ืืื ืืงืจื ืืฉ ืืคื ืืช ืืจืืคื ืืืืืื ืื ืืจืืคื ืืืฉืคืื ืืืืืงื ืืืืจืช ืชืื
Take home messages.โฆ
Physicians trained in the physical examination of young children should see these kids
Good history (high energy mechanism?) and a thorough physical examination is the key:Isolated HI? GCS 13-15 ? Scalp hematoma ?
Ottorhea? Rinorhea ?Depressed skull ? #
Does the neurological examination compatible with the age of the baby?