Abdominal Evaluation: Pediatric Trauma Series 2017

Did you know the number one killer of our kids is one that most of us don't even think about traumatic injuries. It accounts for more childhood deaths than all other causes combined. That's why we started the Children's Institute to save kids' lives. We need to add our voice to the voice of others to help let the world know that it's not acceptable for more of our kids to die from injury than from everything else. So this is all about saving. Not thousands of kids, although that's what we want to do, right? It's really about making a difference in that one child. It is a simple recipe. It's a recipe that's been followed in lots of other diseases and to raise public awareness. We need to attract people into the field. We need to train specialists to treat this problem. We need to get the, get the treatment which is most effective for preventing these deaths out and available to the public and that treatment is, is trauma center care and where possible pediatric trauma center care and we need to do the research and do the science to find better treatments for kids that have serious injuries. The Children's Institute is a group of people uh with a common mission, uh, which is to eliminate death and disability from injury to children. It allows the community physician an opportunity to hopefully save the child's life. And get them to the point that they can be sent to a pediatric facility and if we achieve that goal, we've been successful. We need research funding. Unfortunately, the NIH does not recognize trauma as a disease, and the funding that our society spends on doing research for the number one killer of kids is frankly an embarrassment. You know, adult trauma does get plenty of press and, uh, energy, effort, resources. Pediatric trauma doesn't, and I, I don't know why that is. Children's Institute is committed to creating a network that is capable of studying the treatments and injured kids to find which treatments are better, which treatments are worse, so that that if we can't prevent the injury and the injury still occurs, we could still save those children. We can do something about life-threatening injuries to kids. We can make the country aware just how big this problem is by getting the smartest and most important people in the world to work on this problem. And to make our government leaders realize this is a disease that needs their attention. No one wins alone. That's why we need you on this team. Kids need you on this team to help fight this problem. If we can save one child, it's worth it. The Children's Institute can do it. Our goal is not only for Cincinnati Children's to provide the best care to an injured kid, we want all injured kids to have the best outcome possible. The Pediatric trauma Transformation Collaborative is our effort to really help educate and partner with other hospitals to make sure injured kids are receiving the best care possible. The idea came from some of the folks at the American College of Surgeons who suggested to Saint Mary's, who was our first partnering hospital, that they talk to us about how to improve their pediatric trauma program. Saint Mary's and Cincinnati Children started the collaboration in 2007 when to be re-verified as a pediatric trauma center, it was then a requirement to have a pediatric surgeon. We did not have a pediatric surgeon on staff at the time. We have a group of adult trauma surgeons who care for our pediatric patients, but with this new requirement, we took an alternate pathway to get a pediatric surgeon off site. We established a relationship where they would act as our pediatric surgeon. And act as a director of the performance improvement program, which is key to achieving verification. The process for the program is really like the name says, it's, it's collaborative so we learn from them, they learn from us as well. Same flow sheet regardless. So there's several phases to it. We do our simulation training is really focused on teamwork and communication around pediatric trauma patients. We run them through trauma simulations, patients that are really modeled after our patients. We've even used patients. That they've seen in their emergency room and developed simulations directly around a patient that they really saw so it's not just a made up scenario for them. When we learn processes here, it energizes our staff to take them back to our organization and make change, implement change in things that we do for our pediatric population, improve care for our pediatric population, and overall improve the patient experience. There's a natural reluctance to change, and that was the way it was in the beginning. But after the ball got rolling, after we brought a few people over, after we infected a few, then it was a parade. Now we have a waiting list of people who want to come to Cincinnati. Another pieces we help with their trauma performance improvement process, so they will review cases. I will link to them via video conference most of the time and then during that meeting, which is their multidisciplinary trauma team meeting, go over issues and and opportunities for improvement. The whole concept of trauma is based on a trauma system plan, getting the right patient to the right place in the shortest amount of time. What the relationship with Cincinnati has allowed is allowed patients that can stop with us to stop with us. Patients that historically would have been shipped out of Evansville to a higher level of care no longer shipped. And that has greatly improved not only the patient care but life for the family. And the final pieces we're available really 24/7 for if they have a patient that they have questions about, concerns about, they can reach us by phone. We can get online, look at some of the images if we need to go over plans with them. I think it's going to change the way we do trauma care in this country because there aren't enough pediatric surgeons, and if you don't have enough pediatric surgeons. Then you need to create a bond, a bridge to a facility that has the best, and Cincinnati is one of the best in the world. I think any hospital that wants to be a pediatric level 2 trauma center should jump at the opportunity to join with Cincinnati Children's. We are now verified as a pediatric trauma center via the alternate pathway with Cincinnati Children's for a pediatric surgeon component. We were just reviewed for the 2nd time using this model, and our reviewers had nothing but positive things to say about the collaboration and the relationship and the benefits that we had received from our relationship with Cincinnati Children's. I've been a professor of surgery at two different medical schools. I've been a vice chairman. I've been to war. I led my unit in Desert Storm, and yet this thing that we've accomplished, Saint Mary's, is as big an accomplishment as anything I've ever done. Our goal is not to take over people's trauma programs. Our goal is to make sure kids get better and have the best possible outcome they can. All right. Good evening or good afternoon, depending on, or good morning, depending on where you are. Um, I'm Rich Falcone here in Cincinnati at Cincinnati Children's. Um, and we're excited to have our first of a series of three, trauma talks. This one will be on the abdomen. Our next Next one next month. Um, stay tuned for will be on, uh, AMO or Gun Policy and Gun Prevention, Violence Prevention strategy. Unfortunately, a very important topic right now. And then in January, we'll have another one on, uh, child abuse evaluation and how do you talk to families. So, um, we hope those of you that are on come back uh for those events, um, and share with others, uh, that might be interested in, in our, in care for children to come join us. So with that, I'm gonna introduce our two panelists. Um, I'll do a little introduction and they can further introduce themselves when they, um, start. But we have Chris Streck from the Medical University of South Carolina, beautiful Charleston where we just had our, uh, pediatric trauma Society meeting. Um, Chris is at a, it's, it's a state-verified level one pediatric trauma center combined with an adult trauma center, and he's gonna give us the up to-date on the pediatric literature about which abdomens to scan and how to evaluate the pediatric abdomen. And then we have Roberto Iglesias from Evansville, Indiana, St. Vincent's Hospital. They're a level 2 adult in a level 2 pediatric facility, but they're a pediatric facility that works without constant pediatric surgical involvement. So the majority is managed, or almost all of it is managed by the adult surgeon. So he's going to give Perspective of the adult surgeon who's trying to care for children and the challenges they face, um, and the differences in the adult literature a little bit versus the pediatric literature on who to scan and who to image. Um, and, we hope to have questions from all of you, um, and some debate between the two of them and, and all of us on to, to understand this challenging topic at times. So with that, I'm gonna have Chris further introduce himself and we'll pull up his slides and we'll get started. So first we'll have to get Chris to unmute himself. All right, hey, thanks, Rich, and uh thanks uh to Roberto for being a co-panelist. I am here in Charleston, South Carolina. And as Rich said, uh, this is a, uh, PS, uh, trauma center. Uh, so we, um, the pediatric surgeons and the pediatric EM physicians, uh, do all of the initial evaluation of the trauma patients. The title of the presentation is basically who needs a CT scan following blunt abdominal trauma. Um, Can I have control of the slides? See, or maybe just advance. Oh, yeah. So I'm gonna present uh two cases, and they're patients from the same vehicle and uh try to highlight what I think are salient points about um who needs abdominal imaging and uh who you might be able to safely avoid imaging in. So the first patient is a 6 year old male. He was a restrained backseat passenger in a motor vehicle collision. His, uh, car hit a tree head-on. Uh, there was no reported loss of consciousness. He was, uh, by report from EMS hemodynamically stable en route. In our, uh, trauma system, we have a tiered trauma activation. Uh, Level A is the, um, the highest level. These are the typically the unstable patients or the intubated patients, patients that have a need for emergent, uh, intervention, and then, uh, level B, uh, are typically, um, called that way, um, based on their mechanism of injury. So this patient was a level B activation on primary survey. His airway was patent. He had a respiratory rate of 27, Blood pressure was 111/81, heart rate 131. By Broslow, he was roughly 20 kg and had a GCS of 15. On the secondary survey, he had some mild midline cervical tenderness to palpation. He had uh some moderate abdominal tender tenderness to palpation over a, um, obvious seatbelt contusion. And then, uh, in general, the abdomen was soft, maybe slightly distended, but no obvious peritoneal signs. Next, This is uh a picture of his abdomen. You can see here highlighted, uh, the seatbelt contusion. The head is over here to the left, uh, of the screen, and here the umbilicus, uh, pretty standard, um, seatbelt contusion, uh, that we see, uh, periodically in the, uh, children, particularly if they're, um, not properly restrained. And let's see, next slide. Can we advance? Or maybe not. So that I'll just continue to talk while we're fixing the slides, but the second patient in the vehicle uh was an 11-year-old female. She was a restrained backseat passenger, same vehicle, car versus tree. She was found slumped under the driver's seat. Uh, she did have a reported loss of consciousness, also was hemodynamically stable en route. And presented again as a level B trauma activation. Primary survey, her airway was patent. Her respiratory rate was 28, Blood pressure 84/36, heart rate 118. Uh, 35 kg roughly and GCS of 15. She also had some mild, uh, midline C-spine tenderness to palpation. Uh, she had on, uh, examination of the oropharynx, several fractured incisors, a minor lip laceration. Her midface was stable, and a fairly normal abdominal examination. Uh, next slide. So, um, questions, uh, for co-surgeons or for the audience. Um, how would you have, uh, considered this patient in terms of, uh, activation level? Do you routinely order labs in the trauma bay when you're, uh, doing an assessment of this type of patient? Uh, are these patients, do you order plain films? And if so, what are they? Um, in your center, are they, the labs and imaging standardized by the activation level? Uh, or is it dependent on, um, whether the ED physician or the surgery resident or the adult trauma surgeon or the trauma surgeon happens to be at the bedside. And then finally, um, is this somebody that you would get a fasting? And if you do fast, who performs the fast and who interprets it? And does it really impact your management decision? Uh, so maybe we hear from the panelists and Rich if, um, there are questions or comments, uh, we want to hear them. Yeah, great. So, um, we do have a, uh, the first comment I had was just, uh, that yes, abdominal ultrasound. I don't know. I'm trying to get an answer whether that was for both and yes. They said the abdominal ultrasound for both and that came from, uh, Colombia actually. Um, so, um, Roberto, why don't, why don't you let us know what you, you know, from the adult standpoint, where, why don't you start and I'll kind of add in as well what I think. Certainly, um, now we're saying from an adult perspective, uh, seeing this child, yeah, that comes in, yes, so, I, I do think that it matters as to who sees the patient. Um, honestly, I think that, uh, for the most part, um, our, my, my partners and the trauma surgeons, if we get to the bedside where I think a lot more conscientious, uh, about being conservative with regards to CT scan. Um, and whereas I think we're trying to teach our ER emergency room colleagues, uh, to be a little bit more judicious and when the UCT scans. Uh, and so, I think if one of us gets to the bedside first, we're, we'll, we'll sort of triage and guide whether this kid gets a C, this child gets a CT scan or not. Uh, but if we happen to show, you know, we're in the OR, we get tied up, and we don't get there for 30, 45 minutes, the CT scan is probably already gonna be done for us just because of the seatbelt sign. Um, and I'll tell you, I think one of the interesting things is, if there is a seatbelt sign and there's a seatbelt sign. This, this, this is a perfect picture of a seatbelt sign, but frequently, and I think one of the challenging ones is when a, a child comes in and they have bilateral iliac crest seatbelt sign. I think that should be managed somewhat differently than a true seatbelt sign, which is clearly across the abdomen from a surgeon's perspective. I think that's a great point, Roberta, and hopefully we'll kind of get into a little more of that discussion because that's certainly a piece, even at a peed center that comes up with, with residents. Um, when do you, what's a seatbelt sign, a little abrasion over the iliac crest. That's probably not the same as that picture that, that Chris just showed us that I think raises all our concern a little bit. Um, higher. So I think in our center, cause these would both probably be kind of mid-level activations, um, cause we do mostly based on physiology. So their physiology seemed pretty normal, um, in both of these kids. Um, we don't routinely get labs on, I mean, we get type and screen and a, and an ISA on, on everybody, but we don't routinely get, which I think you'll talk about a little more, kind of the traditional abdominal labs on everybody. Um, we generally just get a chest X-ray, um, as our routine. We don't, uh, we don't routinely get pelvic films, um. If I had to kind of just at this point of the discussion, I'd say we'd probably CT the lap belt kid and we'd probably either simply observe or get some labs on the, the second child. Fast is a whole discussion that I think we'll get to, get into as we go forward a little more probably, but um I don't think I would fast either one of these kids right now. Roberto, do you selectively fast or do you fast everyone and does it depend on activation level? It uh depends on activation level and really in, in children, we tend not to fast, most children because I, I, I do think that uh the data does not support fasting of children, um, as well as it does uh for adults. And I think that has to do with the fact that in order to find a good amount of, in order to do a good fast and find blood, you need to have, they say, the literature says really that about 200 cc's of blood. Um, have to be in the abdomen. Now, we're not even talking about the retroperitoneum. The retroperitoneum is a whole another ballgame. That's very challenging in and of itself. Um, most fasts are not gonna be able to pick up, uh, a significant amount of retroperineal blood. Uh, so 200 cc's of blood, especially in a young kid, is a lot of blood. Uh, and they're typically not going to, uh, present, uh, in a stable situation if they have that much blood in their abdomen. So by and large we do not fast children, but in adults we do. We're pretty liberal with level one. So our level one activations or highest activations we do, uh, we use fast quite a bit. Great. So we'll kind of get more to that. There's one other comment from, uh, a couple. There are a couple of people that said we don't do fast for our pediatric patients, um, as well, um, but that sometimes it's done by the, the ED physicians regardless. But as the pediatric surgeons answering, say they don't, they don't do it. So why don't I let you move along, Chris, and we'll kind of talk more. Can we get the next slide? And I will say at our center, uh, all the patients get a fast, and that's largely because the, um, residents cover both adult and Pete's trauma. And so they're walking across uh to the PDD and basically, um, continuing the same practice that they've been uh trained to do. So the first case, the brother with the seatbelt contusion, hematocrit was 37, his AST was 49, the lipase was normal, uh, base deficit and lactate were not performed, and he had a normal chest X-ray. Uh, next slide was the sister. Uh, she had a hematocrit of 42, and AST of 222. A normal lipase and, uh, again, base deficit and lactate not performed. And on chest X-ray, she had some uh very small, uh, pulmonary contusions. Uh, so, uh, next slide, um, uh, so the kind of the follow-up questions we've eluded this a little bit is who needs, uh, an abdominal, uh, CT. So it sounded like, uh, Roberto, you probably would have scanned the kid with the seatbelt contusion. Would you have scanned, uh, this little girl? With the elevated AST, uh, and pulmonary contusions, but otherwise fairly unremarkable physical exam. Yeah, I, I think we would, we would scan that child as well. And how about you, Rich? So I, I think based on the, the AST would make me probably scan that second child as well. I would have scanned the first child regardless based on that abdominal bruising. So the labs on the first child don't really change my opinion at all, um, but the labs on the second child, I think do influence, uh, my decision. All right. And so those are kind of my follow-up questions. Question 2 is hemodynamically stable patient with tenderness and a seatbelt contusion. I think we would all agree that that patient likely needs a scan. And then, uh, there's some data I'm gonna present um and follow up about screening labs with the idea, uh, that you may be able to avoid CT in some patients, uh, by ordering, uh, imaging. And then finally, we didn't present this patient. What if you have an intubated patient that had a serious MVC but has a normal physical exam and all their labs are normal? Does that patient need a CT scan? Roberto, you want to take that first. We do have some, most people. You know, we heard from a couple of people in the chat that said they'd CT both patients at this point, um, and then if the patient's intubated, they use they would abdominal CT. So Roberto, you want, what would you guys do? Yeah, you know, I, I think one of the things that frequently gets glossed over is mechanism of Injury. Uh, if you have a significant mechanism of injury, then, uh, I would be more liberal with scanning a child that, um, you know, uh, that, that presented is, and is intubated and they can't get, you can't get a reliable physical examination, um, if they had a significant mechanism of injury. If they had a mild injury and they may have aspirated. Um, and they may have a head injury, but not necessarily, you get no other measures of injury that they had a blow to the abdomen, they didn't get kick punched or, or anything of that sort, then I don't think you necessarily need a, an abdominal workup, but I would, I do think that's where abdominal, uh, labs. Come in. I think your AST, ALT, and lipase really come into play. And I would say that the lactate plate, lactate-based deficit also plays a major role in deciding whether a follow-up CT scan would be required down the road, uh, maybe not necessarily immediately, but within the, you know, next hour or when the labs come back. All right, so I agree. I mean, I, I think the, you know, I think the intubated patient is certainly the challenge. I think what you had in quotes on that prior slide is quote, serious, I think, is part of that discussion, how worried am I based on the mechanism. I think it's important though. I don't know that everybody that's intubated from uh NBC or other reason absolutely needs the CT, but I think you need to weigh those pieces. Sure. All right, so we did scan the patient, um, with the seatbelt contusion and this is, there are two cuts, they're very similar cuts, but representative cuts. So, uh, I don't know, can you guys see me moving the mouse over the duodenum? Uh, there's some thickening here around the duodenum. The actual, uh, read was that there was some fluid in the lesser sac and that the radiology, uh, attending, uh, was concerned about a posterior gastric. Uh, wall, uh, perforation. There's fluid in both paracolic gutters, but not a large amount of, uh, free fluid. There was no free air and there was no contrast extravasation. Uh, so that, that, um, was the film on the boy, on the brother. And then, um, the sister had an abdominal CT scan. She's the one we scanned, uh, based on, uh, her elevated AST and the pulmonary contusions on the chest X-ray. She had a CT, uh, scan of the abdomen and it was normal. Uh, so I'll get to what we did in just a moment, but, um, if we can advance the slide, I'll present some of the data, uh, uh, that we've collected on, um, blunt, uh, abdominal trauma with the idea that we may be able to avoid CT and potentially 30 or 40% of the patients that present with a serious, uh, mechanism of, uh, injury. So can you go to the next one? Um, so, uh, Rich and I, uh, participated in a collaborative, uh, group. Uh, it involved 14 pediatric level one, trauma centers, and, uh, this was the focus of our study. Next slide. Uh, you know, as we discussed, um, CT scan is commonly used for the evaluation of children, um, despite the fact that, um, there's a pretty low incidence overall of intraabdominal injury. There's some cost associated with CT. And then, uh, the big concern is with uh the risk of radiation-induced, uh, malignancy. Uh, so next, So, um, several studies in the past have suggested that things like plain films and labs performed in the trauma bay might be useful to stratify children that, that might have an intraabdominal injury. Our goal was to avoid abdominal CT in the low-risk population. And what we did is we collected data prospectively for a year in the trauma bay. We looked at the mechanism of injury, the patient's vital signs, uh, pertinent history and physical examination. Their, uh, labs, urinalysis, chest and pelvis X-ray, and their fast exam. Um, in our study, in previous studies, uh, the data is limited by the retrospective or single institutional, uh, nature. Uh, so, uh, we set forth to do this, uh, as a, a collaborative group in a prospective fashion. In addition, as Roberto uh may, uh, discuss, um, you know, as we move forward, there are a couple of adult papers that looked at PACT and they suggest that PACT, at least in the adult population, may be more cost-effective and miss, uh, fewer injuries, um, and so, it seems to be this is pretty common in adult trauma centers. Next slide. So, um, one study that was recently performed was by a group, uh, called PCARN. This is a group of, uh, emergency physicians. It involved 20 institutions, and they did a prospective multi-institutional study, and their primary outcome was intraabdominal injury requiring an acute intervention, which they defined as urgent surgery, angiography, or transfusion. These are the patients in their mind that they really cared about, the ones, uh, that needed an urgent intervention. And because they had concern that uh labs and imaging weren't standardized across the centers, they really only looked at history and physical exam elements. And the good thing about the pecan rule is it's great uh for predicting um patients that don't need urgent surgery, angio, or transfusion, but this is only about 2 or 3% of the patients that we see. And the concern is that the pecar rule misses a lot of clinically relevant injuries, primarily solid organ injuries, which we might admit or do serial exams or labs on, uh, or at least consider activity restriction. So we set forth to look at a rule that might, uh, capture all the, um, intraabdominal injury. Next slide. So again, the purpose of our study was to derive a clinically prediction rule and use all the, the data in the trauma bay uh available to see who we could potentially avoid a CTN. Next slide. So again, 14 uh institutions, this was only involved patients with blunt trauma. We focused just on patients that arrived within 6 hours of injury, so these weren't delayed presentations. We excluded patients that had a CT scan prior to arrival or a patient that had an isolated head injury or an uh mechanism of injury focal to the extremity. Next slide. Oh, sorry, back one. So again, collected data, did univariate and multivariate analysis, uh, used a Gi splitting technique. To account for uh missing variables and excluded any variable that wasn't collected at least 70% of the time. Next slide. Uh, so over a year, we collected data on 2,188 patients. The median age, uh sorry, the mean age was around 8 years of, uh, age. As you can see from the pie chart, these were all patients that had pretty significant injury, motor vehicle collisions, pedestrian or bicyclist struck by an automobile, an ATV, fall from a height, uh, greater than 10 ft, uh, or bicycle collision. Within the population, about 12% had an injury and 3% had an injury requiring an acute intervention. You can see the numbers, the breakdown for surgery, transfusion, angiography, and death. So death from intraabdominal injury was pretty rare in our population, and overall, 45% of the patients underwent a CT scan and very impressively, amongst the 14 centers, the range of CT scan use ranged from 4% to 96% in a similarly injured population. And, uh, in addition, 75% of the patients were admitted. So these are patients that have a lot of uh coexisting injuries, primarily orthopedic and, uh, and head injuries. So it's a pretty injured population, but most of the injuries aren't intraabdominal requiring intervention. Next slide. So what we came up with um by recursive partitioning was a rule, and this is a chart that ranks the variables that were most um predictive of an intraabdominal injury. Uh, the five variables that had the greatest predictive value were an AST greater than 200. An an abnormal abdominal physical examination, an abnormal chest X-ray, a patient complaining of abdominal pain, and abnormal pancreatic enzymes. And what we identified was that in 34% of the patients, uh, there was a, a very low-risk population that had a 0.6% risk of intraabdominal injury and 0% risk of an injury requiring intervention. So this would suggest Uh, that you do have a population, uh, that even in patients with significant mechanism of injury, with a screening history, physical exam, and some basic labs and imaging, you could safely avoid CT. Uh, overall, our prediction rule had a negative predictive value of 99.4% for intraabdominal injury and 100% uh for an injury requiring an intervention. Uh, again, Uh, a low-risk population, uh, was suggested. Looking at, um, the abnormal variables, so this is, uh, a table showing, um, the risk of injury and injury requiring intervention based on the number of abnormal variables. So if you had just one variable that was abnormal, you still had a fairly low risk of injury, 4.5%, uh, or injury requiring an intervention. And, uh, as the number of, uh, positive variables increased as you might expect, the, uh, risk of an injury or injury requiring intervention increased, uh, pretty significantly. Chris, can I ask a question on that? Yeah. Did, is, was there any difference or did you look at any difference as to which of the, you know, which was the one factor, you know, or was that the average range across? Any one of the, the variables. That's, so that's a really great point. Um, so that, that's the average range for one positive variable, but when you look at the odds ratios for the variables, and just to make the charts easier to read, they're not, uh, in there in, in minute writing, but, um, we did calculate an odds ratio for each variable, and interestingly, the abnormal physical examination, like the patient I presented with the seatbelt sign. is the variable with the highest odds ratio for an injury requiring an intervention. The elevated AST, the AST greater than 200, is the variable with the greatest risk of an injury that did not receive an acute intervention. And so this is why, uh, we feel like a prediction rule that includes labs is helpful, uh, in identifying those patients, primarily liver injuries, but there were some spleen, kidney, uh, and kidney injuries and some Uh, other injuries like a duodenal hematomas and, and those sort of things that didn't require surgery that were identified, the rule was more sensitive for all injury including the labs. Uh, so this is, um, a chart with the same five rules, and this is in the order that, uh, you as the practitioner, uh, identify abnormal findings. And, and we thought this actually was the most practical way to look at the rule, uh, was to sequentially, um, go through this. Does the patient have a complaint of abdominal pain? Uh, yes, um, you know, these are your individual risks, uh, for injury and injury requiring intervention. And then here it should really say no or cannot assess. So we didn't, uh, priority exclude patients that were intubated. Or at a GCS less than 14, that was another difference between our prediction model and the PCCAR model. And it goes uh uh forward uh as you typically find the information, the trauma bay. We often get a chest X-ray pretty rapidly, and then sometimes it takes anywhere from 20 minutes to an hour to get your labs back. And it could be even longer depending on uh your center, but I think you can see from this, um, that even if you're waiting on labs, uh, your risk of, um, an injury is still pretty low. Uh, and then, uh, eventually, you get to that very low-risk population where we can say, hey, these patients really don't need a CT and they probably could go home if they don't have, uh, any other, um, injury, and that's this very low-risk population. But it kinda, uh, I think warrants consideration. Of, uh, just waiting to decide on the CT for the labs to come back if there's no compelling reason, uh, to get a CT and if you kind of pull these populations, you really have a 55% population or more than half of the patients that come in that have a less than 5% risk of an injury. And a less than 0.3% risk of an injury requiring an acute intervention. So, I'm commonly asked, is there time to wait on the labs to come back? And I think the answer is in the absence of the first three variables, there's plenty of time to wait and decide unless there's a compelling reason. So in conclusion, you know, we found that uh previous prediction rules were limited by the retrospective or single institution nature or the fact that they didn't include labs. Uh, our goal as, as the surgeons is to diagnose all the injuries, not just those requiring intervention because we commonly admit these patients through serial labs and exams, uh, and, and often provide, um, information to the, the families and the kids about activity restriction. But overall, we do feel that it's pretty safe to avoid CT in the very low-risk population. Um, in terms of how the patients present, we found 97% had a normal blood pressure for age on arrival. So it's a pretty small population even with these mechanism of injury that require an acute intervention, so it's a pretty large group that you can consider avoiding CTN. And as I said, um, there's pretty significant variability between centers, so that would suggest that we can probably do this better. Um, and these are pediatric trauma centers. So if we looked at adult trauma centers, we might see an even higher rate of CT. Sounds like Roberto is pretty, um, frugal, uh, in that, uh, but I would say, um, we get plenty of referrals that have been paying CT, so, That's not necessarily the mantra everywhere, and there's plenty of patients that don't get seen at a trauma center at all. And I think the providers are just trying to figure out who needs to be transferred and uh who doesn't. And then finally, uh, all of these prediction rules require external validation, and uh we've done that in a, in a separate data set and found that the negative predictive, uh, negative predictive value is really high. So I feel like the next step and hopefully Roberto will, will get us to this, is what are the limitations in implementing a protocol like this, uh, in an adult trauma center, at a combined trauma center, at a non-trauma center, where we might uh make a more global impact on, on TT utility. So I'll just stop there and I think that's all I have. I have 11 question for you, Chris. Did you, one thing that is, uh, regularly done, I think with adults and we do with a lot of our, our kids as well as getting, uh, a pelvic X-ray. Um, and I, I, I think that that is, you know, the radiation dose is so low. Um, if it's negative, I think there's some, there can be some comfort in that there's not a significant injury. Now, if you've got a significant injury where you have a pelvic fracture or even a superior or inferior ramus fracture, I'm probably gonna be more likely to do a CT scan on that child regardless of what labs look like. Um. Did, did you incorporate that into your model? Did you look at that? And if you, if you did not, then why was that not part of the, the algorithm that you looked at? Just getting a plain, a plain film X-ray of the pelvis. Yes, that's a great question. So I didn't list all the variables that we, we looked at, but we did look at um whether a patient had a plain film for a suspected femur fracture, and we looked at whether a patient had a plain film. Uh, uh, of the pelvis. Um, and, uh, as it turned out, the pelvic, um, plain film didn't really add anything to the predict to the prediction model. The negative predictive value was 99.4%. So, uh, on multivariate analysis, it just, uh, kind of fell off, um, the algorithm. Uh, pelvic, uh, X-ray is one of those things. I think there's a lot of variability among centers. So, I think uh one of the challenges is that we didn't order a pelvis plain film on, on all of the patients, but in the end, I don't think it would have added anything to the model. I would say though, that's one of, one of those examples where if on a physical examination, you know, the patient has an unstable pelvis, so they have a tender pelvis. I, I certainly think you're gonna get a pelvic plane film in that case, and that may Uh, as you said, um, prompt you to get a CT, I think that, that's totally reasonable. And a patient that doesn't have any, uh, tenderness to palpation or an unstable pelvis, I don't think a pelvic plane film adds anything to the model. So, in, in our center, we would only get one, if we were concerned, uh, about, uh, a pelvic injury, um, you know, it's one of those questionable cases on On physical exam, you know, you might make the argument you don't need one if you're gonna scan them anyway, and I think, um, at least I see that with my adult colleagues that they've almost stopped doing pelvic plane film altogether because it doesn't, uh, affect their management. It's one more film to get, and they only get it on the back end if Ortho is asking for, uh, you know, inlet and outlet films or something like that because there's a, a fracture on, on CT and they want plain film imaging. So, Chris, that's, that's great. I mean, I think some of the comments are that people are either going to change their practice based on that or at least possibly change their practice based on, based on that data, so that's a start. So, we've, we're trying to look at actually implementing this. I mean, we're lucky to be part of the study, but now we're trying to say, OK, how do we, how do we use this? And some of the questions that I've gotten um from our residents or nurse practitioners, people that might be in the position to, to use this algorithm are, well, We have a lot of kids that when they first walk through the door, they complain of abdominal pain. Um, uh, you know, you then calm them down and that, that pain goes away. We also have kids that have some abdominal bruising and, and like we started to talk about earlier, well, what's, what's a seatbelt sign and, and You know, how do you use that? So what are your thoughts on, on that, um, as far as how to break that part out? Yeah, so that, those are, are both really good questions and Um, so, to be really clear, we're not looking for reasons to scan more patients, right? And so, uh, that, that's one of the challenges with the prediction rule is if someone, uh, doesn't read, uh, the, the whole paper or just looks at, you know, a snapshot of the algorithm and sees a complaint of abdominal pain, um, you know, we have a positive variable, we're gonna scan them. That, that's not the, the concept, and I would actually say, If you look at um those 5 variable charts and you, you get down the algorithm and you just take out complaint of abdominal pain, uh, that was one of the, the least predictive of the 5 factors. So if I had a patient that had 4 negative variables and a complaint of abdominal pain, I'd probably come back and re-examine, examine them, uh, later. And, uh, I think it would be safe to kind of wait to image that patient if you had no other. Uh, compelling reason, and I, and I agree, we often have patients that come in, they're kids, they're scared, uh, they may have distracting injuries, and, uh, so it can be a little, the history can be a little bit, um, uh, challenging. Uh, so I don't think, uh, complaint of abdominal pain alone should mandate a CT. That's, that's not the message, uh, and I, and I agree it can be tough. And the follow-up question to that, remind me again, uh, what was the second thing? So, so kind of what bruising. Oh, the bruising, yeah, bruising, yeah, so, um, if you really dig down in the manuscript, we kind of list what is an abdominal, uh, an abnormal abdominal examination, and when we say, uh, bruising, we're really talking about like handlebar contusions from a bicycle or an abdominal seatbelt contusion. Um, abrasion is listed, and that is, that is the challenging thing. And again, uh, I would say just as you said, not all physical exam findings are equal. Um, so it is the, it is the seatbelt contusion or the, uh, uh, handlebar contusion. The patient with peritoneal signs, those are the ones that, you know, definitely, I would say need an abdominal CT. If you just have a little bruising over the, you know, the iliac wing, or uh maybe there's a small abrasion, uh, near the costal margin, you know, those are ones that, uh, I, I, I would say those don't mandate a CT either, so there's still some need, uh, for judgment. And, um, you know, 75% of these patients get admitted. Uh, so if, if you have a patient that has um a femur fracture or, you know, a humerus or um they have um uh concussion or, you know, um Kind of a mild um TBI and you're gonna admit them anyway. It's a captive audience for you to do serial uh abdominal examinations on. So, you know, you don't have to scan those patients that have those abrasions because many of them are getting admitted uh to the hospital anyway. And I certainly think as I, as I stated, the patient that just has one positive finding, if they have a pretty reliable, uh, family and the only complaint is mild abdominal pain. These are ones that, you know, at some point in time, we might say, well, let's, let's let them go home and, uh, you know, if they live nearby and they seem reliable, we could, uh, you know, ask them to come back if it seems like something has progressed. Great. Um, so right now, I'm just kind of seeing if there's some questions. We have one request for the actual article, so we'll get that, um, you know, let's get the reference out there. The, um, I think we'll move on. The other important fact that I think you alluded to, and I just want to make sure it's emphasized for our participants before we move on to Roberto. One yes answer doesn't mean you have to get a CT. You still have to use some clinical judgment. It's more importantly, everything's no, you don't need that CT, correct? Exactly. All right, so we'll move on to, to Roberto and then we'll have continue some discussion. So Roberto, it's all yours. OK. Trying to, let's see, share screen here we go. All righty. So, again, I'm uh Roberto Iglesias and um I'm at Saint Vincent's Evansville. Uh, we are a level 2 adult trauma center and a level 2 pediatric trauma center. And I am the pediatric trauma director here in Evansville, uh, Indiana. And, uh, I labeled my, uh, my talk pediatric abdominal Challenges and non-pediatric Hospitals. Got no disclosures. And I, I think today really the goal is to uh discuss some of the challenges in taking care of children in predominantly adult hospitals because Um, you know, I, I think medicine is challenging enough, hard enough. There are enough articles out there to keep, keep track of your sub-specialty. Um, certainly when you have to think of, in terms of adults and children, two different worlds. And so, what tends to happen is people tend to just memorize one set of, of, uh, guidelines, um, potentially. And so if you're predominantly taking care of adults, that's Your, your tendency is to learn the adult literature and, and, and your behavioral patterns on children are gonna model what you learned from the adults. And so we'll talk a little bit about, about, uh, some of those challenges and some of the models uh in adults and how, how that affects, uh, taking care of children. And then finally, we'll discuss the adult CT triage data and how it affects triage decisions in children. So, we'll start with a case scenario here. 15-year-old male traveling at 30 MPH. He was restrained. GCS of 14 had mild confusion, small forehead abrasion, right zygomatic contusion. Uh, he had a fracture of the uh right distal radius, treated with a cast. Orthopedic surgeon said that was all that was needed. Complained of abdominal pain, hemodynamically stable with, uh, you know, heart rate in the 110s, so a little tachardic. Abdomen was soft, non-extended, mildly tender to palpation diffusely. The child did not have rebound, no guarding, and basically had faint seatbelt sign, um, to the bilateral iliac crest, uh, to the abdomen and chest. So how many people would pan scan this child is, is, uh, is the question, um, here. So Chris, do you wanna You put me to the test right away. I like it. I'll put you to the test right away. I knew where you were going. So, again, these are like the kind of vague ones, but he has a complaint of mild abdominal pain. I, uh, it sounds like he's tender just tender to palpation, and then you're also saying he has a seatbelt contusion possibly. So this is a patient. I, I probably wouldn't have a lot of heartburn about getting a CT scan. And if you told me it was, um, normal, I, I still, I think, could sleep, uh, comfortably. Uh, knowing that he had, uh, you know, pretty some significant risk factors. OK, great. And um we just put up a, uh, a poll for those in the audience to kind of answer, answer that question, would you pan scan um or not. So we'll, as we go, we'll get some, uh, get some more information maybe on that. So go ahead. OK. So, uh, and I guess the question is, uh, this, this is a, this is a 15 year old, uh, what if, when those of you take care of adults as well, what if there's a 25-year-old male? Uh, my question to you is, Would you treat that individual different than you would a 15 year old? Uh, would you treat that individual different than you would treat an eleven-year-old or a, or, or an eight-year-old? And I think the answer is yes, and the answer probably should be yes. But what I'm gonna talk about now is what some of the, what the adult literature, uh, endorses and what the adult literature really talks about. And I think in looking at the adult data, uh, one of the more significant studies really, uh, in, in the systematic review and meta-analysis that has really shaped the adult data and adult literature and really has pushed more and more adult centers, whether they're level 1, level 2, or level 3, or non-designated, is, uh, pan CT scanning of, uh, certainly the more severe, severely injured adults, which then again translates into children. Um, uh, and, and, and then the, the, the argument really becomes, in, in the less severely injured, uh, individuals, do you pancy to those. But this, this is a very good systematic review and meta-analysis, uh, performed by Caputo, uh, back in 2014. And basically, they looked at, uh, most of the studies are retrospective. Uh, they, they have huge numbers and one of the, one of the studies and probably the one most commonly cited is Huber and Wagner. In 2013, they looked over 16,000 patients, but overall, you're, you're looking at a significant number of patients of almost 25,000 people. Uh, but they basically looked at patients into whole body CT scan, that's what WBCT is, and then selective. And as you can see, the ISS scores were fairly high. They were, um, 29.7 and, uh, about 2026. Um, which is, so one of the things about this particular paper that gets, that gets talked about frequently is that, uh, that maybe there's some selection bias and that the sicker patients were getting pan CTs, whereas, uh, the less sick patients were getting, uh, uh, just a selective CT scans. Um, if you look at the mortality rate, and, and that's what this paper is really looking at. And most of these papers, they focus on mortality. Uh, they don't look at length of stay for the most part, and they don't look at cost data, which we'll talk about in a little bit. But when you look at mortality alone, Basically, there was a a significant decrease in the, in the mortality, 16.9% versus 2.3% when you did the whole body CT scan versus selective CT scanning. And I think that really shook up the trauma world where, where people said, wow, those, those are some staggering differences. There are 25,000 people looked at uh multiple different studies, and they all basically, if you, you look down the line, they essentially all have the same findings that the sicker the patients are, The better off you are in doing whole body CT scans. Uh, and some of these papers were statistically significant. Uh, and the odds ratio, as you can see down at the bottom, um, overall odds ratio also shows the same thing. And so, uh, I think that in the adult world, that is, this really has shaped how we take care of adults, and that is, I think, a more, uh, this is where trauma has been heading, uh, as of late. And unfortunately, I think that's translating to children as well. Any comments on, on what your thoughts are here, Doctor Falcone or, or, or Chris? I, I mean, I think these are interesting data for the, for the adult population, but I, I, I worry about that translation because I think there's still different populations. We know our, especially the older adults, the, the geriatric adults are gonna have a lot more injuries, um. Than, than we see in our kids. We don't see very many of the significant chest injuries um that you see or the C-spine injuries that are, are seen in adults. So I think it's hard to totally translate this. I, I completely agree, uh, but, and I think that's my point that, that. When people, you know, uh, are, are learning and, and when you're, you, you have a, a hospital like mine where you don't have an isolated pediatric hospital, you have crossover and people tend to learn one way of doing things. Uh, why? Because it's difficult to learn multiple different ways for different age groups, you know. Are you gonna teach, uh, you're gonna treat senior citizens different than you are, your middle aged, are, and are you gonna treat your pediatric population different and And those are the real challenges that I think we need to talk about today. Uh, but this is really the landmark paper that I think is really, uh, change, challenging, uh, and changing the way trauma is being looked at. Now, um, what the, some of the criticisms of that paper have been that all those studies, none of them were randomized. Now, this one study is actually randomized. It was, uh, published in Lance in 2016, and, uh, basically four hospitals in the Netherlands and one in Switzerland. Um, they, the average ISS score was about 20 and 19, so not quite as sick. Uh, again, these are all adult patients. Let me be clear about that. And their goal was to assess the effect of total body CT scanning compared with selective CT scanning on in-hospital mortality. And the reason I present this paper in isolation is because, uh, it came out after, uh, Cabuo's paper, and, uh, the, the, one of the biggest criticisms to Cabuo's paper was that, that's fine, but none of these papers are randomized. So, here's a randomized paper. And we can talk about uh this paper briefly. Uh, but I think one of the challenges of this paper is that if you look at ISS scores, overall, ISS scores were similar, but they were actually lower overall. They had about 35% of the population that had, that fell into the lower ISS scores. So it does not translate completely. Um, overall, they looked at about 1400 patients and sub-selected out about 540 in each, uh, category. Um, and if you, there, what's interesting about this paper is that it actually supports the notion that you do not have to pan CT scan everyone. If you look at all patients, this is every single patient that they looked at, there is actually no odds ratio difference uh between, uh, uh, between, uh, older, between pan CT scan and selective CT scanning. And so, now, uh, I, I'm interested to see what's gonna happen with the new wave, now that you have a randomized paper being talked about and, and that's out there in the literature now. Uh, there was actually a, a, a, a, uh, a, a systematic review, um, that was performed. That included this paper and they essentially ignored all the other papers and just included the findings from this paper because it was the only randomized study. So I'm interested to see what's gonna happen going forward, whether uh there's gonna be falling out of, of pan CT scanning versus uh selective CT scanning. But really, what they found is that there is no statistically significant difference in in-hospital mortality. Uh, in all patients that, that were severely injured when you had a total, total body CT scan approach versus selective CT scanning approach. And the other significant finding is that the radiation dose was increased with total body CT scan, uh, and the time to diagnosis was faster with the total body CT scan group. Uh, and I think this final point is really at the crux of a lot of the management decisions that That happen that occur on the front lines, meaning when you're seeing a patient, what is it most emergency rooms, their main goal is to reduce their length of stay. Patients want to get home. Uh, uh, a, a physician wants to see that patient, triage that patient, take care of that physician as quickly as expeditiously and, in a cost-effective, at least cost-effective way as possible, most effective cost way as possible. And so when you look at these triage thing, these triage models, um, everything kind of points towards total body CT scanning as being the most expeditious way of taking care of these patients. And by the way, if you can prove that they decrease mortality. Uh, then I think that's where the bandwagon has really piled on. So Roberto, can I ask you a question because you have it on this slide and, and Chris didn't bring it up and it didn't come up in the discussion, but you have this radiation dose was increased. In the total body CT group, and that's certainly something hot on the minds of of those of us that do primarily pediatrics is what's the lifetime risk of that radiation from those scans versus selectively. I think to be clear, none of us in the pediatric world are saying don't use a CT if it's indicated, um, but want to at least encourage thinking about that increased radiation dose for that child. So I think it's marked here in that study, so I just wanted to bring that up and, and get the, the thoughts on that. OK. Yeah, you know, I really think that radiation, uh, you know, it's interesting when you, when you talk about adults and you take care of adults, uh, radiation almost never comes into the mind of anyone taking care of adults. Now, when you start taking care of kids, uh, that becomes almost, uh, the primary focus to a fault, I think. I do think that the fear of overexposing children to radiation, um, Potentially increases costs and delays care in a lot of children because we are reluctant to Those of us who understand the data and literature with, with children, uh, we're reluctant to scan children because of the increased radiation. Now, I, I think that's, it's a, an important facet, but I think that that's one major facet that really, uh, detracts all, all of us taking care of children from moving forward more expeditiously in a more cost-effective way of taking care of these children. And by the way, if you believe the adult data, it shows that mortality is reduced, and so, I, I think. Uh, I, I, I like, I like, uh, Chris, I like your paper and that it shows that, that really there has not, not been any significant difference with mortality with children because I think that's, that's the most important thing. You're showing that there's no significant difference and if we can prove, obviously radiation doses lessened with, with selective CT scanning rather than total body CT scanning, and we can now put into the model cost reduction, I think you have the trifecta that we need to prove that you don't, we need to stop doing pan CT scans on children. So, right, I have one, a couple of comments and then there's a question from the, the group. So, my comments are, one, I agree that there's a, there's a huge, there was a huge pendulum, pendulum swing to all about radiation and avoiding radiation and, and low as possible to the point that Either some kids that needed scans weren't getting them, or some people lowered their radiation dose that the scan was, was not usable because of the quality. So I think there's a little shift back, but, but we still need to be worried about what the right radiation dose is. I would also say. We, we at least did one paper looking at the teenage population and compared whether they were taking care of an adult or a pediatric group because the adolescents are often a group missed in a lot of these discussions and what we found a little bit to your cost question was That the outcomes were equivalent or slightly better at the pediatric centers, but with less imaging and shorter length of stays and shorter testing, which all would imply cheaper care. So I think you're right. I think we need more of that. There was one of the questions from the audience was, um, in these studies, did anyone look at, you, you alluded to it a little bit that maybe it hasn't been, but separating out the Was there any difference between the 18 to 35 or the 36 to 55 and older? Were there different findings or did anyone look at things, um, As a piece and then someone else kind of commented that pan scanning may take the thinking out of things, um, and, and in kids, we may need to kind of think a little more about those risks and benefits of the imaging. So any comments to those two things. Sure, uh, and so I, I, if you look at the individual papers that they, that the, uh, If you look at the individual papers that are included in, in meta-analysis, yes, they, they break it down by age. But when you look at Cabudo's paper and the latest paper that was, that was, again, another um um uh systematic review of the data that basically expanded on Cabudo's and included this paper that I just talked about, they, they do not break it down by age. They just say 18 and over, uh, and it includes everybody from 18 years of age all the way to You know, potentially 90 years old. And so, there are a lot of fallacies in these papers, but, but, uh, you know, I, I think when you're, when you, you know, I, I, I made a discussion before about uh having to Triage your, your care based on whether they're 50 to 60 or 60 to 70. At some point, you, you have to have algorithms that, that you, you can't be, you can't paralyze the system by having too many different algorithms for everybody because it makes taking care of patients very difficult. And so, I, I really think that that's what these studies have done. They've tried to incorporate all of, all of these, uh, age groups, uh, probably. and it does limit and hinder our ability to be able to take care of the individual age groups. Um, so, so, to answer your question is that, no, they didn't break it down, they did not break it down in the meta-analysis, but the individual papers did. I was, uh, uh, I think that was a great question somebody asked about the age. So, some of the conversations we've had, um, when I started kind of on this journey, uh, we, we also talked about cost and not just radiation. It was interesting, uh, we were sitting in a, a group meeting, the adult, uh, uh, group for peer review and the PES group, and, um, we both announced that we had a cost-saving, uh, plan. And uh my, my cost saving plan was to reduce CT and their cost saving plan was to reduce labs. So, you know, that's the first comment that I would make is, uh, they're both cost saving, but I don't think that the, the savings and cost is probably equivalent because there's also the interpretation, uh, fee for, for the imaging. So I guess my question to you, and this is to kind of piggyback on the question about the age ranges, is, you know, well, a couple of questions. One, why would, why would this, uh, my, uh, concept not work in the, the healthy 18 to 35 year old patients? I wonder if we would see, uh, just as suggested, a more significant Um, impact on P CT if, uh, if we went, uh, over age 40 or 45 and up, and then, uh, kind of furthermore, in your slide that you, you have up, um, maybe kind of alludes to this a little bit. I, I, I think when you say, you know, pan scan trauma patients, um, uh, you know, what, what, um, people may think is that everyone comes in the door, but what I wonder is that 0 to 15 ISS population. If, uh, if those were all, um, taken out of the PA scan algorithm at adult trauma centers, how many CT scans would, would we say then and, and I suspect you're probably not pan-CTing everyone that comes in just based on their mechanism and really focusing on the poly trauma patient. The patient has obvious, you know, head or orthopedic. Uh, injury. And then my final, my final question is, um, how often does the chest CT change what you do on a patient with a, a normal chest X-ray or maybe just, um, a pulmonary contusion on the chest x-ray? How often are you finding that the chest CT really impacts your management? I, I think from a, um, clinical perspective, um, you know, being taking care of patients, uh, I, I agree with you that you can get most of the information. You need from a uh chest X-ray. Now, if you actually look at the data, um, they talk about a missed injury rate of 10 to 15%, and that's actually something that gets uh talked about frequently in uh Cuto's meta-analysis and some of the papers that, that, that's quote, quote, quoted within this study is that there's a, a potential significant number of missed injuries. Um, And, and so, that is one of the arguments that's commonly used and actually, I think on the next, uh, next set of studies that I will talk about, I have one more study to talk about, that that is up to 20% of missed injuries can be significant, can impact care. Um, and And it's only when they were doing these studies that they found out how many people were having missed injuries. And so, that is one of the arguments that's used. It's a very good point, and you're right, we're not pan CT scanning everybody, but one of the points that's used, particularly with your question is chest CT is that, you know, people are missing up to 20%, in some senses up to 20% of uh injuries, uh, which you would not miss by a, a, by a pan CT scan approach. I don't necessarily agree with it, but when, again, when we're looking at the adult data, this is the stuff that's out there, and this is really what I think is motivating and, and, and changing people's habits, that's how they take care of patients. Um. And I'm sorry, you had another question. Well, the, the other thing I asked is, you know, what, what do you think about, um, stratifying based on age. But another comment, you know, that I, that I commonly hear is what happened to the history and physical exam and why, why are we doing fast if we're just gonna pan CT everyone? I, I completely agree. I think it's taking it, taking, uh, being a doctor. I, yeah, I, I think it's completely taken that out of the equation. I, I think you, the pan-CT approach. Um, I, I do think that it may have a role in centers, uh, and I say this as caution, in centers that may not have a lot of resources, uh, in centers that, um, that, uh, have limited, uh, individuals that take trauma or see trauma patients or see an occasional trauma from time to time. Um, uh, I, uh, you know, we don't like to see those patients referred to us with pan CT scans, but, um, uh, I, I, I, I think that Scanning everybody is a, a dangerous way because it does, it's a dangerous thing and it does take out being a clinician. Um, but by the same token, that may not necessarily be a bad thing in centers that don't have a lot of trauma experience and don't see a lot of, um, trauma patients. So Rina, those are great comments. I wanna let you finish. I also wanna recognize our, uh, well, I'll call him the, our godfather of Globalcast, Todd Ponsky, who, who challenged our, our people just pan scanning because they're lazy. I, yeah, I, I think two things. I think that is part of it. I think they are pan scanning because it's easy and they're lazy, and, and, and I, I think the other part of it is, uh. You know, CT scans are a sunk cost. Once you pay for that CT scanner, the rest of your, your variable costs are fairly low. Now, you can bill for each scan, uh, pretty good billing, and your radiologist get to interpret those, those images. So I, I do think that that is, uh, sort of one of the unspoken. Um, realities out there that on the front lines that drives people's behaviors, but you'll never see that on a, on an article cause that article will be shot down and, and, you know, that individual would be laughed at. But, but, uh, uh, when you're taking care of patients, I do think that those are some of the motivating factors. It's, you know, 2 o'clock in the morning, get a pain CT, I'll take a look at it. If everything looks good, you can send the patient home. I think that'd be a very easy thing to do on almost all your patients. But that's not the right thing to do. Uh, and I, I think that's a, a fantastic comment. Um, and, you know, hospitals make money on CT scans is the other driving force. OK, why don't we let you finish? There's some other questions coming in, but we'll discuss them as you get done here. So I won't talk about the limitations here. Uh, I, I think one of the problems with this study, one final thing is that there were about 46% of the patients that, that were supposed to be in the selective CT scan, scan group that actually crossed over into the pan CT scan. So they eventually they got sequential CT scans that, that essentially became a pan CT. Uh, so, if you look at, if you pull up this article and you look at it, um, there are a lot of limitations to it. Now, let's take a look at another patient, uh, 12-year-old restrained head-on motor vehicle collision, uh, moving at 50 MPH, uh, low activation trauma. For us, it's a level two, no loss of consciousness. Uh, in the pre-hospital setting, the patient was brought in by ambulance. The patient had a GCS 15, no nausea and vomiting. The patient complained of abdominal pain, no back pain, no back trauma, hemodynamically stable, and this is sort of what we were talking about earlier earlier today, bilateral iliac crest, quote unquote seatbelt sign, but no seatbelt sign over the abdomen, uh, but tender palpation over the iliac crest and benign abdomen. And, um, I think we've already talked about, uh, this individual, uh, to some degree. The scan or not to scan, uh, but I think that, uh, you know, it's interesting. I, I think that that is a, it seems very obvious when you talk about it, but, um, I think that it is actually a quite challenging set of patients when they have that, you know, a little seatbelt mark over the, over the shoulder or bilateral iliac crest. What do you do with that patient? Can you send that patient home without a CT scan if they're not having nausea, vomiting? Um, so, I think those are important questions and this is an important subset of patients that we see. So can I just say that, that is the perfect patient, I think, to apply the prediction rule and get a chest X-ray and screening labs. And if they were tender over the pelvis, that may be the patient, you, you know, you would get a pelvic plain film on, but I, I would not knee jerk, get an abdominal CT on, on that patient. I'd, and, and our center, they are very attuned. I don't even have to say anything the residents would have already. Uh, ordered the, the studies cause that's our routine. I, I would, I would agree with Chris. I'm not, I, I mean, I get the sense that I'm. I don't know that I would say our residents are as in tune as Chris's cause he probably shares this, this, this study much more frequently with them than, than we have to date, but we certainly would have some residents uh who would flinch on that story and, and at least scan the belly, pro hopefully not the chest. We rarely scan the chest unless there's significant abnormality of the mediastinum on the, on the X-ray or concern there on the X-ray. Um, but I agree, I don't, I think iliac crest. Tenderness and seatbelt over your clavicle where it's supposed to be, I don't think I would routinely jump right to scanning. Now, Richard or Chris, if you don't scan that child and uh are you gonna admit every one of those children, uh, or would you be willing to send that child home from the emergency room without, only, with only a chest X-ray? Yeah, if I got a chest X-ray, you know, the pelvic plane film labs, and they're all normal, and we, you know, that usually takes about 1 hour or 90 minutes to get all that done, we usually will give them a PO challenge. If they can ambulate and they can drink and they're, they're not having any, um, symptoms of abdominal, you know, concern, we'll let those patients go home, particularly if they have a reliable, uh, parent. I would, I think, I think that's the key. Yeah, go ahead, Rich. I'm sorry. No, I was, I, I would agree. I mean, I think I'd watch him for a couple hours in the ED, um, and, and let, and let them eat something and send him home if everything else was normal, you know. Yeah, I, I think we would too. We would, uh, you know, I don't think we need to scan this child to get a chest X-ray, um, and let him eat, and if they wanna take him home, I, I think we'd be OK taking them home even if they lived an hour away. Now, what if the child is vomiting at the scene? The child comes to you now, not vomiting anymore, but had 1 or 2 episodes of vomiting en route to the hospital. Would that change your algorithm? Richard Chris. So in the Parn study they actually uh emesis was one of the factors and they had a seven variable model. So I would say um emesis would probably make me think about it a little bit more, but again, I would, in this particular patient, if they had the exact thing that you showed me and they had vomited once at the scene, uh, you know, I think by the time they get there and they get labs and uh a chest X-ray and a PO challenge and they tolerate it, I still would think they can probably go home if it was 11 or 2 episodes at the scene and nothing subsequent. OK. I would be, I mean, I, I agree with Chris, but I would be, I would probably, I would certainly be more anxious with that kid than without the emphasis, and I think that's what Chris was saying as well, but. I don't know. I, I think it would, this would certainly now we're getting into, well, they had this emmesis, but what's their exam? If the emesis in their exam remains benign, I may still watch them, but it, it certainly piques my interest in, in scanning them. Yeah, but you, but this is a, a patient that, you know, you might say, OK, I don't feel comfortable sending him home, but I could admit him overnight and do serial exams. I, I don't think you have to CT that kid. Now, um, Chris and, uh, Rich, uh, I'll ask a question. Um, you both have residents and fellows. Uh, so admission overnight, uh, uh, forgive me for saying this, but I think it's probably a little bit easier for you than it is for, for the rest of us who, if we admit somebody overnight for serial abdominal exams, we're the ones that have to get up out of bed, examine the patient, and we don't have residents and fellows. Do you think that that Should affect or do you think that affects uh people's decision? Well, I'll say we don't have fellows, and when I say serial exam, uh, sometimes to the residents that's a suggestion. So the serial exam might be, you know, when I come in at 6 or 7 a.m. and, and do the exam, but there, there's pretty, um, good data in the pediatric literature. Certainly we don't. And tend to delay diagnosis of a small bowel injury or a colonic injury, but it's very well tolerated. So, you know, in this patient, I'm, I'm not too concerned that they have a solid organ injury that requires intervention. We would be more concerned about is, you know, a small bowel injury and, um, and still, you know, even if you delayed your next exam for 6 or 8 hours, I don't think that's gonna be harmful to the kid. Agreed, yeah, yeah, yeah, I agree. I'm glad to hear Chris's residents don't always go examine the kids all night either, so. In theory, now, what about mechanism? The car rolled over multiple times. Um, I think we've alluded to this a little bit, but, you know, uh, let's say the child is not vomiting, but the car rolled over multiple times. There was a, you know, thirty-minute extrication to get the child out, same physical exam. Doesn't matter. Doesn't matter. Mm mm, I agree. I don't, I, I wouldn't make that much difference. I try to kind of teach our residents that. It's important to know the exam, so to have it in the back of your mind what other injuries you might be worried about, but to not let that drive all your triage or decision making. OK. See, I, I, I think that's very different with the adult data. Uh, I think mechanism of injury, uh, tends to override a lot of what gets done in the adult population. I think, you know, you've got a 60 year old, multiple rollover, uh, they have a little bruising here and there. Uh, I, I think the trigger for getting a CT scan in an adult would be a lot, a lot lower than it would be for a child. Yeah. Yeah, yeah, and that's, I mean, this is a great discussion. This is why, exactly why I wanted to put this together and have both of you here because these are the challenges um that we all face and then we face when we're talking to our adult counterparts to take care of kids and, and just as a reminder for everybody, you know, most kids are taken care of at adult centers, not pediatric centers after trauma. So, um, that's the audience if we want to really reduce scans and safely do it. Um, we need to quote, convince. You know, what the, what to do. Um, and, and that's a little bit of the, the chatter out there on our, on our chat for this. Um, you know, we've certainly had folks say it's, it's great that this rule is gonna be presented as East to try to start spreading that information, um, further to the general surgery or for the adult, uh, trauma surgeons because I think we can talk about it in pediatric surgery circles, but if it's not getting out there, um, and challenged in the adult population. Um, that's gonna be, nothing's gonna change for the majority of, of kids. Um, so, so I appreciate this. There was one question out here, um, that we didn't really touch on, um, and I don't know that I want to dive into it too deeply right now, but, um, the question about, are we scanning our adult centers a little more likely to scan because they're worried about getting sued, um, in the medical legal part of this, especially when it comes to, to kids perhaps. So you have any thoughts on that? Uh, absolutely, I, I think that, you know, if you, if you are a practicing general surgeon in the United States of America, the uh, the reason you're, and you're taking trauma call, the reason your tra your uh malpractice insurance is, is gonna be higher than a person that does, uh, your malpractice insurance will be higher than the general surgeon that does not take trauma call. Uh, why? Because injuries get messed and, and I do think that, that is always in the back of your head. Um, and I certainly think that, and maybe, maybe I'm wrong in thinking of this, but I, I do think that a lot of people think this way, that as a, a trauma surgeon, adult, you know, uh, I, I, I'm, I'm not a pediatric surgeon. Um, I have no pediatric designation behind my name. It says pediatric trauma director. Um, I have more of a leg to stand on if something were to go awry or wrong with an adult, than, uh, than I would if something were, if I were to miss something on a child. And I do think that that is a fear out there, um, that, and, and I think that that's why people pan CT scanning a lot of kids that I don't, I don't wanna miss anything. I'm concerned about this kid. I, I wanna make sure I get everything. And, and I've actually heard this before from people. I just wanna make sure everything's OK. Uh, but I do think that that's what drives a lot of the behavior. I, I agree. Do you think, what, what are your thoughts, and I, I appreciate you being a little bit of the, the target here cause it's the challenging, you know, why do adult folks do this and, and us pediatric surgeons don't. I think there's a comment on the, on this as well that says, well, maybe the adult surgeons think we're all weird cause we're so worried about scanning kids all the time. And by your quick response, I'm guessing that's probably some truth to. That and there's probably some truth on our part, as we alluded to. The pendulum swung, swung really far to one side of, you know, limiting it radiation, limiting imaging, um, but I think there's probably a balance, as Chris's data would say, you know, there's probably a balance that you can certainly safely avoid scans and What do you think the adult folks will be more, become more comfortable as more data like Chris's um comes out and the pecar data comes out, um, cause that kinda gives you that leg to stand on from a, a legal standpoint. You say, I'm following, you know, Well-done studies and prediction rules, and I, because I, you know, I followed that and that I felt comfortable not scanning and there's a 0.1% chance, but that's, you know, that's pretty much with anything. There's at least a 0.1% chance that we're gonna miss something. Um, so do you think more time and more literature will help further convince adult surgeons that it's OK? See, I, I The issue for me right now is, um, I, Rich, you know, I buy into this, you know, you helped us, uh, really set in a, a radiation reduction program, and, and with your help, we've been able to, you know, set some of your guidelines and protocols and, and reducing our, our CT scanning. But, uh, what, what I find interesting is that the adult data and the pediatric data are going in two completely different directions. And I think that's probably we can sum up this, this webcast, um, in, in one way is that, that, that is really at the crux of it, that they're just completely going a different direction, pansy to all adults, whereas with children, uh, don't scan them because you're gonna give them cancer down the line. I mean, it, it, it, those are seriously the, the two overwhelming sort of uh views. Uh, and I think as more data comes out with, with children, absolutely. I, I think I certainly from a pediatric, and, and I think it is on the pediatric trauma directors, uh, to set the guidelines and policies within your hospital to, and to educate people to change their habits and that say, hey, don't scan every child, don't treat every child just like you would an adult. I, I, I do think it's up to us to change those behaviors and teach people and, and teach our, our colleagues and teach our ER colleagues and, and my partners as well. Um, and the more data that you, you bring out there, uh, I think gives me more leverage to influence my, my partners and, and my colleagues in the hospital. Absolutely. I think I, I mean, if you, if you look at what we presented, if the patient had none of the five variables present, you would have to do about 250 CT scans or scan 250 patients to find 11 intraabdominal injury. That's a whole lot of scans, you know, I do think the adult surgeons say, well, what if I missed something. And that would be how I respond to it. Well, 2, if you scan 250, you'll find, you know, something that the rule didn't pick up. So it's a, it's a pretty good, uh, rule. And then, you know, we were talking about mechanism. Both the Parn study and the study that we did, um, broke out mechanism and we even divided patients into kind of um, um, a made-up category of serious versus not serious injury and then serious injury included. You know, prolonged extrication, uh, you know, rollover unrestrained versus like the NBC that doesn't have that, and in both studies, the mechanism, uh, was not predictive of, of intraabdominal injury. So there is some data to say that, you know, um, you know, mechanism may be important, but it shouldn't be the reason that you decide whether to get a scan or not. So I, I just want to kind of in, in the time, there's a couple of things to, to point out. Um, there is in the chat, the, the website to follow to get your CME for those who participated. You certainly want to take advantage um of that. I also wanna kind of thank, certainly thank both of our presenters. I think this was a great discussion and, and the feedback is positive already. Um. Um, that this was a useful discussion and useful in pointing out, um, as, as you did, Roberto, the, the real crux of the differences, um, of where the literature is going, and I think there's certainly what I, one of the things I take out of this is we need more data to convince each other of what and figure out what the right thing is to do, um, and there's probably opportunities on both sides from the adult literature to say, Why don't we think about using some of these prediction rules to avoid some pan scans, um, and from the pediatric side to say, OK, sometimes the CT is not so bad. Um, so I, I think there's certainly stuff to learn from, from both, and I think that's why I wanted, you know, hopefully we can continue to do discussions like this across adult anded so we can, we can learn from each other and challenge each other to think differently, so. Uh, with that, I don't think there's any other questions. There's a lot of thank yous and appreciation, um, from the folks out there, uh, for what you guys did in the discussion. So, thank you, everyone, and, and good night or good day to those that are at different time zones. Um, and, and hope to see everybody back. December 12th is our next, uh, event, and this one will, will focus, um, it'll have Mike Nance from, from Children's Hospital, Pennsylvania, um, and Vic Garcia from Cincinnati, um, talking about, uh, both. Policy efforts to reduce gun injury, gun violent injuries to children or accidental gun injuries to children, and then community initiatives to try to reduce that as well. So, unfortunately, given the times that we live in, that's going to be an important discussion. So I hope to see a lot of you back there. Thanks all.