Pediatric Corner

Consider alternatives for CT sans in children

Other options may be possible

Nearly 8% of 355,088 children received a CT scan in a 3-year period, with 3.5% of the children receiving more than one, according to a recent study.1

This is important information for ED nurses to consider, according to Adam L. Dorfman, MD, the study's lead author and clinical assistant professor of pediatrics and communicable diseases and of radiology at University of Michigan Health System in Ann Arbor.

CTs are commonly ordered for children in the ED, says Dorfman. "A lot of these tests are ordered without any thought as to the long-term adverse consequences," he says. "Radiation has risks, even more for kids than adults."

Use real evidence

Dorfman notes that in some cases, ED nurses use standing orders for common presenting diagnoses, such as head trauma. "If ED nurses are ordering these directly, they need to have an understanding of when tests are really indicated, and when they're not," he says. "Also, imaging should be limited to the location — not, 'we're sending the patient for a head CT so let's go ahead and get the abdomen.'"

Dorfman says that while CT scans "have saved huge numbers of lives," there is good clinical evidence that CT scans are not necessary for head trauma in children based on specific clinical factors.

"This is an area with excellent data showing that not all patients need this test. Only some of them do," he says. "Use established evidence-based guidelines to determine when a test is needed."

Kimberly E. Applegate, MD, one of the study's authors and vice chair for quality and safety in the department of radiology at Emory University School of Medicine in Atlanta, says she has seen some children get eight CT scans in one year.

"There is no doubt that sometimes these CTs save lives. There are times when we need to do them, and do them quickly, but there are times when we can do other imaging or tests," says Applegate. For instance, it is possible to do ultrasound or magnetic resonance imaging (MRI) instead of a CT scan for suspected appendicitis in a child, says Applegate. (See clinical tip, below, on avoiding CT scans.)

Lowest possible dose

If the CT is necessary, Dorfman says that patients should be getting as low a radiation dose as possible.

Applegate says that the "Image Gently" campaign aims to "child-size" the radiation doses received by children. A more recently launched "Image Wisely" campaign is doing the same for adults, she reports. (For more information, go to www.imagegently.org and www.imagewisely.org.)

"To have an adult protocol with the same dose for all adults, frankly, is not good enough," she says. "A 200-pound adult and 100-pound adult should not get the same dose."

For example, women with recurrent chest pain may get multiple CT scans to rule out pulmonary embolism, adds Applegate. "In this day and age, we have to make judicious clinical decisions to reduce the repeat ionizing radiation tests, especially in younger women believed to be at higher risk of later cancer induction," she says.

ED nurses, she says, should be sure that all patients getting CT scans "walk out of the ED with more info than they came in. It's our duty to educate them about the risks as well as benefits."

Reference

  1. Dorfman AL, Fazel R, Einstein AJ, et al. Use of medical imaging procedures with ionizing radiation in children: A population-based study. Arch Pediatrics Adolesc Med, 2011; DOI: 10.1001/archpediatrics.2010.270.

Sources

For more information on diagnostic testing in pediatric ED patients, contact:

  • Kimberly E. Applegate, MD, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA. Phone: (404) 712-4882. Fax: (404) 712-7387. E-mail: keapple@emory.edu.
  • Adam L. Dorfman, MD, University of Michigan Health System, Ann Arbor. E-mail: adamdorf@med.umich.edu.

Clinical Tip

You can avoid CT in child with VP shunt

One of the most common reasons for a CT scan in a child is concern about the patient's ventricular-peritoneal shunt failing, according to Kimberly E. Applegate, MD, vice chair for quality and safety in the department of radiology and imaging sciences at Emory University School of Medicine in Atlanta. However, a CT may not be necessary, she says.

This usually can be diagnosed without imaging, or if you do need to image, you can do a very fast MRI scan, she says.

"Even if the child moves, you can do very fast sequences and get the answers you need," says Applegate. "All you need to see is whether the ventricular system is bigger or not, and where the tip of the shunt is located."