The Use of Chest Computed Tomographic Angiography in Blunt Trauma Pediatric Population Rabea Hasadia, MD,*† Joseph DuBose, MD,‡§ Kobi Peleg, PhD,|| Jacob Stephenson, MD,¶# Adi Givon, BA,|| Israel Trauma Group and Boris Kessel, MD** Introduction: Blunt chest trauma in children is common. Although rare, associated major thoracic vascular injuries (TVIs) are lethal potential se- quelae of these mechanisms. The preferred study for definitive diagnosis of TVI in stable patients is computed tomographic angiography imaging of the chest. This imaging modality is, however, associated with high doses of ionizing radiation that represent significant carcinogenic risk for pediatric pa- tients. The aim of the present investigation was to define the incidence of TVI among blunt pediatric trauma patients in an effort to better elucidate the usefulness of computed tomographic angiography use in this population. Methods: A retrospective cohort study was conducted including all blunt pediatric (age < 14 y) trauma victims registered in Israeli National Trauma Registry maintained by Gertner Institute for Epidemiology and Health Policy Research between the years 1997 and 2015. Data collected included age, sex, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, and in- cidence of chest named vessel injuries. Statistical analysis was performed using SAS statistical software version 9.2 (SAS Institute Inc, Cary, NC). Results: Among 433,325 blunt trauma victims, 119,821patients were younger than 14 years. Twelve (0.0001%, 12/119821) of these children were diagnosed with TVI. The most common mechanism in this group was pe- destrian hit by a car. Mortality was 41.7% (5/12). Conclusions: Thoracic vascular injury is exceptionally rare among pedi- atric blunt trauma victims but does contribute to the high morbidity and mortality seen with blunt chest trauma. Computed tomographic angiogra- phy, with its associated radiation exposure risk, should not be used as a standard tool after trauma in injured children. Clinical protocols are needed in this population to minimize radiation risk while allowing prompt identi- fication of life-threatening injuries. Key Words: blunt chest trauma, vascular chest trauma, CT angiography, trauma (Pediatr Emer Care 2018;00: 00–00) T horacic injuries are common among pediatric trauma victims. The child's compliant chest wall allows for significant force to be delivered to the internal organs and leads to considerable morbidity and mortality. Available literature suggests that intratho- racic injuries may lead to death in 15% to 25% of cases, constituting 14% of all trauma-related deaths in children. 1,2 Although rare se- quelae of pediatric blunt thoracic trauma, thoracic vascular injury (TVI) is likely associated with significant additional morbidity and mortality in the pediatric population. 3 The early detection of TVI in this population has the potential to afford expedient treat- ment and mitigate the risk for adverse events due to TVI. Among stable patients, computed tomographic angiography (CTA) has emerged as the most effective modality to identify and characterize TVI. In many trauma centers, CTA is used as a screening tool in most patients of all ages with mechanism and clinical concern for significant blunt chest trauma. The use of this modality, however, is associated with high ionizing radiation doses (100–500 times higher than conventional radiography) and represents an appreciable risk for future neoplasm. This is particularly important in children, due to higher dose absorption caused by lower radiation attenua- tion in smaller body frames 4,5 and longer anticipated life spans. Clinical practice observations suggest that the prevalence of TVI among pediatric patients sustaining blunt chest trauma is low. There is currently no established protocol in the literature for radiologic screening for intrathoracic injuries in children after blunt trauma. Dose reduction protocols are being introduced in keeping with the ALARA (as low as reasonably achievable) prin- ciples, but evidence of the prevalence of internal chest trauma such as TVIs is sparse. The primary aim of the present research was to conduct an epidemiologic study of the incidence of TVI af- ter blunt thoracic injury in a pediatric population. In doing so, we hope to both define the incidence of TVI in this population and identify potential risk factors for TVI that may better guide appro- priate use of ionizing radiation for children after injury. METHODS We performed a retrospective cohort study involving all pe- diatric (age < 14 y) blunt trauma patients who were evacuated di- rectly from the scene of injury to the hospital from 1997 to 2015. The data were obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research in the Gertner Institute for Epide- miology and Health Policy Research. This registry records infor- mation concerning all trauma patients hospitalized in 19 hospitals, of which 6 are level I trauma centers and 13 are level II designated facilities. Data collected in the registry include age, sex, mecha- nism of injury, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), initial blood pressure, and incidence of named vessel injuries in the chest according to International Classification of Diseases, Ninth Revision, codes. For the purpose of our study, any injury to the thoracic aorta, brachiocephalic artery/vein, pul- monary artery/vein, subclavian artery/vein, or intrathoracic vena cava was considered a TVI. The primary objective of this study was to identify the rate of TVI among pediatric patients sustaining blunt mechanisms of in- jury. Pediatric patients with the diagnosis of TVI were identified to From the *Division of Surgery, Hillel Yaffe Medical Center, Hadera; and †The Rappaport Medical School, Technion, Haifa, Israel; ‡Divisions of Vascular Sur- gery and Trauma, Acute Care Surgery, and Surgical Critical Care, David Grant Medical Center, Travis AFB; and §University of California-Davis, Davis, CA; || National Center for Trauma and Emergency Medicine Research, Gertner Insti- tute for Epidemiology and Health Policy Research, Tel Hashomer, Israel; ¶Divi- sion of Pediatric Surgery, David Grant Medical Center, Travis AFB; and #Divisions of Vascular Surgery and Trauma, Acute Care Surgery, and Surgical Critical Care, University of California-Davis, Davis, CA; and **Trauma Unit, Division of Surgery, Hillel Yaffe Medical Center, Hadera, Israel. The Israel Trauma Group members are as follows: H. Bahouth, A. Becker, A. Hadary, M. Karawani, Y. Klein, G. Lin, O. Merin, B. Miklosh, Y. Mnouskin, A. Rivkind, G. Shaked, D. Simon, G. Sivak, D. Soffer, M. Stein, and M. Weiss. Reprints: Rabea Hasadia, MD, Division of Surgery, Hillel Yaffe Medical Center (affiliated with the Rappaport Faculty of Medicine, The Technion, Haifa), PO Box 169, Sea Rd, Hadera 38100, Israel (e‐mail: hasadia_69@hotmail.com). Disclosure: The authors declare no conflict of interest. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL ARTICLE Pediatric Emergency Care • Volume 00, Number 00, Month 2018 www.pec-online.com 1 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.