X-Ray Imaging in Pediatric Trauma: Evidence-Based Guidelines
Use evidence-based clinical decision rules to selectively apply X-ray and CT imaging in pediatric trauma, avoiding routine screening studies and prioritizing clinically important injuries while minimizing radiation exposure through validated risk stratification tools. 1
General Principles for Pediatric Trauma Imaging
Imaging decisions must focus on identifying clinically important injuries rather than all radiographically apparent findings (except in suspected child abuse where all injuries require forensic documentation). 1
Key Strategic Considerations:
Obtain advanced imaging only if it enables discharge from the ED or allows the child to remain at the initial facility rather than requiring transfer. 1
For children requiring transfer to a pediatric trauma center, defer advanced imaging at the referring facility unless performed in consultation with the receiving pediatric trauma center. 1 This prevents duplicate imaging and excessive radiation exposure, as transferred patients often receive higher radiation doses at referring facilities (approximately double the dose compared to pediatric trauma centers). 2
Apply evidence-based clinical guidelines and pathways for minor head injury, cervical spine injury, and abdominal trauma to avoid CT in very low-risk patients. 1
Specific Anatomic Region Guidelines
Head Trauma
For children ≥2 years with minor head trauma:
High-risk features requiring immediate CT: GCS ≤14, altered mental status, signs of basilar skull fracture, or post-traumatic seizures (risk of clinically important traumatic brain injury ~4.3%). 3
Intermediate-risk features where CT may be considered: Vomiting, severe headache, loss of consciousness, or severe mechanism of injury (risk ~0.8%). 3
Very low-risk patients who can safely avoid CT: GCS 15, normal mental status, no basilar skull fracture signs, no vomiting, no severe mechanism, no severe headache (risk <0.02%). 3
For children <2 years:
Immediate CT indicated for: GCS ≤14, altered mental status, or palpable skull fracture (risk ~4.4%). 3
Can safely avoid CT if: GCS 15, normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, loss of consciousness ≤5 seconds, no severe mechanism, and acting normally per parents (risk <0.02%, with 100% sensitivity and negative predictive value). 3
Clinical observation before CT decision-making effectively reduces unnecessary radiation without delaying diagnosis, with every additional hour of ED observation associated with decreased CT utilization. 3
Cervical Spine and Chest Imaging
Cervical spine CT and chest CT are seldom indicated as screening studies in pediatric patients. 1
Chest CT rarely changes management beyond what chest X-ray provides, as all emergent or urgent chest interventions (12% of cases) were based on chest X-ray findings, not CT. 4
Chest CT adds significant radiation (8.7 mSv vs 0.017 mSv for chest X-ray) without clinical benefit in most cases. 4
Reserve chest CT for: Abnormal mediastinal silhouette on chest X-ray after significant deceleration injury, suspected blunt mediastinal vascular injury, or wide mediastinum. 5, 4
Abdominal Trauma
Use clinical prediction models and evidence-based pathways to determine need for imaging rather than routine pan-scanning. 1
Routine whole-body CT ("pan-scan") should NOT be performed in pediatric trauma patients. 1 When necessary, perform with single-phase contrast to avoid scanning body regions multiple times. 1
Selective region-specific scanning is preferred unless: The patient has unreliable physical examination due to severe neurotrauma with or without intubation AND high-energy mechanism of injury. 1
Radiation Safety Considerations
Magnitude of Radiation Exposure
Pediatric trauma patients receive substantial radiation burdens during initial evaluation:
Mean effective dose from CT in first 24 hours: 11.4-12.0 mSv. 6, 7
Pan-scan radiation dose: 37.69 ± 7.80 mSv from initial CT scans. 4
Younger children and those with higher injury severity receive higher radiation doses. 6
Why Children Are More Vulnerable
Children have actively dividing cells and longer life expectancy, increasing susceptibility to radiation-induced cancers. 8
Children receive larger organ-specific radiation doses than adults due to smaller body size. 8
Head CT increases risk for cataracts from lens exposure. 8
Estimated lifetime cancer risk from CT radiation: as high as 1/500. 4
Radiation Minimization Strategies
Implement pediatric-specific, reduced-dose CT protocols at all facilities imaging children, following ALARA principles. 8
Use validated clinical decision rules (PECARN) to identify very low-risk children who can safely avoid CT. 8, 3
Ultra-low-dose CT protocols can reduce radiation 20% without compromising image quality. 8
Prioritize ultrasonography as first-line imaging when clinically appropriate (no ionizing radiation). 8
Special Circumstance: Suspected Child Abuse
Different rules apply when abuse is suspected:
Do NOT apply PECARN clinical decision rules to children with suspected abuse, as this population was excluded from validation studies. 1, 8
Skeletal surveys should be performed in children <2 years when abuse is suspected to evaluate for occult or healing fractures. 1
Either noncontrast CT or MRI is recommended for any child with suspected abusive head trauma. 1
For children <6 months, maintain low threshold for neuroimaging given high incidence of occult brain injury. 1
CT is preferred for unstable patients and those with acute trauma and concern for skull fracture. 1
All injuries require documentation for forensic purposes in abuse cases, unlike accidental trauma where only clinically important injuries guide imaging. 1
Interpretation by pediatric radiologist is essential to minimize missed findings or misinterpretation of normal developmental anatomy. 1
Critical Pitfalls to Avoid
Avoid obtaining CT in very low-risk patients who meet PECARN criteria for safe discharge, as this exposes them to unnecessary radiation without clinical benefit. 3
Do not perform routine pan-scans in pediatric trauma—this practice exposes children to 3-4 times the radiation of selective imaging without improving outcomes. 1, 4
Do not obtain skull radiographs instead of CT when CT is indicated, as skull X-rays miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 1, 3
Avoid imaging at referring facilities before transfer unless it will change immediate management or is done in consultation with the receiving pediatric trauma center, as this leads to duplicate studies and excessive radiation. 1, 2
Do not compromise diagnostic quality in pursuit of dose reduction—optimization means achieving appropriate image quality at the lowest achievable dose, not dose reduction at any cost. 8