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2. The challenges associated with accurately diagnosing diaphragmatic rupture with MDCT include the complex shape of the thin diaphragmatic muscle, the horizontal in-plane orientation of the diaphragmatic dome, and the frequency of associated traumatic • abnormalities in the lung bases. • Direct discontinuity of a hemidiaphragm (see Fig. 11), which may allow herniation of intra-abdominal mesenteric fat, parenchymal organs, or viscera, is the most sensitive imaging finding of

3. diaphragmatic rupture. • The “hourglass” or “collar” sign refers to the waist-like constriction of partially herniated viscera by the edges of a small diaphragmatic defect. • On the right side, the same mechanism can appear as a focal indentation of the liver, termed the “rim” sign, which may be subtle and easily overlooked on axial images. • Detection of this sign requires careful analysis of axial images as well as the sagittal and coronal multiplanar reformatted images.

4. The “dependent viscera” sign describes the close contact of the herniated stomach or liver with the posterior chest wall, with no diaphragmatic leaflet holding it up against gravity, and lack of normal interposition of aerated lung tissue posteriorly. • Given the difficulty of reaching an accurate diagnosis, many patients are not diagnosed in the acute setting, possibly as many as 40% to 50%. • A delayed diagnosis is often made days, weeks, or even years later, frequently with a complication of visceral herniation.

5. IMAGING ALGORITHMS • When one endeavors to devise an appropriate imaging algorithm for the investigation of the child who has suffered chest trauma, three key factors have to be considered. First, the imaging modalities used should be as quick and as accurate as possible. Second, the result of these tests should positively direct patient management and help dictate treatment

6. Finally, the nature of the investigative tools should not have any negative effect on the child’s health or, at least, that effect should be minimized. • Whereas the natural inclination would be to immediately use the most accurate and sensitive test, thereby satisfying the first criterion, one has to carefully consider whether such a choice affects the other criteria positively or negatively.

7. MDCT is more sensitive than chest radiography for a multitude of chest injuries. Rib fracture, pneumothorax, hemothorax, pulmonary contusion and laceration, diaphragmatic rupture, and vascular injuries are all more accurately diagnosed with MDCT • Furthermore, MDCT is quick and readily available in most trauma units.

8. The arrival of an injured child in the trauma room is an upsetting event for all involved. Therefore, it is understandable that caregivers might choose a CT scan as their first choice investigation so as to diagnose all injuries within the shortest possible time frame. The potential advantages seem clear; not only is MDCT accurate, but a complete contiguous head-through-pelvis scan may be performed in less than a minute, without the need for repositioning of the critically injured patient

9. The dose from a single continuous total-body scan is less than the individual components performed separately, • although this in itself should not be used as a reason to include all body segments in the CT scan. • The volumetric data set acquired with MDCT allows for multiplanar reconstructions, better demonstrating both soft tissue and skeletal injuries, and potentially foregoing the need for other radiographs, which might require multiple projections.

10. Such total body scanning is advocated by many investigators for the adult population, • but one needs to be more cautious before employing a similar policy for children, taking into consideration the second and third criteria outlined above.

11. With respect to the second criterion, one needs to consider whether the supplemental information provided by a CT scan, over and above the findings on chest radiography, substantially alter patient management. • In a study on chest trauma in an adult population by Trupka and colleagues, the routine addition of a CT scan to chest radiography did not alter patient management in 59% injuries.

12. A more recent adult study reported that the routine use of a CT scan in chest trauma resulted in a greater number of additional diagnoses in 43%, but resulted in a change in patientmanagement in just 17%. • Moreover, in a recent pediatric study, most intrathoracic findings requiring surgical management could be identified on images of the lower chest that are part of routine abdominopelvic CT scan examinations, and chest CT scan findings added relatively little to those of radiography.

13. Therefore, rather then routinely” scanning all potential chest trauma patients, a more selective approach guided by the nature and severity of the trauma, clinical parameters,101 and chest radiographic findings is more prudent. This selective approach has been shown to increase the incidence of clinically significant findings demonstrated by a CT scan that actually alter patient management.

14. Given the relative infrequency of serious cardiovascular and diaphragmatic injuries in children, most abnormalities detected with a CT scan that may affect patient management relate to pneumothoraces and complications of chest tube placement. • Although most radiographically occult pneumothoraces that are detected with a CT scan do not require chest tube placement,

15. if left untreated, they might expand and/or develop into a tension pneumothorax following the institution of positive pressure ventilation. For this reason, a chest CT scan is nearly always indicated in children whose chest injury is severe enough to require mechanical ventilation.

16. In our era of escalating medical costs, one also has to take into account the cost-effectiveness of expensive imaging resource use • . Renton and colleagues103 reported that if CT scans were to replace the chest radiograph as the primary tool for investigating pediatric chest trauma, 200 studies would need to be performed to detect one clinically significant finding, incurring a hospital cost of $39,600 and a patient cost of $180,000.

17. The current medico-legal climate, which encourages defensive medicine, likely results in the over-use of CT scans, ignoring the fact tha many of the injuries demonstrated do not affect patient management or treatment.

18. Another potential problem with performing CT scans is the risk of detecting “pseudodisease” and clinically unimportant findings as a result of overinterpretation of the CT scan images • . This may influence clinicians to perform costly and sometimes invasive additional imaging tests and treatments that are unnecessary, which can lead to iatrogenic complications as well as added expense • . • In the era before the implementation of CT scans, this pseudodisease would have simply remained unnoticed, without adverse effect on patient outcome

19. Finally, one must consider the third criterion, which is that of radiation carcinogenesis and teratogenesis resulting from the indiscriminate use of CT scans. • For a discussion of these risks and their significance, see the article by Donald Frush elsewhere in this issue. The challenge in imaging pediatric chest trauma is to incorporate all of these complex issues in an attempt to derive an appropriate imaging algorithm.

20. The authors believe that the initial imaging evaluation of pediatric trauma should consist of the conventional trauma series (lateral cervical spine in collar, AP pelvis, and chest radiographs). • The sensitivity of the conventional radiographic series may be increased by implementing a novel fullbody digital radiograph system.

21. The initial radiographic findings should be interpreted in conjunction with a careful and rapid triage by an experienced clinician, taking the mechanism and force of injury into account. • This will determin the need for additional imaging. If cross-sectional imaging is required, a CT scan is not the only option. • Ultrasound has been used to demonstrate pleural effusions, hemothorax, pneumothorax, pulmonary contusions, pericardial tamponade, and even sternal fractures.

22. Although ultrasound is frequently more time consuming than CT scanning, the clinical situation may allow for it and spare the patient unnecessary radiation. • However, the exact place of FAST ultrasound11,12 in the diagnostic algorithm of trauma, in particular with regard to the qualifications of its practitioners and the optimal technique, remains somewhat controversial at this time.

23. eventually • undergo a CT scan focused on the area of • impact, because the risk of occult internal injury • is high in these patients. Unconscious patients • and those with suspicion for unstable cervical • spine fractures will generally undergo a CT scan • of the head and cervical spine. Factors that influence • the decision to perform more extensive CT • scanning include the severity of the injuries • demonstrated on the initial radiographic trauma • series, the degree of respiratory compromise, • and the presence of hemodynamic instability.

24. If • a thoracic spine fracture is clinically suspected or • demonstrated on the initial radiographic survey, • a CT scan should be performed, with coronal • and sagittal reformatted images. Fractures of the • upper ribs, shoulder girdle, and sternum will often • necessitate a contrast-enhanced CT scan to look • for vascular injury. If there is persistent hemorrhagic • output from chest tubes or there is • radiographic evidence for progressive pneumomediastinum, • a CT scan is indicated to look for • bronchial and/or vascular injury. Although traumatic • aortic injury in children remains rare, the • associated high mortality dictates that a high index • of suspicion should be maintained for this condition: • unexplained hemodynamic compromise or • an abnormal mediastinum on chest radiography • would indicate the need for an emergent CT • angiogram.

25. SUMMARY • Given the heterogeneous nature of pediatric chest • trauma, the optimal imaging approach is one • tailored to the specific patient. Chest radiography • remains the most important imaging modality for • initial triage. Although the role of ultrasound in the • setting of trauma is currently somewhat controversial, • it may suffice in specific circumstances. The • decision to perform a chest CT scan should be • dictated by the nature of the trauma,

26. the clinical condition of the child, and the initial radiographic findings, taking the age-related, pretest probabilities of serious injury into account. • In the conscious pediatric polytrauma patient who has a normal neurologic function, is not in respiratory failure, has no signs of hemodynamic instability, and who has a normal appearance of the mediastinum on the initial radiograph, there is sufficient evidence to support that a chest CT scan be withheld initially. • If an abdominal CT scan is done for initial evaluation, proper attention should be paid to injuries that are visible in the lower thorax (including the

27. diaphragm). Chest CT scanning is particularly important in children with chest trauma when hemodynamic instability or respiratory failure requiring intubation develops, or when there is persistent drainage of blood or air from chest tubes, suspicion for chest tube malfunction, or a progressive pneumomediastinum • . • In the unconscious polytrauma patient, the performance of a contiguous, headthrough- pelvis MDCT may be considered • . Whenever a CT scan is performed, the principles of as low as reasonably achievable (ALARA) and “Image Gently” should be adhered to. Radiologists should be actively involved in trauma care. • Continued education and close communication between radiologists and the clinical care team are essential to optimize patient care.

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