title: Risks of radiation versus risks from injury: a clinical decision analysis for the management of penetrating palatal trauma in children.
abstract: OBJECTIVE
  Penetrating palatal trauma in children presents a diagnostic dilemma regarding the small but severe risk of injury to carotid vessels. Decisions regarding which children require computed tomography with angiography must be balanced against the risk of radiation-induced malignancy. Our objectives were to compare outcomes between children with and without computed tomography with angiography in the evaluation of palatal trauma and to identify thresholds where the ideal strategy changes in the management of children with palatal trauma through sensitivity analyses.
  
  
  METHODS
  Decision analytic techniques were used to compare management strategies for penetrating palatal trauma.
  
  
  METHODS
  We assigned utilities to the following outcomes: 1) perfect health, 2) future malignancy, 3) carotid injury diagnosed by computed tomography with angiography, and 4) delayed diagnosis of stroke. We calculated outcomes when the risk of stroke ranged from 0.01% to 5.0% for a hypothetical cohort of 10,000 injured children.
  
  
  RESULTS
  Not obtaining computed tomography with angiography is the optimal strategy when the stroke risk is less than 4.5%. In two-way sensitivity analyses that consider a range of probabilities of radiation-induced malignancy and stroke, not obtaining computed tomography with angiography on all patients dominates as a strategy until the risk of stroke exceeds 2.3%, and the risk of malignancy is under 0.24%. Routine imaging would introduce 20 additional malignancies for each additional stroke diagnosed.
  
  
  CONCLUSIONS
  Routine use of computed tomography with angiography for well-appearing children with palatal trauma should be reconsidered, as the risk of radiation-induced malignancy may outweigh the benefit of identifying the rare carotid injury.
  
  
  METHODS
  2b.
authors: Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts 02115, USA. kara.hennelly@childrens.harvard.edu
authors: Kara E
authors: KE
authors: Hennelly
authors: Andrew M
authors: AM
authors: Fine
authors: Dwight T
authors: DT
authors: Jones
authors: Stephen
authors: S
authors: Porter
mesh_terms: D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D010159:Palate / Q000293:injuries* / Q000528:radiation effects*; D011832:Radiation Injuries / Q000453:epidemiology / Q000209:etiology*; D012307:Risk Factors; D014057:Tomography, X-Ray Computed / Q000009:adverse effects* / Q000379:methods; D014481:United States / Q000453:epidemiology; D014711:Vertebral Artery / Q000000981:diagnostic imaging / Q000293:injuries*; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging* / Q000453:epidemiology