Cervical spine injuries and collar complications in severely injured paediatric trauma patients

Abstract

Study design: A retrospective registry review. Objectives: To determine the incidence of cervical spine (CS) injuries and collar complications in severely injured paediatric trauma patients. Setting: Regional Trauma Centre, Children's Hospital. Methods: A retrospective review of 365 paediatric severe trauma patients (0-17 years), defined as an Injury Severity Score (ISS)X12, admitted to the paediatric intensive care unit (PICU). Results: Clinically significant CS injuries occurred in 5% (n ¼ 18/365) of trauma patients, in 9% (n ¼ 13/149) of traumatic brain injury (TBI) patients and in 11% (n ¼ 6/56) of in-hospital trauma deaths. CS injuries were suspected before imaging in 33% (n ¼ 6/ 18) of patients based on either motor/sensory impairment or shock. CS injuries were deemed unstable in 61% (n ¼ 11/18) of patients. Patients with CS injuries had higher ISS, and longer PICU and hospital stays (Po0.05). CS collar complications occurred in 10% of patients, mainly identified by day 6 and consisting of either erythema or ulcers. Patients with CS collar complications were older and more likely to have TBI, lower Glasgow Coma Scale (GCS) scores, longer PICU and hospital stays, and increased days to CS clearance (Po0.05). Three CS X-rays, together with flexion/extension views, were used most frequently for CS clearance. Conclusion: CS injuries were prevalent in severely injured paediatric trauma patients, particularly in those with TBI and in nonsurvivors. CS collar complications were associated with a lower GCS and longer CS clearance times. Attention to CS collar management protocols and earlier CS clearance with computed tomography/magnetic resonance imaging in obtunded patients might reduce CS collar complications.

Cervical spine collar clearance in the obtunded adult blunt trauma patient

“…In addition, we did not address pediatric patients. 67–69 Although we did look for the less important patient-centric outcomes of time to cervical collar clearance and pressure ulcers, we did not capture time to imaging adjunct because there is no evidence that the timing of adjunct imaging (i.e. MRI greater or less than 48 hours) influences imaging quality or interpretation.…”

Missed cervical spine injuries

“…23,24,29,30 Transferring an unconscious intubated patient from an intensive care unit for MRI scans presents a logistical challenge, and also puts the patient at risk of aspiration, secondary brain injury and raised intracranial pressure. [9][10][11]24,25 Currently, routine MRI for all comatose patients is not recommended in the BOAST 2 guidelines and should be reserved for patients with suspected spinal cord injury. 7 Currently, however, these guidelines are only applicable to adult patients.…”

“…7 Prolonged immobilisation is associated with pressure sores and makes management of the airway more difficult. [9][10][11]24,25 A thin slice (2 mm to 3 mm) helical CT has a negative predictive value of 99.7% for cervical spinal injuries. 27 Despite this, 40 hospitals (25%) in our study reported that cervical spine precautions continued until patients regain full consciousness and could be clinically examined.…”

“…4,5 The potential morbidity, with high associated healthcare costs, and medico-legal implications of such a missed injury are significant. [6][7][8][9][10][11][12] In 2008, the British Orthopaedic Association (BOA) published recommendations for the clearance of the spine in multiply injured patients (BOAST 2). 7 The guidelines include advice on the management and clearance of the cervical spine in confused or comatose patients.…”

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre

“…The risk of collar‐related complications such as pressure ulceration appears lower in paediatric multi‐trauma patients. In children, the risk of collar‐related complications increases with obtundation/traumatic brain injury, longer ICU stay and delayed clearance; 10% of obtunded children show pressure injury after 6 days of cervical collar immobilisation . The risk of ulceration in alert children or non‐severe trauma is likely very low.…”