Implementation of a pediatric trauma cervical spine clearance pathway

Luehmann, Natalie C; Pastewski, Jacquelyn; Cirino, Jennifer A.; Al-Hadidi, Ameer; DeMare, Alexander M.; Riggs, Thomas W.; Novotny, Nathan M.; Akay, Begum

doi:10.1007/s00383-019-04544-8

Cited by 10 publications

(12 citation statements)

References 15 publications

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“…Furthermore, Luehmann et al 12 found CT scans reduced from 28% to 23% of children after updated guidelines were introduced. The guidelines reported by Luehmann et al 12 directed clinicians to request a CT scan if an abnormal radiograph finding was noted. A previous audit at our hospital had identified that incorrect interpretation of normal paediatric anatomical variants seen on plain radiograph such as pseudosubluxation as pathological had led to unnecessary CT scans.…”

Section: Discussionmentioning

confidence: 99%

“…11 Pennell et al found guideline modification was associated with a decrease in CT scan use from 14.5% to 5.4%, compared with our study, which decreased from 8.8% to 7.3%. Furthermore, Luehmann et al 12 found CT scans reduced from 28% to 23% of children after updated guidelines were introduced. The guidelines reported by Luehmann et al 12 directed clinicians to request a CT scan if an abnormal radiograph finding was noted.…”

Section: Comparison To Other Studiesmentioning

confidence: 99%

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An audit of computed tomography request practices for suspected cervical spine injury post‐guideline change in a tertiary referral paediatric hospital

Sires

Ovenden

Antoniou

et al. 2021

ANZ Journal of Surgery

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Background Paediatric neck injuries are a common presenting complaint to emergency departments (EDs). Medical imaging can assist diagnosis, however previous research suggests computed tomography (CT) scan results do not alter management in this patient group and therefore expose children to unnecessary radiation. Following an audit by the hospital Trauma Service that identified unnecessary cervical spine CTs in patients at Women's and Children's Hospital (WCH), Adelaide, the Clinical Procedure for imaging and clearance of the cervical spine in conscious patients was modified to include CT scan only at the request of the orthopaedic service. The aim of this study was to evaluate whether a change in hospital guideline resulted in a change in practice and radiation exposure. Methods A retrospective review was performed for patients that presented to the WCH ED with a suspected cervical spine injury during two defined time periods pre‐ and post‐guideline change. Mechanism of injury, imaging requested, radiation exposure and final diagnosis were compared. Results Three hundred seventy‐nine patients were included, with 164 (43.3%) post‐guideline changes. Radiograph use was similar between groups, 132/215 (61.4%) versus 101/164 (61.6%) (p = 0.97). CT scan use was lower post‐guideline modification 19/215 (8.8%) versus 12/164 (7.3%), however was not statistically significant (p = 0.59), with an absolute reduction of 17%. Conclusion Guideline modification at our hospital did not significantly reduce CT scan use or eliminate unnecessary CTs. Unnecessary CT scans followed lack of knowledge of and therefore compliance with guidelines. Individual hospitals should consider strategies to reduce unnecessary CTs, given the association with cancer risk in children.

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Section: Discussionmentioning

confidence: 99%

Section: Comparison To Other Studiesmentioning

confidence: 99%

An audit of computed tomography request practices for suspected cervical spine injury post‐guideline change in a tertiary referral paediatric hospital

Sires

Ovenden

Antoniou

et al. 2021

ANZ Journal of Surgery

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“…All 3 of these protocols were applied to the entire cohort with no lower limit of age. Five paradigms did not explicitly mention NEXUS criteria, but did utilize at least one of the NEXUS criteria as part of their protocol 17,18,27–29. Importantly, none of the studies stratified initial triage criteria by age and all included patients who were younger than 3 years of age, who many consider to be difficult to examine.…”

Section: Resultsmentioning

confidence: 99%

“…Examining the studies that provided rates of delayed and/or missed injuries, there were several studies that reported zero missed injuries, even with low rates of imaging21,28,30 (Supplemental Table 1B–D, Supplemental Digital Content 2, http://links.lww.com/SLA/D854). Two studies reported delayed diagnosis of clinically important injuries.…”

Section: Resultsmentioning

confidence: 99%

“…Five paradigms did not explicitly mention NEXUS criteria, but did utilize at least one of the NEXUS criteria as part of their protocol. 17,18,[27][28][29] Importantly, none of the studies stratified initial triage criteria by age and all included patients who were younger than 3 years of age, who many consider to be difficult to examine. Details of which NEXUS criteria were included per protocol are presented in Table 1.…”

Section: Triage Criteriamentioning

confidence: 99%

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Variability of Pediatric Cervical Spine Clearance Protocols

et al. 2022

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Objective: The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. Background Data: Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. Methods: A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results: There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N = 14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. Conclusions: Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

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