The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department

Abstract

Objective: To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome. Methods: This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in‐hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service. Results: The trauma registry identified 1721 trauma presentations during the 4‐month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long‐term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non‐compliant groups. Conclusions: Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.

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

“…10 The median day for CS clearance was 2 days for those patients who had neither CS injuries nor collar complications. A fast CS clearance time is imperative and clinical CS clearance is ideal, but our rates were relatively low at 13% (adults 20%), 13 likely due to the higher severity of injuries in our trauma population. Indeed, clinical assessment is less reliable for patients with added comorbidities, lower GCSs and distracting injuries.…”

“…Clinical CS clearance requires that patients have no midline cervical tenderness, no intoxication, no pain and no neurological deficits. 19 At our centre, CS clearance follows published protocols for paediatric patients, 13,14 but was before publication of the Trauma Association of Canada consensus guidelines for CS evaluation. 15 Overall, three CS films with flexion/extension views were used most often to clear CSs in trauma patients.…”

“…CS clearance at our institution followed published protocols for paediatric patients, 13,14 but was before the Trauma Association of Canada consensus guidelines for evaluation of paediatric CS. 15 Three views of the CS included an anterior-posterior view, lateral view, and odontoid view.…”

Pediatric Cervical Spine Injury Evaluation After Blunt Trauma: A Clinical Decision Analysis

“…At a probability of cervical spine injury in the NEXUS-positive group of 0.03%, which represents a 18 Buhs et al, 20 Mower et al 19 No change Radiograph specificity 95% 60%-100% Streitwieser et al, 22 Nguyen and Clark, 23 Tins and Cassar-Pullicino 24 No change p(malignancy) 0.4% 0.1%-0.7% Berrington de Gonzalez et al 26 No change CSI utility 0.6 0.4-0. 9 Kaplan et al, 29 Oladeji et al, 27 Ravichandran and Silver 28 No change Figure 2. Once the decision to image has been made, the choice of imaging modality is controversial.…”

“…7 Thus, clinicians remain uncertain about which clinical screening criteria, if any, to use when evaluating children for potential cervical spine injury after blunt trauma. 8,9 For the symptomatic patient, it is generally agreed that radiographic imaging is a necessary adjunct, but there are no consistent recommendations on indications or modality. Adult…”