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Russell LJ, Dodd T, Kendall D, Lazenbury A, Leggett A, Payton-Haines S, Jiang L, Filingeri D, Worsley PR. A bioengineering investigation of cervical collar design and fit: Implications on skin health. Clin Biomech (Bristol, Avon) 2024; 112:106178. [PMID: 38232471 DOI: 10.1016/j.clinbiomech.2024.106178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/13/2023] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Cervical collars restrict cervical spine movement to minimise the risk of spinal cord injury. Collars apply mechanical loading to the skin putting it at risk of skin damage. Indeed, cervical collar-related pressure ulcers are unacceptably prevalent, especially at the occiput, mandibles, and chin. Collar design and fit are often key considerations for prevention. METHODS This comprehensive study evaluated four commercial prehospital and acute care cervical collars. Pressure, microclimate, transepidermal water loss and skin hydration were measured at the interface between the device and the skin. Range of motion restriction was measured to evaluate effective immobilisation. Head, neck, and shoulder morphology was evaluated using three-dimensional scans. FINDINGS The occiput experienced significantly higher interface pressures than the chin and mandibles for most collar designs. Interface pressure at the occiput was significantly higher for the Stiffneck extrication collar compared to the other collar designs. The Stiffneck collar also provided the most movement restriction, though not significantly more than other designs. Relative humidity at the device skin interface was significantly higher for the Stiffneck and Philadelphia collars corresponding to closed cell foam padding, in contrast to the open cell foams lined with permeable fabric used in the other collars. Collar discomfort correlated with both occipital pressure and skin humidity. INTERPRETATION The occiput is at increased risk of cervical collar-related pressure ulcers during supine immobilisation, especially for Stiffneck extrication collars. Lined open-cell foams could be used to minimise skin humidity and increase comfort.
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Affiliation(s)
- Laurence J Russell
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.
| | - Tamara Dodd
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Daniel Kendall
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Amber Lazenbury
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Abigail Leggett
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Sophie Payton-Haines
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Liudi Jiang
- School of Engineering, Faculty of Engineering and Physical Sciences, University of Southampton, Southampton, UK
| | - Davide Filingeri
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Peter R Worsley
- Skin Sensing Research Group, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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Krishnan P, Aditya G. Allergic Contact Dermatitis Due to Cervical Collar. J Neurosci Rural Pract 2022; 13:159-160. [PMID: 35110940 PMCID: PMC8803514 DOI: 10.1055/s-0041-1740454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cervical collars are routinely applied in neurosurgical units following trauma or cervical spine operations. We describe a case of florid allergic contact dermatitis that developed as a complication following collar application in a postoperative patient.
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Affiliation(s)
- Prasad Krishnan
- Department of Neurosurgery, National Neurosciences Centre, Calcutta, West Bengal, India
| | - Grandhi Aditya
- Department of Neurosurgery, National Neurosciences Centre, Calcutta, West Bengal, India
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Rezaee H, Keykhosravi E, Tavallaii A. Characteristics and In-Hospital Outcomes of Pediatric Traumatic Spinal Injuries in A Referral Trauma Center. Bull Emerg Trauma 2021; 9:178-182. [PMID: 34692868 PMCID: PMC8525697 DOI: 10.30476/beat.2021.91333.1275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/25/2021] [Accepted: 09/11/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: To evaluate the characteristics and in-hospital outcomes of traumatic spinal injuries among children admitted to a local trauma center in Iran. Methods: Patients aged 0-18 years who had been admitted to Shahid Kamyab trauma center for acute traumatic spinal injury (Mashhad, Iran) between 2011 and 2018 were evaluated retrospectively. Various demographic, clinical, radiological, and outcome variables were recorded and analyzed. Results: A total of 127,300 trauma patients were evaluated and amongst them, 61 children had spinal trauma. The mean age was 11.1 and there was no significant sex preponderance (54% males). Most of the injuries were occurred in summer (34.4%) and the most common trauma mechanism was motor vehicle accidents (55.7%) followed by falling (36.1%). Almost all patients (95.1%) had vertebral fractures, which were in the cervical, thoracic, and lumbosacral area in order to decrease incidence. 67.2% of patients were managed non-surgically. The mean hospital stay was 8.9 days and 82.0% of patients had been discharged with normal motor function. Conclusion: Pediatric spinal trauma is less studied entity in the field of traumatology due to the lower prevalence of these injuries in pediatric patients worldwide. But our study shows a higher prevalence of such injuries in the pediatric population. Although controversial, the leading cause of these injuries is motor vehicle accidents. Fortunately, short term in-hospital outcome seems to be good in such injuries.
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Affiliation(s)
- Hamid Rezaee
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Akbar children's Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amin Tavallaii
- Department of Neurosurgery, Akbar children's Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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4
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Araghi K, Jacofsky M, McCamley J. Comparison of cervical motion restriction and interface pressure between two cervical collars. Clin Biomech (Bristol, Avon) 2021; 89:105482. [PMID: 34537462 DOI: 10.1016/j.clinbiomech.2021.105482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 02/07/2023]
Abstract
Background Cervical collar treatment is widespread amongst a broad range of ages and conditions. However, these devices are associated with a known correlation between collar usage and adverse effects such as pressure ulcers, infections, exacerbated spinal injury, and higher morbidity. The objective of this study was to determine if the ability of a newly developed DJO Procare XTEND 174 collar to restrict cervical spine motion was similar to that of the previously studied Össur Miami J collar and to determine if this was done while producing similar tissue interface pressures. Methods Three-dimensional kinematic data were obtained for twelve healthy volunteer participants (6 female, 6 male) using a 10-camera infrared motion capture system. Cervical range of motion in each plane was calculated using angles between head and thorax rigid-body axes. Tissue interface pressure was measured between the head and the collar with three flexible pressure sensor pads over the anterior mandibles and occiput. The distribution of interface pressures was obtained in both the seated and supine positions. Findings Both collars significantly restricted range of motion in all movement directions (p < 0.001) compared to no collar. There were no significant differences in restrictiveness nor in tissue interface pressures between the collars. Both collars exhibited similar range of motion restriction and similar interface pressures. Interpretation Our data indicate that the newly developed Procare XTEND 174 collar is not statistically different from the scientifically recognized Miami J benchmark collar regarding cervical range of motion restriction in all three planes and tissue interface pressure.
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Affiliation(s)
- Kasra Araghi
- MORE Foundation, 18444 N 25(th) Ave. Suite 110, Phoenix, AZ 85023, USA.
| | - Marc Jacofsky
- MORE Foundation, 18444 N 25(th) Ave. Suite 110, Phoenix, AZ 85023, USA; The CORE Institute, 18444 N 25(th) Ave. Suite 320, Phoenix, AZ 85023, USA.
| | - John McCamley
- MORE Foundation, 18444 N 25(th) Ave. Suite 110, Phoenix, AZ 85023, USA.
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5
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Konovalov N, Peev N, Zileli M, Sharif S, Kaprovoy S, Timonin S. Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations. Neurospine 2020; 17:797-808. [PMID: 33401857 PMCID: PMC7788416 DOI: 10.14245/ns.2040404.202] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/07/2020] [Indexed: 11/19/2022] Open
Abstract
Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.
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Affiliation(s)
- Nikolay Konovalov
- Burdenko Institute Department of Neurosurgery, Moscow, Russian Federation
| | - Nikolay Peev
- Department of Neurosurgery, Belfast Health and Social Care Trust, Northern Ireland, Belfast, UK
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | - Salman Sharif
- Neurosurgery Liaquat National Hospital & Medical College, Karachi Pakistan, Karachi, Pakistan
| | - Stanislav Kaprovoy
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Stanislav Timonin
- Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
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6
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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Gutierrez X, April M, Maddry J, Hill G, Becker T, Schauer S. Incidence of Pediatric Cervical Spine Injuries in Iraq and Afghanistan. South Med J 2019; 112:271-275. [PMID: 31050794 PMCID: PMC6485296 DOI: 10.14423/smj.0000000000000974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Cervical spine injuries in pediatric trauma patients are uncommon, and subsequently, proper diagnosis and the efficacy of spinal motion restriction in these patients remain a subject of contention. The aim of this study was to describe the incidence of cervical spine injuries in pediatric patients in Iraq and Afghanistan. Objective Military providers frequently treat civilians, including pediatric patients. Cervical spine injuries in pediatric trauma patients occur infrequently, with limited data on the incidence. The aim of this study was to describe the incidence of cervical spine injuries in pediatric patients in Iraq and Afghanistan. Methods We queried the Department of Defense Trauma Registry for all pediatric encounters from January 2007 to January 2016. We searched within that dataset for all cervical spine fractures. Results From January 2007 through January 2016 there were 3439 pediatric encounters. There were 36 subjects identified (1.0%) with a cervical spine fracture. Of those with a cervical spine fracture, 6 (17%) had a prehospital cervical collar placed, which did not improve survival to hospital discharge (collar, 66.7% vs no collar, 83.3%, P = 0.573). Of those with a cervical spine fracture, 6 (17%) had a documented spinal cord injury. The median age of subjects with a cervical spine fracture was 9.5 years and the majority (63.9%) were male. Most were injured by explosion (41.7%). The median composite injury score was higher in subjects with a cervical spine fracture compared with those without one (16.5 vs 10, P < 0.001). Subjects with a cervical spine fracture had longer lengths of stay in the intensive care unit (median 3 days vs 1, P = 0.012) and a trend toward worse survival to hospital discharge (80.6%, n = 29, vs 90.3%, n = 3074, P = 0.079). Conclusions Cervical spine injuries occurred infrequently in pediatric patients in Iraq and Afghanistan. When a fracture was present, almost one in five patients had spinal cord involvement. The pediatric prehospital literature would benefit from the development of a clinical decision tool to guide prehospital personnel as to when a cervical collar is indicated. Moreover, appropriate size equipment should be available when caring for host national civilians.
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Affiliation(s)
- Xandria Gutierrez
- From the 59th Medical Wing, Joint Base San Antonio (JBSA) Lackland Air Force Base, the Department of Emergency Medicine, San Antonio Military Medical Center, JBSA, and Dell Children's Medical Center, Austin, Texas
| | - Michael April
- From the 59th Medical Wing, Joint Base San Antonio (JBSA) Lackland Air Force Base, the Department of Emergency Medicine, San Antonio Military Medical Center, JBSA, and Dell Children's Medical Center, Austin, Texas
| | - Joseph Maddry
- From the 59th Medical Wing, Joint Base San Antonio (JBSA) Lackland Air Force Base, the Department of Emergency Medicine, San Antonio Military Medical Center, JBSA, and Dell Children's Medical Center, Austin, Texas
| | - Guyon Hill
- From the 59th Medical Wing, Joint Base San Antonio (JBSA) Lackland Air Force Base, the Department of Emergency Medicine, San Antonio Military Medical Center, JBSA, and Dell Children's Medical Center, Austin, Texas
| | - Tyson Becker
- From the 59th Medical Wing, Joint Base San Antonio (JBSA) Lackland Air Force Base, the Department of Emergency Medicine, San Antonio Military Medical Center, JBSA, and Dell Children's Medical Center, Austin, Texas
| | - Steven Schauer
- From the 59th Medical Wing, Joint Base San Antonio (JBSA) Lackland Air Force Base, the Department of Emergency Medicine, San Antonio Military Medical Center, JBSA, and Dell Children's Medical Center, Austin, Texas
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8
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Galganski LA, Cox JA, Greenhalgh DG, Sen S, Romanowski KS, Palmieri TL. Cervical Spine Injury in Burned Trauma Patients: Incidence, Predictors, and Outcomes. J Burn Care Res 2019; 40:263-268. [PMID: 30801641 DOI: 10.1093/jbcr/irz022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cervical spine injuries (CIs) carry significant morbidity and mortality; hence, cervical spine immobilization is used liberally in trauma patients, including burns. The incidence, predictors, and outcomes of CI in burn patients are unknown. A retrospective cohort from the National Trauma Data Bank between 2007 and 2012 included all burned patients with and without CI. Predictors of CI were identified by logistic regression. Outcomes with and without CI were compared with Wilcoxon rank sum test. A total of 94,964 patients were identified with burn injuries. The incidence of CI was 0.79% (n = 745). Mechanism of injury, age, and injury severity score (ISS) were significant predictors of CI. Odds of CI were 109.4 (95% CI: 61.2-195.3, P < .0001) for motor vehicle injury, 87.8 (95% CI: 47.0-164.0, P < .0001) for falls, 1.2 (95% CI: 0.6-2.3, P = .66) for fire/flame, and 2.4 (95% CI: 1.0-5.5, P < .0001) for explosion compared with reference of hot object/substance. For every year increase in age, there were 1.02 higher odds of CI (95% CI: 1.01-1.02, P < .0001). For each point increase in ISS, there were 1.05 higher odds of CI (95% CI: 1.04-1.05, P < .0001). Patients with CI had higher mortality (10.3% vs 2.9%, P < .0001), longer total length of stay (12.0 vs 2.0 days, P < .0001), intensive care unit length of stay (4.0 vs 0.0 days, P < .001), and ventilator days (1.0 vs 0.0 days, P < .0001). The incidence of CI in burn patients is low, especially when due to fire, flame, or scalds; however, CI is associated with higher mortality and worse outcomes.
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Affiliation(s)
- Laura A Galganski
- Department of Surgery, Division of Burn Surgery, University of California, Davis, California.,Shriners Hospital for Children - Northern California, Sacramento, California
| | - Jessica A Cox
- Department of Surgery, Division of Burn Surgery, University of California, Davis, California.,Shriners Hospital for Children - Northern California, Sacramento, California
| | - David G Greenhalgh
- Department of Surgery, Division of Burn Surgery, University of California, Davis, California.,Shriners Hospital for Children - Northern California, Sacramento, California
| | - Soman Sen
- Department of Surgery, Division of Burn Surgery, University of California, Davis, California.,Shriners Hospital for Children - Northern California, Sacramento, California
| | - Kathleen S Romanowski
- Department of Surgery, Division of Burn Surgery, University of California, Davis, California.,Shriners Hospital for Children - Northern California, Sacramento, California
| | - Tina L Palmieri
- Department of Surgery, Division of Burn Surgery, University of California, Davis, California.,Shriners Hospital for Children - Northern California, Sacramento, California
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Presenting Characteristics Associated With Outcome in Children With Severe Traumatic Brain Injury: A Secondary Analysis From a Randomized, Controlled Trial of Therapeutic Hypothermia. Pediatr Crit Care Med 2018; 19:957-964. [PMID: 30067578 PMCID: PMC6170689 DOI: 10.1097/pcc.0000000000001676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. DESIGN A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normothermia following severe traumatic brain injury in children. SETTING Fifteen sites in the United States, Australia, and New Zealand. PATIENTS Children (< 18 yr old) with severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Baseline, clinical, and CT characteristics of patients (n = 77) were examined for association with mortality and outcome, as measured by the Glasgow Outcome Scale-Extended Pediatric Revision 3 months after traumatic brain injury. Data are presented as odds ratios with 95% CIs. No demographic, clinical, or CT characteristic was associated with mortality in bivariate analysis. Characteristics associated with worse Glasgow Outcome Scale-Extended Pediatric Revision in bivariate analysis were two fixed pupils (14.17 [3.38-59.37]), abdominal Abbreviated Injury Severity score (2.03 [1.19-3.49]), and subarachnoid hemorrhage (3.36 [1.30-8.70]). Forward stepwise regression demonstrated that Abbreviated Injury Severity spine (3.48 [1.14-10.58]) and midline shift on CT (8.35 [1.05-66.59]) were significantly associated with mortality. Number of fixed pupils (one fixed pupil 3.47 [0.79-15.30]; two fixed pupils 13.61 [2.89-64.07]), hypoxia (5.22 [1.02-26.67]), and subarachnoid hemorrhage (3.01 [1.01-9.01]) were independently associated with worse Glasgow Outcome Scale-Extended Pediatric Revision following forward stepwise regression. CONCLUSIONS Severe traumatic brain injury is a clinically heterogeneous disease that can be accompanied by a range of neurologic impairment and a variety of injury patterns at presentation. This secondary analysis of prospectively collected data identifies several characteristics associated with outcome among children with severe traumatic brain injury. Future, larger trials are needed to better characterize phenotypes within this population.
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10
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Waddell VA, Connelly S. Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project. J Trauma Nurs 2018; 25:38-44. [PMID: 29319649 DOI: 10.1097/jtn.0000000000000340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Quality improvement project. OBJECTIVES Reduce the amount of radiation exposure in the pediatric trauma population 5 years of age and older in relation to cervical spine clearance. BACKGROUND The evaluation of pediatric cervical spine injuries must be accurate and timely to avoid missed injuries. The difficult clinical examination in pediatric trauma patients necessitates the use of radiologic examinations to avoid missing catastrophic injuries. However, exposure to radiation at an early age increases the pediatric patients' risk of developing cancer (R. A. ). METHODS A retrospective chart review was conducted to assess radiation exposure in pediatric patients requiring evaluation for cervical spine clearance. Surgical staff and emergency department physicians received education on the risks related to pediatric radiation exposure and information related to the institution's diagnostic trends for cervical spine clearance. An algorithm was then developed to assist with determining the necessary imaging study for cervical spine clearance. Radiation exposure was monitored following initial education and use of the algorithm to determine its effect on radiation exposure. RESULTS The retrospective chart review identified cervical spine computed tomography (CT) in 34%, with an average radiation exposure of 3.5 mSv. Following education and introduction of an algorithm, 18% of patients underwent CT for cervical spine clearance with an average radiation exposure of 3.2 mSv, representing a 47% decrease in the use of CT. CONCLUSION Staff education and the use of an algorithm show promise in the reduction of radiation exposure and provide safe, effective clearance of the cervical spine in pediatric trauma.
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Affiliation(s)
- Valerie Ann Waddell
- Department of General Surgery, Trauma and Burn, Children's Mercy, Kansas City, Missouri (Dr Waddell) and Department of Nursing, Creighton University, Omaha, Nebraska (Dr Connelly)
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11
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Craxford S, Bayley E, Walsh M, Clamp J, Boszczyk BM, Stokes OM. Missed cervical spine injuries: a national survey of the practice of evaluation of the cervical spine in confused and comatose patients. Bone Joint J 2017; 98-B:825-8. [PMID: 27235527 DOI: 10.1302/0301-620x.98b6.37435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/10/2016] [Indexed: 12/11/2022]
Abstract
AIM Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. PATIENTS AND METHODS All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%). RESULTS Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. TAKE HOME MESSAGE There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.
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Affiliation(s)
- S Craxford
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - E Bayley
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - M Walsh
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - J Clamp
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
| | - B M Boszczyk
- Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK
| | - O M Stokes
- Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
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12
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Buckland AJ, Bressan S, Jowett H, Johnson MB, Teague WJ. Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre. Emerg Med Australas 2016; 28:569-74. [PMID: 27474412 DOI: 10.1111/1742-6723.12650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 05/17/2016] [Accepted: 06/26/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children. METHODS A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence. RESULTS Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting. CONCLUSIONS Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.
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Affiliation(s)
- Aaron J Buckland
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, Victoria, Australia.,NYU Langone Medical Center - Hospital for Joint Diseases, New York, New York, USA
| | - Silvia Bressan
- Trauma Service, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Helen Jowett
- Trauma Service, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Michael B Johnson
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Warwick J Teague
- Trauma Service, The Royal Children's Hospital, Melbourne, Victoria, Australia. .,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia. .,Surgical Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.
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13
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Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ, Delozier MS, Smith LM, Smith MA, Capella JM, Long AM, Cheng JS, Leath TC, Falck-Ytter Y, Haut ER, Como JJ. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015; 78:430-41. [PMID: 25757133 PMCID: PMC4409130 DOI: 10.1097/ta.0000000000000503] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND With the use of the framework advocated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, our aims were to perform a systematic review and to develop evidence-based recommendations that may be used to answer the following PICO [Population, Intervention, Comparator, Outcomes] question:In the obtunded adult blunt trauma patient, should cervical collar removal be performed after a negative high-quality cervical spine (C-spine) computed tomography (CT) result alone or after a negative high-quality C-spine CT result combined with adjunct imaging, to reduce peri-clearance events, such as new neurologic change, unstable C-spine injury, stable C-spine injury, need for post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance? METHODS Our protocol was registered with the PROSPERO international prospective register of systematic reviews on August 23, 2013 (REGISTRATION NUMBER: CRD42013005461). Eligibility criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded using any definition.Quantitative synthesis via meta-analysis was not possible because of pre-post, partial-cohort, quasi-experimental study design limitations and the consequential incomplete diagnostic accuracy data. RESULTS Of five articles with a total follow-up of 1,017 included subjects, none reported new neurologic changes (paraplegia or quadriplegia) after cervical collar removal. There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury, after coupling a negative high-quality C-spine CT result with 1.5-T magnetic resonance imaging, upright x-rays, flexion-extension CT, and/or clinical follow-up. Similarly, there is a best-case 0% (0 of 1,718 subjects in 11 studies) cumulative literature incidence of unstable injuries after negative initial imaging result with a high-quality C-spine CT. CONCLUSION In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Mayur B Patel
- From the Veterans Affairs (VA) Tennessee Valley Healthcare System (M.B.P.), Nashville VA Medical Center; Division of Trauma and Surgical Critical Care (M.B.P., S.S.H., M.A.S., T.C.L.), Department of Surgery, and Department of Neurosurgery (M.B.P., J.S.C.), Section of Surgical Sciences, Department of Radiology and Radiological Sciences (M.A.D.), and Department of Orthopedic Surgery and Rehabilitation (C.J.D.), Vanderbilt University School of Medicine, Nashville; University of Tennessee Health Science Center (M.S.D.), College of Medicine, Memphis; and University General Surgeons (L.M.S.), University of Tennessee Medical Center, Knoxville, Tennessee; Trauma Surgery Section (D.C.C.), Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin; Division of Trauma, Emergency Surgery, and Surgical Critical Care (R.S.J.), Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York; Trauma Service (J.M.C.), University of Pittsburgh Medical Center-Altoona, Altoona, Pennsylvania; Department of Surgery (A.M.L.), Medical Center of Central Georgia, Macon, Georgia; VA Healthcare System of Ohio (Y.F.-Y.), Cleveland VA Medical Center; Division of Gastroenterology (Y.F.-Y.), Department of Medicine, Case Western Reserve University School of Medicine; and Division of Trauma, Critical Care, and Burns (J.J.C.), Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Departments of Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine, Baltimore, Maryland
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14
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Kolman S, Keenan MA, Spiegel D, Namdari S, Hosalkar H, Baldwin KD. What's new in orthopaedic rehabilitation. J Bone Joint Surg Am 2014; 96:1925-34. [PMID: 25410515 DOI: 10.2106/jbjs.n.00875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Samuel Kolman
- Richard D. Wood Center, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
| | - Mary Ann Keenan
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, Two Silverstein, Philadelphia, PA 19104
| | - David Spiegel
- Richard D. Wood Center, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
| | - Surena Namdari
- Rothman Institute at Jefferson, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
| | | | - Keith D Baldwin
- Richard D. Wood Center, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
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15
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Cullen A, Terris M, Ford R. Spinal clearance in unconscious children following traumatic brain injury. Paediatr Anaesth 2014; 24:711-6. [PMID: 24697966 DOI: 10.1111/pan.12395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
Abstract
Spinal clearance in unconscious children following traumatic brain injury is an area of controversy. The risk of significant injury in this high-risk group needs to be balanced against that of prolonged spinal immobilization and all its implications. No national or international guideline exists to aid clinicians faced with such a scenario. This article reviews traumatic spinal injury in children looking at prevalence, risk factors, anatomical considerations, and radiological investigation. Spinal immobilization is discussed along with the use of appropriate and targeted radiological investigations to aid clearance.
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Affiliation(s)
- Aidan Cullen
- Paediatric Intensive Care Unit, Royal Belfast Hospital for Sick Children, Belfast, UK
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