Variability of prehospital spinal immobilization in children at risk for cervical spine injury

Pediatric trauma population spine immobilization during resuscitation: A call for improved guidelines

INTRODUCTION

This review aims to evaluate current practices regarding spine immobilization in pediatric trauma patients to evaluate their efficacy, reliability, and impact on clinical outcomes to guide future research and improved evidence-based practice guidelines.

METHODS

PubMed, ProQuest, Embase, Google Scholar, and Cochrane were queried for studies pertaining to spinal immobilization practices in pediatric trauma patients. Articles were separated into studies that explored both the efficacy and clinical outcomes of spine immobilization. Outcomes evaluated included frequency of spinal imaging, self-reported pain level, emergency department length of stay (ED-LOS), and ED disposition.

RESULTS

Six articles were included, with two studies examining clinical outcomes and 4 studies evaluating the efficacy and reliability of immobilization techniques. Immobilized children were significantly more likely to undergo cervical spine imaging (OR 8.2, p < 0.001), be admitted to the floor (OR 4.0, p < 0.001), be taken to the ICU or OR (OR 5.3, p < 0.05) and reported a higher median pain score. Older children were significantly more likely to be immobilized. No immobilization techniques consistently achieved neutral positioning, and patients most often presented in a flexed position. Lapses in immobilization occurred in 71.4% of patients.

CONCLUSION

Immobilized pediatric patients underwent more cervical radiographs, and had higher hospital and ICU admission rates, and higher mean pain scores than those without immobilization. Immobilization was inconsistent across age groups and often resulted in lapses and improper alignment. Further research is needed to identify the most appropriate immobilization techniques for pediatric patients and when to use them.

Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations

Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations

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.

Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers

BACKGROUND

Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions.

OBJECTIVES

The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma.

METHODS

This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement.

RESULTS

We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients.

CONCLUSIONS

Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.

Comparison of the GlideScope Cobalt® and Storz DCI® Video Laryngoscopes in Children Younger Than 2 Years of Age During Manual In-Line Stabilization: A Randomized Trainee Evaluation Study

OBJECTIVES

Video laryngoscopy facilitates tracheal intubation during manual in-line stabilization in adults, but it is not clear whether these findings translate to children. We compared trainee intubation times obtained using the GlideScope Cobalt® and Storz DCI® video laryngoscopes versus direct laryngoscopy in young children with immobilized cervical spines.

METHODS

Ninety-three children younger than 2 years underwent laryngoscopy with manual in-line stabilization using direct laryngoscopy, GlideScope Cobalt® video laryngoscopy, or Storz DCI® video laryngoscopy. Laryngoscopists were anesthesiology trainees in postgraduate training year of 3 or more. Total time to successful intubation (TTSI), best glottic view, and maximum degrees of neck deviation were recorded. An intubation time difference longer than 10 seconds was defined as clinically significant.

RESULTS

Data are reported as median; 95% confidence interval. The TTSI was similar among groups although Storz times were longer (median, 33.3 seconds; 95% confidence interval, 26.2-43.3 seconds) when compared to direct laryngoscopy (median, 23.3 seconds; 95% confidence interval, 20.7-26.5 seconds; P = 0.02). Obtaining a grade 1 Cormack-Lehane glottic view was less likely with direct laryngoscopy (P = 0.002). Maximum degrees of neck deviation were: Storz (median, 2.0; 95% confidence interval, 1.2-2.8), GlideScope (median, 2.0; 95% confidence interval, 1.4-2.6), and direct laryngoscopy (median, 1.9; 95% confidence interval, 1.2-2.1; P = 0.48).

CONCLUSIONS

Trainees were able to safely perform tracheal intubation in children younger than 2 years using any of the studied laryngoscopes, although Storz use resulted in a longer TTSI when compared to direct laryngoscopy. Video laryngoscopy may enhance best Cormack-Lehane glottic view during manual in-line cervical spine immobilization, but additional technical skills are needed to successfully complete tracheal intubation.

Pediatric spinal cord injury without radiographic abnormality in the era of advanced imaging

PURPOSE OF REVIEW

The current review describes the current evidence on pediatric spinal cord injury without radiographic abnormality (SCIWORA) with attention to the definition, epidemiology, and clinical presentation of the condition, as well as common MRI findings, management strategies, and outcomes.

RECENT FINDINGS

Recent literature demonstrates that with more widespread MRI use, our understanding of SCIWORA has improved. The new literature, although still limited, provides a more granular conceptualization of patterns of injury as well as potential prognostic stratification of patients based on MRI findings. Through case studies and national database analyses, researchers have further defined the epidemiology and outcomes of SCIWORA.

SUMMARY

Although SCIWORA occurs infrequently, thus making robust research a challenge, maintaining a high suspicion in the appropriate clinical setting ought to prompt acquisition of advanced imaging. For patients with persisting neurologic symptoms after trauma, despite negative plain films and cervical spine computed tomography, MRI can be helpful diagnostically as well as prognostically. Once SCIWORA is diagnosed, patients are treated nonoperatively with hard collar immobilization and physical therapy.

Methods for Collecting Paired Observations From Emergency Medical Services and Emergency Department Providers for Pediatric Cervical Spine Injury Risk Factors

OBJECTIVES

Cervical spine injuries (CSIs) after blunt trauma in children are rare, but cause substantial morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) providers routinely use spinal precautions and cervical spine imaging, respectively, during the management of children experiencing blunt trauma. These practices lack evidence, and there is concern that they may be harmful. A pediatric CSI risk assessment tool is needed to inform EMS and ED provider decision making. Creating this tool requires prospective data collection from EMS and ED providers at the time of patient evaluation. The purpose of this article is to describe the methods used to prospectively capture paired EMS and ED provider observations of children cared for after blunt trauma. Given the rarity of prospective observational research with EMS, the novel use of Research Electronic Data Capture (REDCap) in this study, and the potential to inform future studies, we are publishing our methodology in advance of outcome data related to the risk assessment tool.

METHODS

The study was conducted at four tertiary children's hospitals as a prerequisite for a planned larger study to derive a CSI risk assessment tool. We created a web-based, branch-logic questionnaire using the REDCap data collection system. The survey was administered via tablet computer to ED providers evaluating children with blunt trauma and, if applicable, to EMS providers who provided patient care at the scene. We collected information regarding factors determined a priori to be plausibly associated with CSI in children. Eligible children presenting to the ED after blunt trauma with at least one of the following one of the following were included: prehospital EMS spinal precautions, ED trauma team evaluation, or cervical spine imaging in the ED. Exclusions included penetrating trauma, language barrier, or state's custody. Enrollment occurred when research coordinators (RCs) were available, generally 12-16 hours/day. RCs approached EMS providers prior to departing the ED and ED providers after they completed their patient assessments. An ED provider survey was required for enrollment. Enrolled children were followed for 28 days to determine the presence of CSI (primary outcome) by subsequent imaging or by patient/family telephone follow-up for those without imaging.

RESULTS

Over 18 months, we prospectively enrolled 4,144 of 5,764 (71.9%) eligible children, including 74 of 110 (67.3%) children diagnosed with CSI. Enrollment during RC hours was 85.9%. Fifty-three enrolled children were withdrawn from the study. Of those in the final study cohort, 36.5% arrived by EMS scene response in spinal precautions. The remaining 63.5% arrived by EMS scene response without spinal precautions or by private vehicle or interfacility transfer. EMS scene response providers completed surveys for 60.2% of enrolled children arriving in spinal precautions. RCs missed the EMS providers for 37.1% of children; however, EMS declined participation for only 2.6%.

CONCLUSIONS

Our method of data collection demonstrates the ability to prospectively capture paired observations from EMS and ED personnel for children undergoing evaluation after blunt trauma. While this methodology will be used to implement and evaluate a CSI tool in future studies, it may also be adapted to studies requiring prospective data collection from EMS and ED personnel.

Characteristics of Trauma Patients With Potential Cervical Spine Injuries Underimmobilized by Prehospital Providers

STUDY DESIGN

This study was a retrospective chart review to determine characteristics of patients under-immobilized by prehospital providers.

OBJECTIVE

Our goal was to examine the characteristics of patients who met the criteria for spinal immobilization but were inappropriately cleared.

SUMMARY OF BACKGROUND DATA

Many emergency medical services (EMS) use selective spinal immobilization (SSI) based on the NEXUS criteria. However, there is been research examining patients who are under-immobilized by EMS.

METHODS

This was a retrospective chart review over 18 months of a single EMS service. We reviewed all charts dispatched as "motor vehicle crash" (MVC) or "fall". We then determined, whether the patient met the criteria for SSI under Pennsylvania protocols, which mirror the NEXUS criteria.

RESULTS

Our EMS system responded to 1151 falls and MVCs over the study period. Seventy-six patients were immobilized leaving 1075 patients who had clinical clearance of their cervical spine. Of these patients, 4/1075 (0.3%) were considered to be under-immobilized. All 4 of these patients had intoxication or altered mentation mentioned in their charts. Two of these patients had CT scans of their cervical spine, with both being negative. One patient eloped from the ED before any imaging, and 1 patient was clinically cleared.

CONCLUSION

EMTs are very proficient in following the SSI guidelines with an under-immobilization rate of approximately 0.3% in our study. However, all patients who were under-immobilized were under the influence of alcohol. There were no patients who were not immobilized and had cervical spine injuries. This was a limited chart review involving only 2 dispatch categories. EMTs should be cautious while evaluating patients with possible spinal injuries who are under the influence of alcohol.

LEVEL OF EVIDENCE

4.

Spinal clearance in unconscious children following traumatic brain injury

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.

Causes and patterns of spine trauma in children and adolescents in Saudi Arabia: implications for injury prevention

BACKGROUND AND OBJECTIVES

Knowledge regarding traumatic spine injuries (TSIs) is essential for effective prevention strategies, particularly in the developing world, where majority of the population is younger and organized prevention programs are scarce. Therefore, our objective was to describe TSI mechanisms, demographics, patterns, and outcomes in children and adolescents.

DESIGN AND SETTINGS

Retrospective chart review in a major trauma center from May 2001 to May 2009 in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

Detailed chart reviews were done for all consecutive TSI patients ≤18 years old.Cases were identified through the trauma database registry that included admitted patients.

RESULTS

Of the 3796 cases identified, 120 cases (3.2%) sustained 141 TSIs (mean age: 13.5 years; males:83.8%). TSI was most common among children from 16 to 18 years old. Overall, motor vehicle collision (MVC)was the most common injury mechanism (60.8%). However, younger patients (<12 years) sustained more pedestrian injuries (40.6%). Among MVC cases with known seat belt statuses (43.8%), 90.6% were not wearing seat belts. The cervical spine level was the most commonly affected (55.8%) region, especially in children <12 years old (88%). More than 1 affected spinal level was found in 23.3% cases. Spinal cord injuries were found in 19.2% cases. Overall, mortality was 8.3%, and half of these mortalities were secondary to pedestrian injuries. A total of 22.7% of cases were discharged with neurological deficits.

CONCLUSION

The high frequency and severity of MVC and pedestrian injuries observed in the present study raise significant concerns regarding the safety of children on the roads. Spine involvement was age specific;younger patients tended to have more cervical injuries, and older patients exhibited more thoracic spine involvement.