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Leonard JC, Harding M, Cook LJ, Leonard JR, Adelgais KM, Ahmad FA, Browne LR, Burger RK, Chaudhari PP, Corwin DJ, Glomb NW, Lee LK, Owusu-Ansah S, Riney LC, Rogers AJ, Rubalcava DM, Sapien RE, Szadkowski MA, Tzimenatos L, Ward CE, Yen K, Kuppermann N. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:482-490. [PMID: 38843852 PMCID: PMC11261431 DOI: 10.1016/s2352-4642(24)00104-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.
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Affiliation(s)
- Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Monica Harding
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Colorado Children's Hospital, Aurora, CO, USA
| | - Fahd A Ahmad
- Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO, USA
| | - Lorin R Browne
- Department of Pediatrics and Department of Emergency Medicine, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Rebecca K Burger
- Department of Pediatrics, Division of Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Daniel J Corwin
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicolaus W Glomb
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - Lois K Lee
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Sylvia Owusu-Ansah
- Division of Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren C Riney
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander J Rogers
- Department of Emergency Medicine and Department of Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, MI, USA
| | - Daniel M Rubalcava
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Matthew A Szadkowski
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Caleb E Ward
- Division of Emergency Medicine, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, DC, USA
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Health Dallas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
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Albala L, Harris NS, Srivastava S, Lareau SA, Binder W. An Unusual Mountain Biking Injury: Case Records of the Massachusetts General Hospital Wilderness Medicine Fellowship. Wilderness Environ Med 2023; 34:576-579. [PMID: 37696721 DOI: 10.1016/j.wem.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Lorenzo Albala
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - N Stuart Harris
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Sunita Srivastava
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Stephanie A Lareau
- Carilion Clinic Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - William Binder
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI
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Loewenstein SN, Wulbrecht R, Leonhard V, Sasor S, Cook J, Timsina L, Adkinson J. Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations. Hand (N Y) 2021; 16:432-438. [PMID: 31409134 PMCID: PMC8283110 DOI: 10.1177/1558944719866865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.
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Affiliation(s)
| | - Reed Wulbrecht
- Indiana University School of Medicine, Indianapolis, USA
| | | | | | - Julia Cook
- Indiana University School of Medicine, Indianapolis, USA
| | - Lava Timsina
- Indiana University School of Medicine, Indianapolis, USA
| | - Joshua Adkinson
- Indiana University School of Medicine, Indianapolis, USA,Joshua M. Adkinson, Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, USA.
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Hagan NE, Berdel HO, Tefft A, Bernard AC. Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated. Injury 2020; 51:20-25. [PMID: 31648788 DOI: 10.1016/j.injury.2019.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/30/2019] [Accepted: 10/09/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Falls from standing (FFS) have become the most common mechanism of injury at many trauma centers. Liberal imaging of low energy trauma has questionable value. We hypothesize that torso trauma intervention is rare in the FFS population, and physical examination sufficiently screens for torso injuries needing intervention. METHODS We queried our ACS-verified Level 1 trauma center registry for falls from standing from 1/1/14 to 12/31/16. Exclusion criteria were: falls from height, falls associated with penetrating trauma, lack of an abdominal or chest CT, a Glasgow Coma Scale Score (GCS) less than 15, and surgical intervention at another facility prior to arrival at our center. Demographics, historical details, hemodynamics, injuries, injury severity, procedures, initial vital signs, and outcome were recorded. RESULTS 1,654 patients had a FFS during our study period. 728 had an abdominal or chest CT and a GCS of 15 and comprised the evaluable population. Mean age was 56.5 years. 55.8% were female. The mortality rate was 8%. There were 179 chest injuries in 121 patients, and 54 abdominal injuries in 43 patients. 379 patients had a GCS of 15 and underwent thoracic CT, yet only 11 (3%) underwent intervention. The negative predictive value for physical exam was 100% for chest intervention. 349 patients had a GCS of 15 and abdominal CT, yet only 13 (3.7%) underwent procedural intervention. Abdominal physical exam had a negative predictive value of 99.7% for intervention, but when combined with vital signs, the value was 100%. CONCLUSION Torso injuries in FFS are rare. Of our study population, 13 abdominal injuries underwent intervention, and 11 chest injuries underwent intervention. Screening patients by physical examination and vital signs is sufficient and safely allows for the use of selective abdominal and chest CT.
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Affiliation(s)
- Natalie E Hagan
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.
| | - Henrik O Berdel
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Amy Tefft
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Andrew C Bernard
- Section of Trauma and Acute Care Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.
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Chaudry J, Swaminathan N, Gershon RK, Gordy DP, Allred L, Lirette ST, Khan MA. Evaluation of clinical criteria to determine the need for cervical spine imaging in victims of blunt assault. J Clin Neurosci 2019; 71:84-88. [PMID: 31648969 DOI: 10.1016/j.jocn.2019.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/04/2019] [Indexed: 11/28/2022]
Abstract
The purpose of this study is to evaluate effectiveness of clinical criteria, specifically the NEXUS Criteria, in determining the need for cervical spine imaging in victims of blunt assault to head and face. CT results from victims of blunt assault to the head and face were compared with presenting clinical findings. The presence or absence of cervical spine injury was correlated with positive NEXUS criteria to determine if the clinical criteria appropriately risk stratified patients in this population. Incidence of c-spine injury was 1.09% (7/641). For clinically significant injury, the incidence dropped to 0.16% (1/641). PPV of NEXUS criteria in blunt assault to the head and face for any injury in our study was 1.4% (95% CI: 0.6%-2.6%) compared to 2.7% (95% CI: 2.6%-2.8%) in the NEXUS validity study. PPV of NEXUS criteria in blunt assault to the head and face for significant injury in our study was 0.2% (95% CI: 0%-0.9%) compared to 1.9% (95% CI: 1.8%-2.0%) in the NEXUS validity study. The findings demonstrate a statistically significant difference between the PPV of NEXUS criteria in victims of blunt assault to the head and face when compared to all blunt trauma in the NEXUS validity study. This suggests that the clinical criteria do not adequately stratify this low risk population, leading to imaging over-utilization. Limited use of cervical spine imaging in victims of blunt assault will decrease radiation exposure and healthcare costs and will strengthen the validity of clinical risk stratification for more high-risk groups.
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Affiliation(s)
- Joseph Chaudry
- University of Mississippi Medical Center - Department of Radiology, 2500, North State Street, Jackson, MS 39216, United States.
| | - Nisha Swaminathan
- University of Mississippi Medical Center - Department of Radiology, 2500, North State Street, Jackson, MS 39216, United States
| | - Ruth K Gershon
- University of Mississippi Medical Center - Department of Radiology, 2500, North State Street, Jackson, MS 39216, United States
| | - David P Gordy
- University of Mississippi Medical Center - Department of Radiology, 2500, North State Street, Jackson, MS 39216, United States.
| | - Lindsey Allred
- University of Mississippi Medical Center - Department of Radiology, 2500, North State Street, Jackson, MS 39216, United States.
| | - Seth T Lirette
- University of Mississippi Medical Center - Department of Data Science, 2500, North State Street, Jackson, MS 39216, United States.
| | - Majid A Khan
- Johns Hopkins Hospital - Department of Radiology, Phipps B112, 600 N Wolfe St, Baltimore, MD, United States.
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Foster SM, Muller A, Conklin J, Cortes V, Fernandez FB, Geng TA, Reilly EF, Sigal A, Ong AW. Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient? Am J Surg 2019; 218:755-759. [PMID: 31351577 DOI: 10.1016/j.amjsurg.2019.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/07/2019] [Accepted: 07/16/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients. METHODS We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated. RESULTS Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis). CONCLUSION Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary. SUMMARY For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.
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Affiliation(s)
| | - Alison Muller
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
| | - Jeremy Conklin
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
| | - Vicente Cortes
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
| | | | - Thomas A Geng
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
| | - Eugene F Reilly
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
| | - Adam Sigal
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
| | - Adrian W Ong
- Reading Trauma Center, Reading Hospital, Tower Health System, United States
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