Preliminary Results Using a Reduced Radiation Cervical Spine Clearance Algorithm In Pediatric Trauma Patients: A Simplified Approach
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1 Preliminary Results Using a Reduced Radiation Cervical Spine Clearance Algorithm In Pediatric Trauma Patients: A Simplified Approach M A T T H E W M O R O N T M D D I R E C T O R O F T R A U M A S E R V I C E S S T. C H R I S T O P H E R S H O S P I T A L F O R C H I L D R E N
2 NO DISCLOSURES
3 Introduction Cervical spine injuries uncommon 1-2% incidence Devastating consequences Death Paralysis Treatment of cervical spine injuries begins with cervical spine clearance Efficient and safe clearance of the uninjured patient Limit radiation exposure Identification of injured patients
4 Care of Pediatric Cervical Spine Injury is Clinically Challenging for the Trauma Team Limited experience Orthopedic surgery Neurosurgery Trauma Surgery Emergency Medicine Radiology First responders Complex problem Poly-traumatized child
5 Pediatric Cervical Spine Clearance Protocols NO Consensus Trauma Surgery and Neurosurgery literature Awake child vs obtunded child Radiographs vs CT Standardized protocol J Trauma, 2009 J Trauma, 2011
6 Pediatric Cervical Spine Study Group Cervical Spine Clearance Survey 25 Pediatric Trauma Centers NO consensus Primary team responsible for clearance Imaging modalities used ONLY 46% had cervical spine clearance protocol
7 Radiation Exposure Ionizing radiation Increases life-long cancer risk Breast/thyroid most sensitive
8 Institutional Objectives NEED for Improvement Develop a clinical C-spine clearance algorithm which reflected current best practice Reduce radiation exposure without increasing missed injury rate Consistency among providers Emergency medicine Trauma Orthopedics Neurosurgery Radiology
9 2011 C-Spine Clearance Algorithm
10
11 ALGORITHM FOR EVALUATION OF THE TRAUMA PATIENT FOR CERVICAL SPINE INJURY Reliable History and Physical Abnormal Exam OR History or Age < 5 GCS 12 Normal Exam and Physical Leave in C-Collar obtain AP and Lateral C-Spine Xrays Yes No Clear C-Spine Obtain C-Spine Xray Positive finding on Xray No findings on Xray Normal Abnormal Consult Spine Service Re-evaluate in 24 hours Persistent Neck Pain No Clear C-Spine Unreliable Exam Yes Continue C- Collar Re-Evaluate Reliable Exam
12 What Was Different? More frequent Emergency Department re-evaluation Next day re-evaluation Trauma Surgery Increased involvement of the Spine Service Neurosurgery Orthopedics
13 Materials and Methods Inclusion Criteria < 18 y of age All patients with trauma mechanism suspicious for cervical spine injury Emergency Medicine Trauma Service Exclusion Criteria All deaths All patients with cervical spine CT from outside facility 3 study periods Study Group Study Group Study Group Data Points Age MOI ISS GCS on arrival Imaging studies CT findings Time to collar removal Discharged in collar Who cleared C-spine Spine Service Length of stay C-spine injuries Missed/delayed diagnosis
14 Study Population 259 Study Group Trauma Contacts 762 Required C-Spine Clearance 360 Study Group & Study Group
15 Study Group Demographics Male Female 68.4% (521) 31.1% (237) 28% (213) 72% (549) <= 5 years old > 5 years old Mean age 8.8 years
16 Study Population GCS ISS 15 91% (694) Mild (1-8) 85% (646) % (58) Moderate (9-16) 13% (99) <8 1.3% (10) Severe (>16) 2% (17)
17 Sub-Group Analysis SG1 SG2 SG3 Number of CT s p=< %% (233) 42.2% (152) 28.7% (41) LOS Clearance By Emergency Medicine 44% (96) 25% (76) 28% (34) Surgery 44% (97) 46% (141) 48% (58) Spine Service 12% (27) 29% (90) 24% (29) Discharged in Collar = 113
18 Time to Clearance SG1 SG2 SG3 < 13 hours 91% (197) 76% (232) 79% (97) hours 8% (18) 22% (69) 19% (23) > 24 hours 1% (2) 2% (5) 2% (2) Discharged in Collar = 113
19 Study Limitations PILOT study Small numbers Incomplete statistical analysis Retrospective study Historical control
20 Conclusions The increased involvement of the Spine Service in C-spine clearance and NEXT day re-evaluation by the trauma team: An increase time to C-spine Clearance in the hr time period No increase in LOS A significant reduction in the use of CT to obtain C-spine clearance with no increase in missed injury rate
21 Thank You Selected References Eubanks J, Gilmore A, Bess S, Cooperman D: Clearing the Pediatric Cervical Spine Following Injury.Journal of the American Academy of Orthopedic Surgeons 2006;14: Hannon M, Mannix R, Dorney K, Mooney D, Hennelly K. Pediatric Cervical Spine Injury Evaluation After Blunt Trauma: A Clinical Decision Analysis. Ann Emerg Med Oct 16. pii: S (14) (Epub ahead of print). Henry M, Scarlata K, Riesenburger RI, Kryzanski J, Rideout L, Samdani A, Jea A, Hwang SW: Utility of STIR MRI in Pediatric Cervical Spine Clearance after Trauma. Journal of Neurosurgery: Pediatrics 2013;12(1): Jones TM, Anderson PA, Noonan KJ: Pediatric Cervical Spine Trauma. Journal of the American Academy of Orthopedic Surgeons 2011;19: Kreykes NS, Letton, Jr RW: Current Issues in the Diagnosis of Pediatric Cervical Spine Injury. Seminars in Pediatric Surgery 2010;19: Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Cervical spine injury patterns in children. Pediatrics May;133(5):e doi: /peds Puisto V, Kaarianen S, Impinen A, et al: Incidence of spinal and spinal cord injuries and their surgical treatment in children and adolescents: A population based study. Spine (Phila 1976). 2010;35: Sun R, Skeete D, Wetjen K, Lilienthal M, Liao J, Madsen M, Lancaster G, Shilyansky J, Choi K. A pediatric cervical spine clearance protocol to reduce radiation exposure in children. J Surg Res Jul;183(1): (Epub 2013 Jan 16). Vanderhave K, Chiravuri S, Caird M, Farley F, Graziano G, Hensinger R, Patel R: Cervical Spine Trauma in Children and Adults: Perioperative Considerations. Journal of the American Academy of Orthopedic Surgeons 2011;19:
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