Clearance Algorithm In Pediatric Trauma Patients: A Simplified - - PowerPoint PPT Presentation

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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

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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

Preliminary Results Using a Reduced Radiation Cervical Spine Clearance Algorithm In Pediatric Trauma Patients: A Simplified Approach

SLIDE 2

NO DISCLOSURES

SLIDE 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

SLIDE 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

SLIDE 5

Pediatric Cervical Spine Clearance Protocols

J Trauma, 2009 J Trauma, 2011

NO Consensus

Trauma Surgery and

Neurosurgery literature

Awake child vs obtunded

child

Radiographs vs CT
Standardized protocol

SLIDE 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

SLIDE 7

Radiation Exposure

 Ionizing radiation

 Increases life-long cancer risk  Breast/thyroid most sensitive

SLIDE 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

SLIDE 9

2011 C-Spine Clearance Algorithm

SLIDE 10

SLIDE 11

ALGORITHM FOR EVALUATION OF THE TRAUMA PATIENT FOR CERVICAL SPINE INJURY Reliable History and Physical GCS ≤ 12 Abnormal Exam OR History or Age < 5 Normal Exam and Physical Leave in C-Collar

btain AP and Lateral

C-Spine Xrays Consult Spine Service Reliable Exam Unreliable Exam Clear C-Spine Normal Abnormal Persistent Neck Pain Clear C-Spine Positive finding on Xray No findings

n Xray

Re-evaluate in 24 hours Continue C- Collar Obtain C-Spine Xray Yes Yes No No Re-Evaluate

SLIDE 12

What Was Different?

 More frequent Emergency Department re-evaluation  Next day re-evaluation

 Trauma Surgery

 Increased involvement of the Spine Service

 Neurosurgery  Orthopedics

SLIDE 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

utside facility

 3 study periods

 Study Group 1

2011

 Study Group 2

2012-13

 Study Group 3

2014  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

SLIDE 14

Study Population

Trauma Contacts

3632

Required C-Spine Clearance

762

Study

Group 1

2011

259

Study

Group 2

2012 &

2013

360

Study

Group 3

2014

143

SLIDE 15

Study Group Demographics

> 5 years
ld
<= 5

years old

Female
Male

68.4% (521) 31.1% (237) 72% (549) 28% (213)

Mean age 8.8 years

SLIDE 16

Study Population

ISS Mild (1-8) 85% (646) Moderate (9-16) 13% (99) Severe (>16) 2% (17) GCS 15 91% (694) 8-14 7.6% (58) <8 1.3% (10)

SLIDE 17

Sub-Group Analysis

SG1 SG2 SG3 Number of CT’s

p=<0.0001

90%% (233) 42.2% (152) 28.7% (41) LOS 2.51 2.45 2.27 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

SLIDE 18

Time to Clearance

SG1 SG2 SG3 < 13 hours 91% (197) 76% (232) 79% (97) 13-24 hours 8% (18) 22% (69) 19% (23) > 24 hours 1% (2) 2% (5) 2% (2) Discharged in Collar = 113

SLIDE 19

Study Limitations

 PILOT study  Small numbers  Incomplete statistical analysis  Retrospective study  Historical control

SLIDE 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 13-24 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

SLIDE 21

Thank You



Eubanks J, Gilmore A, Bess S, Cooperman D: Clearing the Pediatric Cervical Spine Following Injury.Journal of the American Academy of Orthopedic Surgeons 2006;14:552-64.



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. 2014 Oct 16. pii: S0196-0644(14)01259-1.(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):1333-338



Jones TM, Anderson PA, Noonan KJ: Pediatric Cervical Spine Trauma. Journal of the American Academy of Orthopedic Surgeons 2011;19:600-11.



Kreykes NS, Letton, Jr RW: Current Issues in the Diagnosis of Pediatric Cervical Spine Injury. Seminars in Pediatric Surgery 2010;19:257-64.



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. 2014 May;133(5):e1179-88. doi: 10.1542/peds.2013-3505.



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;35:104-107.



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. 2013 Jul;183(1):341-6. (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;19:319-27.

Selected References