Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Trauma
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Discussion with Dr. Richard Falcone that touches on multiple topics in pediatric trauma.Dr. Ponsky: Let’s jump right into it. Actually I want to ask you, Rich, can you tell us, before we jump into things, can you tell us a little bit about
podcast56:05 · Dec 2020
Cervical Spine Injury: Update Course 2016
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At the 4th Annual Stay Current in Pediatric Surgery Update Course in 2016, Dr. Shawn Safford, Surgeon-in-chief, Carilion Clinic Children's Hospital, lead a case based discussion ofvarious cervical spine injury case presentations, with panel
video21:01 · Jan 2019
#APSA50: Top Educational Content
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This episode reviews the Top Educational Content sessions from the APSA 50th Anniversary meeting. It is part of our collaboration with the Behind the Knife podcast.-Dr. Aaron Jensen discusses Cervical Spine Clearance in Pediatric Trauma.-Dr
podcast1:07:24 · Dec 2020
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Pediatric cervical spine clearance has evolved toward clinical examination and selective imaging, driven by recognition that C-spine injury risk is low in most trauma presentations. Evidence now supports clinical clearance without imaging for truly awake children (GCS 14–15) who lack midline tenderness, distracting injuries, neurologic deficits, and can move their head freely in all directions. The Trauma Association of Canada emphasizes clinical exam as the first-line test, reserving imaging for cases where clinical clearance fails. For children over 8 with normal radiographs and neurologic exams, re-examination is preferred over immediate CT; advanced imaging is reserved for those with abnormal neurologic findings. In children ≤2 years, CT adds minimal diagnostic value beyond adequate plain films, though high cervical injuries in this age group may be missed on physical exam even when the child appears neurologically intact. MRI remains the gold standard for ligamentous injury and SCIWORA,[e861-c18,e861-c19] but requires anesthesia in young children. For obtunded or severely head-injured patients, the protocol is CT followed by MRI if CT is clear before collar removal. Collar-related pressure ulcers occur in 6–38% of ICU patients, prompting efforts to shorten immobilization duration. At Cincinnati, 90% of children left collared overnight can be clinically cleared the next morning when less distracted.
- Awake children (GCS 14–15) without midline tenderness, distracting injuries, or neurologic deficits can be clinically cleared without imaging.
- In children >8 years with normal X-rays and neurologic exam, re-examination is preferred over immediate CT; advanced imaging reserved for abnormal exams.
- CT adds minimal diagnostic value beyond plain films in children ≤2 years, though high cervical injuries may be missed on exam.
- MRI is the gold standard for ligamentous injury and SCIWORA; obtunded patients require CT then MRI if CT clear before collar removal.
- Collar-related pressure ulcers occur in 6–38% of ICU patients; 90% of children collared overnight can be clinically cleared next morning.
For patients & families
When a child is injured in an accident, doctors worry about the neck (cervical spine) because injuries there can be very serious. The good news is that neck injuries in children are actually quite rare. Doctors have learned that many children don't need X-rays or scans at all — if your child is awake, can move their head normally, has no neck pain when the doctor touches the midline of the neck, and has no other distracting injuries, the neck can often be cleared safely without any imaging. For very young children (under age 3), neck injuries are even more uncommon, but when they do happen they tend to be high up in the neck and can be harder to detect on exam. That's why doctors are extra careful with toddlers and babies. If imaging is needed, plain X-rays are usually the first step for older children, while CT scans give more detail but deliver much more radiation — one neck CT equals 600 plain films. MRI is the best test for seeing ligament injuries and spinal cord problems, but it requires anesthesia in young children. Most children who arrive in a neck collar can have it removed the next morning after a careful recheck when they're calmer.
When a child is injured in an accident, doctors worry about the neck (cervical spine) because injuries there can be very serious. The good news is that neck injuries in children are actually quite rare. Doctors have learned that many children don't need X-rays or scans at all — if your child is awake, can move their head normally, has no neck pain when the doctor touches the midline of the neck, and has no other distracting injuries, the neck can often be cleared safely without any imaging. For very young children (under age 3), neck injuries are even more uncommon, but when they do happen they tend to be high up in the neck and can be harder to detect on exam. That's why doctors are extra careful with toddlers and babies. If imaging is needed, plain X-rays are usually the first step for older children, while CT scans give more detail but deliver much more radiation — one neck CT equals 600 plain films. MRI is the best test for seeing ligament injuries and spinal cord problems, but it requires anesthesia in young children. Most children who arrive in a neck collar can have it removed the next morning after a careful recheck when they're calmer.
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Trauma
Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 trauma patients annually.
clinicalRich Falcone3:08 ↗
At Cincinnati Children's, the emergency department physician serves as team leader for all traumas, chosen because they are present when every patient arrives.
clinicalRich Falcone3:32 ↗
The ultimate risk of C-spine injury in pediatric trauma is actually pretty low.
epidemiologicalRich Falcone4:36 ↗
At Cincinnati, 90% of children left in C-collars overnight can be clinically cleared the next morning when less distracted and not in the trauma bay.
clinicalRich Falcone4:50 ↗
The Trauma Association of Canada Pediatric Subcommittee published evidence-based C-spine clearance recommendations emphasizing clinical examination as the first test, with imaging only if clinical clearance is not possible.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position6:04 ↗
For children over 8 with normal X-rays and normal neurologic exam, the Canadian guidelines recommend re-examination rather than immediate CT, with CT or MRI reserved only for those with abnormal neurologic exams.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position7:20 ↗
Getting CT early in kids with normal neurologic exam and C-spine tenderness is not useful because clinicians won't feel comfortable removing the collar based on imaging alone without resolution of clinical tenderness.
clinicalRich Falcone9:20 ↗
There is enough evidence now that truly awake children without distracting injuries and no midline tenderness do not need X-rays for C-spine clearance.
clinicalRich Falcone9:50 ↗
For obtunded patients with severe TBI, Cincinnati's protocol is CT to rule out bony abnormalities followed by MRI if CT is clear, before removing the C-collar.
clinicalRich Falcone13:17 ↗
A multi-site study published in Journal of Trauma 2009 developed a scoring system for children under 3: 3 points for GCS <14, 2 points for GCS injury score of 1, 2 points for motor vehicle collision, 1 point for age 2-3. Scores of 0-1 had 0.0% chance of C-spine injury; scores of 7-8 had 21% chance.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position16:07 ↗
In the multi-site study of children under 3, pediatric Level 1 centers obtained C-spine CTs only 17% of the time compared to adult centers which obtained them 24-45% of the time, indicating pediatric centers do too many CTs overall.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position18:48 ↗
The primary challenge in pancreatic trauma is determining whether there is a pancreatic duct injury, which is the number one concern.
clinicalRich Falcone21:35 ↗
There is increasing evidence that true pancreatic duct disruption is better treated with early distal pancreatectomy, ideally splenic-preserving, for grade 3 injuries.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position22:00 ↗
CT scans can show significant pancreatic injuries with large cracks through the neck, but ERCP or MRCP may still show the duct is intact, and those children will heal without surgery.
clinicalRich Falcone22:40 ↗
ERCP has the advantage of being potentially therapeutic with stent placement but the disadvantage of injecting dye that can cause pancreatic inflammation, a risk not present with MRCP.
clinicalRich Falcone23:20 ↗
Conservative management of pancreatic duct disruption can work and pseudocysts are manageable and drainable, but this approach takes longer with more TPN time and longer hospital length of stay compared to early pancreatectomy.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position24:00 ↗
Centers that perform frequent pancreatic operations and are comfortable with laparoscopic distal pancreatectomy have better outcomes operating on pancreatic trauma; centers that rarely operate on the pancreas may put patients at more complication risk and should consider non-operative management.
opinionRich Falcone24:40 ↗
The literature increasingly agrees that if operating for pancreatic duct disruption, it should be done within the first 24 hours, not as an immediate surgical emergency but within that window.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position26:45 ↗
Cincinnati implemented standardized screening where all children under 2 admitted with head injuries from non-publicly-witnessed mechanisms receive skeletal surveys and social work evaluation, eliminating clinician bias in screening decisions.
clinicalRich Falcone28:04 ↗
Literature shows clinicians are less likely to suspect abuse in families who look like them, are from the same neighborhood, and are from higher socioeconomic groups, even with identical injury patterns, compared to lower SES or minority families.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position29:20 ↗
Before implementing standardized screening, Cincinnati was more likely to perform skeletal surveys on low SES or minority children with head injuries than on middle/upper class non-minority families with identical injuries.
clinicalRich Falcone30:20 ↗
After implementing unbiased standardized screening criteria, Cincinnati's positive abuse rate remained at 50% despite evaluating more children, indicating they were finding abused children who would not have been screened under the previous biased system.
epidemiologicalRich Falcone31:00 ↗
A screening test with nearly 50% positive rate for abuse in admitted children under 2 with head injuries is more productive than most screening tests used for other conditions.
opinionRich Falcone31:40 ↗
Families find standardized screening more reassuring because clinicians can explain it is done for every family with this injury type without making judgments about truthfulness.
clinicalRich Falcone33:09 ↗
Cincinnati does not routinely perform ophthalmologic exams for non-accidental trauma screening, only obtaining them if skeletal survey is positive or there are other concerning findings like bruising or abnormal head findings inconsistent with the given story.
clinicalRich Falcone33:20 ↗
The PECARN study published in Annals of Emergency Medicine 2013 identified children at very low risk (0.1%) of clinically important blunt abdominal injuries: no abdominal wall trauma, GCS 14-15, no abdominal tenderness, no thoracic wall trauma, no abdominal pain, normal breath sounds, and no vomiting.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position34:48 ↗
The PECARN study found that if their very low-risk criteria were followed and everyone else was scanned, it would actually recommend more CTs than pediatric trauma centers currently perform.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position36:24 ↗
Abnormal liver function tests greater than 150-200 indicate a good chance of some abdominal injury, but normal LFTs provide very little evidence of safety and may create false security.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position37:00 ↗
Cincinnati has gone away from getting LFTs, amylase, and lipase as routine in trauma patients, only obtaining them if there are other indications for CT scan such as abdominal bruising or tenderness.
clinicalRich Falcone37:50 ↗
FAST ultrasound is very user-dependent and has low sensitivity. Normal FAST in stable healthy children may miss injuries if trusted too much. FAST remains useful for hypotensive patients to identify intra-abdominal blood.
Host summaryRich Falcone summarizing a resource — not the host's own clinical position38:30 ↗
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