Cervical Spine Clearance - APSA Practice Gaps 2019

Uh so, we are going to uh be bringing in uh a new guest faculty here. Dr. Mira Kotagal, who is at Cincinnati Children's. And she is going to be work, she's been working with the PDC. She's going to give a topic that the PDC had, which was cervical spine clearance. And and she's going to be giving that presentation. Uh and then we'll have some interaction with with everyone here, the PDC on on their comments and and and beat up mirror and tell her she had it all wrong or whatever. That's perfect. All right, so Mira. All right, so we are going to talk about cervical spine clearance. Um, I we'll start with the case because I think that's a nice way to get everybody thinking about things. So, uh the patient is a 2-year-old male who is the restrained passenger in an MVC. Um, it was a high-speed motor vehicle crash going about 60 miles an hour. There was significant intrusion into the passenger side um of the vehicle, but the driver was also severely injured. And you see this patient when they present to the trauma Bay. They are crying loudly and moving all four extremities. The heart rate is 120, blood pressure is 98 over 65 with sats of 97% on room air. Um, there's some bruising on the abdomen and the forehead, but no other obvious injuries that you can tell uh on initial primary survey. They were they are in a C collar which was placed by EMS um in the field. So the question uh to start with is what would you do next? And we have a poll. This patient has no distracting injuries? Has no distracting injuries that you're you can't I mean, he's two, so a little bit more challenging to know whether or not. He has abdominal pain because he does have bruising of the abdomen. Okay. Um, and some bruising of his forehead, so hard to know kind of from a pain standpoint. Okay. Um, but has some evidence obviously of being in a significant mechanism blunt trauma. Um, but otherwise, yes, no distracting injuries. Okay. Neurologically relatively normal. You would say GCS 15, moving all extremities spontaneously. I didn't give you all the things for GCS, but let's say that the patient GCS. Okay. So while we're waiting, so just so you know, there's a 60 second delay they see you 60 seconds after you give you So we'll wait a little bit. What would you all do? So if if you think that the kid doesn't really have any distracting injuries and you can clinically clear him in the trauma bay, clinically clear him in the trauma bay. What's the answer? So I don't know that there's necessarily a right answer, which is part of what this question. I asked you if I could pick a question that didn't have a right answer. So I think there's a couple options for things that are appropriate. I think I tried to make the patient seem like they were screaming and not consolable at at least in the in the bay because I think it is sometimes hard to clear them in the bay, particularly when there's a lot of activity and they're two and they're, you know, agitated hard to figure out whether your clinical exam is reliable or not reliable. So, I think a lot of times people would leave it in place and reexamine later and you should be able to clinically clear that patient. I think for some patients, particularly when they have a high mechanism, um injury and you're concerned about whether or not they have, you know, intracranial findings or abdominal findings, some people might get plain films before they before they remove the collar. But I I think any of those are appropriate. Obviously in a neurologically normal kid, you don't need to jump to an MR. So I have a question. So in a 2-year-old, their most likely injury is going to be ligamentous. That's great. And what use are plain films without any point tenderness or anything else? What what are the purpose of your plain films and how would that change your If you think the kid has tenderness, you'd leave the collar on. Right. Probably get an MRI, consult neurosurgery. Yeah, the data suggests that, you know, about 50% of the injuries in that age group under eight, right, are are bony and about 50% are ligamentous or, you know, spinal cord injury without radiological abnormality. So, I guess there's some chance that they could have a bony injury, especially if you think you can't get a clear exam. If you can get a clear exam, there's no, uh there's no reason that you need to get films. All right, do you want to me to go. Do you have any other comments about what's been said so far? No, I think just to emphasize the point if you can clinically clear the patient, that would be the best way to do it. Uh this is a particularly difficult age group, but in older children, particularly the the the uh mechanism of injury should not play a role in that. But in this age group, there may be uh in the younger patients, particularly those with suspected, um, um, um, non-intentional trauma, have a higher risk of cervical injury. So those are the ones that you may want to image more, but but in a motor vehicle collision in older children like this, you can clear clinically. So we uh Go ahead. Can I ask a question? We standardly include a C spine film as part of our skeletal survey in children where you're concerned about non-exal trauma. Do you do that? Do you think that's necessary? Do you think that's overkill? I I think that would be great. Yeah. So I just want to hear that again. In a suspected NAT. When we get a skeletal We changed that name, by the way. The name is now child abuse. It's not NAT anymore. Right? Tell explain that again real quick. Who's who said that? It's like the CDC. Uh they have I guess in the past year or so, like transitioned back over to calling it child abuse. Um institutionally, it's still going to vary place to place. But nationally, CDC calls it child abuse now. Interesting. Yeah, if you look at the Axa position statement that was just released, they'll call it child abuse and you can see what Axa recommends for its management as well. Okay, and that can be found on the Axa website. Uh and on our app and social media. And on the State Current app. Nice. And um last month's. Last month's art uh edition of JBS. Okay, so um so no, just that those kids who you think have concern for child abuse or non-accidental trauma, whatever you want to call it, um need a skeletal survey as part of their evaluation in addition to often times we get belly labs if we're concerned about abdominal trauma as part of screening, but as part of that skeletal survey, you need at least a single view of the cervical spine. So I want I need help. Tell me how you clear your babies. What do you do? You tick off the collar. So a lot a lot of times people do just active motion. So watching them, seeing if they seem to splint. Um, I think you don't want to necessarily like force them one direction or another because you if they're not comfortable doing that, you may cause them an injury. Um, so a lot of times we will just take off the collar and observe them and see if they see like they seem like they're uncomfortable. We do, you know, palpate obviously along the midline, um, looking for for tenderness and some response, but it's a little bit challenging. We do the same thing. Okay. Take off the collar and watch. Maybe feel the spine. Probably um there's there's more evidence to go towards a risk-based kind of algorithm, which I think you're going to probably talk about. So I'll just say that. Okay. Thank you very much. Um, okay, so we're going to just talk very briefly. Obviously, Oh, sorry. I was just going to say at our institution, the neurosurgeons are very bought into pediatric trauma and they we actually have a protocol, any child three and under gets cleared by the neurosurgeons. Interesting. Wow. Does anyone else have a policy like that? Okay. Interesting. Okay. But I I do think and we'll come back to this, but one of the biggest points, I think in thinking about cervical spine clearance is you need a protocol. You need some guideline that your institution follows. There was a recent study done by the uh it's an orthopedic group that looks at pediatric spine injury and they found that 46% of places don't have a protocol for cervical spine clearance in children. So you need some sort of pathway and you can decide based on and the evidence gives you lots of options for how to proceed, but you need some sort of pathway. So since we don't have a poll for that, let me just ask people to put in the chat, uh do you have a cervical spine clearance protocol at your hospital. Go ahead, Mira. Okay, so cervical spine injury is not super common, obviously, in kids. It's about 1 to 2% of all pediatric traumas. Um, in older children, like we were just sort of talking about, they tend to follow adult patterns. 70 to 80% of those injuries are bony injuries, whereas in younger children, like Dr. Willken mentioned, they're more likely to have ligamentous injury. So about 50% of kids less than or equal to eight will have isolated fractures, but 50% will have ligamentous injury, dislocations or spinal cord injury without radiologic abnormality or scora, which is obviously a fun word to say. Um, 60 to 80% of vertebral injuries in kids will be in their cervical spine compared to in adults where you're more likely to see thoracic and lumbar uh injuries. So 34 to 40% of uh vertebral injuries in adults will be in the C spine. So much higher rate of cervical spine injury amongst the vertebral injuries, although they're not that common. And then like I mentioned, greater concern for ligamentous injury uh in children. So, um, I guess before we go there, let me just mention obviously everyone knows sort of Nexus criteria and the Canadian cervical spine criteria that were established in the late 1990s, early 2000s. Um, and a lot of people still use those and in older children, they're a totally reasonable way to think about how you clear older children. But like we've discussed, it's the younger kids that are the most challenging and particularly those kids sort of less than three. So the AAST actually did a study to try to understand what are the things that are predictors of cervical spine injury and how can we think about clinical clearance in that younger population? So kids younger than three. Um, they looked at over 12,000 kids who'd undergone blunt trauma. Um, and looked for rates of cervical spine injury and and they think they found 87, it's a pretty low um low percentage. Uh, 0.6% of kids had some sort of cervical spine injury. And when they looked at them, they were four independent predictors, GCS less than 14, a GCS eye of one, they were involved in a motor vehicle crash. So they actually included mechanism for those younger kids. And then whether or not they were greater or or equal to two years. And they gave points for each of those. And if you add up the points that you get when you assess your patient, patients who had zero to one points had a negative predictive value for having a C spine injury of over 99%. So those kids did not need imaging by their recommendations. Those with two to 4%, two to four points need some clinician discretion and then obviously the more points you have, five to eight, they recommend that you get some imaging. And I think it's worth noting there were five patients that had a cervical spine injury score less than two, but actually had injury, but those patients had concurrent significant uh traumatic injuries. So facial fracture, skull fracture, long bone fractures and uh loss of consciousness. And then the other thing, neck pain and splinting, which makes sense, right? We would not clinically clear patients who seem like they're in pain or have splinting. And so those patients need some imaging and would automatically sort of fall out of the no imaging category. Really quickly, on the the imaging, we have a question from the audience asking which single view, um x-ray should you get for the C spine? Should it be AP or lateral? So when we do it for a skeletal, we include a lateral. That's the that's their view that's in the skeletal survey. Um, obviously if you're using imaging because you think you need it to clear for cervical spine, you need two views at least. Um, you need an AP and lateral, but as part of our routine skeletal survey where you have a low suspicion for cervical spine injury, but you think you're doing it to rule out child abuse or non-accidental trauma, they need they we use a lateral as our single view. And just um be clear, if people want a lot of people are writing no that they don't have a C spine protocol, where can they get? Yes. So, I mean, we can obviously share um What can you? Is that what what would you want to share? Is there one There's a slide uh right after the question slide. There's there's the protocols that include since I our protocols which we're happy to share with people for both patients with a reliable exam and patients with an unreliable exam. Jen no hurry. We can do this at the at some point, we will put that C spine protocol um make it available. You should also be able to go to trauma.pm. I can never get it in the right order. Well, it's on our app, so that one's easier for me. Perfect. It's on it's on the State Current app. You can also go there's a trauma website uh for all of the Cincinnati Children's trauma protocols and I will remember what it is and tell you. I think it's trauma. Yeah, exactly.cincinnaticildren.com. But this is going to be a plug, but it but so um because of this, the the app for those of you who don't know, there's an app we we'll give you information that has all these guidelines. Uh you go to the guidelines section and and all the guidelines are in there uh that you can download, share uh what have you. So we'll we'll get that help give you um the link to that later. Yeah. Absolutely. We're happy to share them. search it in the stores. It's in the App Store and the Google Play Store. State. State Current pediatric surgery. State Current in pediatric surgery. Okay. So the all the only other thing that I, you know, really want to show and this is um this is from Canada. So uh shortly in 2011, shortly after that AAST study was published, um the Canadian pediatric surgery uh group got together and basically did develop some national consensus guidelines for for their recommendations on clearance. And so this is another place if you want an example of a guideline for how to think about clearing patients. They have guidelines for both reliable and unreliable patients. It's obviously very hard to see that on the slide because they're pretty small. But um the guy and they basically walk you through that process of does the patient have an abnormal neurologic exam? If they do, you obviously can't clinically clear them. Those patients need an MRI. If they have an abnormal neurologic exam, if they are reliable on exam and they have a normal exam, you can walk through clinically clearing them. If you are unable to do that because they seem like they're in pain, they have tenderness, they, you know, any of the other findings that you might go down, you can either move towards x-rays or in the rare instance CT. We obviously don't do CTs that commonly um in kids uh for cervical spine injury because they're not deemed to be that necessary and most of their injuries are not going to be bony, they're going to be ligamentous and so we move more towards MRI if you think you need cross-sectional imaging. Um, so we can share these with people, but I think that's in the unreliable patient, you a lot of times can come back and reexamine those patients. So you leave them in a collar, you wait till they calm down or the anxiety passes or they're, you know, pains under control or any of those pieces and then you may be able to actually examine them and clinically clear them at that point. That was awesome. Um, I I still think, you know, this is um unfortunately quite still a bit of variability at different institutions. Absolutely. Yeah. And I think our I think the biggest recommendation is develop a, you know, use the existing pathways that are out there, whether that's, you know, from this Canadian paper or from the AAST or from, you know, institutions that have them and develop a guideline that people follow because that allows you to be more consistent. And standardize in your approach to examining these kids and the particular challenge are these really young kids, the three and under children. And and and by the way, if there's anything that we talked about today, um, just email me, Tpsky@gmail. Uh, and I can get you in can connect you with the faculty here if you have a specific question for them or we can send you the guidelines or get you what you need. We really want this stuff dispersed. So if if you didn't get it here, email me and I will get it for you. These I just put up there, Ted. This is the one I was referring to. So this is these are the Cincinnati Children's ones. They're obviously lots of other guidelines and options. This is just ours, but, you know, you can use that many institutions and we're happy to share them with you if people want uh to use them. I'd just like to put in a plug Axa on their website has an area where they are making protocols and guidelines publicly available. So if you have a good protocol, please send it to Axa, so they can put it on the website so it can be shared with others. Now, I have a few questions. Um, does someone vet those? What if it's a junky protocol? Number two is how do they send it to Axa? And number three, where do they live? So I think is it Megan Comerford? I don't know what email they should send. We have to figure out. So the one we used last year is think@eapsa.org. Can can you write that in there? And we'll this is if if they have something to submit to Axa or is that a to the PDC and to the review for the review of it. So I I guess I would send it to David Powell and then have him forward it to whomever it needs to be forwarded to. But they are trying to take they want institutions to share their their pathways that they've created for DVT prophylaxis, for sepsis, for cervical spine clearance because there are so many institutions that are interested in developing pathways and developing protocols. So if you have if you have some that are available to you, to review and to look at to help you in your organization, make your protocols and make your pathways, that's the purpose of that. So I don't think that they're quote vetted by experts. I think it's put out there and then it's up to you to decide if you like it or you don't like it. I love that. And so again, we're going to try to provide you as many resources as we can throughout the day uh to get you access to what is current. Okay. Awesome. Thank you, Mira.