EMS Predictors of Pediatric C-Spine Injury

Written by Clay Smith

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EMS assessment of children with blunt trauma found these variables were were associated with c-spine injury (CSI): axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. But these criteria need validation before using them in practice.

Why does this matter?
The PECARN group performed a retrospective derivation study in the ED and found 8 predictors of CSI in children with blunt trauma: altered mental status, focal neurologic deficits, neck pain, torticollis, substantial torso injury, conditions predisposing to CSI, diving mechanism, and high-risk motor vehicle collision. But these haven’t been prospectively validated. EMS has to make the initial call and usually places rigid collars in most children with blunt trauma who are transported. However, c-collar use may complicate airway management, raise intracranial pressure, increase patient discomfort, and increase the use of imaging in the ED. Is there an EMS rule that would allow them to clear children for CSI and avoid placing a c-collar altogether?

It’s a start
This was a planned secondary analysis of prospective multicenter study of EMS personnel transporting children 0-17 years old with blunt trauma. The authors considered this a pilot study to determine univariate association of EMS-observed variables with CSI. The following variables were associated with CSI in these children: axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. They also asked the EMS personnel all the 8 PECARN CSI criteria mentioned above. EMS assessment using PECARN criteria had sensitivity 96%, NPV 99.8%, specificity 38.5%, PPV 2.8%. This study was designed to identify candidate variables for a larger, prospective validation study. So, EMS personnel should not use this in practice yet. However, it does give us an idea which features matter most in predicting pediatric CSI. All the features associated with CSI, except perhaps axial load, would be seen in children with more severe and extensive injuries. What this tells me is that we likely can’t glean much from mechanism. We also won’t get much from the history. Children with signs of severe or multisystem injuries should have a c-collar placed. However, until there is a larger, prospective validation of these clinical variables, we should use caution and follow current local protocols.

Source
Prehospital Factors Associated With Cervical Spine Injury in Pediatric Blunt Trauma Patients. Acad Emerg Med. 2021 May;28(5):553-561. doi: 10.1111/acem.14176. Epub 2020 Dec 15.

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