Package, Ship, & Scan?
Immobilization and Imaging in the
Pediatric Population
Morgan Scaggs, NREMT-P
KYEMSC Project Director
Pediatric Emergency Care Applied
Research Network
• PECARN
• The first federally-funded pediatric emergency
medicine research network in the US
• Conducts high-priority, multi-institutional
research on the prevention and management
of acute illnesses and injuries
• Supported by cooperative agreements
between six academic medical centers, HRSA,
MCHB, and EMSC
http://www.pecarn.org/
Objectives
• discuss risks/benefits of ionizing radiation
exposure for children
• discuss challenges and potential risks associated
with spinal immobilization of children
• describe the factors associated with cervical spine
injury in children after blunt trauma
• discuss plain radiographs vs. CT for identification
of cervical injuries
• describe the validated prediction rules for
identifying children at low risk of clinically
important Traumatic Brain Injuries (ciTBI)
Can we safely reduce unnecessary
immobilization and imaging in the pediatric
population without missing clinically significant
injuries?
We will look at research on:
• Potential adverse effects of spinal immobilization in children
• Factors associated with c-spine injuries in kids
• Plain radiographs vs. CT for identification of c-spine injuries in
kids
• Identifying children at low-risk for clinically important TBI
after minor blunt trauma to reduce CT use
Potential concerns regarding
immobilization and imaging?
• Efficacy
• Increased pain
• Interference with
assessment
• Respiratory difficulty
• Risk of aspiration
• Airway management
• Pressure ulcers
• Increased intracranial
pressure
• Distraction forces
• Additional forces to area
of injury
• Tissue hypoxia
• Claustrophobia/anxiety
• Delays in care/transport
• Increased imaging rates
• Increased admission rates
• Increased risk of radiation
induced malignancy
Ionizing Radiation
Benefits
• noninvasive and painless
diagnosis of disease and
monitoring of therapy
• support of medical and
surgical treatment planning
• facilitates interventional
procedures
Risks
• tissue effects
– cataracts
– skin reddening
– hair loss
• a small increase in the
possibility that a person
exposed to X-rays will
develop cancer later in life
– Dose dependent
– Age at exposure
– Gender (women are more
radiosensitive than men)
– Target organ
www.fda.gov/Radiation-EmittingProducts
Pediatric Patients
• are more radiosensitive than adults (i.e., the
cancer risk per unit dose of ionizing radiation
is higher)
• have a longer expected lifetime for any effects
of radiation exposure to manifest as cancer
• use of equipment and exposure settings
designed for adults may result in excessive
radiation exposure if used on smaller patients
www.fda.gov/Radiation-EmittingProducts
FDA Initiative to Reduce Unnecessary
Radiation Exposure from Medical Imaging
• Justification: The imaging procedure should be judged to do more
good than harm to the individual patient. Therefore, all
examinations using ionizing radiation should be performed only
when necessary to answer a medical question, help treat a disease,
or guide a procedure. The clinical indication and patient medical
history should be carefully considered before referring a patient for
any imaging examination.
• Dose Optimization: Medical imaging examinations should use
techniques that are adjusted to administer the lowest radiation
dose that yields an image quality adequate for diagnosis or
intervention (i.e., radiation doses should be "As Low as Reasonably
Achievable"). The technique factors used should be chosen based
on the clinical indication, patient size, and anatomical area scanned,
and the equipment should be properly maintained and tested.
www.fda.gov/Radiation-EmittingProducts
Spinal Immobilization in Penetrating Trauma
• Haut et al.
• The Journal of Trauma; 2010; 68, 1, 115-121
doi: 10.1097/TA.0b013e3181c9ee58
• Retrospective analysis of 45,284 penetrating
trauma patients in the National Trauma Data
Bank
Spinal Immobilization in Penetrating Trauma
• Twice as likely to die if immobilized
• No benefit for any specific population group
• Even with ISS<15, SI was independently
associated with significantly decreased
survival
• GSW with hypotension - 3x increased risk of
death with SI
• Stab wounds - no statistical impact of SI on
mortality
Spinal Immobilization in Penetrating Trauma
IMPACT:
• 1,032 penetrating trauma patients have
to be immobilized to potentially benefit 1
patient
• For every 66 penetrating trauma patients
immobilized, the immobilization
potentially contributes to 1 death
Spinal Immobilization in Penetrating Trauma
Conclusion: pre-hospital spine
immobilization is associated with
higher mortality in penetrating trauma
and should not be routinely used in
every patient with penetrating trauma
Potential Adverse Effects of Spinal
Immobilization in Children
•
•
•
•
Leonard, J., Mao, J., & Jaffe, D.
Prehospital Emergency Care 2012;16:513–518
With the assistance of PECARN
Prospective study of children presenting to
the ED for evaluation following trauma
• 173 Spine Immobilized Children
• 112 who met ACS criteria for SI but were not
Potential Adverse Effects of Spinal
Immobilization in Children
• Immobilized children
– Had higher median pain scores (3 vs 2)
– More likely to undergo cervical radiography
(56.6% vs 13.4%)
– More likely to be admitted to the hospital
(41.6% vs 14.3%)
• Comparison groups had similar length of stay
in the ED
Potential Adverse Effects of Spinal
Immobilization in Children
• There were differences in between the groups
which included age, mechanism of injury and
proportion transported by EMS but the
comparison groups had comparable PTSs and
GCSs
• Independent of markers of injury severity, spinal
immobilization following trauma in children is
associated in some way with increased pain, use
of imaging studies to clear the cervical spine of
injury, and admission to the hospital
• Further study warranted
A re-conceptualization of acute spinal care
• Mark Hauswald
• Emerg Med J 2012;00:1-4.
doi:10.1136/emermed-2012-201847
• Analysis of basic physics, biomechanics and
physiology
• “Discarding the fundamentally flawed
emphasis on decreasing post injury motion
and concentration on efforts to minimize
energy deposition to the injured site….”
A re-conceptualization of acute spinal
care – Authors Conclusions
Specific treatments that are irrational and can be safely
discarded include
• The use of backboards for transportation
• Cervical collar use except in specific injury types
• Immobilization of ambulatory patients on backboards
• Prolonged attempts to stabilize the spine during
extrication
• Mechanical immobilization of uncooperative or seizing
patients and forceful in line stabilization during airway
management
NEXUS
National Emergency X-Radiography Utilization Study
A prospective, observational study involving 21 centers across the United
States that evaluated 34,069 stable patients with blunt trauma who were at
risk for cervical spine injury
1. Tenderness at the posterior midline of the cervical spine
2. Focal neurologic deficit
3. Decreased level of alertness
4. Evidence of intoxication
5. Clinically apparent pain that might distract the patient from the pain of a
cervical spine injury
The presence of any one of the above findings is considered to be
clinical evidence that a patient is at increased risk for cervical spine
injury and requires radiographic evaluation
Canadian C-spine Study
A prospective,
observational study
involving 10 centers across
Canada that evaluated
8,924 alert and stable
patients with blunt
trauma who were at risk
for cervical spine injury
*Alert and stable trauma
patients
Challenges with Assessment of
Children
•
•
•
•
•
Particularly those < 5 years
Unreliable patient
Communication barrier
Fear/anxiety
In cases where the child resists immobilization
significantly there may be less risk in providing
a gentle, comfortable ride. Forcing a fighting
child into immobilization may cause greater
harm.
Factors Associated With Cervical Spine Injury
in Children After Blunt Trauma
•
•
•
•
Leonard et al.
Ann Emerg Med. 2011;58:145-155
Cervical spine injuries in children are rare
Immobilization and imaging for potential cspine injury after trauma are common
• Risk factors for c-spine injury have been
developed to safely limit immobilization and
imaging in adults but not children
Factors Associated With Cervical Spine
Injury in Children After Blunt Trauma
• Case-control study of children <16, with blunt
trauma, who received c-spine radiographs at
17 hospitals in the PECARN Network
• Reviewed records of
–
–
–
–
540 children with c-spine injury
1,060 random controls
1,012 mechanism of injury controls
702 EMS controls
• Identified an 8-variable model for cervical
spine injury in children after blunt trauma
Predictors of Cervical Spine Injury In
Children
•
•
•
•
•
•
•
•
Altered Mental Status
Focal Neurological Findings
Neck pain
Torticollis
Substantial torso injury
Conditions predisposing to cervical spine injury
Shallow-water diving accidents
High-risk MVCs (ejections, high speeds, etc.)
Predictors of Cervical Spine Injury In
Children
•
•
•
•
•
•
Altered Mental Status
Focal Neurological Findings
Neck pain
Torticollis
Substantial torso injury
Conditions predisposing to
cervical spine injury
• Shallow-water diving
accidents
• High-risk MVCs
• 98% sensitive for injury
– One indicator present in
98% of cervical spine
injuries
• 26% specific
– Presence of one
indicator signifies only a
26% chance of injury
Child Safety Seats
•
•
•
•
Are not spinal immobilization devices
Prevent complete assessment
May prevent proper positioning
May not be possible to properly secure within
the ambulance
• May not be safe to use after a crash
Utility of Plain Radiographs in Detecting Traumatic
Injuries of the Cervical Spine in Young Children
• Nigrovic et al. for the PECARN Cervical Spine
Study Group
• Pediatric Emergency Care, Volume 28,
Number 5, May 2012
• Retrospective cohort of children <16 with
blunt trauma-related bony or ligamentous
cervical spine injury evaluated at 1 of 17
PECARN hospitals
Utility of Plain Radiographs in Detecting Traumatic
Injuries of the Cervical Spine in Young Children
• Cervical injuries in children are rare
• Ionizing radiation exposure 30x higher in CT vs
plain radiography
• Adult studies demonstrated a sensitivity for Cspine injury of 80% for single cross-table view
and >90% for a 3-view series
• Is this applicable in children? (different injury
patterns and greater anatomic variability)
Utility of Plain Radiographs in Detecting Traumatic
Injuries of the Cervical Spine in Young Children
Specifically excluded SCIWORA
• 206 patients enrolled
– 186 had adequate plain radiographs
– 168 had definite or possible cervical spine injuries
identified by plain radiographs for a sensitivity of
90% (95% CI, 85%-94%)
– C-spine radiographs failed to identify 15 children
with fractures and 3 with ligamentous injury
Utility of Plain Radiographs in Detecting Traumatic
Injuries of the Cervical Spine in Young Children
• Of those “missed”
– Half (9) had either altered mental status or focal
neurological findings
– 8 children had fractures and 1 had isolated ligamentous
injury, none required neurosurgical intervention or were
left with persistent neurological deficits
• Conclusion: Plain radiographs had a high sensitivity
for cervical spine injury in this pediatric cohort
• Advanced imaging likely provides a higher sensitivity,
it often comes with increased costs and significantly
higher radiation exposure, need further study to
determine which children will benefit
Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective
cohort study
• Kupperman et al. for PECARN
• Lancet 2009; 374:1160-70, published online
September 15, 2009
doi:10.1016/S0140-6736(09)61558-0
• Goal – to identify those at low risk for ciTBI
and validate a prediction rule to guide
decision for CT
Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective
cohort study
• Prospective cohort study of patients younger
than 18 years presenting within 24h of head
trauma with GCSs of 14-15 in 25 EDs in the
pediatric research network
• Enrolled and analyzed 42,412 children
– 25% (10,718) were < 2 years of age
• Derived and validated age-specific prediction
rules for ciTBI
Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective
cohort study
• Severe mechanism of injury
– MVC with patient ejection, death of other
occupant, or rollover
– Pedestrian or bicyclist without helmet struck by a
motorized vehicle
– Falls of more than 3 feet (< 2 yrs) or 5 feet (2+ yrs)
– Head struck by a high-impact object
Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective
cohort study
Suggested CT algorithm for children younger than 2 years
Negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100.0)
And sensitivity of 25/25 (100.0%, 86.3-100.0) of 694 CT-imaged patients in this
low-risk group
Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective
cohort study
Suggested CT algorithm for children aged 2 years and older
Negative predictive value for ciTBI of 3798/3800 (99.95%, 99.81-99.99)
And sensitivity of 61/63 (96.8%, 89.0-99.6) of 2223 CT-imaged patients in this lowrisk group
Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective
cohort study
• ¶ Risk of ciTBI exceedingly low, generally lower
than risk of CT-induce malignancies, CT scans
are not indicated for most patients in this
group
• Neither rule missed neurosurgical need in
validation populations
• These validated rules identified children at
very low risk of ciTBI for whom CT can
routinely be obviated
Do Children With Blunt Head Trauma and Normal Cranial
Computed Tomography Scan Results Require Hospitalization
for Neurologic Observation?
• Holmes et al.
and the TBI Study Group for PECARN
• @2010 by the ACEP
doi:10.1016/j.annemergmed.2011.03.060
• Prospective, multicenter observational cohort
study of children <18 yrs. with blunt head
trauma, GCSs of 14-15 and normal ED CT scan
results
• 13,543 children enrolled
Do Children With Blunt Head Trauma and Normal Cranial
Computed Tomography Scan Results Require Hospitalization
for Neurologic Observation?
• Of the 11,058 patients discharge home from
the ED
– 197 (2%) received subsequent CT or MRI
– 5 (0.05%) had abnormal CT/MRI results
– None (0%; 95% CI 0%-0.03%) received a
neurosurgical intervention
Do Children With Blunt Head Trauma and Normal Cranial
Computed Tomography Scan Results Require Hospitalization
for Neurologic Observation?
• Of the 2,485 hospitalized patients
– 137 (6%) received subsequent CT or MRI
– 16 (0.6%) had abnormal CT/MRI scan results
– None (0%; 95% CI 0%-0.2%) received a
neurosurgical intervention
Do Children With Blunt Head Trauma and Normal Cranial
Computed Tomography Scan Results Require Hospitalization
for Neurologic Observation?
• The negative predictive value for
neurosurgical intervention for a child with an
initial GCS score of 14-15 and a normal CT
scan result was 100% (95% CI 99.97%-100%)
• Hospitalization of children with minor head
trauma after normal CT scan results for
neurological observation is generally
unnecessary
morgan.scaggs@kctcs.edu