1. Immobilization and Imaging in the Pediatric Population
Package, Ship, & Scan?
Immobilization and Imaging in the Pediatric Population
Morgan Scaggs, NREMT-P
KYEMSC Project Director

3. 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

5. 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)

6. We will look at research on:
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

7. 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

8. 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

9. 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

10. 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.

11. Spinal Immobilization in Penetrating Trauma
Haut et al.
The Journal of Trauma; 2010; 68, 1, doi: /TA.0b013e3181c9ee58
Retrospective analysis of 45,284 penetrating trauma patients in the National Trauma Data Bank

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. A re-conceptualization of acute spinal care
Mark Hauswald
Emerg Med J 2012;00:1-4. doi: /emermed
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….”

19. 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

20. 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

21. 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

22. 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.

23. Factors Associated With Cervical Spine Injury in Children After Blunt Trauma
Leonard et al.
Ann Emerg Med. 2011;58:
Cervical spine injuries in children are rare
Immobilization and imaging for potential c-spine 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

24. 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

25. 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.)

26. 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

28. 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

31. 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

32. 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 C-spine 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)

33. 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

34. 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

35. Kupperman et al. for PECARN
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Kupperman et al. for PECARN
Lancet 2009; 374: , published online September 15, doi: /S (09)
Goal – to identify those at low risk for ciTBI and validate a prediction rule to guide decision for CT

36. Enrolled and analyzed 42,412 children
Identification of children at very low risk of clinically-important 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 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

37. Severe mechanism of injury
Identification of children at very low risk of clinically-important 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

38. Suggested CT algorithm for children younger than 2 years
Identification of children at very low risk of clinically-important 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 )
And sensitivity of 25/25 (100.0%, ) of 694 CT-imaged patients in this low-risk group

39. Identification of children at very low risk of clinically-important 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%, )
And sensitivity of 61/63 (96.8%, ) of 2223 CT-imaged patients in this low-risk group

40. Neither rule missed neurosurgical need in validation populations
Identification of children at very low risk of clinically-important 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

41. Holmes et al. and the TBI Study Group for PECARN
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: /j.annemergmed
Prospective, multicenter observational cohort study of children <18 yrs. with blunt head trauma, GCSs of and normal ED CT scan results
13,543 children enrolled

42. Of the 11,058 patients discharge home from the ED
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

43. Of the 2,485 hospitalized patients
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

44. 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 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