EIIC: Interpreting the PECARN Blunt Cervical Spine Trauma Tool for Children

Interpreting the PECARN Blunt Cervical Spine Trauma Tool for Children

Host:

• Dr. Ilene Claudius, Director, Process and Quality Improvement, Health Sciences Clinical Professor of Emergency Medicine at Harbor-UCLA Medical Center

Guests:

• Dr. Aaron Jensen, Trauma Medical Director, Associate Professor of Surgery at UCSF Benioff Children's Hospital, Oakland, and a national leader with the Emergency Medical Services for Children Innovation and Improvement Center (EIIC).
• Dr. Brian Yorgitis, Division Chief of Acute Care Surgery at Indiana University, former Pediatric Trauma Medical Director and PICU Director at the University of Florida

Episode Focus:

This episode delves into the new 2024 PECARN Blunt Cervical Spine Trauma Decision Tool, designed to evaluate cervical spine injuries in pediatric blunt trauma cases and to specifically include a trauma surgeon and a pediatric surgeon’s perspective of this tool. Developed from a study of 22,000 children under 18, the tool introduces a three-tiered algorithm based on injury risk, clinical presentation, and imaging requirements.

Key Insights:

• Overview of the PECARN Study:
  • Approximately 1.9% of children in the study had confirmed cervical spine injuries.
  • The tool stratifies children into three groups based on Glasgow Coma Scale (GCS) scores and physical exam findings:
    • High Risk (12.1% injury rate): GCS 3-8, unresponsive on AVPU, focal neurologic deficit, or abnormal ABCs—CT recommended.
    • Moderate Risk (2.8% injury rate): GCS 9-14, presence of neck pain, midline tenderness, or associated injuries—plain films (x-rays) recommended.
    • Low Risk (0.2% injury rate): No significant abnormal findings—clinical clearance recommended
• Strengths and Methodology:
  • Broad inclusion criteria, including young children (<3 years) and cases of suspected child abuse.
  • Validated through a robust dataset, ensuring generalizability across pediatric populations.
• Clinical Impact:
  • Promotes clinical clearance of c-spine for low-risk children, thus reducing unnecessary imaging.
  • Supports plain film imaging in moderate-risk cases instead of a CT scan, aligning with best practices in radiation minimization.
  • Encourages CT angiography for high-risk children when vascular injury (e.g., BCVI) is suspected.
• Considerations for Young Children (<3 Years):
  • Challenges remain in assessing this group due to unique head and neck anatomy and physiology, and from a trauma surgeon’s perspective, more data is needed to ensure these recommendations are applicable to children younger than 3.
  • Future subgroup analyses are in progress, which may provide more targeted guidelines for this group of children.
• Radiation Minimization and Collaboration:
  • Importance of avoiding over-imaging to reduce long-term risks, such as radiation-induced malignancy.
  • Emphasis on partnerships between non-pediatric and pediatric trauma centers to ensure optimal care.
  • Leveraging teleradiology for expert interpretation of pediatric plain films at non-specialized centers.
• Practical Application:
  • The tool empowers clinicians to clinically clear low-risk patients, minimizing prolonged cervical collar use and its associated complications (e.g., skin breakdown).
  • Encourages timely transfer of complex cases to pediatric trauma centers, often avoiding imaging delays at non-specialized facilities.

Takeaways for Providers:

• Use clinical judgment alongside the PECARN tool to guide imaging and management decisions.
• High-risk cases warrant consideration of CT angiography for comprehensive assessment.
• Plain films remain a valuable diagnostic tool for moderate-risk patients when interpreted with pediatric expertise.

Future Directions:

• Upcoming studies will focus on subgroup analyses, including children under three and cases involving child abuse.
• Continued efforts to integrate pediatric-specific trauma protocols into broader clinical practice.

Closing Thoughts:
Dr. Brian and Dr. Jensen advocate for balanced, evidence-based approaches to pediatric cervical spine evaluation, emphasizing the importance of radiation safety, collaboration, and ongoing research to refine best practices.

For additional pediatric trauma resources, visit PEAK Multisystem Trauma

References

• Leonard JC, Harding M, Cook LJ, Leonard JR, Adelgais KM, Ahmad FA, Browne LR, Burger RK, Chaudhari PP, Corwin DJ, Glomb NW, Lee LK, Owusu-Ansah S, Riney LC, Rogers AJ, Rubalcava DM, Sapien RE, Szadkowski MA, Tzimenatos L, Ward CE, Yen K, Kuppermann N. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024 Jul;8(7):482-490. doi: 10.1016/S2352-4642(24)00104-4. Epub 2024 Jun 4. Erratum in: Lancet Child Adolesc Health. 2024 Dec;8(12):e17. doi: 10.1016/S2352-4642(24)00311-0. PMID: 38843852; PMCID: PMC11261431.
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• Dorney K, Kimia A, Hannon M, Hennelly K, Meehan WP 3rd, Proctor M, Mooney DP, Glotzbecker M, Mannix R. Outcomes of pediatric patients with persistent midline cervical spine tenderness and negative imaging result after trauma. J Trauma Acute Care Surg. 2015 Nov;79(5):822-7. doi: 10.1097/TA.0000000000000847. PMID: 26496108.