Journal of Pediatric Surgery 49 (2014) 333–337
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Cervical spine computed tomography utilization in pediatric trauma patients Kathleen M. Adelgais a,⁎, Lorin Browne b, Maija Holsti c, Ryan R. Metzger d, Shannon Cox Murphy e, Nanette Dudley c a
Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO Department of Pediatrics, Pediatric Emergency Medicine Section, Medical College of Wisconsin, Milwaukee, WI Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT d Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT e Primary Care Partners, Grand Junction, CO b c
a r t i c l e
i n f o
Article history: Received 8 October 2013 Accepted 9 October 2013 Key words: Pediatric Computed tomography Trauma
a b s t r a c t Background: Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs). Methods: Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression. Results: 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p b 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p b 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. Conclusions: Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED. © 2014 Elsevier Inc. All rights reserved.
Trauma is one of the most common causes of morbidity and mortality in the pediatric population. Differences exist in the frequency of injury and type of injuries between pediatric and adult blunt trauma patients. The largest prospective study of cervical spine injury (CSI) performed in the United States found a rate of 1% among patients less than 18 years of age compared to 2.4% among patients 19 years and older [1–3]. Though CSI rates are lower in pediatric patients, they have higher rates of ligamentous injury due to increased ligamentous laxity [4]. For these reasons, differences may exist in the evaluation of CSI in pediatric and adult patients. Due to significant morbidity and mortality from CSI, care must be taken in the evaluation of patients with potential CSI. Several studies have attempted to determine which patients require radiographic evaluation of the cervical spine. The largest of these, The National Emergency X-Radiography Utilization Study (NEXUS), developed a set of criteria to define patients at low risk for CSI, however, the study Abbreviations: CSI, Cervical Spine Injury; CSCT, Cervical Spine Computed Tomography; CSXR, Cervical Spine Radiographs; GED, General Emergency Departments; PTC, Pediatric Trauma Center; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale. ⁎ Corresponding author. Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA. Tel.: +1 303 724 2578. E-mail address: [email protected] (K.M. Adelgais). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.10.006
investigators recommended caution when using these criteria with children given the lower numbers of enrolled patients b 18 years [5]. Several studies suggest that cervical spine CT (CSCT) is a more efficient and effective screen for CSI in the adult patient [6–8]. These studies have led to changes in the recommendations of the American College of Surgeons Committee on Trauma on the evaluation of the cervical spine for injury to include routine use of CSCT for adult blunt trauma patients [9]. These are in contrast to current published guidelines recommending that pediatric blunt trauma patients be screened initially using plain radiography with adjunctive CT of select areas if concern for injury exists [10–12]. These guidelines are based on a published sensitivity of plain radiography for CSI in pediatric blunt trauma patients between 89% and 95% [13–15]. As the use of CT in evaluating the adult blunt trauma patient has increased, there is also evidence that the use of CT in the evaluation of children is on the rise [16,17]. CSCT results in a significant increase in the dose of ionizing radiation to the thyroid compared to that seen with cervical spine radiography CSXR [18,19]. This higher dose along with increased usage could lead to a significant overall exposure of ionizing radiation to the pediatric population [20,21]. The objective of our study was to compare the utilization of CSCT and plain radiography between a pediatric trauma center (PTC) and referral general emergency departments (GEDs) in a pediatric trauma
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population. We hypothesized that referral GEDs utilize CT more often to screen the cervical spine for injury among their pediatric trauma patients compared to the PTC. 1. Methods This study was a retrospective review of patient medical records and radiographic studies of trauma patients evaluated at Primary Children’s Medical Center (PCMC), an American College of Surgeons Level 1 pediatric trauma center (PTC) between January 1, 2002 and December 31, 2011. This study was approved by the University of Utah Institutional Review Board. 2. Data source The PCMC trauma registry is a database containing patient information, physiologic data and clinical outcomes including survival status at hospital discharge and duration of hospital stay. Patient data from medical charts are abstracted and entered directly into the trauma registry by registrars who have completed the Abbreviated Injury Scale (AIS) Course through the Association of the Advancement of Automotive Medicine. For the purposes of this study, all patients with a level-1 or -2 trauma activation were enrolled. PCMC employs commonly used criteria to define trauma activation levels: Trauma 1: shock, significant penetrating injury, acute intracranial hematoma with mass effect, obvious severe open cranial injury, intubation, GCS b 10, traumatic paralysis, proximal extremity amputation, or traumatic arrest. Trauma 2 activations include GCS 11 to 14, severe hypothermia, stable with multiple injuries or high-energy mechanism of injury [22]. Trauma 3 patients are stable, without the above criteria and were not included in our study. We obtained and analyzed data from the registry including demographics; year of enrollment, measures of injury severity including Injury Severity Scores (ISS), AIS for head and neck injury; mechanism of injury; emergency department disposition; hospital of initial presentation; use of CSXR and CSCT; presence and type of CSI; operative management of CSI. CSI was defined as any fracture, ligamentous injury with and without subluxation, spinal cord injury, spinal cord injury without radiographic association (SCIWORA), or a combination of these. Cervical spine strain was not considered a CSI for the purposes of this study. 3. Data analysis Our primary outcome was the percentage of patients with a CSCT on initial evaluation at the PTC or GED and the change in that percentage over time. For the purposes of this study, patients who presented to the PTC after an evaluation at a GED without a CSCT were classified as no CSCT. Secondary outcomes included use of CSXR to evaluate the cervical spine, incidence of patients with CSI and operative management for CSI. Descriptive statistics, including medians, interquartile range, and percentages were initially calculated for gender, age, GCS, mechanism of injury, ISS, Head injury AIS, emergency department disposition, and trauma level categorization as a function of initial site of care (i.e., PTC vs. GED). Preliminary analyses to test for group differences between PTC and GED patients were also conducted. These included Mann Whitney U test for age, a chi-square test for gender, and contingency tables for GCS, mechanism of injury, CSI, ISS, Head Injury AIS, disposition, and trauma level categorization. To test whether certain factors were associated with use of CSCT, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for the predictor variables using multivariate logistic regression modeling. In the model, we dichotomized age into two categories: less than 8 years and equal to or greater than 8 years as this is the age when children become anthropomorphically similar to adults with the cervical spine fulcrum located at the C3–C4 level [23].
Similarly we dichotomized GCS into b12 and 13 or above, a cutoff frequently used to distinguish patients with more mild traumatic brain injury from those with more moderate to severe injury. ISS and Head Injury AIS were also dichotomized for the purposes of the multivariate regression. Factors tested in the model included age, gender, initial site of care, year, presence of CSI, GCS, ISS, Head Injury AIS, and trauma triage category. Reference categories were age b 8 years, male, PTC, year 2011, no CSI, GCS ≥ 13, ISS b15, Head Injury AIS b 3, and Trauma Level 2. All statistical analyses were performed using SPSS (SPSS, Inc., Chicago, IL, Version 20.0). 4. Results During the study period, a total of 5148 Trauma I and II patients were evaluated at the PTC. Of those patients, 2142 (41.6%) presented directly to the PTC and 3006 (58.4%) were evaluated initially at a GED. The patient characteristics of the two groups are presented in Table 1. The groups were similar with regard to age, gender, and initial GCS upon presentation. Patients evaluated at a GED had a higher median ISS (14 vs. 9, p b 0.05) and median AIS for head and neck injury (3 vs. 2, p b 0.05). They were more likely to be admitted to the ICU (44.3% vs. 26.1%, p = 0.001) and have non-accidental trauma as their mechanism of injury (5.3% vs. 1.4%, p b 0.001). Over the study period, ISS for both PTC and GED patients remained stable. 4.1. Use of radiographic imaging Over the study period, a total of 15.2% (CI = 14, 16) of patients had CSR at the GED compared to 76.2% (CI = 74, 78) at the PTC. The proportion of patients with CSCT at the PTC increased from 3.5% to 16.1% (mean 9.6% 95% CI = 8, 11) compared to the GED where utilization increased from 6.8% to a maximum of 42.0% (mean 22.6%, CI = 25, 28) over the study period. Fig. 1 shows the trend of utilization of CSCT during the study period. A comparison of PTC and GED patients who underwent CSCT is shown in Table 2. The two groups were similar with regard to percent with CSI, median Head AIS, and percent admitted to the ICU. Patients undergoing CSCT who presented to the PTC tended to be older (median years 11 vs. 8), and had a lower median ISS (14 vs.16) than those presenting to the GED. 4.2. Rate of CSI Overall, 120 (2.3%) patients had a cervical spine injury. Total percentage of patients with CSI over the study period presenting to the PTC was 1.4% compared to 2.6% of patients presenting to the referral GED (p b 0.05). Despite mild fluctuations, overall the Table 1 Comparison of Patient Characteristics between PTC and GED. Hospital Patient Characteristics Age, median years (IQR) Male % (95% CI) C-spine Injury % (95% CI)a GCS, median (IQR) Injury Severity Score, median (IQR)a Head Injury AIS, median (IQR) Admission to ICU % (95% CI)a Admitted directly to OR % (95% CI)a Trauma 1 Activation % (95% CI)a Mechanism of Injury MVC % (n) Fall % (n) Pedestrian % (n) Sports Injury % (n) Non-Accidental Trauma % (n)a a
p b 0.05.
PTC (n = 2142)
GED (n = 3006)
8 (3, 12) 63.1% (60, 65) 1.4 (1, 2) 15 (14, 15) 9 (5, 17) 2 (2, 3) 26.1 (23, 28) 9.1% (2, 4) 18.0 (34, 39)
6 64.9% 2.6 15 16 3 44.3 11.6.% 24.1
27.3 19.1 13.6 13.8 1.4
(585) (410) (293) (296) (36)
27.2 25.1 8.2 7.3 5.3
(2, 11) (63, 67) (2, 3) (14, 15) (9, 21) (3, 4) (41, 45) (6, 8) (17, 21) (610) (756) (247) (220) (160)
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50%
Table 3 Comparison of CSI types and outcome between PTC and GED.
GED CSI PTC CSI
Percent of patients with CSI and CSCT
335
40% GED CSCT PTC CSCT
30% 20% 10% 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year Fig. 1. Unadjusted rates of patients with C-spine injury and C-spine CT by year and hospital type. PTC = Pediatric Trauma Center; GED = General Emergency Department.
proportion of patients with CSI remained stable over the study period (Fig. 1). Of those patients with CSI, 78 had fractures, 25 had isolated ligamentous injuries, 15 had isolated cord injuries, and 13 were diagnosed with a combination of injury types. Table 3 compares injury types and outcomes between the PTC and the GED. Patients presenting to the GED were more likely to have a fracture than patients at the PTC (p = 0.003). Overall, 51 patients (1.0%) had operative treatment for their cervical spine injuries and the proportion of patients undergoing operative management was similar between both groups (0.9% vs. 1.0%). 4.3. Factors associated with cervical spine CT Several factors were found to be associated with use of CSCT in a multivariate analysis (Table 4). Patients who received care at a GED were 3.5 times more likely to have a CSCT when controlling for presence of CSI, age, gender, hospital type, year, ISS, Head Injury AIS, initial GCS, and trauma triage category (95% CI 2.87, 4.40). Other factors associated with use of CSCT included presence of CSI, GCS b 12, and age ≥ 8 years. The year the patient was evaluated was also strongly associated with use of CSCT with a decreased likelihood of use of CSCT for all years from 2002 to 2007. 5. Discussion Trauma is the most common cause of morbidity and mortality in children N 1 year of age. The overwhelming majority of pediatric trauma is blunt in nature. Although CSI is uncommon, a timely evaluation of the cervical spine is important for any child sustaining blunt traumatic injuries. We found a substantial increase in the utilization of CSCT to screen for CSI among pediatric trauma patients evaluated in our referral
Table 2 Characteristics of patients with CSCT. Hospital
PTC (n = 206)
GED (n = 794)
Patient Characteristics Age, median years (IQR) Male % (95% CI) C-spine Injury % (95% CI) GCS, median (IQR) Injury Severity Score, median (IQR) Head Injury AIS, median (IQR) Admission to ICU % (95% CI) Admitted directly to OR % (95% CI) Trauma 1 Activation % (95% CI)
11 (5, 14) 69.4 (56, 76) 8.7 (2, 11) 14 (7, 14) 14 (6, 25) 3 (2, 4) 48.0 (40, 58) 8.7 (2, 10) 35.4 (28, 42)
8 (3, 12) 62.9 (56, 66) 5.9 (3, 7) 15 (3, 15) 16 (10, 21) 3 (2, 4) 49.7 (42, 51) 9.6 (7, 13) 30.2 (27, 33)
Hospital
PTC (n = 2142)
GED (n = 3006)
p
CSI Injury % (n) Fracture % (n) Ligamentous % (n) Cord injury % (n) Combination % (n) CSI surgery % (n)
1.70 (36) 0.61 (13) 0.32 (7) 0.28 (6) 0.47 (10) 0.91 (20)
2.70 1.73 0.60 0.30 0.01 1.00
0.03 0.003 0.39 0.77 0.26 0.09
(84) (52) (18) (9) (3) (31)
GED’s over a 10-year period, compared to a smaller increase observed for those presenting to the PTC. This is the first study to specifically evaluate factors associated with use of CSCT in a population of pediatric trauma patients. The rise in use of CT in pediatric patients occurred predominately in the last decade. Larson et al. demonstrated an increase in use of CT in non-pediatric specific emergency department visits from 1995 to 2008, with an exponential rise after 2002 [24]. Similarly, Blackwell et al. found an increase in the use of head CT among a national sample of patients despite no significant change in the rate of patients diagnosed with head injury. They also found that CT use was more frequent in GED compared to pediatric-specific emergency departments [25]. In our study, we found a rise in pediatric CSCT use over the study period at both the PTC and the GEDs. The majority of the rise in CSCT among GED sites was prior to 2008 at which time it plateaued to approximately 40%. The use of CSCT increased more notably at the PTC from 2008. Protocol changes in imaging and a more recent publication from 2007 suggesting the need to measure the atlantooccipital junction with CT have recently changed the use of CSCT at the PTC [26]. Despite this, the use of CSCT in GED increased to a much greater extent and plateaued at a higher rate than that at the PTC, despite a constant rate of observed CSI in our study population over the decade. Use of CSCT has been on the rise in other regions as well. Broder et al. noted a 344% increase in use of CSCT within their own institution from 2000 to 2006 [27]. Mannix et al. examined hospital and patient characteristics and found that in their region, pediatric patients evaluated at general hospitals compared to the PTC were two times more likely to have a CSCT [26]. That study was limited to lower acuity patients that were discharged to home from the ED. We found that Table 4 Multivariable Analysis of Factors Associated with CSCT in Pediatric Trauma Patients (pseudo r2: 0.205). Factor Hospital Type GED PTC (ref.) Patient Characteristics Sex: Female Age N 8 years Presence of CSI GCS ≤12 ISS N15 Head Injury AIS ≤3 Trauma Triage Category Trauma 1 Trauma 2 (ref.) Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 (ref)
N (%)
aOR
95% CI
p
3006 (58.3) 2142 (41.7)
3.56 1.00
2.87, 4.40
b0.001
1295 (36.9) 1553 (44.2) 68 (1.9) 866 (24.6) 1480 (42.1) 2047 (58.3)
1.07 2.11 4.26 2.00 1.036 1.105
0.89, 1.77, 2.47, 1.46, 0.83, 0.89,
0.45 b0.001 b0.001 b0.001 0.74 0.37
938 (26.7) 2576 (73.3)
1.09 1.00
0.79, 1.50
0.05 0.12 0.29 0.35 0.41 0.43 0.82 0.74 0.84 1.00
0.02, 0.07, 0.18, 0.24, 0.28, 0.30, 0.58, 0.52, 0.58,
304 389 519 518 562 990 521 528 433 385
(5.9) (7.6) (10.1) (10.1) (10.9) (19.2) (10.1) (10.3) (8.4) (7.5)
1.29 2.52 7.35 2.75 1.29 1.37
0.18 0.22 0.42 0.52 0.59 0.60 1.17 1.06 1.22
0.60
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 .28 .10 .37
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although CSCT was associated with the presence of CSI, it was not independently associated with ISS and Head Injury AIS. We found other factors associated with increased use of CSCT in our study. Children 8 years and older were 1.5 times more likely to have a CSCT than younger children. Other studies have found similar increases in use of CSCT among older children and adolescents. However one study also found increased CSCT use in the very young, particularly among patients seen in non-pediatric specific facilities [27,29]. Our study was limited to patients entered into our pediatric trauma registry and we could not compare use of CSCT among adults as site specific CT use is not currently tracked in our state trauma registry [30]. Current pediatric trauma recommendations indicate that the cervical spine should be initially screened with plain radiography and that CSCT should be used only to evaluate areas of concern [10– 12]. In our study, only 5.9% of patients who were evaluated at the GED with CSCT also had plain radiography. In the majority of cases, a CSCT was the only cervical spine imaging obtained during their evaluation. In contrast, 42.2% of patients evaluated at the PTC had CSR obtained in association with their CSCT. The majority of pediatric patients are cared for in non-pediatric facilities where pediatric protocols may not be available. Studies in the literature have found differences in the way patients are cared for by physicians with special training in pediatric emergency care [31–33]. To date, there are multiple studies suggesting that the use of CSCT in adult blunt trauma patients is more cost-effective and timely compared to plain radiographs, especially if that patient has indications for cranial CT [6,7]. For this reason, certain centers developed trauma protocols to screen the head and the cervical spine simultaneously [7,34]. In pediatric patients, where the risk of cervical spine injury is approximately 1%, plain films have a sensitivity of 90% or greater in identifying CSI and the additional yield of CSCT is low and not necessarily more timely [15,35,36]. Despite this, the use of CT to evaluate the pediatric patient has increased with notable implications [36,37]. Exposure to ionizing radiation in younger patients increases their lifetime risk of fatal malignancy [20,21]. The exposure of the cervical spine to ionizing radiation has particular risk for the thyroid gland. Current estimates of thyroid cancer from ionizing radiation suggest that the risk is increased even down to levels of 4–10 cGy [38,39]. Doses of ionizing radiation from CSCT are approximately 5 cGy compared to a maximum of 0.0006 cGy from CSXR (a 4-view radiograph series) [18,19]. Pediatric patients evaluated at non-pediatric specific facilities compared to pediatric specific facilities may be exposed to higher doses as well [16,17,24]. In the era of As Low As Reasonably Achievable (ALARA), current data suggest only that pediatric-specific facilities are making changes in CT imaging algorithms to reduce dose, however, there are no studies to date that show a difference in actual radiation dose in CSCT [40]. With the development of predictive models of CSI in pediatric trauma patients, we can better target appropriate imaging strategies and keep to ALARA principles to reduce radiation exposure in children [41]. This study has certain limitations. First, our study was subject to referral bias as our analysis was limited to a population of pediatric trauma patients ultimately cared for at the PTC. We are unable to make conclusions regarding patients that were discharged home from outside facilities, yet another study demonstrated the CSCT rate remained higher in low acuity patients evaluated at GEDs compared to the PTC [28]. Also, there may be a lower ascertainment of the number of plain films obtained at the outside facilities. The standard of care for transferred patients is to send radiographs and medical records along with the patient, but we cannot be certain that a higher number of cervical spine plain films were obtained and not transferred. We classified patients in the analysis who were transferred without a CSCT and subsequently had a study performed at the PTC
as not having a CSCT to reflect the practice at the institution doing the primary evaluation. Although this would result in selection bias by underestimating the use of CSCT at the PTC, the total number of these patients is small, 2.3% (138) of the entire study population. Lastly, we did not capture indications for imaging. Although we note a higher use of CSCT among patients with CSI, we do not know the frequency of reported neck tenderness or physical exam findings among those patients who had CSCT. There was an increase in use among patients with a lower GCS suggesting use of CSCT to image patients with altered mental status. 6. Conclusion Despite a stable rate of CSI between 2002 and 2011, usage of CSCT increased six-fold among pediatric trauma patients initially evaluated at referral hospitals while the rate of CSCT remained relatively low at the pediatric trauma center. This trend is noted even after adjusting for several hospital and patient specific characteristics. The majority of pediatric patients are evaluated at GEDs and as a result, higher rates of CSCT pose a risk of ionizing radiation exposure affecting patient safety. Targeted education on current existing recommendations on the directed use of CSCT for the evaluation of the cervical spine in children may hopefully result in a similar trend of decreased use of CT as that seen in the evaluation of closed head injury [42]. Current American Academy of Pediatrics and American College of Emergency Physician guidelines for pediatric patients in the ED setting recommend reducing radiation exposure using ALARA principles [43]. Collaboration to develop pediatric specific imaging protocols may further reduce use of unnecessary CT among pediatric trauma patients. References [1] Bondio WA. Cervical spine trauma in children: part II. Mechanisms and manifestations of injury, therapeutic considerations. Am J Emerg Med 1993;11(3):256–78. [2] Viccellio P, Simon H, Pressman B, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108(2):1–6. [3] Lowery DW, Wald MM, Browne BJ, et al. Epidemiology of cervical spine injury victims. Ann Emerg Med 2001;38(1):12–6. [4] Manary MJ, Jaffe DM. Cervical spine injuries in children. Pediatr Ann 1996;25(8): 423–8. [5] Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000;343(2): 94–9. [6] Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999;212(1):117–25. [7] LeBlang SD, Nunez DB. Helical CT of cervical spine and soft tissue injuries of the neck. Radiol Clin North Am 1999;37(3):515–32. [8] Keenan HT, Hollingshead MC, Chung CJ, et al. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. AJR Am J Roentgenol 2001;177(6):1405–9. [9] Como JJ, Diaz J, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma 2009;67(3):651–9. [10] Fuch S, Gausche-Hill M, Yamamoto L, editors. Advanced pediatric life support: the pediatric emergency medicine course. Elk Grove Village: American Academy of Pediatrics; 2007. p. 91–102. [11] Head injury: triage, assessment, investigation and early management of head injury in infants, children and adult. National Institute for Health and Clinical Excellence Clinical Guidelines. 2007:2-231. http://www.nice.org.uk/nicemedia/ live/11836/36260/36260.pdf. Accessed June 8, 2012. [12] Chung S, Mikrogianakis A, Wales PW. Trauma Association of Canada Pediatric Subcommittee national pediatric cervical spine evaluation pathway: consensus guidelines. J Trauma 2011;70(4):873–84. [13] Nigrovic LE, Rogers AJ, Adelgais KM, et al, Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care 2012 May;28(5):426–32. [14] Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med 1999;17(3):230–4. [15] Garton HJ, Hammer MR. Detection of pediatric cervical spine injury. Neurosurgery 2008 Mar;62(3):700–8 discussion 700–8. [16] Linton OW, Mettler Jr FA. National conference on dose reduction in CT, with an emphasis on pediatric patients. AJR Am J Roentgenol 2003;181(2):321–9.
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Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Cervical spine computed tomography utilization in pediatric trauma patients Kathleen M. Adelgais a,⁎, Lorin Browne b, Maija Holsti c, Ryan R. Metzger d, Shannon Cox Murphy e, Nanette Dudley c a
Department of Pediatrics, Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO Department of Pediatrics, Pediatric Emergency Medicine Section, Medical College of Wisconsin, Milwaukee, WI Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT d Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT e Primary Care Partners, Grand Junction, CO b c
a r t i c l e
i n f o
Article history: Received 8 October 2013 Accepted 9 October 2013 Key words: Pediatric Computed tomography Trauma
a b s t r a c t Background: Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs). Methods: Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression. Results: 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p b 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p b 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. Conclusions: Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED. © 2014 Elsevier Inc. All rights reserved.
Trauma is one of the most common causes of morbidity and mortality in the pediatric population. Differences exist in the frequency of injury and type of injuries between pediatric and adult blunt trauma patients. The largest prospective study of cervical spine injury (CSI) performed in the United States found a rate of 1% among patients less than 18 years of age compared to 2.4% among patients 19 years and older [1–3]. Though CSI rates are lower in pediatric patients, they have higher rates of ligamentous injury due to increased ligamentous laxity [4]. For these reasons, differences may exist in the evaluation of CSI in pediatric and adult patients. Due to significant morbidity and mortality from CSI, care must be taken in the evaluation of patients with potential CSI. Several studies have attempted to determine which patients require radiographic evaluation of the cervical spine. The largest of these, The National Emergency X-Radiography Utilization Study (NEXUS), developed a set of criteria to define patients at low risk for CSI, however, the study Abbreviations: CSI, Cervical Spine Injury; CSCT, Cervical Spine Computed Tomography; CSXR, Cervical Spine Radiographs; GED, General Emergency Departments; PTC, Pediatric Trauma Center; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale. ⁎ Corresponding author. Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA. Tel.: +1 303 724 2578. E-mail address: [email protected] (K.M. Adelgais). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.10.006
investigators recommended caution when using these criteria with children given the lower numbers of enrolled patients b 18 years [5]. Several studies suggest that cervical spine CT (CSCT) is a more efficient and effective screen for CSI in the adult patient [6–8]. These studies have led to changes in the recommendations of the American College of Surgeons Committee on Trauma on the evaluation of the cervical spine for injury to include routine use of CSCT for adult blunt trauma patients [9]. These are in contrast to current published guidelines recommending that pediatric blunt trauma patients be screened initially using plain radiography with adjunctive CT of select areas if concern for injury exists [10–12]. These guidelines are based on a published sensitivity of plain radiography for CSI in pediatric blunt trauma patients between 89% and 95% [13–15]. As the use of CT in evaluating the adult blunt trauma patient has increased, there is also evidence that the use of CT in the evaluation of children is on the rise [16,17]. CSCT results in a significant increase in the dose of ionizing radiation to the thyroid compared to that seen with cervical spine radiography CSXR [18,19]. This higher dose along with increased usage could lead to a significant overall exposure of ionizing radiation to the pediatric population [20,21]. The objective of our study was to compare the utilization of CSCT and plain radiography between a pediatric trauma center (PTC) and referral general emergency departments (GEDs) in a pediatric trauma
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population. We hypothesized that referral GEDs utilize CT more often to screen the cervical spine for injury among their pediatric trauma patients compared to the PTC. 1. Methods This study was a retrospective review of patient medical records and radiographic studies of trauma patients evaluated at Primary Children’s Medical Center (PCMC), an American College of Surgeons Level 1 pediatric trauma center (PTC) between January 1, 2002 and December 31, 2011. This study was approved by the University of Utah Institutional Review Board. 2. Data source The PCMC trauma registry is a database containing patient information, physiologic data and clinical outcomes including survival status at hospital discharge and duration of hospital stay. Patient data from medical charts are abstracted and entered directly into the trauma registry by registrars who have completed the Abbreviated Injury Scale (AIS) Course through the Association of the Advancement of Automotive Medicine. For the purposes of this study, all patients with a level-1 or -2 trauma activation were enrolled. PCMC employs commonly used criteria to define trauma activation levels: Trauma 1: shock, significant penetrating injury, acute intracranial hematoma with mass effect, obvious severe open cranial injury, intubation, GCS b 10, traumatic paralysis, proximal extremity amputation, or traumatic arrest. Trauma 2 activations include GCS 11 to 14, severe hypothermia, stable with multiple injuries or high-energy mechanism of injury [22]. Trauma 3 patients are stable, without the above criteria and were not included in our study. We obtained and analyzed data from the registry including demographics; year of enrollment, measures of injury severity including Injury Severity Scores (ISS), AIS for head and neck injury; mechanism of injury; emergency department disposition; hospital of initial presentation; use of CSXR and CSCT; presence and type of CSI; operative management of CSI. CSI was defined as any fracture, ligamentous injury with and without subluxation, spinal cord injury, spinal cord injury without radiographic association (SCIWORA), or a combination of these. Cervical spine strain was not considered a CSI for the purposes of this study. 3. Data analysis Our primary outcome was the percentage of patients with a CSCT on initial evaluation at the PTC or GED and the change in that percentage over time. For the purposes of this study, patients who presented to the PTC after an evaluation at a GED without a CSCT were classified as no CSCT. Secondary outcomes included use of CSXR to evaluate the cervical spine, incidence of patients with CSI and operative management for CSI. Descriptive statistics, including medians, interquartile range, and percentages were initially calculated for gender, age, GCS, mechanism of injury, ISS, Head injury AIS, emergency department disposition, and trauma level categorization as a function of initial site of care (i.e., PTC vs. GED). Preliminary analyses to test for group differences between PTC and GED patients were also conducted. These included Mann Whitney U test for age, a chi-square test for gender, and contingency tables for GCS, mechanism of injury, CSI, ISS, Head Injury AIS, disposition, and trauma level categorization. To test whether certain factors were associated with use of CSCT, we calculated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for the predictor variables using multivariate logistic regression modeling. In the model, we dichotomized age into two categories: less than 8 years and equal to or greater than 8 years as this is the age when children become anthropomorphically similar to adults with the cervical spine fulcrum located at the C3–C4 level [23].
Similarly we dichotomized GCS into b12 and 13 or above, a cutoff frequently used to distinguish patients with more mild traumatic brain injury from those with more moderate to severe injury. ISS and Head Injury AIS were also dichotomized for the purposes of the multivariate regression. Factors tested in the model included age, gender, initial site of care, year, presence of CSI, GCS, ISS, Head Injury AIS, and trauma triage category. Reference categories were age b 8 years, male, PTC, year 2011, no CSI, GCS ≥ 13, ISS b15, Head Injury AIS b 3, and Trauma Level 2. All statistical analyses were performed using SPSS (SPSS, Inc., Chicago, IL, Version 20.0). 4. Results During the study period, a total of 5148 Trauma I and II patients were evaluated at the PTC. Of those patients, 2142 (41.6%) presented directly to the PTC and 3006 (58.4%) were evaluated initially at a GED. The patient characteristics of the two groups are presented in Table 1. The groups were similar with regard to age, gender, and initial GCS upon presentation. Patients evaluated at a GED had a higher median ISS (14 vs. 9, p b 0.05) and median AIS for head and neck injury (3 vs. 2, p b 0.05). They were more likely to be admitted to the ICU (44.3% vs. 26.1%, p = 0.001) and have non-accidental trauma as their mechanism of injury (5.3% vs. 1.4%, p b 0.001). Over the study period, ISS for both PTC and GED patients remained stable. 4.1. Use of radiographic imaging Over the study period, a total of 15.2% (CI = 14, 16) of patients had CSR at the GED compared to 76.2% (CI = 74, 78) at the PTC. The proportion of patients with CSCT at the PTC increased from 3.5% to 16.1% (mean 9.6% 95% CI = 8, 11) compared to the GED where utilization increased from 6.8% to a maximum of 42.0% (mean 22.6%, CI = 25, 28) over the study period. Fig. 1 shows the trend of utilization of CSCT during the study period. A comparison of PTC and GED patients who underwent CSCT is shown in Table 2. The two groups were similar with regard to percent with CSI, median Head AIS, and percent admitted to the ICU. Patients undergoing CSCT who presented to the PTC tended to be older (median years 11 vs. 8), and had a lower median ISS (14 vs.16) than those presenting to the GED. 4.2. Rate of CSI Overall, 120 (2.3%) patients had a cervical spine injury. Total percentage of patients with CSI over the study period presenting to the PTC was 1.4% compared to 2.6% of patients presenting to the referral GED (p b 0.05). Despite mild fluctuations, overall the Table 1 Comparison of Patient Characteristics between PTC and GED. Hospital Patient Characteristics Age, median years (IQR) Male % (95% CI) C-spine Injury % (95% CI)a GCS, median (IQR) Injury Severity Score, median (IQR)a Head Injury AIS, median (IQR) Admission to ICU % (95% CI)a Admitted directly to OR % (95% CI)a Trauma 1 Activation % (95% CI)a Mechanism of Injury MVC % (n) Fall % (n) Pedestrian % (n) Sports Injury % (n) Non-Accidental Trauma % (n)a a
p b 0.05.
PTC (n = 2142)
GED (n = 3006)
8 (3, 12) 63.1% (60, 65) 1.4 (1, 2) 15 (14, 15) 9 (5, 17) 2 (2, 3) 26.1 (23, 28) 9.1% (2, 4) 18.0 (34, 39)
6 64.9% 2.6 15 16 3 44.3 11.6.% 24.1
27.3 19.1 13.6 13.8 1.4
(585) (410) (293) (296) (36)
27.2 25.1 8.2 7.3 5.3
(2, 11) (63, 67) (2, 3) (14, 15) (9, 21) (3, 4) (41, 45) (6, 8) (17, 21) (610) (756) (247) (220) (160)
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50%
Table 3 Comparison of CSI types and outcome between PTC and GED.
GED CSI PTC CSI
Percent of patients with CSI and CSCT
335
40% GED CSCT PTC CSCT
30% 20% 10% 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year Fig. 1. Unadjusted rates of patients with C-spine injury and C-spine CT by year and hospital type. PTC = Pediatric Trauma Center; GED = General Emergency Department.
proportion of patients with CSI remained stable over the study period (Fig. 1). Of those patients with CSI, 78 had fractures, 25 had isolated ligamentous injuries, 15 had isolated cord injuries, and 13 were diagnosed with a combination of injury types. Table 3 compares injury types and outcomes between the PTC and the GED. Patients presenting to the GED were more likely to have a fracture than patients at the PTC (p = 0.003). Overall, 51 patients (1.0%) had operative treatment for their cervical spine injuries and the proportion of patients undergoing operative management was similar between both groups (0.9% vs. 1.0%). 4.3. Factors associated with cervical spine CT Several factors were found to be associated with use of CSCT in a multivariate analysis (Table 4). Patients who received care at a GED were 3.5 times more likely to have a CSCT when controlling for presence of CSI, age, gender, hospital type, year, ISS, Head Injury AIS, initial GCS, and trauma triage category (95% CI 2.87, 4.40). Other factors associated with use of CSCT included presence of CSI, GCS b 12, and age ≥ 8 years. The year the patient was evaluated was also strongly associated with use of CSCT with a decreased likelihood of use of CSCT for all years from 2002 to 2007. 5. Discussion Trauma is the most common cause of morbidity and mortality in children N 1 year of age. The overwhelming majority of pediatric trauma is blunt in nature. Although CSI is uncommon, a timely evaluation of the cervical spine is important for any child sustaining blunt traumatic injuries. We found a substantial increase in the utilization of CSCT to screen for CSI among pediatric trauma patients evaluated in our referral
Table 2 Characteristics of patients with CSCT. Hospital
PTC (n = 206)
GED (n = 794)
Patient Characteristics Age, median years (IQR) Male % (95% CI) C-spine Injury % (95% CI) GCS, median (IQR) Injury Severity Score, median (IQR) Head Injury AIS, median (IQR) Admission to ICU % (95% CI) Admitted directly to OR % (95% CI) Trauma 1 Activation % (95% CI)
11 (5, 14) 69.4 (56, 76) 8.7 (2, 11) 14 (7, 14) 14 (6, 25) 3 (2, 4) 48.0 (40, 58) 8.7 (2, 10) 35.4 (28, 42)
8 (3, 12) 62.9 (56, 66) 5.9 (3, 7) 15 (3, 15) 16 (10, 21) 3 (2, 4) 49.7 (42, 51) 9.6 (7, 13) 30.2 (27, 33)
Hospital
PTC (n = 2142)
GED (n = 3006)
p
CSI Injury % (n) Fracture % (n) Ligamentous % (n) Cord injury % (n) Combination % (n) CSI surgery % (n)
1.70 (36) 0.61 (13) 0.32 (7) 0.28 (6) 0.47 (10) 0.91 (20)
2.70 1.73 0.60 0.30 0.01 1.00
0.03 0.003 0.39 0.77 0.26 0.09
(84) (52) (18) (9) (3) (31)
GED’s over a 10-year period, compared to a smaller increase observed for those presenting to the PTC. This is the first study to specifically evaluate factors associated with use of CSCT in a population of pediatric trauma patients. The rise in use of CT in pediatric patients occurred predominately in the last decade. Larson et al. demonstrated an increase in use of CT in non-pediatric specific emergency department visits from 1995 to 2008, with an exponential rise after 2002 [24]. Similarly, Blackwell et al. found an increase in the use of head CT among a national sample of patients despite no significant change in the rate of patients diagnosed with head injury. They also found that CT use was more frequent in GED compared to pediatric-specific emergency departments [25]. In our study, we found a rise in pediatric CSCT use over the study period at both the PTC and the GEDs. The majority of the rise in CSCT among GED sites was prior to 2008 at which time it plateaued to approximately 40%. The use of CSCT increased more notably at the PTC from 2008. Protocol changes in imaging and a more recent publication from 2007 suggesting the need to measure the atlantooccipital junction with CT have recently changed the use of CSCT at the PTC [26]. Despite this, the use of CSCT in GED increased to a much greater extent and plateaued at a higher rate than that at the PTC, despite a constant rate of observed CSI in our study population over the decade. Use of CSCT has been on the rise in other regions as well. Broder et al. noted a 344% increase in use of CSCT within their own institution from 2000 to 2006 [27]. Mannix et al. examined hospital and patient characteristics and found that in their region, pediatric patients evaluated at general hospitals compared to the PTC were two times more likely to have a CSCT [26]. That study was limited to lower acuity patients that were discharged to home from the ED. We found that Table 4 Multivariable Analysis of Factors Associated with CSCT in Pediatric Trauma Patients (pseudo r2: 0.205). Factor Hospital Type GED PTC (ref.) Patient Characteristics Sex: Female Age N 8 years Presence of CSI GCS ≤12 ISS N15 Head Injury AIS ≤3 Trauma Triage Category Trauma 1 Trauma 2 (ref.) Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 (ref)
N (%)
aOR
95% CI
p
3006 (58.3) 2142 (41.7)
3.56 1.00
2.87, 4.40
b0.001
1295 (36.9) 1553 (44.2) 68 (1.9) 866 (24.6) 1480 (42.1) 2047 (58.3)
1.07 2.11 4.26 2.00 1.036 1.105
0.89, 1.77, 2.47, 1.46, 0.83, 0.89,
0.45 b0.001 b0.001 b0.001 0.74 0.37
938 (26.7) 2576 (73.3)
1.09 1.00
0.79, 1.50
0.05 0.12 0.29 0.35 0.41 0.43 0.82 0.74 0.84 1.00
0.02, 0.07, 0.18, 0.24, 0.28, 0.30, 0.58, 0.52, 0.58,
304 389 519 518 562 990 521 528 433 385
(5.9) (7.6) (10.1) (10.1) (10.9) (19.2) (10.1) (10.3) (8.4) (7.5)
1.29 2.52 7.35 2.75 1.29 1.37
0.18 0.22 0.42 0.52 0.59 0.60 1.17 1.06 1.22
0.60
b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 .28 .10 .37
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although CSCT was associated with the presence of CSI, it was not independently associated with ISS and Head Injury AIS. We found other factors associated with increased use of CSCT in our study. Children 8 years and older were 1.5 times more likely to have a CSCT than younger children. Other studies have found similar increases in use of CSCT among older children and adolescents. However one study also found increased CSCT use in the very young, particularly among patients seen in non-pediatric specific facilities [27,29]. Our study was limited to patients entered into our pediatric trauma registry and we could not compare use of CSCT among adults as site specific CT use is not currently tracked in our state trauma registry [30]. Current pediatric trauma recommendations indicate that the cervical spine should be initially screened with plain radiography and that CSCT should be used only to evaluate areas of concern [10– 12]. In our study, only 5.9% of patients who were evaluated at the GED with CSCT also had plain radiography. In the majority of cases, a CSCT was the only cervical spine imaging obtained during their evaluation. In contrast, 42.2% of patients evaluated at the PTC had CSR obtained in association with their CSCT. The majority of pediatric patients are cared for in non-pediatric facilities where pediatric protocols may not be available. Studies in the literature have found differences in the way patients are cared for by physicians with special training in pediatric emergency care [31–33]. To date, there are multiple studies suggesting that the use of CSCT in adult blunt trauma patients is more cost-effective and timely compared to plain radiographs, especially if that patient has indications for cranial CT [6,7]. For this reason, certain centers developed trauma protocols to screen the head and the cervical spine simultaneously [7,34]. In pediatric patients, where the risk of cervical spine injury is approximately 1%, plain films have a sensitivity of 90% or greater in identifying CSI and the additional yield of CSCT is low and not necessarily more timely [15,35,36]. Despite this, the use of CT to evaluate the pediatric patient has increased with notable implications [36,37]. Exposure to ionizing radiation in younger patients increases their lifetime risk of fatal malignancy [20,21]. The exposure of the cervical spine to ionizing radiation has particular risk for the thyroid gland. Current estimates of thyroid cancer from ionizing radiation suggest that the risk is increased even down to levels of 4–10 cGy [38,39]. Doses of ionizing radiation from CSCT are approximately 5 cGy compared to a maximum of 0.0006 cGy from CSXR (a 4-view radiograph series) [18,19]. Pediatric patients evaluated at non-pediatric specific facilities compared to pediatric specific facilities may be exposed to higher doses as well [16,17,24]. In the era of As Low As Reasonably Achievable (ALARA), current data suggest only that pediatric-specific facilities are making changes in CT imaging algorithms to reduce dose, however, there are no studies to date that show a difference in actual radiation dose in CSCT [40]. With the development of predictive models of CSI in pediatric trauma patients, we can better target appropriate imaging strategies and keep to ALARA principles to reduce radiation exposure in children [41]. This study has certain limitations. First, our study was subject to referral bias as our analysis was limited to a population of pediatric trauma patients ultimately cared for at the PTC. We are unable to make conclusions regarding patients that were discharged home from outside facilities, yet another study demonstrated the CSCT rate remained higher in low acuity patients evaluated at GEDs compared to the PTC [28]. Also, there may be a lower ascertainment of the number of plain films obtained at the outside facilities. The standard of care for transferred patients is to send radiographs and medical records along with the patient, but we cannot be certain that a higher number of cervical spine plain films were obtained and not transferred. We classified patients in the analysis who were transferred without a CSCT and subsequently had a study performed at the PTC
as not having a CSCT to reflect the practice at the institution doing the primary evaluation. Although this would result in selection bias by underestimating the use of CSCT at the PTC, the total number of these patients is small, 2.3% (138) of the entire study population. Lastly, we did not capture indications for imaging. Although we note a higher use of CSCT among patients with CSI, we do not know the frequency of reported neck tenderness or physical exam findings among those patients who had CSCT. There was an increase in use among patients with a lower GCS suggesting use of CSCT to image patients with altered mental status. 6. Conclusion Despite a stable rate of CSI between 2002 and 2011, usage of CSCT increased six-fold among pediatric trauma patients initially evaluated at referral hospitals while the rate of CSCT remained relatively low at the pediatric trauma center. This trend is noted even after adjusting for several hospital and patient specific characteristics. The majority of pediatric patients are evaluated at GEDs and as a result, higher rates of CSCT pose a risk of ionizing radiation exposure affecting patient safety. Targeted education on current existing recommendations on the directed use of CSCT for the evaluation of the cervical spine in children may hopefully result in a similar trend of decreased use of CT as that seen in the evaluation of closed head injury [42]. Current American Academy of Pediatrics and American College of Emergency Physician guidelines for pediatric patients in the ED setting recommend reducing radiation exposure using ALARA principles [43]. Collaboration to develop pediatric specific imaging protocols may further reduce use of unnecessary CT among pediatric trauma patients. References [1] Bondio WA. Cervical spine trauma in children: part II. Mechanisms and manifestations of injury, therapeutic considerations. Am J Emerg Med 1993;11(3):256–78. [2] Viccellio P, Simon H, Pressman B, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108(2):1–6. [3] Lowery DW, Wald MM, Browne BJ, et al. Epidemiology of cervical spine injury victims. Ann Emerg Med 2001;38(1):12–6. [4] Manary MJ, Jaffe DM. Cervical spine injuries in children. Pediatr Ann 1996;25(8): 423–8. [5] Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000;343(2): 94–9. [6] Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999;212(1):117–25. [7] LeBlang SD, Nunez DB. Helical CT of cervical spine and soft tissue injuries of the neck. Radiol Clin North Am 1999;37(3):515–32. [8] Keenan HT, Hollingshead MC, Chung CJ, et al. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. AJR Am J Roentgenol 2001;177(6):1405–9. [9] Como JJ, Diaz J, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma 2009;67(3):651–9. [10] Fuch S, Gausche-Hill M, Yamamoto L, editors. Advanced pediatric life support: the pediatric emergency medicine course. Elk Grove Village: American Academy of Pediatrics; 2007. p. 91–102. [11] Head injury: triage, assessment, investigation and early management of head injury in infants, children and adult. National Institute for Health and Clinical Excellence Clinical Guidelines. 2007:2-231. http://www.nice.org.uk/nicemedia/ live/11836/36260/36260.pdf. Accessed June 8, 2012. [12] Chung S, Mikrogianakis A, Wales PW. Trauma Association of Canada Pediatric Subcommittee national pediatric cervical spine evaluation pathway: consensus guidelines. J Trauma 2011;70(4):873–84. [13] Nigrovic LE, Rogers AJ, Adelgais KM, et al, Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care 2012 May;28(5):426–32. [14] Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med 1999;17(3):230–4. [15] Garton HJ, Hammer MR. Detection of pediatric cervical spine injury. Neurosurgery 2008 Mar;62(3):700–8 discussion 700–8. [16] Linton OW, Mettler Jr FA. National conference on dose reduction in CT, with an emphasis on pediatric patients. AJR Am J Roentgenol 2003;181(2):321–9.
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