PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study

Authors

Julie C. Leonard, Division of Emergency Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA. Electronic address: julie.leonard@nationwidechildrens.org.
Monica Harding, Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
Lawrence J. Cook, Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
Jeffrey R. Leonard, Department of Neurosurgery, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
Kathleen M. Adelgais, Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Colorado Children's Hospital, Aurora, CO, USA.
Fahd A. Ahmad, Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO, USA.
Lorin R. Browne, Department of Pediatrics and Department of Emergency Medicine, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA.
Rebecca K. Burger, Department of Pediatrics, Division of Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
Pradip P. Chaudhari, Division of Emergency and Transport Medicine, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA.
Daniel J. Corwin, Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Nicolaus W. Glomb, Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, Benioff Children's Hospital, San Francisco, CA, USA.
Lois K. Lee, Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
Sylvia Owusu-Ansah, Division of Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
Lauren C. Riney, Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Alexander J. Rogers, Department of Emergency Medicine and Department of Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, MI, USA.
Daniel M. Rubalcava, Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
Robert E. Sapien, Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
Matthew A. Szadkowski, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, USA.
Leah Tzimenatos, Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA.
Caleb E. Ward, Division of Emergency Medicine, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, DC, USA.
Kenneth Yen, Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Health Dallas, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Nathan Kuppermann, Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA.

Document Type

Journal Article

Publication Date

7-1-2024

Journal

The Lancet. Child & adolescent health

Volume

8

Issue

7

DOI

10.1016/S2352-4642(24)00104-4

Abstract

BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS: In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION: Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

APA Citation

Leonard, Julie C.; Harding, Monica; Cook, Lawrence J.; Leonard, Jeffrey R.; Adelgais, Kathleen M.; Ahmad, Fahd A.; Browne, Lorin R.; Burger, Rebecca K.; Chaudhari, Pradip P.; Corwin, Daniel J.; Glomb, Nicolaus W.; Lee, Lois K.; Owusu-Ansah, Sylvia; Riney, Lauren C.; Rogers, Alexander J.; Rubalcava, Daniel M.; Sapien, Robert E.; Szadkowski, Matthew A.; Tzimenatos, Leah; Ward, Caleb E.; Yen, Kenneth; and Kuppermann, Nathan, "PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study" (2024). GW Authored Works. Paper 5031.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/5031

Department

Pediatrics