deveoping a spinal clearance guideline for picu
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Developing a spinal clearance guideline for
Paediatric Intensive Care
Dr Ruth FordST7 Anaesthetics Trainee
RBHSC
Trauma is leading cause of mortality over 1 year of age Paediatric spinal injury is thankfully rare
Occurs in 1-2% of all paediatric trauma Hutchings and Willett, 2009
The problem of spinal injury in paediatrics
Missed injury
Prolonged immobilisation
“An acute spinal cord injury that results in sensory and/or motor deficits without radiographic evidence of vertebral fractures or bony misalignment on plain radiographs or CT”
Pang and Wilberger, 1982
Although rare, more prevalent in children than adults Malleable spine – tolerates loading and deformity
Relatively lax ligaments Horizontal facet joints Incomplete development of spinous processes
Kreykes et al, 2010
SCIWORA
Risk of pressure ulceration from cervical collar Liew and Hill, 1994
Increased if circulation and/or nutrition compromised Requiring deeper sedation (+/- addition of muscle relaxant) Restricted respiratory physiotherapy and ↑ chest infection
Meduri and Estes, 1995
Practical difficulties Airway management Venous access Nursing demands
Risk of complications escalates after 72 hrsPowers et al, 2006
Prolonged immobilisation
Lack of current evidence Consensus only on immediate management
CT head and C-spine within 1 hour of all children with severe head injuryNICE, 2007
Full-body CT within 1 hour of presentation following severe polytrauma in children NCEPOD, 2007
Small numbers seen in single PICU departments each year Inconsistent approach
Variable approach to imaging requirements, time-frame to clearance, and specialties involved Cullen et al, 2012
Our concerns
Approached different specialties involved General surgery, Neurosurgery, Orthopaedic surgery Paediatric radiology PICU Consultants
Variable responses to request for comments on the draft protocol
Agreed Consultant-led process essential Always a balance of risks Need to allow for clinical judgment in specific cases
Multidisciplinary
Specificity of CT for bony injury of spine approaches 100%
Role of MRI increasing to identify soft tissue injuryAnderson et al, 2010; Flynn et al, 2002
Limitations: Very sensitive – unclear clinical significance of radiological findings Controversy over ideal time frame for scanning – within 48 hrs?
Benzel et al, 1996
Practical difficulties
The role for MRI
Patients under age of 14 sedated and ventilated in PICU following severe head injury, where clinical examination is not expected to be possible within 72 hours of admission
Expected that initial trauma management will follow usual ATLS principles including spinal immobilisation
Consultant-led, multidisciplinary approach AIM = spinal clearance within 72 hours of admission to
PICU.
Our protocol
Clinical Assessment of clinical suspicion for spinal injury
Mechanism of injury – RTA, falls, sports injury, NAI Clinical examination – external injury, step deformity etc Consider likely timescale until patient is likely to be awake
Radiological CT of C-spine (in head injury) or full spine (in polytrauma)
Within 1 hour of admission Arrange MRI spine if clinical suspicion of injury high and patient likely to be
sedated for > 72 hrs
Imaging should be reported promptly by consultant radiologist Spinal precautions to continue until imaging complete & reports available If CT and MRI do not identify injury, spinal precautions may be discontinued
Our protocol
Patients not suitable for MRI Clinical instability - remote MRI incompatibility
Resources MRI-trained consultant anaesthetist, technician, two
paediatric nurses Transport MRI availability
Limitations
Policy submitted for Service Group Review (Paediatric Governance meeting)
Current practice is reflective of the proposed protocol
Ongoing audit will be required when protocol formally approved
Policy should continue to reflect best practice and any new evidence
Where do we stand?
Anderson R et al. Utility of a cervical spine clearance protocol after trauma in children between 0-3 years of age. Journal of Neurosurg Pediatrics 2010;5:292-296
Benzel EC, Hart BL, Bill PA et al. MRI for the evaluation of patients with occult cervical spine injury. Journal of Neurosurgery 1996;85(5):824-9
Cullen A, Terris M and Mullan B. Spinal clearance in unconscious children with traumatic brain injury: a survey of current practice in paediatric intensive care units in Great Britain and Ireland. J Neurosurg Anesthesiol 2012; 24(3)
Flynn JM et al. The efficacy of MRI in the assessment of pediatric cervical spine injuries. Journal of pediatric orthopaedics 2002;22:573-77
Hutchings L and Willett K. Cervical spine clearance in pediatric trauma. A review of current literature. Journal of trauma, injury, infection and critical care 2009; 67(4): 687-691
Kreykes N et al. Current issues in the diagnosis of pediatric cervical spine injury. Seminars in pediatric surgery 2010; 19: 257-264
Liew SC and Hill DA. Complication of hard cervical collars in multi-trauma patients. Aust N Z J Surg 1994; 64(2): 139-140Meduri GU and Estes RJ. The pathogenesis of ventilator-associated pneumonia. Intensive Care Medicine 1995; 21(5): 452-61National Confidential Enquiry into Patient Outcome and Death, 2007. Trauma: Who Cares? London: National Confidential
Enquiry into Patient Outcome and DeathNational Institute for Health and Care Excellence, 2007. Triage, assessment, investigation and management of head injury in
infants, children and adults. CG56. London: National Institute for Health and Care ExcellencePang D and Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982; 57: 114-129Powers J et al. The incidence of skin breakdown associated with cervical collars. J Trauma Nurs 2006; 13(4): 198-200
References
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