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