Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project

Waddell, Valerie A.; Connelly, Susan

doi:10.1097/jtn.0000000000000340

Cited by 8 publications

(6 citation statements)

References 16 publications

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“…Repeat posttransfer CT was less common in transfers from nondesignated hospitals than Level III/IV trauma centers, probably because nondesignated hospitals are often large urban centers with the ability to transfer rapidly and to perform and transfer high‐quality advanced imaging. Similarly, the reduced odds of repeat posttransfer imaging in pediatric centers are likely to be related to better adherence to clinical guideline recommendations due to greater awareness of the impact of ionizing radiation in children in these centers 33 …”

Section: Discussionmentioning

confidence: 99%

“…Similarly, the reduced odds of repeat posttransfer imaging in pediatric centers are likely to be related to better adherence to clinical guideline recommendations due to greater awareness of the impact of ionizing radiation in children in these centers. 33 A recent qualitative review identified the following root causes of low-value pretransfer CT imaging in trauma transfers in U.S. studies: meeting the expectations of the receiving center, legal responsibility, lack of clear clinical indications, and physicians' personal judgment. 32 In terms of low-value repeat posttransfer CT, 32 The influence of pretransfer CT on increased transfer time has also been observed in a U.S. study in patients with head injuries.…”

Section: Discussionmentioning

confidence: 99%

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Pre‐ and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study

Abiala

Bérubé

Mercier

et al. 2022

Academic Emergency Medicine

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Background Multiple clinical practice guidelines recommend minimizing radiation in trauma patients but there is a knowledge gap on the importance of this problem for trauma transfers. We aimed to estimate the incidence of pretransfer and repeat posttransfer computed tomography (CT) overall and in patients with an indication for immediate transfer, to assess interhospital practice variation, to identify predictors, and to quantify the influence of pretransfer CT on time to transfer. Methods We conducted a retrospective multicenter cohort study on patients transferred to major trauma centers from 2013 to 2019. Multilevel generalized linear regression was used to generate intraclass correlation coefficients (ICCs) to assess interhospital variation, multilevel logistic regression to generate odds ratios for each predictor, and geometric mean ratios to quantify the influence of CT on time to transfer. Results Of 18,244 patients included, 8501 (47%) had a pretransfer CT and one‐quarter (26%) had a repeat posttransfer CT. Interhospital variation was moderate for pretransfer CT (5%–66%, ICC 12.5%) and for repeat posttransfer CT (7%–44%, ICC 14.7%). Pretransfer imaging was more frequent in elders and in males and repeat posttransfer imaging decreased over the study period but was more frequent in patients transferred in from Level III/IV centers than nondesignated hospitals. Time to transfer was doubled in patients who had a pretransfer CT. Conclusions Results suggest that pretransfer CT and repeat posttransfer CT are frequent and are subject to significant practice variation. In addition, pretransfer CT is associated with increased times to transfer though additional studies are needed to demonstrate causation. These results highlight potential opportunities to reduce low‐value imaging for trauma transfers.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Pre‐ and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study

Abiala

Bérubé

Mercier

et al. 2022

Academic Emergency Medicine

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“…While cervical spine fractures occur in only 0.7% of all blunt trauma patients and constitute 19.38% of all spine fractured patients, failing to diagnose this relatively small proportion could lead to catastrophic neurologic disability. [ 8 ] The US modality provides a useful adjunct for emergency physicians in evaluating multiple trauma patients and achieving notable information in a short span of time. The current study enrolled and assessed severe multiple trauma patients with altered consciousness.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Accuracy and Prognostic Significance of Point-Of-Care Ultrasound (POCUS) for Traumatic Cervical Spine in Emergency care setting: A Comparison of clinical outcomes between POCUS and Computed Tomography on a Cohort of 284 Cases and Review of Literature

Ravikanth¹

2021

J Craniovert Jun Spine

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Background: The cervical spine is injured in approximately 3% of major trauma patients, and 10% of patients with serious head injury. Therefore, clearance of the cervical spine in multitrauma patients is a critically important task. This is particularly important, considering that there is a positive correlation between a Glasgow Coma Scale of <14 and cervical spine injury. Radiography is not sensitive enough to rule out cervical spine injury, especially as radiography done in the trauma setting is usually technically unsatisfactory. Objective: The current study aims to assess the diagnostic accuracy and prognostic significance of using bedside point-of-care ultrasound (POCUS) in traumatic cervical spine injuries compared to computed tomography (CT) as the reference standard. Materials and Methods: This comparative study enrolled 284 patients with severe multiple trauma at a tertiary care center between July 2017 and March 2020. The inclusion criteria included an indication of cervical spine CT scan, satisfaction of patients with participation in the study, and the lack of history of injury and severe traumatic events. The exclusion criteria were the history of a previous cervical spinal trauma, spondylosis, scoliosis, spinal tuberculosis, degenerative vertebral changes, and patients who refused to give consent to participate in research or CT scanning. The data were analyzed by SPSS software, and sensitivity, specificity, and positive predictive value (PPV)/negative predictive value (NPV) were determined based on CT findings. Results: The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). POCUS had a sensitivity of 78.5%, specificity of 98.4%, PPV of 93.2%, NPV of 92.8%, and accuracy of 93.2% in detecting all types of spinal injuries in comparison with CT scan as the standard modality. POCUS had a sensitivity of 100%, specificity of 92.3%, PPV of 62.3%, NPV of 100%, and accuracy of 91.7% in cases with the movement of injured particles. POCUS had a sensitivity of 32.2%, specificity of 100%, PPV of 100%, NPV of 91.4%, and accuracy of 90.8% in detecting the fracture of transverse process. POCUS had a sensitivity of 36.1%, specificity of 100%, PPV of 100%, NPV of 98.1%, and accuracy of 98.4% in ≤14-year age multitrauma patients. In comparison, the current study achieved a sensitivity of 79.4%, specificity of 95.7%, PPV of 92.1%, NPV of 86.3%, and accuracy of 88.6% in >14-year age multitrauma patients. Conclusion: POCUS for cervical spine is feasible using portable ultrasound machine and by neurosurgeons/radiologists/emergency physicians with basic training. It holds great potential in resource-starved settings and in unstable patients for ruling out unstable cervical spine injuries and injuries associated with the movement of fractured or dislocated particles. POCUS examination of the cervical spine was possible in the emergenc...

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“…Four clinical decision-making tools utilized NEXUS criteria alone for initial clearance [22][23][24][25] ; however, 2 of these protocols limited the use of the tool to children over 3 years and 5 years, respectively. 23,24 Three additional protocols supplemented NEXUS with an additional novel clearance element. 15,16,19,26 To elaborate, the protocol in Sun et al 16 and McMahon et al, 15 whose studies utilized the same algorithm, added appropriate communication to NEXUS criteria; the protocol in Moore et al 19 added normal range of motion; and, the protocol in Chaudhry et al 26 added PEDSPINE criteria 2 (Supplemental Table 2A, Supplemental Digital Content 3, http://links.lww.com/SLA/D855).…”

Section: Triage Criteriamentioning

confidence: 99%

“…Despite the variability, when we assessed algorithm characteristics, we found that 12 of the 16 protocols (75%) incorporated some or all NEXUS criteria, either as initial touchpoints or embedded into the algorithm. Four clinical decision-making tools utilized NEXUS criteria alone for initial clearance [22][23][24][25] ; however, 2 of these protocols limited the use of the tool to children over 3 years and 5 years, respectively. 23,24 Three additional protocols supplemented NEXUS with an additional novel clearance element.…”

Section: Triage Criteriamentioning

confidence: 99%

Variability of Pediatric Cervical Spine Clearance Protocols

et al. 2022

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Objective: The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. Background Data: Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. Methods: A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results: There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N = 14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. Conclusions: Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

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Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project

Abstract: Staff education and the use of an algorithm show promise in the reduction of radiation exposure and provide safe, effective clearance of the cervical spine in pediatric trauma.

Cited by 8 publications

References 16 publications

Pre‐ and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study

Pre‐ and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study

Diagnostic Accuracy and Prognostic Significance of Point-Of-Care Ultrasound (POCUS) for Traumatic Cervical Spine in Emergency care setting: A Comparison of clinical outcomes between POCUS and Computed Tomography on a Cohort of 284 Cases and Review of Literature

Variability of Pediatric Cervical Spine Clearance Protocols

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