Julie C. Leonard

Factors Associated With Cervical Spine Injury in Children After Blunt Trauma

STUDY OBJECTIVE Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. METHODS We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the models sensitivity and specificity. RESULTS We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. CONCLUSION We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

Priorities for Pediatric Prehospital Research

Up to 3 million US children are cared for by emergency medical services (EMSs) annually. Limited research exists on pediatric prehospital care. The Pediatric Emergency Care Applied Research Network (PECARN) mission is to perform high-quality research for children, including prehospital research. Our objective was to develop a pediatric-specific prehospital research agenda. Methods: Representatives from all 4 PECARN nodes and from EMS agency partners participated in a 3-step process. First, participants ranked potential research priorities and suggested others. Second, participants reranked the list in order of importance and scored each priority using a modified Hanlon method (prevalence, seriousness, and practicality of each research area were assessed). Finally, the revised priority list was presented at a PECARN EMS summit, and consensus was sought. Results: Forty-two representatives participated, including PECARN representatives, EMS agency leaders, and nationally recognized prehospital researchers. Consensus was reached on the priority ranking. The prioritization processes resulted in 2 ranked lists: 15 clinical topics and 5 EMS system topics. The top 10 clinical priorities included (1) airway management, (2) respiratory distress, (3) trauma, (4) asthma, (5) head trauma, (6) shock, (7) pain, (8) seizures, (9) respiratory arrest, and (10) C-spine immobilization. The 5 EMS system topics identify methods to improve prehospital care on the system level. Conclusions: PECARN has identified high-priority EMS research topics for children using a consensus-derived method. These research priorities include novel EMS system topics. The PECARN EMS pediatric research priority list will help focus future pediatric prehospital research both within and outside the network.

Massive transfusion policies at trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program.

BACKGROUND Massive transfusion protocols (MTPs) have been developed to implement damage control resuscitation (DCR) principles. A survey of MTP policies from American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) participants was performed to establish which MTP activation, hemostatic resuscitation, and monitoring aspects of DCR are included in the MTP guidelines. METHODS On October 10, 2013, ACS-TQIP administration administered a cross-sectional electronic survey to 187 ACS-TQIP participants. RESULTS Seventy-one percent (132 of 187) of responses were analyzed, with 62% designated as Level I and 38% designated as Level II ACS-TQIP trauma centers. Sixty-nine percent of sites indicated that they have plasma immediately available for MTP activation. By policy, in the first group of blood products administered, 88% of sites target high (≥1:2) plasma–to–red blood cell (RBC) ratios and 10% target low ratios. Likewise, 79% of sites target high platelet-to-RBC ratios and 16% target low ratios. Eighteen percent of sites reported incorporating point-of-care thromboelastogram into MTP policies. The most common intravenous hemostatic adjunct incorporated into MTPs was tranexamic acid (49%). Thirty-four percent of sites reported that some or all of their emergency medical service agencies have the ability to administer blood products or hemostatic agents during prehospital transport. There were minimal differences in MTP policies or capabilities between Level I and II sites. CONCLUSION The majority of ACS-TQIP participants reported having MTPs that support the use of DCR principles including high plasma-to-RBC and platelet-to-RBC ratios. Immediate availability of plasma and product use by emergency medical services are becoming increasingly common, whereas the incorporation of point-of-care thromboelastogram into MTP policies remains low.

Cervical spine injury patterns in children

BACKGROUND AND OBJECTIVE: Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children. METHODS: We conducted a 5-year retrospective review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher’s exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries. RESULTS: A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput–C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3–7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries. CONCLUSIONS: We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.

A multicenter randomized controlled trial of intravenous magnesium for sickle cell pain crisis in children

Magnesium, a vasodilator, anti-inflammatory, and pain reliever, could alter the pathophysiology of sickle cell pain crises. We hypothesized that intravenous magnesium would shorten length of stay, decrease opioid use, and improve health-related quality of life (HRQL) for pediatric patients hospitalized with sickle cell pain crises. The Magnesium for Children in Crisis (MAGiC) study was a randomized, double-blind, placebo-controlled trial of intravenous magnesium vs normal saline placebo conducted at 8 sites within the Pediatric Emergency Care Applied Research Network (PECARN). Children 4 to 21 years old with hemoglobin SS or Sβ(0) thalassemia requiring hospitalization for pain were eligible. Children received 40 mg/kg of magnesium or placebo every 8 hours for up to 6 doses plus standard therapy. The primary outcome was length of stay in hours from the time of first study drug infusion, compared using a Van Elteren test. Secondary outcomes included opioid use and HRQL. Of 208 children enrolled, 204 received the study drug (101 magnesium, 103 placebo). Between-group demographics and prerandomization treatment were similar. The median interquartile range (IQR) length of stay was 56.0 (27.0-109.0) hours for magnesium vs 47.0 (24.0-99.0) hours for placebo (P = .24). Magnesium patients received 1.46 mg/kg morphine equivalents vs 1.28 mg/kg for placebo (P = .12). Changes in HRQL before discharge and 1 week after discharge were similar (P > .05 for all comparisons). The addition of intravenous magnesium did not shorten length of stay, reduce opioid use, or improve quality of life in children hospitalized for sickle cell pain crisis. This trial was registered at www.clinicaltrials.gov as #NCT01197417.

Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging

BACKGROUND This study aimed to compare children diagnosed with cervical spinal cord injury without radiographic abnormality (SCIWORA) relative to whether there is evidence of cervical spinal cord abnormalities on magnetic resonance imaging (MRI). METHODS We conducted a planned subanalysis of a cohort of children younger than 16 years with blunt cervical spine injury presenting to Pediatric Emergency Care Applied Research Network centers from January 2000 to December 2004 who underwent cervical MRI and did not have bony or ligamentous injury identified on neuroimaging. We defined SCIWORA with normal MRI finding as children with clinical evidence of cervical cord injury and a normal MRI finding and compared them with children with SCIWORA who had cervical cord signal changes on MRI (abnormal MRI finding). RESULTS Of the children diagnosed with cervical spine injury, 55% (297 of 540) were imaged with MRI; 69 had no bony or ligamentous injuries and were diagnosed with SCIWORA by clinical evaluation; 54 (78%) had normal MRI finding, and 15 (22%) had cervical cord signal changes on MRI (abnormal MRI finding). Children with abnormal MRI findings were more likely to receive operative stabilization (0% normal MRI finding vs. 20% abnormal MRI finding) and have persistent neurologic deficits at initial hospital discharge (6% normal MRI finding vs. 67% abnormal MRI finding). CONCLUSION Children diagnosed with SCIWORA but with normal MRI finding in our cohort presented differently and had substantially more favorable clinical outcomes than those with cervical cord abnormalities on MRI. LEVEL OF EVIDENCE Epidemiologic study, level III.

Characteristics of the Pediatric Patients Treated by the Pediatric Emergency Care Applied Research Network's Affiliated EMS Agencies

Abstract Objective. To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Networks (PECARNs) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. Methods. We conducted a retrospective analysis of electronic patient care data from PECARNs partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. Results. Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4–9), scene time 15 minutes (IQR: 11–21), and transport time 9 minutes (IQR: 6–13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. Conclusions. Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

Potential Adverse Effects of Spinal Immobilization in Children

Abstract Objective. The purpose of our study was to describe potential adverse effects associated with spinal immobilization following trauma among children. Methods. We conducted a prospective cohort study of children presenting to the emergency department (ED) for evaluation following trauma over a 13-month period. Children were eligible if they underwent spinal immobilization prior to physician evaluation or if they met the American College of Surgeons (ACS) guidelines for spinal immobilization but were not immobilized. We compared children who were immobilized with those who were not immobilized for self-reported pain, use of radiography to evaluate the cervical spine, ED length of stay, and ED disposition. We also report the characteristics of the cohort. Results. One hundred seventy-three spine-immobilized children and 112 children who met ACS criteria but were not immobilized were enrolled. There were differences between the two study groups, which included age, mechanism of injury, and proportion transported by emergency medical services. However, the comparison groups had comparable Pediatric Trauma Scores (PTSs) and Glasgow Coma Scale scores (GCSs). Immobilized children had a higher median pain score (3 versus 2) and were more likely to undergo cervical radiography (56.6% versus 13.4%) and be admitted to the hospital (41.6% versus 14.3%). The comparison groups had similar lengths of stay in the ED. Conclusion. Despite presenting with comparable PTSs and GCSs, children who underwent spinal immobilization following trauma had a higher degree of self-reported pain, and were much more likely to undergo radiographic cervical spine clearance and be admitted to the hospital than those who were not immobilized. Future studies are warranted to determine whether these differences are related to spinal immobilization or differences in the mechanisms of injury, injury patterns, or other variables.

Intravenous magnesium for pediatric sickle cell vaso‐occlusive crisis: Methodological issues of a randomized controlled trial

Multiple recent Sickle Cell Disease studies have been terminated due to poor enrollment. We developed methods to overcome past barriers and utilized these to study the efficacy and safety of intravenous magnesium for vaso‐occlusive crisis (VOC). We describe the methods of the Intravenous Magnesium in Sickle Vaso‐occlusive Crisis (MAGiC) trial and discuss methods used to overcome past barriers. MAGiC was a multi‐center randomized double‐blind placebo‐controlled trial of intravenous magnesium versus normal saline for treatment of VOC. The study was a collaboration between Pediatric Hematologists and Emergency Physicians in the Pediatric Emergency Care Applied Research Network (PECARN). Eligible patients were randomized within 12 hours of receiving intravenous opioids in the Emergency Department (ED) and administered study medication every 8 hours. The primary outcome was hospital length of stay. Associated plasma studies elucidated magnesiums mechanism of action and the pathophysiology of VOC. Health‐related quality of life was measured. Site‐, protocol‐, and patient‐related barriers from prior studies were identified and addressed. Limited study staff availability, lack of collaboration with the ED, and difficulty obtaining consent were previously identified barriers. Leveraging PECARN resources, forging close collaborations between Sickle Cell Centers and EDs of participating sites, and approaching eligible patients for prior consent helped overcome these barriers. Participation in the PECARN network and establishment of collaborative arrangements between Sickle Cell Centers and their affiliated EDs are major innovative features of the MAGiC study that allowed improved subject capture. These methods could serve as a model for future studies of VOCs. Pediatr Blood Cancer 2014;61:1049–1054.

Utility of Plain Radiographs in Detecting Traumatic Injuries of the Cervical Spine in Children

Objective The objective of this study was to estimate the sensitivity of plain radiographs in identifying bony or ligamentous cervical spine injury in children. Methods We identified a retrospective cohort of children younger than 16 years with blunt trauma–related bony or ligamentous cervical spine injury evaluated between 2000 and 2004 at 1 of 17 hospitals participating in the Pediatric Emergency Care Applied Research Network. We excluded children who had a single or undocumented number of radiographic views or one of the following injuries types: isolated spinal cord injury, spinal cord injury without radiographic abnormalities, or atlantoaxial rotary subluxation. Using consensus methods, study investigators reviewed the radiology reports and assigned a classification (definite, possible, or no cervical spine injury) as well as film adequacy. A pediatric neurosurgeon, blinded to the classification of the radiology reports, reviewed complete case histories and assigned final cervical spine injury type. Results We identified 206 children who met inclusion criteria, of which 127 had definite and 41 had possible cervical spine injury identified by plain radiograph. Of the 186 children with adequate cervical spine radiographs, 168 had definite or possible cervical spine injury identified by plain radiograph for a sensitivity of 90% (95% confidence interval, 85%–94%). Cervical spine radiographs did not identify the following cervical spine injuries: fracture (15 children) and ligamentous injury alone (3 children). Nine children with normal cervical spine radiographs presented with 1 or more of the following: endotracheal intubation (4 children), altered mental status (5 children), or focal neurologic findings (5 children). Conclusions Plain radiographs had a high sensitivity for cervical spine injury in our pediatric cohort.