Abstract
OBJECTIVES:
Spinal motion restriction (SMR) is commonly applied to injured children with potential cervical spine injuries (CSI). There are, however, risks to indiscriminate SMR application. We recently derived the Pediatric Emergency Care Applied Research Network (PECARN) CSI clinical prediction rule. Effective implementation of this prediction rule requires an accurate understanding of current emergency medical services (EMS) SMR practices. Little is known about the prevalence of prehospital SMR application in children. Our primary objective was to determine the proportion of children sustaining blunt trauma who are placed in SMR by EMS. Our secondary objective was to identify factors associated with SMR placement.
METHODS:
We conducted a secondary analysis of data collected during a prospective study of children 0–17 years with blunt trauma transported by EMS to one of 18 PECARN-affiliated emergency departments. Prehospital clinicians completed surveys regarding CSI risk factors and SMR application. We summarized SMR prevalence, techniques used, reasons for application, and clinician suspicion for CSI by patient age. We conducted univariable and multivariable logistic regression to determine factors associated with SMR placement.
RESULTS:
Of 13,453 children transported by EMS, we enrolled a convenience sample of 7,721 (57.4%) of whom 1.6% had a CSI and 41.5% had SMR placed. Older children were more likely to have SMR placed (35.5–50.4%) compared to those < 2 years (22.0%). Factors associated with SMR placement included patient demographics (non-Hispanic White race/ethnicity, age > 2 years), mechanisms of injury (high-risk motor vehicle crash (MVC), unrestrained MVC passenger, high-risk fall, axial load), clinical history (loss of consciousness, self-reported neck pain, paresthesia, numbness, or extremity weakness) and physical examination findings (altered mental status, neck tenderness, inability to move neck, focal neurological deficits, and substantial head or torso injuries).
CONCLUSIONS:
Of children transported by EMS after blunt trauma in this study, 41.5% had SMR placed, while only 1.6% had CSIs. Factors associated with SMR placement included patient demographics, mechanism of injury, history, and examination findings. Many of these factors are not in the new PECARN CSI clinical prediction rule. Implementation of a risk-centered EMS decision aid for SMR in children after blunt trauma must address this discrepancy.
Keywords: emergency medical services, trauma, pediatrics, neck injuries
INTRODUCTION
Cervical spine injuries (CSI) occur in 1 – 2% of children sustaining blunt trauma (1, 2). While uncommon, pediatric CSI can cause devastating morbidity and mortality (3, 4). The prehospital application of spinal motion restriction (SMR) by emergency medical services (EMS) clinicians has been standard clinical practice for many decades based on the hypothesis that post-injury movement of the spinal column may cause or exacerbate neurological deficits (5). There is, however, limited evidence of patient benefit from placement of SMR (6–10). Placing children in SMR increases the likelihood that a clinician will elicit tenderness on examination (11–16), and thus subject the child to radiographic evaluation of the spine and long term risk of iatrogenic cancer (17–20). SMR is associated with several other notable harms for critically ill patients, including the development of pressure sores (21–23), impaired ventilation (24–26), difficulties performing airway interventions (27), and elevated intracranial pressure (28).
Previous clinical prediction rules, including the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine rule have been validated and have excellent sensitivity for detecting CSI in adults (29–32). Implementing these clinical prediction rules in prehospital and hospital settings has resulted in safe reduction in SMR placement and X-ray utilization for adults (33–36). These rules were derived with very small numbers of pediatric patients and have not been widely adopted for children (4). A recent Cochrane review noted insufficient evidence to determine the accuracy of either rule in detecting CSI in children (37). The Pediatric Emergency Care Applied Research Network (PECARN) C-spine Study Group recently validated a clinical prediction rule based on a prospective observational study of more than 20,000 injured children (including more than 400 with confirmed CSIs) (Figure 1) (38).
Figure 1:
PECARN cervical spine injury (CSI) Clinical Decision Rule
1 GCS score 9 – 14 or Voice or Pain on the AVPU scale or other signs of altered mental status.
2 Substantial injuries defined as those warranting inpatient observation or surgical intervention.
Validating and implementing evidence-based decision aids for injured children has been identified as a priority area for pediatric prehospital research (39, 40). A prerequisite to effectively implementing the recently derived PECARN CSI prediction rule in the prehospital setting is an accurate understanding of current SMR practices by EMS clinicians (41). This will allow tailored implementation strategies to maximize impact of the prediction rule. Previous studies analyzing SMR use in children have significant limitations. Many studies do not include data on the prevalence of SMR application for injured children (42–44). Furthermore, most involve small single-center cohorts (42, 45), are based on retrospective chart reviews (42–45), or surveys of clinicians regarding hypothetical situations (46). It is, therefore, unknown what proportion of injured children are placed in SMR by EMS or what factors are associated with the decision to place SMR. Our primary objective was to determine the proportion of children sustaining blunt trauma who are placed in SMR by EMS clinicians. Our secondary objective was to identify patient and encounter factors associated with the placement of SMR for children sustaining blunt trauma.
METHODS
Study design, setting, and inclusion criteria
This was a planned secondary analysis of data collected during the prospective observational study to derive and validate the PECARN CSI prediction rule (38). For the parent study, we enrolled children aged less than 18 years who experienced blunt trauma and were evaluated at one of 18 PECARN-affiliated emergency departments (EDs) between December 2018 and December 2021. Children were eligible for enrollment if they were transported from the scene of injury via EMS, underwent trauma team evaluation, and/or had cervical spine imaging. Children with solely penetrating trauma mechanisms were excluded. This secondary analysis was restricted to enrolled participants who were transported from the scene of injury by EMS and had data forms completed by both ED and EMS clinicians. A single institutional review board at the University of Utah approved this study. Complete details of the parent study methodology have been published previously (38).
Data collection and variables
Trained research coordinators screened patients in the ED for eligibility. For eligible patients, the research coordinators provided ED clinicians with an electronic case report form to complete. A similar case report form was administered to a convenience sample of EMS clinicians immediately following the transfer of their patient to ED staff. Variables on the case report forms included CSI risk factors that have high clinical plausibility and inter-rater reliability in previous studies (3, 47–50). These variables included patient demographic factors, predisposing medical conditions, physical examination findings, mechanism of injury and markers of mechanism severity.
Outcomes
The primary outcome for this secondary analysis was whether participants were placed in SMR by EMS. The secondary outcome was the specific type of SMR used. We defined ‘full SMR’ as placement of a cervical collar and rigid longboard (or vacuum mattress). Other categories of SMR were cervical collar, rigid longboard or vacuum mattress, towel placement, and other.
Statistical analysis
Descriptive statistics were used to summarize SMR prevalence, techniques used, reasons for placement, and EMS clinician suspicion for CSI stratified by patient age. Patient age was grouped into the following clinically meaningful categories: 0 to < 2, 2 to < 8, 8 to < 16 and ≥ 16 years old. Frequencies and percentages were reported for categorical variables. Differences in participant characteristics were assessed using standard methods (chi-square tests or Fisher’s exact test were used for nominal variables). The proportion of children placed in different modalities of SMR was plotted over time. Cochrane-Armitage tests were used to analyze for linear trends over time.
Univariable logistic regression was used to determine factors associated with SMR placement. After limiting the variables to those with univariable statistical significance (p-value ≤0.05), multivariable logistic regression with a LASSO penalty was used to identify a final model to predict SMR placement.
RESULTS
Of the children enrolled in the parent study, EMS transported 13,453 participants who were eligible for this secondary analysis. EMS clinicians completed a case report form for 7,721 (57.4%) of these children (Figure 2). The demographic characteristics, mechanisms of injury and ED dispositions were similar for the enrolled and missed eligible cohorts (Supplemental File Table 1). The rate of CSI for the enrolled cohort was 1.6% (95% CI 1.3 – 1.9). Patients transported by EMS where an EMS case report form was not completed had a similar CSI rate (1.3%, 95% CI 1.0 – 1.5). When compared to children without any SMR, children at high risk for CSI with SMR application had higher rates of neck computed tomography (CT) (46.8 vs. 20.7%) and overall neck imaging (plain radiograph, CT or magnetic resonance imaging (MRI)) (88.1 vs. 40.5%) (Supplemental File Table 2).
Figure 2:
STROBE diagram showing participant enrollment
1 Missed eligible participants.
2 Eligible participants.
Prehospital clinicians placed 3,206 (41.5%) children in SMR. The most common SMR techniques used were cervical collar (52.7%) and full SMR with a cervical collar and rigid longboard or vacuum mattress (35.5%) (Table 1). EMS clinicians indicated the most common reasons for choosing to place a child in SMR were severe mechanisms of injury (59.3%), young age (38.6%), complaints of neck pain (27.8%), agency protocols (23.3%), and altered mental status (13.8%) (Table 1).
Table 1:
Spinal motion restriction (SMR) prevalence, techniques used, reasons for application and clinical suspicion for cervical spine injury (CSI) by participant age
| Age (years) | ||||||
|---|---|---|---|---|---|---|
| Overall (N = 7,721) |
0 – <2 (N = 927) |
2 – <8 (N = 2,304) |
8 – <16 (N = 3,711) |
≥16 (N = 779) |
P-value | |
| Spinal Motion Restriction (SMR) Prevalence 1 | ||||||
| SMR used during EMS transport | 3,206 (41.5%) | 204 (22.0%) | 819 (35.5%) | 1,790 (48.2%) | 393 (50.4%) | <.0016 |
| Full SMR2 | 1,137 (35.5%) | 30 (14.7%) | 266 (32.5%) | 703 (39.3%) | 138 (35.1%) | <.0016 |
| Cervical collar only | 1,689 (52.7%) | 54 (26.5%) | 429 (52.4%) | 977 (54.6%) | 229 (58.3%) | <.0016 |
| Rigid longboard or Vacuum mattress only | 162 (5.1%) | 35 (17.2%) | 50 (6.1%) | 65 (3.6%) | 12 (3.1%) | <.0016 |
| Towel only3 | 55 (1.7%) | 32 (15.7%) | 19 (2.3%) | 3 (0.2%) | 1 (0.3%) | <.0017 |
| Other | 163 (5.1%) | 53 (26.0%) | 55 (6.7%) | 42 (2.3%) | 13 (3.3%) | <.0016 |
| No SMR | 4,515 (58.5%) | 723 (78.0%) | 1,485 (64.5%) | 1,921 (51.8%) | 386 (49.6%) | <.0016 |
| Reasons for applying SMR 1 | ||||||
| Severe mechanism of injury | 1,900 (59.3%) | 127 (62.3%) | 528 (64.5%) | 1,027 (57.4%) | 218 (55.5%) | 0.0026 |
| Young age | 1,236 (38.6%) | 118 (57.8%) | 424 (51.8%) | 606 (33.9%) | 88 (22.4%) | <.0016 |
| Complaint of neck pain | 892 (27.8%) | 1 (0.5%) | 163 (19.9%) | 557 (31.1%) | 171 (43.5%) | <.0016 |
| Agency protocol | 746 (23.3%) | 49 (24.0%) | 189 (23.1%) | 415 (23.2%) | 93 (23.7%) | 0.9896 |
| Decreased mental status | 442 (13.8%) | 50 (24.5%) | 121 (14.8%) | 215 (12.0%) | 56 (14.2%) | <.0016 |
| Abnormal torso examination4 | 190 (5.9%) | 4 (2.0%) | 35 (4.3%) | 121 (6.8%) | 30 (7.6%) | 0.0036 |
| Distracting Injury | 151 (4.7%) | 1 (0.5%) | 47 (5.7%) | 93 (5.2%) | 10 (2.5%) | 0.0166 |
| Complaint of limited neck mobility | 150 (4.7%) | 0 (0.0%) | 12 (1.5%) | 112 (6.3%) | 26 (6.6%) | <.0016 |
| Placed by previous provider | 136 (4.2%) | 6 (2.9%) | 32 (3.9%) | 83 (4.6%) | 15 (3.8%) | 0.1646 |
| Abnormal head examination | 125 (3.9%) | 11 (5.4%) | 47 (5.7%) | 63 (3.5%) | 4 (1.0%) | 0.0266 |
| Focal neurologic deficit on examination | 92 (2.9%) | 5 (2.5%) | 19 (2.3%) | 52 (2.9%) | 16 (4.1%) | 0.3826 |
| Complaint of focal neurologic deficit | 66 (2.1%) | 0 (0.0%) | 5 (0.6%) | 41 (2.3%) | 20 (5.1%) | <.0016 |
| Abnormal neck examination | 63 (2.0%) | 2 (1.0%) | 13 (1.6%) | 37 (2.1%) | 11 (2.8%) | 0.3696 |
| Advised by medical direction | 46 (1.4%) | 4 (2.0%) | 10 (1.2%) | 24 (1.3%) | 8 (2.0%) | 0.6206 |
| Predisposing condition | 9 (0.3%) | 0 (0.0%) | 2 (0.2%) | 5 (0.3%) | 2 (0.5%) | 0.3746 |
| Unknown | 6 (0.2%) | 0 (0.0%) | 1 (0.1%) | 5 (0.3%) | 0 (0.0%) | 0.5886 |
| Other reason for SMR | 157 (4.9%) | 16 (7.8%) | 50 (6.1%) | 80 (4.5%) | 11 (2.8%) | 0.0136 |
| Clinical suspicion of CSI 5 | ||||||
| Clinical suspicion for presence of CSI | 0.0036 | |||||
| < 1% | 5,176 (67.0%) | 645 (69.6%) | 1,594 (69.2%) | 2,459 (66.3%) | 478 (61.4%) | |
| 1–5% | 1,430 (18.5%) | 169 (18.2%) | 386 (16.8%) | 706 (19.0%) | 169 (21.7%) | |
| 6–10% | 555 (7.2%) | 61 (6.6%) | 167 (7.2%) | 273 (7.4%) | 54 (6.9%) | |
| 11–50% | 406 (5.3%) | 36 (3.9%) | 120 (5.2%) | 196 (5.3%) | 54 (6.9%) | |
| > 50% | 154 (2.0%) | 16 (1.7%) | 37 (1.6%) | 77 (2.1%) | 24 (3.1%) | |
Percentages for specific types of SMR and reasons for applying SMR are out of those that had any SMR only.
Full SMR is defined as the application of cervical collar and rigid longboard or vacuum mattress.
Towel was defined by programmatically word searching for appropriate terms within the open text of ‘other specify’.
Abnormal torso examination indicates that the EMS clinician chose either: Abnormal chest examination, abnormal back examination, abnormal abdominal examination, or abnormal pelvic examination.
Clinical suspicion of CSI taken from the EMS provider form.
Pearson chi-square test of independence.
Fisher’s exact test of independence.
Patient age was associated with both the decision to employ SMR and the type of SMR used. Despite young age being a reason for SMR, SMR placement was more prevalent in older children compared to those < 2 years old (35.5 – 50.4% vs. 22.0%). Prehospital clinician suspicion for a child having a CSI varied modestly by patient age group. Prehospital clinicians indicated there was < 1% chance of a CSI for 69.6% of children < 2 years compared to 61.4 – 69.2% of children in older age groups. Of those placed in SMR, children less than 2 years old were much more likely to have alternative types of SMR including sole use of a rigid longboard or vacuum mattress only (17.2%), application of a towel roll (15.7%) or other alternatives (26.0%) (Table 1 and Figure 3).
Figure 3:
Proportion of children placed in spinal motion restriction (SMR) by child age
1 Full SMR defined as application of cervical collar and rigid longboard or vacuum mattress.
2 Other SMR defined as application of cervical collar or any other means of SMR that did not meet criteria for full SMR.
We observed a modest decrease over time in the proportion of children placed in SMR during the study, with the exception of quarter 2 in 2020 (coinciding with the early novel Coronavirus-19 (COVID-19) pandemic) (Figure 4). Cochran-Armitage trend tests confirmed statistically significant trends for each SMR type over time (decrease in full SMR and other SMR, with a corresponding increase in participants with no SMR) (Supplemental File Figure). We also observed a difference in SMR rates based on the degree of EMS clinician suspicion for CSI (Table 2). Prehospital clinicians utilized SMR in 87.7% of those gauged to be at high risk (> 50%) as opposed to 25.9% of those deemed to be at minimal risk (< 1%). The types of SMR employed also varied by risk assessment. Children evaluated to be at higher risk of CSI had a higher prevalence of full SMR or rigid cervical collar only and lower prevalence of alternative modes of SMR (Table 2).
Figure 4:
Proportion of children placed in spinal motion restriction (SMR) over time
1 Full SMR defined as application of cervical collar and rigid longboard or vacuum mattress.
2 Other SMR defined as application of cervical collar or any other means of SMR that did not meet criteria for full SMR.
Table 2:
Spinal motion restriction (SMR) prevalence and techniques used by emergency medical services (EMS) clinician suspicion for injury
| EMS clinician suspicion for injury | |||||||
|---|---|---|---|---|---|---|---|
| Overall (N = 7,721) |
< 1% (N = 5,176) |
1–5% (N = 1,430) |
6–10% (N = 555) |
11–50% (N = 406) |
> 50% (N = 154) |
P-value | |
| Spinal Motion Restriction (SMR) Prevalence 1 | |||||||
| SMR used during EMS transport | 3,206 (41.5%) | 1,338 (25.9%) | 949 (66.4%) | 429 (77.3%) | 355 (87.4%) | 135 (87.7%) | <.0014 |
| Full SMR2 | 1,137 (35.5%) | 383 (28.6%) | 343 (36.1%) | 182 (42.4%) | 160 (45.1%) | 69 (51.1%) | <.0014 |
| Cervical collar only | 1,689 (52.7%) | 803 (60.0%) | 497 (52.4%) | 199 (46.4%) | 141 (39.7%) | 49 (36.3%) | <.0014 |
| Rigid longboard or Vacuum mattress only | 162 (5.1%) | 66 (4.9%) | 48 (5.1%) | 19 (4.4%) | 21 (5.9%) | 8 (5.9%) | 0.8865 |
| Towel only3 | 55 (1.7%) | 23 (1.7%) | 17 (1.8%) | 6 (1.4%) | 9 (2.5%) | 0 (0.0%) | 0.4145 |
| Other | 163 (5.1%) | 63 (4.7%) | 44 (4.6%) | 23 (5.4%) | 24 (6.8%) | 9 (6.7%) | 0.4604 |
| No SMR | 4,515 (58.5%) | 3,838 (74.1%) | 481 (33.6%) | 126 (22.7%) | 51 (12.6%) | 19 (12.3%) | <.0014 |
Percentages for specific types of SMR and reasons for SMR are out of those that had any SMR only.
Full SMR is defined as the application of cervical collar and rigid longboard or vacuum mattress.
Towel was defined by programmatically word searching for appropriate terms within the open text of ‘other specify’.
Pearson chi-square test of independence.
Fisher’s exact test of independence.
Multivariable analysis identified several factors associated with placement of SMR (Table 3). These included patient demographics (non-Hispanic White race/ethnicity, age > 2 years), mechanisms of injury (high-risk motor vehicle crash (MVC), unrestrained passenger in MVC, high-risk fall, axial load mechanism), clinical history (loss of consciousness, self-reported neck pain, paresthesia, numbness, or extremity weakness) and physical examination findings (altered mental status, neck tenderness, inability to move neck, focal neurological deficits, and substantial head or torso injuries) (Table 3).
Table 3:
Factors associated with placement of spinal motion restriction (SMR) by emergency medical services (EMS) clinicians
| Univariable analysis | Multivariable analysis | ||||
|---|---|---|---|---|---|
| Overall (N = 3,206)1 |
Unadjusted Odds ratio (95% CI) | P-value | Adjusted Odds ratio (95% CI) | P-value | |
| Age (in years) | <.001 | <.001 | |||
| 0 – < 2 | 204 (6.4%) | Reference | Reference | ||
| 2 – < 8 | 819 (25.5%) | 1.95 (1.64, 2.34) | 1.95 (1.59, 2.40) | ||
| 8 – <16 | 1,790 (55.8%) | 3.30 (2.80, 3.92) | 3.05 (2.50, 3.73) | ||
| ≥16 | 393 (12.3%) | 3.61 (2.93, 4.46) | 2.30 (1.79, 2.96) | ||
| Sex | 0.103 | ||||
| Male | 1,946 (60.7%) | Reference | |||
| Female | 1,253 (39.1%) | 0.91 (0.83, 1.00) | |||
| Unknown | 7 (0.2%) | 1.59 (0.53, 4.93) | |||
| Race/Ethnicity | <.001 | <.001 | |||
| Non-Hispanic White | 1,338 (41.7%) | Reference | Reference | ||
| Non-Hispanic Black | 969 (30.2%) | 0.49 (0.44, 0.55) | 0.59 (0.52, 0.67) | ||
| Hispanic or Latino | 491 (15.3%) | 0.58 (0.51, 0.67) | 0.64 (0.54, 0.75) | ||
| Asian | 51 (1.6%) | 0.58 (0.40, 0.82) | 0.71 (0.46, 1.08) | ||
| Other | 357 (11.1%) | 0.86 (0.73, 1.02) | 0.89 (0.73, 1.08) | ||
| High risk motor vehicle crash (MVC) 2 | <.001 | <.001 | |||
| No | 2,620 (81.7%) | Reference | Reference | ||
| Yes | 586 (18.3%) | 2.20 (1.93, 2.52) | 2.31 (1.96, 2.72) | ||
| Unrestrained/None seat belt | <.001 | <.001 | |||
| No | 2,890 (90.1%) | Reference | Reference | ||
| Yes | 316 (9.9%) | 1.97 (1.66, 2.35) | 1.67 (1.35, 2.07) | ||
| Fall from height of greater than 10 feet | <.001 | <.001 | |||
| No | 2,980 (93.0%) | Reference | Reference | ||
| Yes | 226 (7.0%) | 3.19 (2.52, 4.05) | 4.27 (3.26, 5.62) | ||
| Diving | 0.857 | ||||
| No | 3,199 (99.8%) | Reference | |||
| Yes | 7 (0.2%) | 1.10 (0.39, 2.94) | |||
| Sports or recreation related | <.001 | ||||
| No | 2,771 (86.4%) | Reference | |||
| Yes | 435 (13.6%) | 1.54 (1.34, 1.78) | |||
| Axial Load | <.001 | <.001 | |||
| No | 2,861 (89.2%) | Reference | Reference | ||
| Yes | 345 (10.8%) | 2.33 (1.96, 2.78) | 1.56 (1.25, 1.93) | ||
| History of loss of consciousness (LOC) | <.001 | <.001 | |||
| No | 2,486 (77.5%) | Reference | Reference | ||
| Yes | 720 (22.5%) | 4.57 (3.95, 5.31) | 2.63 (2.20, 3.14) | ||
| Self reported neck pain 3 | <.001 | <.001 | |||
| No | 2,088 (65.1%) | Reference | Reference | ||
| Yes | 1,118 (34.9%) | 8.10 (7.04, 9.34) | 4.57 (3.82, 5.46) | ||
| Self reported Inability to move neck | <.001 | ||||
| No | 3,035 (94.7%) | Reference | |||
| Yes | 171 (5.3%) | 6.00 (4.31, 8.54) | |||
| Self reported Paresthesia | <.001 | 0.039 | |||
| No | 3,038 (94.8%) | Reference | Reference | ||
| Yes | 168 (5.2%) | 5.37 (3.90, 7.55) | 1.58 (1.02, 2.46) | ||
| Self reported Numbness | <.001 | 0.001 | |||
| No | 2,925 (91.2%) | Reference | Reference | ||
| Yes | 281 (8.8%) | 3.43 (2.77, 4.27) | 1.66 (1.22, 2.25) | ||
| Self reported Extremity weakness | <.001 | 0.047 | |||
| No | 2,823 (88.1%) | Reference | Reference | ||
| Yes | 383 (11.9%) | 1.45 (1.25, 1.68) | 0.81 (0.66, 1.00) | ||
| Abnormal airway, breathing, or circulation findings 3 | <.001 | 0.283 | |||
| No | 2,915 (90.9%) | Reference | Reference | ||
| Yes | 291 (9.1%) | 2.52 (2.08, 3.07) | 1.14 (0.90, 1.46) | ||
| Altered mental status 3 | <.001 | <.001 | |||
| No | 2,440 (76.1%) | Reference | Reference | ||
| Yes | 766 (23.9%) | 4.66 (4.04, 5.39) | 3.20 (2.68, 3.84) | ||
| AVPU: AVP vs. U 3 | <.001 | ||||
| U | 80 (2.5%) | 4.10 (2.70, 6.43) | |||
| AVP | 3,126 (97.5%) | Reference | |||
| Glasgow Coma Score 3 | <.001 | ||||
| 3–8 | 137 (4.3%) | Reference | |||
| 9–13 | 258 (8.0%) | 0.76 (0.49, 1.14) | |||
| 14–15 | 2,811 (87.7%) | 0.19 (0.13, 0.27) | |||
| Signs of substantial head injury 3 | <.001 | <.001 | |||
| No | 2,748 (85.7%) | Reference | Reference | ||
| Yes | 458 (14.3%) | 4.29 (3.58, 5.16) | 2.74 (2.20, 3.42) | ||
| Neck pain upon examination 3 | <.001 | <.001 | |||
| No | 2,513 (78.4%) | Reference | Reference | ||
| Yes | 693 (21.6%) | 9.77 (8.05, 11.94) | 2.74 (2.14, 3.52) | ||
| Inability to move the neck upon examination | <.001 | 0.028 | |||
| No | 2,954 (92.1%) | Reference | Reference | ||
| Yes | 252 (7.9%) | 7.47 (5.56, 10.23) | 1.48 (1.04, 2.14) | ||
| Substantial torso injury 3 | <.001 | <.001 | |||
| No | 3,032 (94.6%) | Reference | Reference | ||
| Yes | 174 (5.4%) | 4.26 (3.19, | 2.64 | ||
| 5.78) | (1.89, 3.72) | ||||
| Substantial thoracic injury | <.001 | ||||
| No | 3,153 (98.3%) | Reference | |||
| Yes | 53 (1.7%) | 4.45 (2.63, 7.92) | |||
| Rib fracture (including flail chest) | 0.005 | ||||
| No | 3,195 (99.7%) | Reference | |||
| Yes | 11 (0.3%) | 5.18 (1.62, 22.90) | |||
| Scapula fracture | 0.380 | ||||
| No | 3,204 (99.9%) | Reference | |||
| Yes | 2 (0.1%) | 2.82 (0.27, 60.60) | |||
| Substantial abdominal injury | <.001 | ||||
| No | 3,126 (97.5%) | Reference | |||
| Yes | 80 (2.5%) | 3.28 (2.22, 4.94) | |||
| Bruising to the abdomen | <.001 | ||||
| No | 3,158 (98.5%) | Reference | |||
| Yes | 48 (1.5%) | 2.73 (1.70, 4.50) | |||
| Seat belt sign | 0.007 | ||||
| No | 3,182 (99.3%) | Reference | |||
| Yes | 24 (0.7%) | 2.42 (1.27, 4.81) | |||
| Substantial pelvic injury | <.001 | ||||
| No | 3,169 (98.8%) | Reference | |||
| Yes | 37 (1.2%) | 3.75 (2.07, 7.19) | |||
| Pelvic bone tenderness | <.001 | ||||
| No | 3,177 (99.1%) | Reference | |||
| Yes | 29 (0.9%) | 4.57 (2.25, 10.26) | |||
| Thoracic spine tenderness | <.001 | ||||
| No | 3,170 (98.9%) | Reference | |||
| Yes | 36 (1.1%) | 17.08 (6.16, 70.85) | |||
| Lumbar spine tenderness | <.001 | ||||
| No | 3,174 (99.0%) | Reference | |||
| Yes | 32 (1.0%) | 9.09 (3.87, 26.63) | |||
| Focal Neurologic Deficits 1 | <.001 | <.001 | |||
| No | 2,962 (92.4%) | Reference | Reference | ||
| Yes | 244 (7.6%) | 5.31 (4.07, 7.01) | 1.86 (1.32, 2.65) | ||
Overall percentages are out of those with any SMR.
High risk MVC defined as MVC with any one of the following: intrusion, ejection, death, telemetry
Variables that are included in the PECARN C-SPINE prediction rule.
DISCUSSION
This is the first large prospective observational study analyzing pediatric prehospital SMR practices. In this study, 42% of children transported by EMS after sustaining blunt trauma were placed in SMR, with less than 2% ultimately having a CSI. The most common reasons EMS clinicians applied SMR were severe mechanism of injury, young age, and complaint of neck pain. These reasons only partially aligned with the results of a multivariable regression analysis looking for factors associated with SMR placement. Several factors were associated with SMR placement including patient demographics (>2 years old and non-Hispanic White race and ethnicity), mechanism of injury factors (high-risk MVC or unrestrained in MVC, fall from > 10 feet and axial load), clinical history (LOC, self-reported neck pain, paresthesia or numbness) and examination findings (altered mental status, signs of substantial head or torso injury, neck tenderness, inability to move neck and focal neurological deficits).
The rate of SMR application observed in this study is slightly higher than previous pediatric estimates of 23 – 28% (42, 45). Previous studies analyzing SMR practices involve small single-center cohorts (42, 45), are based on retrospective chart reviews (42–45), or surveys of clinicians regarding hypothetical situations (46). Our study captures a much larger population of injured children in a prospective study and likely provides a more accurate estimate for the prevalence of SMR application in the US.
Despite EMS clinicians frequently reporting young age as the reason for SMR placement, we found that children < 2 years old were less likely to be placed in SMR and more likely to have a towel as the sole means of SMR. This variability in SMR practices by age was not entirely attributable to differences in EMS clinician suspicion for CSI. This finding is consistent with previous studies that have shown younger children are less likely to be placed in SMR (42, 51). This variability by age may be due to a perceived lack of appropriate SMR options for young children (42), or more general discomfort for EMS clinicians in assessing and managing young children (51, 52).
While we are unaware of previous studies looking at racial or ethnic disparities in SMR application, our study adds to a growing body of literature showing disparities in EMS care based on patient race and ethnicity. We found that non-Hispanic white children had higher odds of being placed in SMR compared to non-Hispanic Black and Hispanic children. A recent scoping review identified 61 articles describing disparities based on patient race or ethnicity in all phases of EMS care, including symptom recognition, treatment, and transport (53). Our finding warrants further analysis to identify differences in patient presentation and EMS prehospital interventions based on race and ethnicity.
Most of the factors associated with SMR application in our study have been included in one or more previous clinical prediction rules (CDR) including the National Emergency X-ray Utilisation Study (NEXUS) criteria (4, 29), Canadian C-spine rule (31, 35), PEDSPINE (54), National Institute for Health and Care Excellence (NICE) guidelines (55), and previous PECARN studies (50, 56). A small number of variables were associated with SMR placement in this study and not included in any of these previous CDRs or guidelines, including patient demographic factors, history of loss of consciousness and signs of a substantial head injury. Of the variables included in the recently validated PECARN CSI prediction rule (38), altered mental status, focal neurological deficits, self-reported neck pain or neck tenderness on exam, and substantial head or torso injury were all associated with SMR placement. Abnormal airway, breathing or circulation findings were not associated with SMR placement (Supplemental File Table 3).
These findings have several important implications. First, given the established harms of SMR (including increased likelihood of undergoing radiographic evaluation for clearance (17–20), development of pressure sores (21–23), impaired ventilation (24–26), difficulties performing airway interventions (27), and elevated intracranial pressure (28)) SMR must be placed judiciously. Our study highlights the need for evidence-based clinical prediction rules validated in the EMS setting to guide the selective application of SMR in children sustaining blunt trauma. These prediction rules must be not only sensitive but also specific if they are to help reduce the proportion of children placed in SMR. Further research is needed to determine whether implementation of the PECARN CSI prediction rule reduces the proportion of children placed in SMR and also reduces unwarranted clinical variation between patient subgroups based on age and race/ethnicity. Many factors were associated with the placement of SMR that are not in the PECARN CSI prediction rule, while other factors in the prediction rule are not associated with SMR placement. This discrepancy must be addressed in education initiatives and future implementation trials.
LIMITATIONS
There are several limitations of this study. First, EMS case report forms were only completed for 57% of eligible patients. While this may bias our results, the enrolled and missed eligible cohorts had similar demographics and clinical outcomes. The rate of CSI was also similar for enrolled and missed eligible participants. Second, these findings are based on EMS clinician documentation. We cannot verify that the SMR documented in the study case forms was actually used (or correctly applied). Third, this study was conducted at Level I Pediatric Trauma Centers, primarily in urban environments. While this may limit generalizability, the EMS clinician observations were drawn from paramedics and emergency medical technicians from any agency transporting to these centers. We did not collect information about the EMS clinician or agency and are therefore unable to determine whether clinician or agency factors are associated with SMR placement. Finally, we did not collect data on the potential complications of SMR application (other than rates of neck imaging) and are therefore unable to comment on the prevalence of complications associated with different modalities of SMR.
CONCLUSIONS
In this large prospective observational study, 42% of children transported by EMS after sustaining blunt trauma were placed in SMR, while only 1.6% had a CSI. Several factors associated with use of SMR are not part of the new PECARN CSI clinical prediction rule and provide potential focus areas for future implementation of the rule in the prehospital setting. Further research is needed to determine whether implementing the PECARN CSI clinical prediction rule reduces the proportion of children placed in SMR and mitigates unwarranted clinical variation or potential inequities in SMR use by prehospital clinicians.
Supplementary Material
ACKNOWLEDGEMENTS:
We acknowledge the research staff and clinicians at our participating hospital emergency departments for their tireless efforts: Nationwide Children’s Hospital (Columbus, OH, USA), Boston Children’s Hospital (Boston, MA, USA), Children’s Health Care of Atlanta (Atlanta, GA, USA), Children’s Hospital Los Angeles (Los Angeles, CA, USA), Children’s Hospital of Philadelphia (Philadelphia, PA, USA), Children’s Hospital of Pittsburgh (Pittsburgh, PA, USA), Children’s Hospital of Wisconsin (Milwaukee, WI, USA), Children’s Medical Center of Dallas (Dallas, TX, USA), Children’s National Hospital (Washington, DC, USA), Cincinnati Children’s Hospital Medical Center (Cincinnati, OH, USA), Colorado Children’s Hospital (Aurora, CO, USA), CS Mott Children’s Hospital (Ann Arbor, MI, USA), Primary Children’s Hospital (Salt Lake City, UT, USA), St Louis Children’s Hospital (St Louis, MO, USA), Texas Children’s Hospital (Houston, TX, USA), UC Davis Medical Center (Sacramento, CA, USA), UCSF Benioff Children’s Hospital (San Francisco, CA, USA), and University of New Mexico Health Sciences Center (Albuquerque, NM, USA).
FUNDING SOURCES:
This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; 5R01HD091347 Development and Testing of a Pediatric Cervical Spine Injury Risk Assessment Tool). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by NICHD or the US Government. The study was also funded by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS), in the Maternal and Child Health Bureau, under the Emergency Medical Services for Children program through the following cooperative agreements: Data Coordinating Center at the University of Utah (Salt Lake City, UT, USA; UJ5MC30824), Great Lakes Emergency Medical Services for Children Research Node (GLEMSCRN) at Nationwide Children’s Hospital (Columbus, OH USA; U03MC28844), Hospitals of the Midwest Emergency Research Node (HOMERUN) at Cincinnati Children’s Hospital Medical Center (Cincinnati, OH, USA; U03MC22684), Pediatric Emergency Medicine Northeast, West and South (PEMNEWS) at Columbia University Medical Center (New York, NY, USA; U03MC00007), Pediatric Research in Injuries and Medical Emergencies (PRIME) at University of California at Davis Medical Center (Sacramento, CA, USA; U03MC00001), Charlotte, Houston, Milwaukee Prehospital EMS Research Node (CHaMP) node at the State University of New York at Buffalo (Buffalo, NY, USA; U03MC33154), West/ Southwest Pediatric Emergency Medicine Research (WPEMR) at Seattle Children’s Hospital (Seattle, WA, USA; U03MC33156), and San Francisco-Oakland, Providence, Atlanta Research Collaborative (SPARC) at Rhode Island Hospital and Hasbro Children’s Hospital (Providence, RI, USA; U03MC33155). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.
Footnotes
DECLARATION OF INTEREST STATEMENT: The authors report there are no competing interests to declare.
DECLARATION OF GENERATIVE AI IN SCIENTIFIC WRITING: The authors did not use a generative artificial intelligence (AI) tool or service to assist with preparation or editing of this work. The authors take full responsibility for the content of this publication.
DATA SHARING STATEMENT:
De-identified individual data that support the results will be shared from 9 months to 36 months after publication provided the investigator who proposes to use the data has approval from an Institutional Review Board and executes a data use or sharing agreement with the PECARN data coordinating center. Data can be accessed by contacting the data coordinating center director (https://pecarn.org/datasets/).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
De-identified individual data that support the results will be shared from 9 months to 36 months after publication provided the investigator who proposes to use the data has approval from an Institutional Review Board and executes a data use or sharing agreement with the PECARN data coordinating center. Data can be accessed by contacting the data coordinating center director (https://pecarn.org/datasets/).