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Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024.
Date: Oct 15, 2024
Dr. Tabitha Cheng
Guest Skeptic: Dr. Tabitha Cheng is a Southern California native and board-certified emergency medicine physician and completed an EMS fellowship as well. The learning didn’t end because she then completed another fellowship in pediatric emergency medicine at Harbor UCLA.
Case: An 8-year-old girl is brought in by EMS after a car accident. She was seat belted, sitting in the backseat of the family’s car when they were hit from the side by another vehicle that ran a red light. The airbags deployed, and the car spun a few times. When EMS arrived on the scene, they found both parents unconscious and the girl appeared slightly dazed and confused.
EMS places her in a cervical collar and brings her to the emergency department (ED). On your examination, you see she is scared but answering questions appropriately. She does have some abrasions from her seatbelt and complains of pain around her ankle. The rest of her exam is unremarkable.
After your evaluation, you are informed that her grandmother has arrived to be with the girl as her other family members are being treated. She looks at the contraption on the girl’s neck and asks you, “Is she okay? Is something wrong with her neck? Does she need an X-ray or CT scan?”
Background: Pediatric cervical spine (c-spine) injuries are uncommon (1-3% of blunt trauma). These injuries typically result from blunt trauma caused by motor vehicle accidents, falls, sports injuries, or physical abuse. Although C-spine injuries represent a small fraction of pediatric trauma cases, their potential severity makes accurate and timely diagnosis critical.
Younger kids tend to have big lollipop heads which makes them more prone to injury in the upper cervical spine compared to adults (their fulcrum is higher).
It is also sometimes difficult to get a scared child to give an accurate history or cooperate with an exam. Many of us use CT or X-rays to help detect cervical spine injuries in this population.
Clinicians working in EDs must strike a balance between ensuring they do not miss these rare but serious injuries and avoiding unnecessary imaging, particularly computed tomography (CT), which exposes children to ionizing radiation. Given the sensitivity of developing tissues to radiation, especially in younger children, avoiding unnecessary imaging is a high priority in pediatric care.
Traditional diagnostic approaches often lead to the overuse of imaging tools, like CT scans and X-rays, even in low-risk children. This has prompted a movement toward more refined, evidence-based methods for identifying pediatric C-spine injuries, particularly through the development of clinical decision rules (CDRs). CDRs are designed to assist clinicians in making more accurate decisions about when imaging is truly necessary by identifying key clinical predictors of serious injuries.
The Pediatric Emergency Care Applied Research Network (PECARN) has been instrumental in developing one of the most widely recognized CDRs for pediatric C-spine injuries. Based on large, multicenter studies, this tool identifies critical risk factors that signal the need for imaging, such as altered mental status, focal neurological deficits, and certain mechanisms of injury. The PECARN rule, validated in clinical settings, has demonstrated high sensitivity in detecting C-spine injuries, while also reducing unnecessary imaging.
There are multiple CDRs for identifying pediatric c-spine injuries besides PECARN. The SGEM recently covered the Cochrane systematic review on pediatric CDRs on SGEM #441.
Clinical Question: Can the new PECARN clinical prediction rule (tool) guide imaging decisions in detecting pediatric cervical spine injuries without missing significant cervical spine injuries (CSI)?
Dr. Julie Leonard
Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024.
- Population: Children aged 0–17 years with known or suspected blunt trauma presenting to the ED across 18 US hospitals.
- Exclusions: Patient with penetrating trauma.
- Intervention: Derivation and validation of the PECARN CDR prediction rule to guide imaging decisions for pediatric c-spine injuries
- Comparison: None
- Outcome:
- Primary Outcome: Identification of cervical spine injuries within 28 days that warranted inpatient observation or surgical intervention.
- Secondary Outcomes: Reduction in unnecessary imaging, particularly CT and X-ray use.
- Type of Study: Prospective observational cohort study
Guest Authors
Dr. Caleb Ward
Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and Emergency Medicine at Children’s National Hospital and The George Washington School of Medicine and Health Sciences in Washington, DC. He is the principal investigator for EMSC State Partnership in Washington, DC and is also involved in various multi-center EMS studies with the Pediatric Emergency Care Applied Research Network (PECARN).
Dr. Julie Leonard is a pediatric emergency medicine attending and Associate Division Chief for Research at Nationwide Children’s Hospital. She’s also a Professor of Pediatrics at the Ohio State University College of Medicine. Dr. Leonard serves as the Principal I investigator of the Great Lakes Atlantic Emergency Medical Services for Children Research Node of PECARN.
Authors’ Conclusions: “Incorporated into a clinical algorithm ,the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the ED and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community EDs.”
Quality Checklist for Clinical Decision Tools:
-
The study population included or focused on those in the ED. Yes - The patients were representative of those with the problem. Yes
- All important predictor variables and outcomes were explicitly specified. Yes
- This is a prospective, multicenter study including a broad spectrum of patients and clinicians (level II). Yes
- Clinicians interpret individual predictor variables and score the clinical decision rule reliably and accurately. Unsure.
- This is an impact analysis of a previously validated CDR (level I). No
- The follow-up was sufficiently long and complete. Unsure
- The effect was large enough and precise enough to be clinically significant. Yes
- Any financial conflicts of interest? None.
Results: The cohort consisted of 22,430 children. To put this into perspective, the Cochrane review that we critically appraised included 5 studies and only had 21,379 children. There were 11,857 included in the derivation cohort and 10,573 included in the validation cohort. Around 2% had confirmed cervical spine injuries.
Key Result: They created a 3-tiered risk stratification system with associated imaging recommendations.
- High Risk Children (>12% risk of injury), consider CT scan
- Abnormal airway, breathing, circulation
- Focal neurologic deficits
- Intermediate Risk (~3% risk of injury), consider X-ray
- GCS 9-14, V or P on AVPU, other altered mental status
- neck pain or midline tenderness
- substantial head or torso injury
- No Risk (0.2% risk of injury), consider clinical clearance.
The new prediction rule had a 94.3% sensitivity, 60.4% specificity, 99.9% negative predictive value, and 0.09 negative likelihood ratio.
Tune in to the podcast to hear the authors answer our questions.
Follow Up
Some of the children in this study did not undergo any imaging. You report that in these cases, the guardians were contacted by phone to see whether they had a C-spine injury. This could lead to verification bias where not all patients received the gold standard imaging, potentially affecting specificity.
What proportion of children did not have imaging? Out of the ones you had to contact for phone follow-up, what percent were lost to follow-up? How do you think this may impact your results?
Who Completes the Clinical Decision Rule
This study was performed at academic centers with a mix of pediatric emergency medicine, trauma surgery, and prehospital teams. You report that you looked back at the children with c-spine injuries that were missed by the prediction rule and noted that there was a risk factor recorded in the medical record or case report form which would have improved the test characteristics of the rule.
Could you comment on the interrater reliability of people completing the clinical decision rule? Ideally, who do you think should be the one completing it (EMS, EM, surgery, or a mix)?
Moderate Risk Patients
In the moderate risk criteria, the CDR recommends an X-ray.
What kind of X-ray should be gotten? Lateral neck, 2 view, 3 view, any of the above with flexion and extension?
Assuming that the X-ray ends up being normal, but the child is having persistent neck pain, what would you do?
Prehospital Application
This CDR was designed for implementation in the ED.
Do you think there’s a potential application of risk stratification for the prehospital environment?
Child Abuse
The study included 1,327 (5.9%) children with the mechanism of injury as “suspected child abuse.” You performed a separate analysis after these patients were removed that showed similar test characteristics.
Can you comment on the application of this CDR specifically in this vulnerable population?
Bonus Question: Implementation
The study found that had the prediction rule been in place, the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%).
A limitation of this study was that it was conducted at academic children’s hospitals.
Do you think you would see the same impact when implemented more generally?
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.
SGEM Bottom Line: The new PECARN cervical spine prediction tool helps risk stratify children with C-spine injury and guide imaging.
Case Resolution: After you assess the child, you do not note anything remarkable in her primary survey. Her secondary survey is only notable for a small abrasion on her forehead and shoulder. You ask someone to hold her head still as you prepare to examine her neck. You tell her very clearly, “I am going to ask you if you are having any pain around the area that I am touching. Do not nod or shake your head. Just answer yes and no.” After noting that she does not have any tenderness to palpation of her neck and testing the range of motion of her neck, you clinically clear her C-collar and avoid additional imaging.
Clinically Application: The new PECARN CDR for cervical spine trauma in children can help guide imaging decisions. Remember, we refer to these as clinical decision “tools” rather than rules. Considering all three pillars of evidence-based medicine, the scientific literature, clinical judgement, and patient/family values and preferences.
What Do I Tell the Patient’s Grandmother?
I understand that you are worried about your granddaughter. We examined her closely. She is acting appropriately and answering questions. She is not having any pain when she moves her neck or when we touch her neck. We try to balance the possible harms and benefits when thinking about whether we need to do X-rays or CT scans on children because we want to minimize radiation exposure. Based on her reassuring exam, I have low suspicion that she has a serious injury to her neck.
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.
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