Developing a spinal
clearance guideline for
Paediatric Intensive Care
Dr Ruth Ford
ST7 Anaesthetics Trainee
RBHSC
The problem of spinal injury
in paediatrics
Trauma is leading cause of mortality over 1 year of age
Paediatric spinal inju...
SCIWORA

“An acute spinal cord injury that results in sensory and/or
motor deficits without radiographic evidence of verte...
Prolonged immobilisation

Risk of pressure ulceration from cervical collar

Liew and Hill, 1994

Increased if circulation ...
Our concerns

Lack of current evidence
Consensus only on immediate management
CT head and C-spine within 1 hour of all chi...
Multidisciplinary

Approached different specialties involved
General surgery, Neurosurgery, Orthopaedic surgery
Paediatric...
The role for MRI

Specificity of CT for bony injury of spine approaches 100%
Role of MRI increasing to identify soft tissu...
Our protocol

Patients under age of 14 sedated and ventilated in PICU
following severe head injury, where clinical examina...
Our protocol
Clinical
Assessment of clinical suspicion for spinal injury
Mechanism of injury – RTA, falls, sports injury, ...
Limitations

Patients not suitable for MRI
Clinical instability - remote
MRI incompatibility

Resources
MRI-trained consul...
Where do we stand?

Policy submitted for Service Group Review (Paediatric
Governance meeting)
Current practice is reflecti...
References
Anderson R et al. Utility of a cervical spine clearance protocol after trauma in children between 0-3 years of ...
Upcoming SlideShare
Loading in …5
×

Deveoping a Spinal Clearance Guideline for picu

450 views

Published on

2013 Northern Ireland Intensive Care Society Coppel Prize presentation by Dr Ruth Ford

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Deveoping a Spinal Clearance Guideline for picu

  1. 1. Developing a spinal clearance guideline for Paediatric Intensive Care Dr Ruth Ford ST7 Anaesthetics Trainee RBHSC
  2. 2. The problem of spinal injury in paediatrics 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 Missed injury Prolonged immobilisation Hutchings and Willett, 2009
  3. 3. SCIWORA “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
  4. 4. Prolonged immobilisation 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 hrs Powers et al, 2006
  5. 5. Our concerns Lack of current evidence Consensus only on immediate management CT head and C-spine within 1 hour of all children with severe head injury NICE, 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
  6. 6. Multidisciplinary 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
  7. 7. The role for MRI Specificity of CT for bony injury of spine approaches 100% Role of MRI increasing to identify soft tissue injury Anderson 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
  8. 8. Our protocol 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.
  9. 9. 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
  10. 10. Limitations Patients not suitable for MRI Clinical instability - remote MRI incompatibility Resources MRI-trained consultant anaesthetist, technician, two paediatric nurses Transport MRI availability
  11. 11. Where do we stand? 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
  12. 12. References 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: 257264 Liew SC and Hill DA. Complication of hard cervical collars in multi-trauma patients. Aust N Z J Surg 1994; 64(2): 139-140 Meduri GU and Estes RJ. The pathogenesis of ventilator-associated pneumonia. Intensive Care Medicine 1995; 21(5): 452-61 National Confidential Enquiry into Patient Outcome and Death, 2007. Trauma: Who Cares? London: National Confidential Enquiry into Patient Outcome and Death National 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 Excellence Pang D and Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982; 57: 114-129 Powers J et al. The incidence of skin breakdown associated with cervical collars. J Trauma Nurs 2006; 13(4): 198-200

×