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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Jun 28, 2015

When we want to clinically clear the adult cervical spine, what do we do? We whip out a handy dandy decision instrument. Canadian C-spine? Yes! NEXUS? Boom, you betcha! But when it comes to kids, there's just nothing out there that even resembles a prospectively validated clearance tool. We're left with are gestalt, experience, and hoping for the best. A recent article (retrospective review) from the Journal of Trauma and Acute Care Surgery found that "...missing a cervical spine injury in asymptomatic preelementary patients is extremely low." The authors suggests that high risk findings for pediatric C-spine injury include:

  • Abnormal neurological exam
  • Decreased mental status
  • Neck Pain
  • Torticollis

But. There's a big but. The authors go on to say, "...however if the child is asymptomatic defined by a normal neurologic examination result, appropriate mental status, with absence of neck pain or torticollis, our first step is to remove the cervical collar. We examine the patient for cervical tenderness if they are able to communicate and observe the child for normal range of motion of the neck. In preverbal patients, we simply observe neck range of motion with the collar removed. If the child seems to move his or her neck without discomfort and full range of motion, then we do not pursue any further radiologic evaluation."

Andy Sloas from the PEM ED podcast joins the show to give his take on this article and the nebulous, contentious, and controversial topic of the pediatric cervical spine...

References:

Emergency Medicine Literature of Note review of the article Hale, Diane F., et al. "Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger." Journal of trauma and acute care surgery 78.5 (2015): 943-948.

PEM ED review of pediatric C-spine clearance