背景:儿童颈椎损伤并不常见,但具有潜在的破坏性;创伤后不分青红皂白的颈部成像使儿童不必要地暴露于电离辐射。这项研究的目的是得出并验证儿科临床预测规则,该规则可以纳入算法中,以指导急诊科儿童对颈椎损伤的影像学筛查。
方法:在这项前瞻性观察队列研究中,我们在美国儿科急诊应用研究网络(PECARN)附属医院的18个专门儿童急诊科筛查了0-17岁已知或疑似钝性创伤的儿童.通过满足以下标准之一,受伤儿童有资格参加推导或验证队列:由急诊医疗服务从受伤现场转移到急诊科;由创伤小组评估;并在到达PECARN附属急诊科之前或之前进行颈部成像,以关注颈椎损伤。排除了仅出现穿透性创伤的儿童。在查看登记的儿童颈部成像结果之前,主治急诊科临床医生完成了临床检查,并在电子问卷中前瞻性记录了颈椎损伤的危险因素.在急诊室就诊后21-28天内,通过影像学报告和监护人的电话随访确定颈椎损伤,儿童神经外科医生证实了颈椎损伤。通过具有稳健误差估计的双变量Poisson回归确定与颈椎损伤高风险(>10%)相关的因素。通过分类和回归树(CART)分析确定与不可忽略风险相关的因素.在颈椎损伤预测规则中组合变量。感兴趣的主要结果是初始创伤后28天内的颈椎损伤,需要住院观察或手术干预。为推导和验证队列计算规则绩效度量。在研究人群中应用了一种临床护理算法,用于确定哪些危险因素需要对钝性外伤后的颈椎损伤进行影像学检查,以评估对减少儿科急诊科CT和X射线使用的潜在影响。这项研究在ClinicalTrials.gov注册,NCT05049330。
结果:九个急诊科参加了派生队列,9人参加了验证队列.总的来说,22430名出现已知或疑似钝性创伤的儿童被纳入(派生队列中的11857名儿童;验证队列中的10573名儿童)。占总人口的433(1·9%)已确认颈椎损伤。以下因素与颈椎损伤的高风险相关:精神状态改变(格拉斯哥昏迷量表[GCS]评分3-8分或警报上反应迟钝,言语,疼痛,意识无反应量表[AVPU]);异常气道,呼吸,或循环发现;和局灶性神经功能缺损,包括感觉异常,麻木,或弱点。在出现至少一种风险因素的衍生队列中,928人中,118人(12·7%)患有颈椎损伤(风险比8·9[95%CI7·1-11·2])。通过CART分析,以下因素与不可忽视的颈椎损伤风险相关:颈部疼痛;精神状态改变(GCS评分为9-14;AVPU的言语或疼痛;或其他精神状态改变的迹象);严重的头部受伤;严重的躯干受伤;和中线颈部压痛。高风险和CART衍生因素组合并应用于验证队列,敏感性为94·3%(95%CI90·7-97·9),60·4%(59·4-61·3)特异性,和99·9%(99·8-100·0)的阴性预测值。如果将该算法应用于所有参与者以指导成像的使用,我们估计,在不增加接受X线平片检查的儿童数量的情况下,在22430名儿童中,接受CT检查的儿童数量可能从3856名(17·2%)减少到1549名(6·9%).
结论:纳入临床算法,颈椎损伤预测规则显示出很强的潜力,可以帮助临床医生确定哪些钝性外伤后到达急诊科的儿童应该接受X线颈部成像检查以发现潜在的颈椎损伤。临床算法的实施可以减少急诊科不必要的射线照相测试的使用,并消除高风险的辐射暴露。未来的工作应该在更一般的环境中验证预测规则和护理算法,例如社区急诊科。
背景:EuniceKennedyShriver国家儿童健康与人类发展研究所以及美国妇幼保健局卫生与人类服务部卫生资源与服务管理局在紧急医疗服务儿童计划下。
BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this
study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department.
METHODS: In this prospective observational cohort
study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children\'s emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child\'s neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the
study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This
study is registered with ClinicalTrials.gov, NCT05049330.
RESULTS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays.
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 emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments.
BACKGROUND: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.