PECARN Prediction Rule for Pediatric Cervical Spine Injuries – PediaCast 564
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Show Notes
Description
- Drs Julie and Jeffrey Leonard visit the studio as we consider kids and teens with traumatic neck injuries. Do they all need X-rays? Or could we develop criteria that determine who needs films and who doesn’t? This would save some young patients from radiation exposure while ensuring bony neck injuries are not missed. We hope you can join us!
Topics
- PECARN Prediction Rule
- Cervical Spine (Neck) Injuries
Guests
Links
- Pediatric Emergency Medicine at Nationwide Children’s Hospital
- Pediatric Neurosurgery at Nationwide Children’s Hospital
- PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study
Episode Transcript
Dr Mike Patrick: This episode of PediaCast is brought to you by Pediatric Emergency Medicine and Pediatric Neurosurgery at Nationwide Children's Hospital.
Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 564. We're calling this one PECARN prediction rule for pediatric cervical spine injuries.
We want to welcome all of you to the program. I know that was a lot of words that some of you may or may not be familiar with, but we're going to break everything down as we usually do on this podcast. Uh, first, you know, it is a familiar scene, a child or teenagers injured. Um, EMS arrives, and they place a rigid neck collar to protect the bones in the neck.
So, you know what I'm talking about. It's the, the cervical collar that goes around the neck to protect it, so you don't move your neck in case there is an injury. And if you've ever taken a first aid class, you know, we try to keep the neck still when someone has a traumatic injury that potentially involves the head or cervical spine and cervical spine is just a fancy way of saying the bones in the neck.
So, our patient is rushed to the hospital and before their cervical collar is removed and their neck examined, they are likely to get x rays of their neck or their cervical spine, just in case there is a problem. But do all children with a traumatic injury and a cervical collar placed in the prehospital setting, do all of them really need x rays of their neck?
Now as you know, x rays result in radiation exposure, CAT scans do as well. And they also prolong the period of time the child wears the collar, which can be uncomfortable and a pretty scary for kids. So perhaps we could use some criteria to determine which kids would benefit from x rays and CT scans.
Thank you. And which kids would not, you know, doing so would save time and money and anxiety and radiation exposure. Now these would have to be really good and well-studied criteria because we would be using them to determine if an x ray is needed. You know, we want our criteria to have. High sensitivity and high specificity, meaning that they do a good job of predicting who is at risk and needs the x rays and those who do not, because, you know, we want to minimize the number of kids who are exposed to radiation while hopefully not missing any child who actually does have a bone injury in the neck.
So, this is important work, and it has been a long journey of developing and verifying the criteria that would be used to determine if cervical spine x rays are necessary when a child has a traumatic injury to the head or neck. So today we have two authors of a study recently published in the Lancet Medical Journal of Child and Adolescent Health.
The article is called PECARN Prediction Rule for Cervical Spine Imaging of Children. Presenting to the emergency department with blunt trauma, a multi-center prospective observational study. So again, that's a lot of words, but in our usual PediaCast fashion, we're going to break down their meaning shortly as two authors of the paper, both from Nationwide Children's Hospital join us in just a few minutes.
They are Dr. Julie Leonard with pediatric emergency medicine and Dr. Jeffrey Leonard with pediatric neurosurgery. We'll meet them shortly. First, I do want to remind you the information presented in PDA Cast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
If you're concerned about your child's health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at PediaCast. org. So let's take a quick break. We'll get Dr. Julie and Jeffrey Leonard connected to the studio, and then we will be back to talk about the PECARN prediction rule for pediatric cervical spine injuries.
It's coming up right after this.
Dr. Julie Leonard is a pediatric emergency medicine physician at Nationwide Children's Hospital and a professor of pediatrics at the Ohio State University College of Medicine. Dr. Jeffrey Leonard is chief of pediatric neurosurgery at Nationwide Children's. And a professor of neurosurgery at Ohio state.
This wife and husband team has a passion for supporting children and families impacted by traumatic neck injuries. And they coauthored an article recently published in the Lancet medical journal of child and adolescent health called PECARN prediction role for cervical spine imaging of children presenting to the emergency department.
with blunt trauma, a multicenter prospective observational study. Again, we will break down the meaning and usefulness of their work in a moment, but first let's offer a warm PDA cast. Welcome to Drs. Julie and Jeffrey Leonard. Thank you both so much for visiting us today.
Dr Julie Leonard: Thanks for having us, Mike. We're excited to be here.
Dr Jeff Leonard: Thank you very much for the opportunity to come and talk with you about cervical spine injury and blood trauma.
Dr Mike Patrick: Yes, and we are very excited to talk about this as well. Let's start with just an introduction of PECARN and the PECARN prediction rule that you guys have been working on. What is PECARN and then how does this rule aid in the assessment of kids with neck injuries?
Uh, Julie?
Dr Julie Leonard: Yeah, Mike. PECARN stands for the Pediatric Emergency Care Applied Research Network, and it's a network of 18 children's hospitals around the United States that have banded together to conduct research that benefits children that are cared for in emergency departments around the United States.
And for this particular endeavor, we got together, and our goal was to develop a decision rule that could aid emergency physicians in deciding which children should undergo screening for cervical spine injuries after blunt trauma.
Dr Mike Patrick: And then Jeff, what kind of injuries are we talking about when we think about blunt trauma and why are those particularly concerning for children?
Dr Jeff Leonard: It's important because when you talk about blunt trauma, that can be a wide range of injuries. These injuries can be related to children after they undergo a motor vehicle crash, or babies after they fall out of, out of a bed. And being able to screen those children in a way that's medically appropriate, that really uncovers the ones that have the really severe injuries.
The ones that say have ones that are injuries that are life threatening versus those that will heal whether they're in a collar or not are particularly important in the pediatric population. So being able to really identify these is why this prediction role is exceedingly important.
Dr Mike Patrick: Yeah. And how common then are cervical spine or neck injuries in children evaluated at trauma centers?
Dr Jeff Leonard: They're, they're not that common, which is, which is why this prediction rule is important. There's a ton of children undergoing imaging at trauma centers. However, the pediatric cervical spine injury, when you take blunt trauma for some of the kinds of things that we see in the major metropolitan areas, they're 1%.
So, you can image a hundred kids and you'll find cervical spine in one of them. You go to the average folks, the average ER or emergency room or private practice neurosurgeon group that sees a child, the chance is even less in that respect. So, it's like, it's like hunting for a needle in a haystack and being able to do that rather than imaging all the children in, in sort of a haphazard fashion is exceedingly important, which is why Julie has really done a yeoman's work in.
Really developing this prediction role. Yeah.
Dr Mike Patrick: And, uh, this kind of follows on the heels of another PECARN rule that relates to head injuries that we have talked about in this program before. And so in a similar way, you know, kids, when they get bonked in the head, which happens very often in childhood, you know, it used to be that if they had any concerning symptoms at all, and that could include medium sized headache, that they would just get a CAT scan to make sure that they didn't have a skull fracture or a brain bleed.
Yeah. But just like this, we determine, you know, discovered that most of those are negative when we do those cat scans. So, if there's a rule of specific symptoms that makes it more likely that the cat scan will be positive, then maybe we only do the CT scan for those set of kids. And that has worked out really well and saved a lot of money and a lot of radiation exposure for children.
And so, then this study, I was really looking at a similar set of rules for cervical spine injuries so that we're not just x-raying every kid's neck that comes in just because that's part of our usual evaluation, unless they have specific symptoms or mechanisms present. Is that a good summing up, Julie?
Absolutely.
Dr Julie Leonard: Absolutely. So, one of the nice legacies of PECARN is that we, this was one of our main research questions was developing these set of just like clinical prediction rules to help us limit the radiation exposure in children through obtaining CT scans by using our good clinical judgment aided by these decision rules.
Importantly, though, we want to make sure not to miss injuries. So, one of the key characteristics of these decision rules is that they are very, very sensitive to picking up those children that are high risk for having an injury.
Dr Mike Patrick: So, you're going to have fewer kids who get, get the x rays that didn't necessarily need them, but hopefully you're not going to get so tight in predicting who's going to get the x rays.
That you miss people who really do have the injuries. So how do you design a study to, to determine what the rules ought to be in order to meet that goal?
Dr Julie Leonard: Yeah, absolutely. So, the way that we go about developing the decision rules are to conduct these very large prospective observational studies and what a prospective observational study is.
It's a study where we just make very, very careful observations of the patient's history, physical exam, and outcomes. And we gather that information directly from the clinicians that are caring for the patient so that we don't, you know, miss or skip any important findings. And when I say large, I'm talking large.
So, important to these studies is that we have enough children with injuries that we can produce a very robust clinical prediction rule. So, in this study, we observed greater than 22, 000 children at 18 medical centers. Took us about two and a half to three years at each center to observe that many children.
So, in terms of how we actually build a, a clinical prediction rule, so basically, we took this rule building exercise sort of in two parts. First, we knew that there were some children that by how they injured themselves and how they presented to us. They would be at really significant risk of cervical spine injuries.
So as opposed to being at risk one out of a hundred children, these children would be injured at a rate of about one out of every ten children. So, we first wanted to identify that very high-risk group of patients because honestly those are the kids where the risk of radiation induced cancer is, it's, it's sort of offset by the risk of missing that injury.
So, we define that first set of criteria based on sort of that risk threshold. So those are children that they basically come into the emergency department and they're not responding to us. So, they're completely unresponsive to, to pain. And they have often abnormal breathing pattern, or blood pressure, or heart rate, or they have very specific neurological findings on their examination that suggest that they've had a spinal cord injury.
So that's a group, again, that we would recommend that they go straight to CT scan to be evaluated for prognosis. Particular for a cervical spine injury. And then we have the second set where, you know, there is somewhat greater increased risk for cervical spine injury. So as opposed to one out of a hundred of the children having cervical spine injury, it is three out of a hundred children will have cervical spine injury.
So that, that next category, we conduct a particular type of exercise by which you Sort of find the set of variables that is most precise at identifying that second tier of Children. And so those are Children. Whereas they We wouldn't necessarily think that we have to screen them all with CT scan, we would recommend that they at least have plain x rays for screening.
And those findings are having any kind of altered mental status, so, you know, sort of where they're maybe confused and not responding as well, so some sort of hint that they've had a blow to their head, a very substantial blow to their head. Any self-reported neck complaints in a child or when we examine their neck, they have neck tenderness along the spine and in the back of their neck, or if they have any kind of surgical injury or substantial injury to their head or torso, so torso meaning any part of their body between their sort of shoulders and their pelvis, And the reason those two regions of the body are important is that the areas of the body right next to the spine, and so if you have enough blunt force that you're injuring those areas of the body, there's higher likelihood that you could also be injured.
Injuring that part of your spine as well. The cervical spine. Yeah.
Dr Mike Patrick: It would seem that this, that thinking about these rules are not only important for determining whether we're going to get x rays or a CT scan, but maybe even in the field for the EMS folks to determine whether to put the kid in a cervical collar.
And the reason I say that is it seems that when a kid arrives in a collar, whether they needed that or not, our attention goes right to, oh, they must have a significant neck injury and I need to image it. So, I think like if the EMS people were on board with who they put in a collar, that might help down downstream.
Dr Julie Leonard: Absolutely. Prior sort of decision making. You know, by E. M. S. Personnel and even by families had really been based on mechanism of injury. So, you know, was it a car crash? Was it a motorcycle crash? You know, did a child fall out of a window and that you know, those were indicators by which we would say, oh, you have to go to the emergency department and get evaluated.
And then, of course, Once they're in the emergency department, there's this sort of compulsion almost to do a lot of things to care for that child. This decision rule also will be helpful in like indicating, okay, you know, which children really need a medical evaluation after they've had one of these major mechanisms.
So, it really helps us out in that way too, where, where maybe we can avoid some of that spinal motion restriction and transport to the hospital. Yeah.
Dr Mike Patrick: So then, uh, once you have that set of rules, how effective have those been in, did you, were there, so there was initial study to figure out You know, which ones were important, and then did you test those rules on maybe a larger population of kids to be sure that they were the right rules?
Dr Julie Leonard: Yeah. Continuing on, like thinking about how we design decision rules, it's important for us to have what we call a derivation population. So, we develop the decision rule in a population of, of patients. And then we turn around and we validate or verify that it works in a separate population of children.
So, in this study, we, we had those 22, 000 children, but we split them into two groups of unique hospitals. So, they were very, very different. Distinct hospitals from each other so that we could demonstrate that the rule we built, then when we put it in other hospitals that actually worked, it was the, you know, performed the same way.
And in fact, in our study, it performed better in the validation group.
Dr Mike Patrick: Yeah, that is, that's really fantastic. And then once a study like this is published, then how do you get emergency medicine folks, both in the field and in emergency departments? To begin acting on this rule.
Dr Julie Leonard: Yeah, so it's a great question.
So, we developed this Rule, but we have to turn it into some sort of decision aid and so often you have the type of decision aid in mind before you start building the rule. So, in our circumstance, you know, our primary goal for this study is to decrease emergency department imaging. So, in our mind, we wanted to create this tiered decision rule because we wanted it to align with risk thresholds for getting imaging and, uh, sort of the cost benefit of imaging or not in those categories. But also important to the decision rule and how you'll ultimately implement it is this concept of risk tolerance. So, in this particular disease process, nobody wants to miss one of these injuries, so we want it to be near perfect in picking up injuries, and we'll compromise a little bit of extra imaging in order not to miss that injury. And so, you know, then we take the rule, and then we create like an algorithm that is very easy for clinicians to remember, and then Ultimately use in their practice.
So, sort of a practice guideline when it's all said and done.
Dr Mike Patrick: Yeah. And again, just to, to clarify what those rules are, it really has to do with mental status changes. And the worse that those are, the more likely you should just do a CT scan. And if they're just mild mental status changes, then at least think about the x rays.
And then if they have pain in the back of their neck in the midline as you're pushing on the bones, then that would be an indication as well. Those are the two big ones, correct?
Dr Julie Leonard: Correct. I mean, I think that, you know, the, the neurologic findings and then the next symptoms.
Dr Jeff Leonard: Well, I would just like to offer, uh, that the, the fact that mental status was part of the pediatric cervical spine prediction rule is not a surprise.
In general, increased mechanisms cause severe injury in a lot of parts of the body. In specifically, in what's been previously done in head injury has been, as you decrease
Metal status decreases, your incidence of having cervical spine injury does go up with each point of your Glasgow coma scale that, that, that you lose in that respect. So, it sort of makes sense when looking at the pediatric cervical spine injury that metal status is one of the, one of the big predictors of cervical spine injury.
Dr Julie Leonard: The other categories of injuries, which really are those sort of substantial injuries that we're talking about, those are really related to biomechanical forces and having sort of the force that's enough to injure your cervical spine. And then sometimes it's hard for children lower in their necks to distinguish that low neck pain from back pain.
And, and so there's, you know, so those are Important not to overlook, but the most important are the mental status changes, the neurologic changes on your exam. And then as you pointed out, the neck complaints of neck pain and neck tenderness. If
Dr Mike Patrick: there's a high mechanism of, of energy that we're worried there could be a neck injury.
A lot of those kids do come in as traumas and then there are each institution may have their own protocols for what they do in a trauma. Because again, there's higher risk and they may have a distracting injury and not be able to say that their neck hurts because their belly hurts so much, or you know what I mean?
Something of that nature,
Dr Julie Leonard: correct? But we wanted to be very clear about the painful, distracting injury because the better proxy is actually these central injuries. So just because a child has a really painful arm injury does not make it more likely that they will have a neck injury. So that's one of the chief differences in our clinical prediction rule as compared to the adult clinical prediction rules,
Dr Mike Patrick: so, it really is central blunt trauma, not just a distracting injury in any location.
Correct. Good to know. And then what about the kids who may be at a higher risk for neck injuries? So, kids with down syndrome, for example, or with those, you wouldn't necessarily use the rules for those Children, right? Because they don't fit your population that you studied.
Dr Julie Leonard: Yeah, actually, they were included in our study, so we included all comers.
We did not, we did not restrict this in any way by mechanism or by having a predisposing condition. I think what's important to know about those children with predisposing conditions is that Is that you just absolutely cannot overlook their risk for injury after minor blunt trauma. So, the take home message is that after they've had blunt trauma, they should have a medical examination.
And, and those kids were still picked up by this particular clinical prediction rule. We didn't miss any of them, but those parents are likely parents that knew their child had an elevated risk and got them to medical attention to for a physical exam. Yeah,
Dr Mike Patrick: absolutely. And the going back to the reason that we're doing this in the first place, if, if neck imaging was completely benign and it didn't cost anything, like you would just, you know, get a picture of every kid's neck and not miss anyone.
But we do know that radiation exposure can cause problems down the road. And we want to mitigate that risk when it's safe to do so. So, Jeff, could you talk a little bit about, uh, radiation exposure and how that is related to cancers?
Dr Jeff Leonard: Parallels can also be drawn in the head CT, in the head CT and shunt population.
The more the incidence of cancer in kids is up, and so all the decisions that we make when they're three, four, five, you know, young children are, are important because there's acute, there's a risk with every single exposure radiation, whether it be to the thyroid in terms of the brain. So, the reason this is important is because there's a lot of outside hospitals that are getting CT scans of all these children that come in with blood trauma, regardless of mechanism, regardless of what the child looks like.
And being able to begin to push that, that rate down is going to be exceedingly important because these children do have an increased risk for thyroid cancer, do have an increased risk for brain cancer. And there are implications that we only are beginning to understand when they get to be 20 and 30 years of age.
Dr Mike Patrick: And then, Julie, how can parents really benefit from this role? Like, we're really speaking to an audience of moms and dads right now. How can they take this information and use it to advocate for their kids?
Dr Julie Leonard: Well, I think the, uh, Key message to parents out there is that to understand a clinician's thinking when they're ordering a test, so one of the, you know, they should be critical thinkers and, and ask their physicians questions, you know, so, so what are the indications or what are you seeing on my Child's evaluation that is, you know, prompting your, you know, that this is the best, you know, test for this, you know, child, you know, it's important for parents to share in the decision making around the imaging.
So, as an example, you know, that those children that sort of are in that middle category. of risk, they may have multiple complaints and, and therefore be sort of at higher, slightly higher risk of, of injury. And so, they should have a conversation if that, you know, first set of plain x rays we get is, is negative.
You know what, you know, ask the physician what's the next step, you know, because my child's still, you know, complaining of neck pain or if they feel like that the test is being ordered unnecessarily because their child doesn't have any of these, you know, complaints, you know, to speak up and sort of question the care.
So, it really does empower both physicians and their decision making, but also in parents to sort of advocate or ensuring that their child is not getting unnecessary testing.
Dr Mike Patrick: Yeah, yeah, the job of the parent often really starts as soon as the injury occurs when there is blunt trauma of a child, whether that be head, neck, the torso, the chest and back.
What should parents do? What's sort of the emergency response to get them to the hospital?
Dr Julie Leonard: Yeah, absolutely. So, if their child, any mental status changes in their child really should be evaluated by a physician. So that, you know, could mean cervical spine injury, but it could mean an injury around the brain as well.
If their child has any sort of difficulty walking or, or ambulating after an injury, very important to get them checked out. Kids are also very reliable reporters of pain. So, you and I and Jeff know as pediatric providers that if you don't touch a kid, and ask them where they hurt, they will tell you what part of their body hurts.
You can just say, you know, where do you hurt and they'll point right to the most, you know, serious injury on their body. And unlike adults, neck pain is, it's a pretty uncommon complaint in children. So, by the time you're 70, about 1 in 10, Individuals will walk around and have daily neck pain, but a child that's it's very uncommon for a child to actually complain of neck pain.
So, neck pain and a child would be another, you know, after an injury would be a clear indication as well.
Dr Mike Patrick: And then once, so we want to take these injuries seriously. You want to call EMS if there's been significant blunt trauma so that they can have that initial medical screen and possibly get the cervical collar on.
The rigid one, and then they get taken to the hospital and then the physician hopefully is going to use these prediction rules to determine if imaging is necessary. Um, are there any limitations on the rule or, you know, you, you said it performed very, very well. So, is this something that is trustworthy or are there some limitations we should think about?
Dr Julie Leonard: Yeah, there, there are, and, and this is, gets back to what Jeff had sort of can speak more to as an individual who's asked to follow children that have sort of persistent awareness Complaints, but this is like is meant to be in the hands of emergency medicine providers to decide who to test and who not to test.
Ultimately, though, some of these injuries will require testing beyond what we're recommending. And so that begins to be a more nuanced care. That belongs in the hands of a specialist. So, as an example, if there is some particular finding of concern on the first test that we recommend, we, you know, there's going to be a need to enlist the aid of a spine specialist to guide you in what your, you know, next best test is.
Likewise, there might be some children that have persistent complaints despite the first test being negative, and then again, that would warrant going on for further evaluation, so that might be A child who has some sort of weakness or sensory changes, and we've said first test is CT scan, but you need, you know, ultimately, if that's negative, they're likely going to get an MRI.
Yeah. So again, this is like first pass. Screen or not. And then what is your first test that you should elect to screen them with? Yeah.
Dr Mike Patrick: And especially as these rules are sort of young and you know, some people may not be aware of them and we're trying to raise awareness. That's one of the points of this podcast.
But you don't necessarily want to absolutely refuse to get tests done. If physician that you're seeing can explain to you why they're worried and why they want to get it done. So, as you said, I mean, it's really a great tool for parents to be able to at least have the conversation, but if you, you know, if your child is injured.
By blunt trauma and a physician that you are seeing is saying, I think we need to do this, you know, push, you can push back and say why and let them explain. But at the end of the day, you do have to put your trust in the, in the person who's seeing your child and hopefully they can explain things in a way that that's understandable.
Does that make sense? Yeah,
Dr Julie Leonard: absolutely.
Dr Mike Patrick: And then, uh, Jeff, what kind of actual injuries do you typically see? So once something is identified, they see a neurosurgeon like yourself. What, what are some of the most common cervical spine injuries that you encounter?
Dr Jeff Leonard: Well, it's highly variable and that's one of the big problems or why a prediction rule is exceedingly important because there can be everything from the young children that can have life threatening injuries, such as occipital cervical dislocation, which is fatal.
If going undiagnosed, a certain percentage of these children do present to the hospital and they're awake, alert, they've usually had high mechanism of injury. But if you don't recognize that they have that it's exceedingly important to do that So the proper precautions are taken there can be everything to the to the children that have point tenderness that have Spinous process fractures which are by no means life threatening nor unstable which simply require pain control before they go away.
So, there's a wide range of injuries and a wide range of mechanisms, whether they be burst fractures that occur after a football injury or other things when children fall from four feet out a window or some of the other things that we see over the course of evaluating the blunt trauma patients. So, There's a wide range of injuries that also vary based on age, whereas the spine matures, you start to get more adult type injuries that move lower in the cervical spine versus the young kids that really have the upper cervical spine injuries that we generally see because of the fact of the head to, uh, head to spine ratio is, is dramatically different in the children than the adults.
So, it's a sign, which is why specific pediatric studies, such as this, is exceedingly important because to use words that you know, a child is not just a little adult. So, you have to be able to tease out those nuances that change as the children get older. Yeah.
Dr Mike Patrick: When there is a neck injury present, how likely is it that a child would need a surgery or have neurological problems after that injury?
Dr Jeff Leonard: The nice thing for my sanity and my peace of mind is it's very rare. And it's only handled in very specific instances. So, not, in fact, most of our, most of our pediatric spine injuries based on this. In this study, and in some of the other ones that we've done, have been non operative. But, again, to emphasize why the prediction rule is important, you need to identify these, you need to determine what's stable versus not, and you need to be able to operate on the rare children that need cervical spine injury.
This is nowhere near the same percentages that you see in adults. But it is still when it happens. It's something that none of the other providers want to miss.
Dr Mike Patrick: Yeah. Yeah, absolutely Julie, how does this then fit into the field of pediatric emergency medicine? You know we have there's a lot of things that take place in kids Just you know as we treat and manage children that we have just always done and now you know when we start asking Questions and doing the kind of studies that you're doing This is how change really ends up happening.
How is this going to change the way that that we practice emergency medicine as it relates to kids?
Dr Julie Leonard: Yeah, so hopefully the change will happen quickly. So, the good part about this study is that we were able to complete that derivation and validation, which I spoke about. So, we feel like it's a very trustworthy decision role, and the key is getting it out into the hands of providers.
So. Basically disseminating it and getting it in textbooks online, you know, promoting it through different educational platforms like podcasts, as your podcasts, get it into the hands and in use. And what we project will happen is that we will likely decrease CT rates by 50%. Which, which would be amazing, have an amazing effect on long term health of children in terms of that radiation exposure, the cost of health care, because obviously getting these imaging tests costs money and time and for both parents and, and health care providers.
We anticipate that we will, you know, have these great health care savings and improved health care by reducing CT without compromising, you know, the care for injured children and that, you know, this particular decision rule Was able to predict almost every child that had a cervical spine injury. So very, very sensitive to identifying those kids that were injured.
But again, specific enough, not overly, you know, you know, generalizing, we were able to get it specific enough that we, we could actually make a meaningful cut in the use of diagnostic testing. So, what we anticipate is. You know, really a paradigm shift in how we're approaching, evaluating these kids and caring for these kids.
Dr Mike Patrick: You know, the PECARN rule for head injuries, we've been able to bake into our electronic medical records. So, you know, when the child is triaged, whether it's a nurse or a physician who's doing an initial exam, data gets input into the electronic medical record. And then there's a tool that then will notify like, hey, this kid should or shouldn't get head CT.
Is there going to be a similar thing for the cervical spine rule in terms of being sort of baked into the electronic medical record?
Dr Julie Leonard: Yeah, absolutely. So, what's really interesting is the there's been almost more than a decade between these two rules in terms of rolling them out and are electronic resources or care and our understanding about how that improves care has changed dramatically.
So, and we're able to get these tools. In electronic formats much more quickly. So as an example, already are, you know, up to date a common reference online reference for physicians has already made the update to their algorithm. Another platform called MD calc again is a platform that physicians could pull up and use on their iPhones has already made this change.
Epic is in the process of inserting the decision support into their platform, and there are other vendors out there that have similar decision support platforms that we're already partnered with to get this out in those electronic mechanisms so that it's You know, put in front of the physicians as quickly as, as possible in their decision making.
Dr Mike Patrick: Yeah, it's really interesting though, you know, what, how electronic technology has really ballooned since the head injury rule came out, Jeff, what, where do we go from here? What, what is future to look like as we think about kids with blunt trauma?
Dr Jeff Leonard: I mean, you see the differences. That occur at a major medical center that is already beginning to implement the decision-making rules.
It, whereas you're still having children that say fall from four feet, are they getting CT scans at outside community hospitals? So I think where it's going is taking the, the data that we take at these, in these hospitals, these major academic medical centers and disseminating community such that, I just hearken back to what one thing that Julie did back when she did her spinal cord injury work, where she was able to show that it's going to be really hard to do any spinal cord injury work in the pediatric population because the majority of those folks are cured, are not cured for it, at major academic medical centers.
So really the implementation that she's talking about is where this goes from here. And it's exceedingly important because these children are cared for at your private medical centers, your Close to home emergency room, and they don't follow the, the standard rules and it, the implementation of this is going to be exceedingly important.
And then carrying it out to all the various other subspecialties too, which is exceedingly important that we've seen in the, in the rollout of this, of the, of Her Lancet article is that it's, it's making its way into the orthopedic literature. It's making its way into the neurosurgical literature. It's being implemented across specialties, which is exceedingly important and having something like this is sort of where, where this goes in its next steps.
Dr Mike Patrick: Yeah. Yeah. Very, very important. And you make a great point. You know, the folks who work in academic pediatric emergency departments are way more likely to hear about this rule, you know, through the mechanisms that we have described and then to uptake that in terms of it being a part of their practice.
But when we think about urgent care centers and community emergency rooms, it may be a little bit slower to percolate out there. What can emergency departments do, Julie, to maybe increase uptake and awareness of other places that refer to them, if that makes sense?
Dr Julie Leonard: Absolutely. So, the key is outreach efforts and, you know, sort of ensuring that the community emergency departments get connected with their closest children's hospital. So, if I were to put on another hat and talk to about the EMS for children program. Basically, it's this concept that there needs to be focused effort in emergency departments that don't care for a lot of children to make sure that they are prepared, and they have tools and resources available to them as You know references and guidelines for when that child actually arrives.
So, we advocate for all emergency departments, big and small to have individuals that are focused as pediatric champions. So, bringing sort of the best evidence for care for Children and You know, advocating for that care and their emergency department so that again could be creating pediatric guidelines that are used in general emergency department settings.
You know, making sure that their group of physicians and staff all have a pediatric educational opportunities throughout the year to sort of maintain their knowledge regarding, um, Children because obviously once they leave training and they go out to a center that doesn't focus on children You know that knowledge base rapidly, you know gets behind and so having a pediatric champion there that's constantly You know bringing to them new guidelines new evidence, you know, that's sort of a critical way that our Emergency medical system in the United States can, you know, bring themselves up to a higher standard for caring for Children.
Dr Mike Patrick: Yeah, it seems like really pediatric emergency departments ought to have outreach folks, you know, who proactively go out to all of those places, which, you know, can be done virtually these days with zoom meetings. But just, you know, that personal touch and not just rely on well, maybe they'll hear about it and maybe they won't.
But really, yeah. Being proactive and getting the latest information out there to, to those folks who see kids. Well, uh, we really appreciate both of you stopping by and chatting with us today. We're going to have several links in the show notes over at PediaCast. org for this episode 564. We'll put a link to pediatric emergency medicine in pediatric neurosurgery at Nationwide Children's Hospital.
Folks want to find out more information about what you guys do. And then we'll also put a link to the article in Lancet, PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma, a multi-center prospective observational study. And hopefully now those words make a little bit more sense to parents who are listening to them.
But Dr. Julie Leonard with Pediatric Emergency Medicine and Dr. Jeff Leonard with Pediatric Neurosurgery, thank you both so much for stopping by today.
Dr Julie Leonard: Mike, thanks for having us. It was a pleasure, as always.
Dr Jeff Leonard: Yeah, Mike, thanks for having us.
Dr Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Julie Leonard with Pediatric Emergency Medicine and Dr. Jeffrey Leonard with Pediatric Neurosurgery at Nationwide Children's Hospital. Don't forget. You can find us wherever podcasts are found or in the Apple and Google podcast apps, I heart radio, Spotify, SoundCloud, Amazon music, YouTube, and most other podcast apps for iOS and Android. Our landing site is PediaCast. org. You'll find our entire archive of past programs there, along with show notes for each of the episodes, our terms of use agreement, and the handy contact page, which If you would like to suggest a future topic for the program, reviews are helpful wherever you get your podcasts.
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We do turn the science up a couple of notches and offer free continuing medical education credit for those who listen. And that includes doctors, of course, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And since nationwide children's is jointly accredited.
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Thanks again for stopping by and until next time. This is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids. So long, everybody.
