From
StayCurrentMD
#APSA50: Top Educational Content
With Dr. Aaron Jensen & Dr. Samir Gattapoli · hosted by Dr. Alex Cassar
Part of
Cervical Spine Injury 4 items
Chapter 1 of 6 · Evidence & Research
C-spine imaging
Introduction and Cervical Spine Trauma Imaging Guidelines
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Pediatric surgeons self-admittedly over-image C-spines in trauma, as demonstrated by show of hands in a room of pediatric surgery experts.
Children with GCS 14-15 who are not intoxicated can be cleared clinically for C-spine injury unless they have a painful distracting injury, according to AANS/CNS evidence-based guidelines from 2013.
Children age 3 and under with high-risk mechanisms of injury, particularly child abuse, should be screened radiographically even if they appear totally fine, because C-spine injury rates are very high in child abuse.
Clinical clearance of C-spine requires no neurologic deficits, no midline cervical tenderness, no painful distracting injury, no unexplained hypotension, and ability to move head in all directions without limitation.
In a Boston study of 300 children with no fractures on ED imaging, only 2% had ligamentous injury on MRI and none required surgery, demonstrating safety of sending patients home in collar with follow-up.
84% of children sent home in a collar after normal initial imaging had their collar clinically cleared at first clinic visit 1-2 weeks later.
Pressure ulcers from cervical collars occur in 6-38% of patients, most commonly in ICU patients who receive fluid resuscitation and require ventilation, with ulcers occurring on clavicles, back of head, and base of neck.
Meta-analysis of 5 adult studies with 1000 patients showed that among those with completely normal CT scans, 9% had stable injuries on MRI requiring no treatment, and no patient required surgery.
The adult recommendation to remove collars based on normal CT scan may not apply to children, who have greater frequency of ligamentous injury and unstable ligamentous injury.
The ACS TQuip program offers a free downloadable resource with standardized evidence-based guidelines for imaging trauma patients, including pediatric-specific sections developed with input from five pediatric surgeons.
For infants, clinical clearance requires certainty that the mechanism is not high-risk and that child abuse is not present, as clinical clearance has not been validated with high mechanism in young children.
70,000 children are hospitalized with sepsis annually in the United States, with 7,000 deaths—three times more than pediatric cancers, approximately 20 deaths per day.
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, with no distinction of 'severe sepsis' anymore.
Quick SOFA (sequential organ failure assessment) defines organ dysfunction using three criteria: mental status changes, elevated respiratory rate (22 in adults, age-appropriate in children), and low blood pressure (systolic <100 in adults, with heart rate being a better marker than blood pressure in children).
Sepsis has a 10% mortality rate (1 in 10), while septic shock has a 40% mortality rate (more than 1 in 3).
Three major trials (ProCESS, ProMISe, and ARISE) showed no difference with goal-directed or protocol-based resuscitation in sepsis.
For each hour delay in antibiotic administration after sepsis diagnosis, mortality increases (Kumaral, Critical Care Medicine, 2006).
Procalcitonin is a biomarker specific for bacterial infections, with trending more important than absolute values; when it reaches normal levels, antibiotics can be stopped.
The STOP-IT trial showed that for abdominal sepsis, antibiotics can be stopped at 4 days once adequate source control is achieved.
The sepsis clock starts from the time blood pressure is checked and found low to when antibiotics are actually hung, sometimes requiring IV placement within the first hour.
The Andromeda shock study (2019, Hernandez et al., JAMA) found capillary refill was as good as or better than lactate levels for resuscitation endpoints, with 35% mortality in the cap refill group versus 43% in the lactate group (p=0.06).
The lactate group in the Andromeda study received significantly more fluid, and over-resuscitation is associated with worse outcomes.
30 mL/kg of isotonic fluid is a good initial volume for sepsis resuscitation.
The FEAST trial showed that fluid boluses in African children with severe infections increased mortality, demonstrating that over-resuscitation increases mortality in pediatric sepsis.
The ALBIOS trial showed that albumin use in sepsis decreases the amount of fluid needed to achieve resuscitation goals.
The TRISS trial identified that a hemoglobin of 7 is an adequate transfusion threshold in septic shock.
For pressor selection, dopamine is used in babies and norepinephrine in older children, with most pediatric sepsis patients having good heart function.
The VANISH trial showed vasopressin is a good adjunct to use in septic shock with renal failure.
Milrinone is recommended for warm shock (adequate blood pressure but inadequate perfusion) as it provides good inotropic support.
Steroids should be started when initiating a second pressor, with no data supporting routine STIM testing; hydrocortisone 1.5-2 mg/kg every 6 hours is the typical dose.
ECMO should be considered when patients are on two pressors with hydrocortisone, but ECMO helps with oxygenation and cardiac output while having difficulty with SVR, so pressors may still be needed on VA ECMO.
On ECMO, if SVO2 is 70%, there is adequate flow; at that point, reassess source control, antibiotics, and monitoring rather than increasing ECMO flow (McLaren et al., Australia).
CVP is trended intermittently rather than continuously in pediatric patients because limited central line lumens are often occupied by sedation drips and antibiotics.
Bedside ultrasound for sepsis management includes checking IVC for respiratory variation and collapse, right atrium for dilation and pulmonary hypertension, and heart function for dynamic contractility.
In sepsis, diastolic blood pressure typically drops significantly (e.g., 70/30 or 80/20) due to loss of systemic vascular resistance.
Fluid overload is associated with acute kidney injury, and most children do not need 10 liters of resuscitation fluid despite older teaching.
Each resuscitation intervention should be followed by reassessment after approximately 20 minutes to determine if the intervention made a difference.
A mildly elevated lactate (e.g., 2.5) that plateaus should not be aggressively chased to normal if the patient has good blood pressure, urine output, improving kidney function, and normal mental status.
Procalcitonin serves as a second-line test to support stopping antibiotics when the patient is clinically improving, preventing the common practice of extending antibiotics 'just a couple more days.'
Over 40% of all patients undergoing clean surgical procedures without foreign body implantation at freestanding children's hospitals receive unindicated antibiotic prophylaxis.
Over 50% of patients who appropriately receive antibiotic prophylaxis have it extended well past incision closure, with colorectal procedures averaging 2.5 days of prophylaxis.
Almost 30% of patients receive antibiotic agents broader than recommended guidelines, with double coverage (Flagyl and Zosyn) being common.
The three major areas of inappropriate antibiotic use in pediatric surgery account for 85% of inappropriate utilization: prophylaxis for clean cases without foreign bodies (50%), prophylaxis after incision closure (30%), and anaerobic coverage for proximal GI procedures (remaining portion).
Cochrane reviews show no strong conclusion on antibiotic prophylaxis for central line placement, but there is a trend toward reduced infection rates in the oncology population.
Adult literature shows that for colorectal procedures, giving antibiotics past incision closure provides no benefit.
NSQIP data shows surgical site infection rates in children are much lower than adults when adjusting for procedure type and RVUs, because children lack risk factors like morbid obesity, diabetes, and tobacco use.
Bratzler consensus guidelines from the Infectious Disease Society of America, Surgical Infection Society, and American Society of Hospital Pharmacists agree that routine fungal coverage is not necessary because SSI data does not show fungal infections.
The NSQIP collaborative of 84 hospitals will collect data on 85,000 children over one year, providing the first rigorous data relating prophylaxis to surgical site infections in pediatric surgery.
In a collaborative to reduce CT utilization for appendicitis, CT rates decreased from 25% to 15% within NSQIP hospitals, but 50% of transferred patients had already received CTs at outside hospitals, highlighting the need for community outreach.
For pediatric patients with suspected appendicitis who are not thought to have perforation, starting with cefoxitin or ceftriaxone and Flagyl rather than anti-pseudomonal agents is the most important stewardship intervention in pediatric surgery.