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Removing the Pediatric Cervical Collar
Current Practice Patterns
Hisham A. Omran, MD;
M. Denise Dowd, MD, MPH;
Jane F. Knapp, MD
Arch Pediatr Adolesc Med. 2001;155:162-166.
ABSTRACT
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Objectives To identify the current practice patterns of emergency medicine practitioners
and the typical criteria used in discontinuing cervical spine immobilization
(CSI) in the pediatric patient.
Design Mail-in survey.
Participants All physicians on the mailing list of the American Academy of Pediatrics
Section of Emergency Medicine and an equal number of randomly chosen members
of the American College of Emergency Physicians. The total number of participants
was 1360.
Methods The survey consisted of a case scenario describing a 3-year-old child
brought to the emergency department with CSI. The approach to such a scenario
was assessed. Surveys were mailed with self-addressed stamped envelopes; repeat
mailings were sent at 4 and 8 weeks after the first mailing. Those not currently
in active practice or not involved in the decision to discontinue CSI were
excluded from the study.
Results The response rate was 55%. Most respondents were younger than 44 years
(71%), in practice less than 10 years (56%), and practiced in an urban setting
(68%). Nearly two thirds (62.6%) had completed residency training in pediatrics,
24% in emergency medicine and 36% a pediatric emergency medicine fellowship.
Most (63%) would discontinue CSI without obtaining radiographs. Factors associated
with removal were residency training in pediatrics and being in practice for
less than 10 years. The most common criteria for discontinuing CSI were normal
neurological (96%) and cervical spine (98%) examinations, normal mental status
(92%), and absence of neck pain (93%).
Conclusions Discontinuing CSI without obtaining radiographs is common, especially
among those with residency training in pediatrics and those in practice for
less than 10 years. Knowledge of current practice is essential to future development
of guidelines for managing pediatric trauma patients for whom cervical spine
injury is a consideration.
INTRODUCTION
PEDIATRIC cervical spine injuries are a rare complication of pediatric
blunt trauma, with an estimated incidence of 14 per 1 million cases.1 Despite its rarity, pediatric cervical spine injuries
can be devastating2 and necessitate a cautious
approach in the prehospital setting, such as those specified by current Advanced
Trauma Life Support protocols.3 These guidelines
recommend that all patients with trauma above the clavicle be considered to
have cervical spine injury and undergo out-of-hospital cervical spine immobilization
(CSI) until further evaluation at the treating hospital.
Therefore, many children come to the emergency department requiring
an assessment for potential cervical spine injury; however, rarely will they
have this type of injury. Despite the absence of established pediatric guidelines
for clinically clearing the cervical spine, emergency medicine physicians
commonly discontinue CSI without obtaining radiographs for those patients
they deem not to have a cervical spine injury. Little is known about this
practice, specifically frequency of occurrence and factors influencing the
decision to discontinue CSI without obtaining cervical spine radiographs.
Knowledge of current physician practice and its variability is essential
as a prelude to establishing acceptable guidelines for discontinuing CSI without
radiography. This study describes the typical practice pattern of emergency
medicine physicians in the management of pediatric trauma patients who present
with CSI. Eventually, tested guidelines may lead to the avoidance of unnecessary
cervical spine radiography, prolonged cervical immobilization, and the inconvenience,
time,4 and expense associated with them.
METHODS
A survey was mailed to all physicians on the mailing list of the American
Academy of Pediatrics (AAP) Section of Emergency Medicine and an equal number
of randomly chosen members of the American College of Emergency Physicians
(ACEP). Only 1 survey was sent to individuals on both mailing lists. The survey
consisted of a 2-page questionnaire with an attached cover letter, signed
by the chief of the Division of Emergency Medicine, that introduced the investigators
and explained the purpose of the study. The survey contained a statement of
purpose and an assessment of demographic and professional characteristics,
including years in practice (<5 years, 5-10 years, or  10 years), type
of practice (urban, rural, suburban, or other), training (residency or fellowship),
age (25-34 years, 35-44 years, 45-54 years, or 55 years), annual emergency
department census (<30 000, 30 000-60 000, or >60 000),
percentage of patients younger than 19 years (<40%, 40%-59%, 60%-79%, or
>80%), and presence of rotating residents in the emergency department.
This was followed by a short case scenario describing
a three-year-old child who was a rear seat unrestrained
passenger struck broadside by another car moving at 30 MPH. He was
immobilized at the scene, and transported by paramedics to the ED
[emergency department]. He was awake, with normal vital signs, and
other than abrasions on the forehead had a negative physical
examination. He cried but calmed on arrival of his parents.
The scenario was followed by 9 close-ended questions addressing the
respondent's approach to such a patient. These questions included whether
respondents would remove the collar without obtaining radiological studies,
and criteria they deemed necessary for removal of the collar without obtaining
radiography. Respondents were asked to select the criteria they felt must
be met to clinically clear the case child's cervical spine. A set of 13 choices
were presented, plus an open-ended option of adding any other criteria necessary
to clear the cervical spine without radiography. Choices included the following:
no complaints of neck pain, no history of loss of consciousness, full state
of alertness, a score of 15 on the Glasgow Coma Scale, absence of painful
or distracting injuries, no evidence of intoxication, a normal cervical spine
examination (nontender, full range of motion, no step-offs on palpation, no
swelling, and no other abnormalities), normal neurologic examination, a history
of ambulation at the scene, no other injuries above the clavicle, no medical
history of high risk for cervical spine instability (eg, Down syndrome) or
of a high-risk mechanism for cervical spine injury, no history of ejection
from the vehicle, and restraint at the time of the crash. The interpretation
of each item was left to the survey respondent, and no further explanation
or guidance was given. Additional questions concerning the reasons for obtaining
or not obtaining radiographs were asked along with close-ended answers presented
in a list. The scenario and questions were evaluated for clarity and appropriateness
by the faculty of the Division of Emergency Medicine, with the goal of recreating
a common case scenario experienced by physicians working in an emergency department
setting.
The survey was mailed with a self-addressed stamped envelope. A repeat
mailing was sent to those who had not replied 4 weeks after the first one.
A third and final mailing was sent to those who had not responded 4 weeks
after the second one. There was an identifying mark on the response sheets
to allow for follow-up mailings to those not responding. No personal identifiers
were recorded or tracked. Those who were neither currently in active practice
nor involved in the decision to remove the cervical collar in trauma patients
were excluded from the study. The survey was conducted between February 1998
and November 1998.
The respondents were made aware of the purpose of the study, and their
responses remained anonymous. Institutional review board approval was obtained.
Frequency distributions were generated for demographic and professional characteristics,
and differences were assessed for statistical significance with a  2 test. P<.05 was considered significant.
Univariate analysis to assess individual characteristics associated with removal
of CSI without radiography was performed, and results were expressed as odds
ratios (ORs) with 95% confidence intervals (CIs). To control for confounders
and identify characteristics significantly associated with the decision to
remove the cervical collar, a multivariate logistic regression was performed.
For analysis purposes, certain continuous variables such as age of respondents,
annual emergency department census, and percentage of patients younger than
19 years were collapsed into dichotomous variables. All data analysis was
performed with the Statistical Product and Service Solutions 8.0 software
package.
RESULTS
A total of 1360 surveys were mailed (equal numbers from both groups),
and 753 (55%) were returned. A total of 114 respondents were excluded because
they were not currently practicing or were not involved in the decision to
remove the cervical collar; the final study group was 639 participants. The
group consisted of 395 physicians (61.8%) from the AAP Section of Emergency
Medicine mailing list and 244 (38.2%) from the ACEP mailing list. The respondents'
demographics and professional characteristics are provided in Table 1. Most respondents (71.2%) were younger than 44 years, in
practice for less than 10 years (55.7%), and practiced in an urban setting
(68.0%). Nearly two thirds (62.6%) completed residency training in pediatrics,
24.2% in emergency medicine and 36% a pediatric emergency medicine (PEM) fellowship.
Most (69.4%) reported an annual emergency department volume of at least 30 000
visits, and half of the respondents stated that 60% or more of the patients
seen were younger than 19 years.
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Table 1. Characteristics of Respondents*
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In response to the case scenario, 63.2% of the respondents would discontinue
CSI without radiological evaluation (Table
2). Factors associated with discontinuing CSI included residency
training in pediatrics (OR, 2.1; 95% CI, 1.4-3.2), PEM training (OR, 2.0;
95% CI, 1.4-2.8), and working in an emergency department where residents rotate
(OR, 2.2; 95% CI, 1.5-3.3). Other factors associated with removal of CSI included
being in practice for less than 10 years (OR, 1.7; 95% CI, 1.2-2.3), practicing
in an urban setting (OR, 1.7; 95% CI, 1.2-2.4), age of 44 years or younger
(OR, 1.5; 95% CI, 1.1-2.2), and practicing in a setting where patients younger
than 19 years accounted for at least 60% of the patients (OR, 2.0; 95% CI,
1.4-2.8). The total number of annual visits did not appear to be associated
with removal of the cervical collar. A logistic regression revealed those
characteristics independently associated with removal of CSI. Those trained
in pediatrics were nearly twice as likely to remove CSI as those trained in
emergency medicine (OR, 1.9; 95% CI, 1.1-3.5). Additionally, those in practice
for less than 10 years were 1.7 times more likely to remove CSI than those
in practice for more than 10 years (OR, 1.7; 95% CI, 1.1-2.6).
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Table 2. Factors Associated With Physician Decision to Remove the Cervical
Collar Without Obtaining Radiographs in Sample Case Scenario*
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For those who would remove CSI without radiography (n = 404), the most
common criteria deemed mandatory were normal cervical spine examination results
(98.5%), normal neurologic examination results (95.7%), absence of neck pain
(93.0%), and a Glasgow Coma Scale score of 15 (92.2%) (Table 3). The least likely criteria were history of restraint (7.3%),
ambulation at the scene (17.5%), and absence of injuries above the clavicle
(26.1%).
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Table 3. Percentage of Physicians Reporting Factors as Mandatory for
Removing the Cervical Collar Without Obtaining Radiographs*
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We elicited the rationale for such practice from this group of physicians
(Table 4). Most respondents (81%)
stated that they trusted their abilities to obtain a history and perform an
appropriate physical examination in this case scenario. There was no difference
in rationale for removal of CSI between those with pediatric residency training
and those with emergency medicine training. Nearly half (45.6%) believed that
there was a low risk of cervical spine injury in this case scenario. The least
common reason for discontinuing CSI before obtaining radiography was concern
about patient exposure to radiation (13.8%).
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Table 4. Rationale for Removing the Cervical Collar Without Obtaining
Radiography Based on the Clinical Scenario*
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A total of 227 respondents decided not to discontinue CSI without radiography
in this case scenario (Table 5).
The reasons for this choice included discomfort with such a decision for the
nonverbal pediatric patient (78.8%) and the belief that radiography was medically
indicated in this case scenario (68.6%).
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Table 5. Rationale for Not Removing the Cervical Collar Without Obtaining
Radiography*
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The final question asked whether the respondents felt that out-of-hospital
criteria should be developed to limit CSI. Almost half stated that criteria
should not be developed, irrespective of whether they would (47.8%) or would
not (51.8%) remove CSI themselves.
COMMENT
Although pediatric trauma patients commonly come to the emergency department
with CSI, no published data describe the physician approach to the situation.
In this hypothetical case with a nonverbal child, and despite the absence
of clinical guidelines for removal of CSI in pediatrics, PEM practitioners
(63.2%) frequently discontinued CSI without obtaining radiographs. Because
the approach to the nonverbal child is more cautious in comparison with all
pediatric trauma patients, the overall prevalence of CSI removal without radiographs
is probably higher than 63.2%.
After correction for other confounders, only 2 factors were associated
with removal of CSI without radiographs. Physicians with pediatrics residency
training were more likely to remove CSI without obtaining radiographs than
those trained in other specialties. This is possibly due to greater comfort
and confidence in their abilities to assess the young anxious child. Interestingly,
PEM training was not associated with an increased likelihood of CSI removal,
suggesting that further training did not add to the confidence or ability
to assess the young child.
Physicians practicing for less than 10 years were more likely to remove
CSI without obtaining radiography. Reasons may include a more recent exposure
to pediatrics and an increasing emphasis on pediatrics in emergency medicine
and family practice residencies. Other reasons possibly include a change in
approach over time; those with more recent training may have been exposed
to newer research about the hazards of CSI practices4, 5, 6, 7
or evidence showing that immobilization has no effect on neurologic outcome.8
Clinical guidelines for removal of CSI have been developed for adults,9 and the set of criteria used to clinically determine
the absence of cervical spine injury has recently been validated in a large,
mostly adult multicenter study.10 This study
identified 5 criteria that must be met to clinically rule out cervical spine
injury: no posterior midline cervical spine tenderness, no evidence of intoxication,
normal level of alertness, no focal neurological deficit, and no painful or
distracting injuries. This set of clinical criteria was found to be 99% sensitive
for identifying blunt-trauma patients with cervical spine injury. All 5 items
were selected as mandatory for clearing the cervical spine by most respondents
in our study (Table 2). Interestingly,
most respondents also indicated that additional criteria such as absence of
neck pain and no history of high-risk preconditions should be met. The present
study was conducted prior to publication of the validated set of criteria.
There is a growing interest in developing and validating clinical decision
standards for ruling out cervical spine injuries in pediatric patients.11 Because of the rarity of pediatric cervical spine
injuries, a prohibitively large number of pediatric trauma patients would
need to be studied to construct an outcome-based decision rule with sufficiently
high sensitivity. Additionally, because clinical criteria such as examination
findings are by nature subjective, agreement between practitioners will be
essential to create a reliable instrument. Although good-to-excellent interobserver
reliability has been demonstrated in the decision rule tested by Hoffman et
al,10 measurement of agreement in a predominately
pediatric population will be necessary to prove reliability for the injured
child.
Acceptability of clinical guidelines is influenced by many factors,
including perceived confidence with the decision.12, 13
Most respondents (81%) who would remove the cervical collar without obtaining
radiographs appeared confident with their abilities to obtain a history and
perform an appropriate physical examination. To become widely adopted, clinical
guidelines must be based on sound outcome data and be perceived as useful
by physicians. The perception of usefulness is based on such factors as how
acceptable the guidelines are to those currently in practice and to what degree
they improve confidence in clinical decision making. Understanding current
practice will be helpful in gauging acceptability of future guidelines. This
is supported by studies on other clinically validated guidelines, including
a prediction rule for the triage of emergency department patients with chest
pain that has not been widely accepted because of lack of perceived usefulness.13, 14
Those who would not remove CSI in our scenario stated their discomfort
with the nonverbal pediatric patient as the most common reason, although past
unfavorable experiences with removal of the cervical collar were not addressed.
Despite the fact that most respondents would discontinue CSI without obtaining
radiographs, there is no outcome data to support this widespread practice.
Future studies should address the safety of this practice.
Approximately half of the respondents believed that criteria should
not be developed to limit CSI in the out-of-hospital setting. It is apparent
that development of out-of-hospital guidelines, although possibly advantageous
in limiting discomfort and unnecessary delays, is not related to current physician
practice regarding CSI removal. This is especially interesting for those physicians
who would remove CSI without obtaining radiographs. They may believe that
a short period of discomfort prior to arrival in the emergency department,
where an assessment can be performed more easily, is preferable to attempting
to avoid all unnecessary immobilizations.
The limitations of the study should be addressed. It was not possible
to obtain information about the nonrespondents, which precluded a comparison
with respondents. This is of particular interest because there was a significant
difference in the nonresponse rate of those from the ACEP mailing list vs
those from the emergency medicine section of the AAP. This is important because
those identified from the AAP list are more likely to have been trained in
pediatrics than those on the ACEP list. Because pediatrics training was related
to the tendency to remove the collar in the case scenario, the group result
may not accurately reflect the practice of all emergency medicine physicians.
Certainly this selection bias may limit ability to generalize the results.
Generalizing the behavior of cervical collar removal to other clinical situations
is limited, as only 1 scenario was presented. The survey described physicians'
statements of their practices; because actual application may differ, extrapolation
to a real-life situation must be done with caution. We attempted to minimize
the potential for such a difference by keeping the scenario short and simple
and by ensuring anonymity.
Emergency medicine physicians commonly discontinue CSI without radiography.
The criteria these physicians use for removal of CSI may lay the foundation
for outcome-based prediction rules. These rules must address both current
practice patterns and perceived comfort with this practice.
AUTHOR INFORMATION
Accepted for publication October 1, 2000.
This study was supported in part by the Katherine Berry Richardson Research
Fund of Children's Mercy Hospital, Kansas City, Mo.
Presented as a poster at the annual meeting of the Pediatric Academic
Societies, San Francisco, Calif, May 1-4, 1999.
From the Division of Emergency Medicine, Children's Mercy Hospital,
University of Missouri, Kansas City.
Corresponding author and reprints: Hisham A. Omran, MD, Division
of Emergency Medicine, St Christopher's Hospital for Children, Erie Avenue
at Front Street, Philadelphia, PA 19134 (e-mail: Hisham_omran{at}hotmail.com).
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