In the 2014 paramedic Standards of Proficiency by the Health and Care Professions Council (HCPC), it is outlined that HCPC registered paramedics must be able to thoroughly assess and examine patients of all ages. It is also highlighted that HCPC registered paramedics must safely and skillfully apply appropriate therapy and treatment, while ensuring patients are suitably positioned or immobilised if necessary (HCPC, 2014). As a rare presentation to the emergency services, cervical spine injury (CSI) in children and young people has limited evidence-based guidance to support pre-hospital practitioners with their treatment and management (Anders et al, 2014). In light of this, the Pediatric Emergency Care Applied Research Network have highlighted CSI immobilisation as a research priority with the recent development of a paediatric-specific pre-hospital research agenda (Foltin et al, 2010). This critical appraisal therefore aims to review the evidence base underpinning UK paramedic practice, when managing children and young people at risk of CSI, with particular focus towards immobilisation. Furthermore, clinical practice challenges and potential patient safety and risks shall be debated.
Literature review methodology
A literature review was performed using the following databases: CINAHL, Medline and Pubmed. The search terms used were ‘prehospital’, ‘paramedic’, ‘emergency medical service’, ‘cervical spine’, ‘cervical immobilisation’, ‘paediatric’ and ‘children’. The search was limited to the English language, with articles from 1998–2014 being included for review (Aveyard, 2010). Articles and studies were chosen pragmatically, dependent on whether they were related to the topic area. Subsequent articles were also retrieved from the reference lists of the initial articles if they met the inclusion criteria (Aveyard, 2010).
Mechanism of injury
Full spinal immobilisation is the standard of care for children and young people suspected of having sustained a vertebral fracture or spinal cord injury (National Collaborating Centre for Acute Care (NCCAC), 2007). This is in order to maintain neutral alignment of the spine, reduce spine motion and thus minimise neurological injury (NCCAC, 2007; Leonard et al, 2012; Theodore et al, 2013). Although rare, appropriate and effective management of children and young people at risk of CSI is also crucial in order to reduce the risk of life-threatening complications such as severe hypotension, apnoea and cardiac arrest (Mortazavi et al, 2010).
An integral element when managing paediatric trauma is recognition of potential injury, achieved by considering the mechanism of injury (MOI) and analysing initial assessment findings (Advanced Life Support Group, 2011). At present, guidelines for UK paramedics advocate immobilisation if the MOI suggests a risk of CSI, until full spinal assessment can be conducted (Association of Ambulance Chief Executives (AACE), 2013).
A split consensus is, however, seen in the literature when discussing the value of MOI as a predictor of injury. Courses such as the Advanced Trauma Life Support and Pre-hospital Trauma Life Support, among other literature, suggest MOI as the main deciding factor for pre-hospital immobilisation, regardless of assessment findings (Thompson et al, 2009; Advanced Life Support Group, 2011; National Association of Emergency Medical Technicians, 2011). Conversely, this has been refuted in literature where no link was established between MOI and spinal injury (Domeier et al, 1999; Connor et al, 2013). Here it is deemed that the subjective element of injury prediction through MOI may result in over-triage and thus clinicians should give priority to more objective factors such as age (Domeier et al, 1999; Connor et al, 2013). This conflict of opinion is also expressed where MOI is incorporated into the Canadian C-Spine Rule (CCSR), while not featuring in the National Emergency X-Radiography Utilization Study Group (NEXUS) criteria (Hoffman et al, 2000; Stiell et al, 2001). Current guidelines for UK paramedics compliment this by arguing that MOI has not been proven as an independent predictor of injury (AACE, 2013). Consideration of both arguments therefore suggests that a pragmatic approach to injury prediction by the practitioner should be undertaken when considering the risk or benefit of CSI and immobilisation in children and young people.
Anatomical differences
Alongside consideration of MOI, current guidelines advocate a rapid clinical assessment to establish signs and symptoms of CSI, while attempting to ascertain the level of spinal cord injury (AACE, 2013). This presents a challenge to clinicians, since children and young people present with a multitude of anatomical differences compared with adults, producing unique injury patterns and presentations (Advanced Life Support Group, 2011; Mohseni et al, 2011).
Firstly, it is well documented that children and young people have underdeveloped neck musculature, with lax inter-spinous ligaments and incompletely ossified bony anatomy (Junewick, 2010; Mohseni et al, 2011; Tilt et al, 2012). These anatomical differences, alongside the additional weight from a larger head to body size, produce an increased pivotal range with reduced support for the cervical spine (Junewick, 2010; Tilt et al, 2012). Hyper-mobility of the paediatric cervical spine compared to the spinal cord is also a noted feature, whereby cord damage may precede vertebral damage, while transmitted forces are more likely to cause multiple vertebral fractures (Mortazavi et al, 2010; Vaccaro et al, 2010). Importantly, movement of the cervical spine has shown to be greatest at C2–3 in infants, C3–4 at ages 5–6 years and C5–6 at adolescence, which may be taken into consideration when attempting to assess the potential level of CSI in children and young people (Mortazavi et al, 2010; Vaccaro et al, 2010).
In addition, a retrospective review conducted by Mohseni et al (2011) reported on the incidence of confirmed CSI in children and young adults, comparing age groups to level of CSI. Here a higher incidence of upper CSI (C1–C4) is noted in younger children in age groups from 0–9 years, while lower CSI (C5–C7) incidence increases in ages 9 years and older. This difference in the level of CSI is postulated to occur due to ossification and maturation of the vertebrae, alongside additional changes to the shape of the vertebral bodies in children around the age of 9 years and older (Mohseni et al, 2011). A knowledge of these developmental changes through education and improved guidelines may therefore improve clinical decision-making surrounding the potential level of CSI in children and young adults.
Knowledge of the anatomical differences of the upper airway anatomy is also important when considering the most efficient care for children at risk of CSI. In these younger patients, larger tongues, small nares and obligate nasal breathing in children under 5 years may potentiate the risk of upper airway obstruction, particularly when immobilised (Lander and Newman, 2010). This may also be compounded by the potential for the softer cartilaginous structures, such as the trachea, to become compressed (Lander and Newman, 2010). This risk of obstruction is important when considering the risk versus benefit of applying a cervical collar, a task made more difficult due to the child's short and wide neck, in many circumstances (Lander and Newman, 2010).
As previously mentioned, an important anatomical feature to consider in children and young adults is the larger head to body size ratio compared to adult patients, notably in the occipital region (Leonard et al, 2010; Advanced Life Support Group, 2011). This presents an issue for UK paramedics as immobilisation using a hard cervical collar and firm spinal board has been shown to result in excessive flexion of the cervical spine (Pandie et al, 2010). An increase in paediatric cervical spine neutral alignment has, however, been demonstrated with the use of a thoracic elevation device (TED) (Pandie et al, 2010). Though this equipment is not currently available to paramedics within the UK, it may be argued that adoption of more simple methods, such as the use of blankets to promote thoracic elevation, may provide benefit for the immobilised paediatric patient and should be considered in practice. It is, however, noted that no literature has been found within this review to support the use of blankets for thoracic elevation. Furthermore, a risk over benefit analysis must be undertaken when considering such interventions, as further movement by log-rolling may be necessary to promote thoracic elevation, potentiating negative sequelae such as clot disruption and pain (Moss et al, 2013).
Upon review of the literature, it is apparent that current guidelines for UK paramedics from AACE (2013) are lacking guidance surrounding paediatric anatomy in comparison to other literature sources. An increased provision of such guidance to underpin knowledge may prove beneficial to UK paramedics when assessing children and young people at risk of CSI (Mortazavi et al, 2010; Reavley, 2014).
Analysis of current immobilisation algorithms
Paramedics in the UK are also guided in their assessment of patients at risk of spinal injury by the immobilisation algorithm published by AACE (2013). Here, UK paramedics are guided to assess patients for spinal or vertebral tenderness or deformity, neurological deficit, altered mental status, distracting injury or evidence of intoxication (AACE, 2013). A limitation of this algorithm, however, is that it is intended for use on adult patients, while offering no paediatric specific algorithm. Although this presents an issue, it is noted that the criteria is of the same basic structure as the NEXUS criteria, which after evaluation has been regarded as safe for use in children (Hoffman et al, 2000). However, in addition to requiring a more recent review, this study is limited as few of its participants were under 9 years of age, with none aged below 2 years (Hoffman et al, 2000). Furthermore, a study by Ehrlich et al (2009) concluded that both the CCSR and NEXUS criteria were not sensitive enough for use in children. This appears logical in the case of the CCSR, which was formulated using patients over 16 years of age (Stiell et al, 2001). Additionally, Maxwell and Jardine (2007) report a case in which a paediatric patient deemed low-risk according to NEXUS criteria had actually suffered an odentoid peg fracture. This demonstrates the need for a globally accepted, paediatric specific immobilisation tool for the pre-hospital provider. Moreover, further general guidance towards paramedic assessment and management strategies for children and young people suspected of having CSI may prove beneficial to patient care (NCCAC, 2007).
Spinal immobilisation techniques and equipment
Alongside the AACE (2013) guidelines, current literature reports a shortage in the evidence base for the most effective spinal immobilisation techniques and equipment (Connor et al, 2013). It is, however, commonly accepted that two main methods exist for spinal immobilisation. These include either manual stabilisation while supporting the back, or stabilisation with the use of adjuncts such as collars, straps, head-blocks or sandbags, alongside a form of backboard or mattress splint (NCCAC, 2007; Ahn et al, 2009; Warner, 2010). Historically, UK paramedics would conduct immobilisation and transport of patients using the traditional rescue board (Warner, 2010). Recently, however, a multitude of studies highlighting the negative implications of this device have consequently advocated its use for extrication purposes only (Ahmad and Butler, 2001; Luscombe and Williams, 2003; Morris et al, 2004; Krell et al, 2006; Warner, 2010; Moss et al, 2013). A literature review by Ahn et al (2011) suggests that the optimal form of immobilisation is found by applying a cervical collar, head immobilisation and either a padded spinal board or vacuum mattress. Within this review, notable studies reported increased sacral and occipital pressures, motion and discomfort with use of the traditional unpadded rescue boards, although it is noted that only two studies of the 25 reviewed in this section relate to paediatric immobilisation (Main and Lovell, 1996; Luscombe and Williams, 2003; Krell et al, 2006; Sheerin and de Frein, 2007). Connor et al (2013), however, also agree with Ahn et al (2009), recommending rescue boards as extrication devices only and outlining vacuum mattresses or scoop stretchers as superior alternatives. Alternatively, a study by Markenson et al (1999) advocate the use of the Kendrick Extrication Device for effective paediatric spinal immobilisation, although more recent literature regarding this is warranted. It is therefore clear that there is a lack of high quality, paediatric-specific evidence generalisable to UK paramedic practice that quantifies the most effective immobilisation technique and equipment (Kwan et al, 2001). Further studies into this subject may therefore provide UK paramedics with a greater evidence-based rationale to underpin practice.
In addition to discussions surrounding the effectiveness of spinal boards, the use of cervical collars in children and young people has recently been discussed. The Royal College of Surgeons, among other literature, argue that manual in-line stabilisation should be adopted over cervical collars for the pre-hospital management of children and young people with potential CSI (Benger and Blackham, 2009; Connor et al, 2013). As a substitute, this method reduces the risk of raising intracranial pressure and may reduce agitation in potentially combative patients, while allowing for more effective management of compromised airways (Benger and Blackham, 2009; Connor et al, 2013). Within UK paramedic management, this method may also reduce the risk of hyper-flexion of the paediatric cervical spine upon application of a cervical collar, as previously mentioned (Pandie et al, 2010).
Risk over benefit
In addition to the consideration of best practice for children and young people with potential CSI, a continuing risk over benefit debate exists regarding pre-hospital immobilisation (Kwan et al, 2001). This has become apparent over discussion surrounding the minimal occurrence of CSI when compared to children and young people who are immobilised in the pre-hospital field (Polk-Williams et al, 2008; Parent et al, 2011; Connor et al, 2013). Studies have also shown that spinal injury is received at the time of impact by mechanisms greater than that of any secondary movement post-incident, which are deemed too small to produce further injury, thus negating the necessity of immobilisation (Hauswald et al, 1998; Hauswald and Braude, 2002). Additionally, it is suggested that current protocols underpinning pre-hospital immobilisation stem from a more historical approach, rather than a reliable evidence base (Kwan et al, 2001; Benger and Blackham, 2009). Within this literature, it is also claimed that the patient's own natural muscle spasm and position of comfort will act as a superior protective measure, even when guidelines state immobilisation is warranted (Kwan et al, 2001; Benger and Blackham, 2009). This relates heavily to UK paramedic management of such paediatric presentations and could arguably become a consideration of adopted future practice.
The prominence of arguments against pre-hospital spinal immobilisation also stems from areas of literature that argue the risks of immobilisation, such as raised intracranial pressure; pain and sympathetic stimulation; pressure sores; and airway compromise, such as decreased respiratory efficacy, airway opening and increased risk of aspiration (Kwan et al, 2001; Abram and Bulstrode, 2010; Leonard et al, 2012; Walker, 2012; Bruijns et al, 2013). In contrast, it has been reported by Kwan et al (2001) that no high level evidence exists to measure the effect of immobilisation compared to no immobilisation on harmful effects to patients. It is therefore clear that UK paramedics must reflect on the risks and benefits of immobilisation when confronted with this decision, in order to provide the most beneficial care to children and young adults.
Moreover, a further consideration is the time required to perform effective immobilisation of children and young adults and the impact this may have on transport time to definitive care, an important co-factor for patient outcome in trauma (McCoy et al, 2013). The argument surrounding a ‘stay and play’ or ‘scoop and run’ approach within pre-hospital trauma care systems is heavily debated and noted to be influenced by available resources, distance to definitive care and mechanism of injury (Beuran et al, 2012). Though there is a paucity in high-level literature evidencing increased survival rates when minimal time from injury to theatre admission is achieved, robust retrospective studies support early surgical intervention in patients suffering traumatic injuries (Smith et al, 2007; Martin et al, 2009). In light of this evidence, the European Task Force for Advanced Bleeding Care in Trauma advocate efforts to minimise elapsed time between injury and surgery, particularly for patients in need of surgical haemorrhage control (Spahn et al, 2013). In response to such consensuses, UK paramedics are expected to minimise on-scene to hospital time and triage appropriate patients to trauma centres, which has proven to benefit patient outcome (National Audit Office, 2010; Haas et al, 2012; McCoy et al, 2013). It may therefore be argued that the additional time necessary to perform immobilisation may be detrimental in children requiring rapid transport to definitive care, due to factors such as airway compromise or haemorrhagic injuries. These impacts should be considered when formulating a management plan for children and young adults with such presentations.
Equipment and education
Finally, a noted lack of equipment, exposure and in the author's experience poor availability of relevant ongoing education for UK paramedics, provides potential care limitations when presented with children and young people (Houston and Pearson, 2010; Breon et al, 2011; Murphy et al, 2013). A recent national survey of UK ambulance provision for children found that only 1 out of 13 services provided paediatric vacuum mattresses, while only two provided paediatric spinal boards (Houston and Pearson, 2010). Conversely, although it may be logical to assume that paediatric-specific equipment will benefit patient care, there is minimal evidence to suggest this (Ahn et al, 2009). Results of this survey also highlighted a considerable lack of paediatric-specific education available for UK paramedics (Houston and Pearson, 2010). This, alongside a noted lack of exposure to children and young people with potential CSI, may arguably be detrimental to practitioner confidence, management and thus overall care for the patient (Breon et al, 2011; Reavley, 2014).
Conclusions
While paediatric CSI is rare, guidance for UK paramedics in this area is limited, with an additional lack of evidence to underpin practice (NCCAC, 2007; Ahn et al, 2011; AACE, 2013). Upon review of the evidence base it is clear that a pragmatic approach to injury prediction, physical assessment and immobilisation is fundamental when presented with such patients. Additional anatomical knowledge, education and exposure set against an improved evidence base is also key in allowing UK paramedics to consider the potential risks and benefits when managing children and young people with potential CSI (Houston and Pearson, 2010; Breon et al, 2011; Reavley, 2014).