O1025: Prevalence of and Factors Associated with the Application of Spinal Motion Restriction by Emergency Medical Services (EMS) for Children at Risk for Cervical Spine Injury

Background: Cervical spine injuries (CSI) in children are uncommon but potentially devastating. Spinal motion restriction (SMR) remains the standard of care for children with potential CSI. There are, however, risks to indiscriminate application of SMR by Emergency Medical Services (EMS). We recently derived the Pediatric Emergency Care Applied Research Network (PECARN) CSI clinical decision rule for children experiencing blunt trauma. To effectively implement this decision rule, an accurate understanding of current EMS SMR practices is needed. Little is known about the prevalence of, and factors associated with, SMR application by EMS. Our primary objective was to determine the proportion of children sustaining blunt trauma who are placed in SMR by EMS. Our secondary objective was to identify factors associated with SMR placement by EMS.

Methods: We conducted a secondary analysis of data collected during a prospective study of children 0-17 years with blunt trauma transported by EMS to one of 18 PECARN emergency departments. EMS clinicians completed surveys regarding CSI risk factors and the application of SMR. We summarized SMR prevalence, techniques used, reasons for application, and EMS clinician suspicion for CSI by age group. We conducted univariable and multivariable logistic regression to determine factors associated with SMR placement.

Results: Of the 13,453 children transported by EMS, we enrolled a convenience sample of 7,721 (57.4%) where EMS surveys were completed. The CSI rate for enrolled children in this secondary analysis was 1.6%, compared to 1.2% for children transported by EMS but where EMS surveys were not completed. Prehospital SMR was applied to 41.5% of children. The proportion of children with SMR application increased as EMS provider suspicion for CSI increased, ranging from 25.9% (CSI suspicion < 1%) to 87.7% (CSI suspicion > 50%). Children < 2 years were less likely to have SMR placed (22.0%) compared to older age groups (35.5–50.4%) (Table 1). In multivariable analysis, factors associated with SMR placement included patient demographics (non-Hispanic white race/ethnicity, age > 2 years), mechanisms of injury (high-risk motor vehicle crash (MVC), unrestrained passenger in MVC, high-risk fall, axial load mechanism), clinical history (loss of consciousness, self-reported neck pain, paresthesia, numbness, or extremity weakness) and physical exam findings (altered mental status, neck tenderness, inability to move neck, focal neurological deficits, and substantial head or torso injuries) (Table 2).

Conclusion: In this study, 41.5% of children transported by EMS after blunt trauma had SMR placed, while only 1.6% had CSIs. Multiple factors were associated with SMR placement including patient demographics, mechanism of injury, history, and exam findings. Most factors associated with placement of SMR were not in the new PECARN CSI clinical decision rule. Future implementation of a risk-centered EMS decision aid for placement of SMR in children after blunt trauma must address this discrepancy.