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Performance of the PECARN cervical spine injury prediction rule based on EMS clinician observations
Lorin R Browne1, Caleb E Ward, Monica Harding
1From the Departments of Pediatrics and Emergency Medicine (L.R.B.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pediatrics (C.E.W.), The George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, District of Columbia; EMSC Data Center (M.H.), University of Utah School of Medicine; Department of Pediatrics (L.J.C.), University of Utah School of Medicine, Salt Lake City, Utah; Department of Pediatrics (K.M.A.), University of Colorado School of Medicine, Aurora, Colorado; Department of Pediatrics (F.A.A.), Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri; Department of Emergency Medicine (R.B.), Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Pediatrics (P.P.C.), Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics (D.J.C.), Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics (N.W.G.), University of California, Benioff Children's Hospital, Oakland; Department of Pediatrics (N.K.), University of California, Davis School of Medicine, Sacramento, California; Department of Pediatrics (L.K.L.), Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts; Department of Neurologic Surgery (J.R.L.), Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Emergency Medicine (S.O.-A.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics (L.C.R.), University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Emergency Medicine (A.J.R.), University of Michigan School of Medicine, Ann Arbor, Michigan; Department of Pediatrics (D.M.R.), Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; Department of Emergency Medicine (R.E.S.), University of New Mexico Health Sciences Center, Albuquerque, New Mexico; Department of Pediatrics (M.A.S.), University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah; Department of Emergency Medicine (L.T.), University of California, Davis School of Medicine, Sacramento, California; Department of Pediatrics (K.Y.), Children's Health Dallas, University of Texas Southwestern Medical Center, Dallas, Texas; and Department of Pediatrics (J.C.L.), Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio.
Insights
The Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury (CSI) rule accurately identifies children with blunt trauma. Applying this rule in emergency medical services (EMS) could reduce unnecessary spinal motion restriction.
Area of Science:
- Emergency Medicine
- Pediatric Trauma
- Clinical Decision Rules
Background:
- Pediatric cervical spine injury (CSI) carries significant risks.
- The PECARN CSI prediction rule aids in evaluating pediatric blunt trauma patients in the ED.
- This study assesses the rule's performance using pre-hospital emergency medical services (EMS) clinician observations.
Purpose of the Study:
- To evaluate the accuracy of the PECARN CSI prediction rule.
- To assess the rule's performance based on EMS clinician observations in children with blunt trauma.
- To determine the potential impact on spinal motion restriction (SMR) practices.
Main Methods:
- A multicenter prospective observational study involving children under 18 with blunt trauma.
- EMS clinicians completed case report forms detailing CSI risk factors based on their observations.
- PECARN CSI prediction rule performance was evaluated using EMS data, with CSI as the primary outcome.
Main Results:
- The PECARN CSI rule demonstrated a sensitivity of 88.5% and a specificity of 63.1% using EMS data.
- Negative predictive value was high at 99.7%, indicating effective identification of children without CSI.
- Applying the rule could have decreased SMR from 41.5% to 37.7% and longboard use from 17.0% to 9.8%.
Conclusions:
- The PECARN CSI prediction rule shows good accuracy for identifying CSI in pediatric blunt trauma patients based on EMS observations.
- Implementing the rule in EMS settings could lead to a reduction in both SMR and longboard use.
- This supports the utility of the PECARN rule in pre-hospital settings for optimizing pediatric trauma care.
Background:
Pediatric cervical spine injury (CSI) is associated with substantial morbidity and mortality. The Pediatric Emergency Care Applied Research Network (PECARN) developed a CSI prediction rule for evaluating children after blunt trauma in the emergency department (ED). The objective of this study was to evaluate the performance of the PECARN CSI prediction rule using emergency medical services (EMS) clinician observations.
Methods:
We conducted a multicenter prospective observational study of children younger than 18 years with blunt trauma who were transported to one of 18 participating PECARN EDs by EMS. A convenience sample of EMS clinicians completed case report forms regarding CSI risk factors based on their clinical observations. We then evaluated rule performance with 95% confidence intervals (CI) by applying the PECARN prediction rule using the EMS clinical observations with the primary outcome of CSI. We also calculated rates of spinal motion restriction (SMR) had the algorithm been followed for the study population.
Results:
Emergency medical services clinicians completed case report forms for 7,721 (57.4%) patients. Using these EMS cohort data, the PECARN CSI prediction rule had a sensitivity of 88.5% (95% CI, 82.9-94.2%), specificity of 63.1% (95% CI, 62.0-64.2%), positive predictive value of 3.7% (95% CI, 3.0-4.4%), and negative predictive value of 99.7% (95% CI, 99.6-99.9%). The proportion of children placed in SMR would have decreased from 41.5% to 37.7%, and longboard use would have decreased from 17.0% to 9.8% had the rule been applied to this cohort.
Conclusion:
The PECARN CSI prediction rule based on EMS clinician observations had good accuracy for CSI in children experiencing blunt trauma. Application of the prediction rule to our EMS patient population would have reduced both SMR and longboard use.
Level Of Evidence:
Prognostic and Epidmiologic; Level III.
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