Cervical Collar Placement and Radiographic Evaluation Is Not Necessary in Most Obtunded Children Presenting Without a Known Traumatic Mechanism

Background: Pediatric trauma protocols recommend the application of a cervical spine collar (c-collar) for protection until the cervical spine (c-spine) can be evaluated to rule out injury. Many children who present obtunded are placed in a c-collar even when traumatic processes are not suspected. This can result in over-imaging and/or prolonged periods of neck immobilization. The purpose of this study was to investigate the incidence of c-spine injury and necessity of c-collars in children who present obtunded without a known traumatic process.

Methods: We conducted a single institution 10-year retrospective chart review from January 2009-January 2019 of all patients under 18 years old admitted to the PICU unconscious or obtunded due to a low-risk, non-traumatic mechanism. Exclusion criteria included consciousness or known traumatic mechanism of injury. Data extracted included patient demographics, diagnosis, outcomes, presence of c-collar, methods of c-collar clearance, and rates of c-spine injury. Data is presented as descriptive statistics. This study was granted institutional research ethics board approval.

Results: 382 patients met our inclusion criteria; 45 (11.8%) were placed in a c-collar. Overall, seizure was the most common diagnosis; only 4/161 (2.5%) of these patients were placed in a collar. All patients presenting with self-hanging and accidental asphyxiation and 17/18 (94%) near-drownings were placed in a collar (Table 1). In order to clear the c-spine of patients in a collar, 53% underwent radiographs (0% demonstrating injury), 40% CT scans (2.2% demonstrating injury) and 28.3% MRI (4.4% demonstrating injury). Only 5/377 patients without a collar were imaged, with no injuries identified. Overall, two patients had imaging consistent with potential c-spine ligamentous injuries, both of which had a collar in place. The injured patients had final diagnoses of self-hanging and child abuse. No patient required surgery for an identified injury. The collar group was more likely to have a pediatric surgery consult (72.3% versus 12.2%). Overall, only 0.5% of all children admitted obtunded without a clear history of trauma had a c-spine injury.

Conclusion: The overall risk of c-spine injury is low in obtunded pediatric patients who lose consciousness through low-risk, non-traumatic mechanisms. C-collars may be eliminated from the treatment algorithms for most patients with non-traumatic mechanisms with altered level of consciousness. There should be consideration for c-collar placement and imaging in children presenting with self-hanging or those with unclear etiologies that are suspicious for child abuse. If a collar is placed in cases of potential abuse, it can be safely removed without imaging if history confirms lack of traumatic mechanism.