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MANAGEMENT OF PATIENTS WITH SUSPECTED SPINAL INJURY

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Children who present to the emergency department with considerable trauma such as motor vehicle crash, motor vehicle-pedestrian accident, fall from high elevations, sports injuries, and/or neurologic complaints should alert the provider about the potential for spinal cord injury. Management of children with spinal injuries usually starts in the prehospital setting and begins with rapid cardiorespiratory resuscitation. Immobilization of the cervical spine must be provided immediately and maintained until evaluation and assessment is performed.

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IMMOBILIZATION

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Children with suspected spinal injuries should be immobilized on a spine board. The neck should be protected against unwanted movements with a rigid cervical collar and sandbags on the sides with tape across the forehead. Because of the relatively large size of the head compared with the torso in children, immobilization on a spine board may produce an undesirable flexion of the cervical spine. This can be avoided by elevating the torso on additional supports such as a thin mattress or blanket or using a spine board with a recess that allows the head to be lowered relative to the rest of the body. Spine boards are mainly used for extrication and transport to the emergency department, and should be removed once the primary survey is completed. Once in the emergency department, the rigid collar should be changed to a semi-rigid collar (Miami J, Aspen). Some pediatric patients with potential spinal column or cord injuries may present to the emergency department wearing a helmet (football or motorcycle). Using a two-person technique, the helmet should be removed extremely carefully with no movement of the cervical spine.

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TECHNIQUE FOR MOVING THE PATIENT

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In-line spinal stabilization and axial alignment should be maintained at all times. In order to remove the spine board, three assistants are usually needed. The first assistant holds the head and maintains C-spine stabilization and controls the turn. The second and third assistants stand on one side of the patient to maintain thoracic and lumbar spine alignments. The patient is log-rolled on a count of three. The physician then inspects and palpates the back of the head and the entire length of the spine and removes the board. If the patient will be transferred quickly to computed tomography (CT), a slider board can be introduced at the time the long board is removed, which will minimize patient motion. It is important to remember that immobilization on a backboard or slider board can result in pressure sores and unnecessary discomfort. In addition, rapid removal of the pediatric patient from the spine board is important because the board itself causes pain. Examination of the child who has lain on the spinal board for a prolonged period, will lead to unnecessary radiographic imaging of areas not injured, but are painful just by being immobilized on the hard spine board.

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AIRWAY MANAGEMENT

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