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All trauma evaluations begin with attention to the ABCs: airway, breathing, and circulation. Airway obstruction is common in the unconscious or severely injured child and should be treated rapidly. The unconscious child may be unable to cough or clear mucus, vomitus, blood, or other debris. Be cognizant of the potential for a cervical spine injury, which could be worsened by excessive motion of the spine (Fig. 24-1), and stabilize the cervical spine.
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The spine-injured patient may become hypopneic because of diminished diaphragmatic activity or intercostal muscle paralysis. Provide oxygen, assist ventilations. Although the bag-mask technique will permit ventilation, its prolonged use increases the likelihood of aspiration of gastric contents. Cervical spine immobilization with an orthotic device makes direct laryngoscopy three times more difficult compared with manual immobilization during intubation.20 Manual in-line cervical stabilization, rapid sequence induction, and oral endotracheal intubation are the preferred techniques to achieve airway stabilization in children with suspected cervical spine injury (Fig. 24-2). In children, blind nasotracheal intubation is unreliable because it can be technically difficult. The emergency physician must ensure an adequate airway and should not delay doing so while waiting for the cervical spine to be cleared.
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Hypotension in the injured child may be secondary to either hypovolemia or spinal shock. A clue to differentiating these is the pulse, which is slow in spinal shock and rapid in hypovolemic shock. Adequate fluid (crystalloid, colloid, and blood) is administered to combat hypovolemia. In the case of spinal shock, vasopressors, such as dopamine, may be needed. The patient with spinal shock may be more sensitive to temperature variations than other patients and may require warming or cooling if subjected to extreme environmental temperatures either at the scene or during transport. Protect areas of the body that may have lost sensation from hard, protruding objects, as they may cause skin necrosis, especially on long transports.
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Once the patient's cardiopulmonary status is stabilized, a thorough physical assessment and neurologic examination is performed carefully. Sensation should be checked, both light touch and pressure. Evaluate for weakness by having the child handle an item or hold each extremity off of the stretcher for a count of 5 if the child is conscious and old enough to follow commands. More ingenuity is needed for the infant and toddler. A useful diagnostic mnemonic is to evaluate the “six P's”: pain, position, paralysis, paresthesia, ptosis, and priapism. Conscious children old enough to talk may complain of pain localized to the involved vertebra. Head injury with diminished level of consciousness or intoxication may make the localization of cervical pain unreliable. The patient's head and neck positioning may indicate a spine injury. A head tilt may be associated with a rotary subluxation of C1 on C2 or a high cervical injury. The prayer position (arms folded across the chest) may signify a fracture in the C4 to C6 area. Paresis or paralysis of the arms or legs should always suggest spine injury. Paresthesia, a “pins and needles” sensation or numbness or burning, may be related to peripheral nerve injury; however, these symptoms when occurring bilaterally can be taken as indicators of potential spine injury. Some patients complain of a transient shock-like or electrical sensation transmitted down the spine during neck flexion and/or rotation (Lhermitte's sign). Horner's syndrome (ptosis and a miotic pupil) suggests a cervical cord injury. Priapism is present only in approximately 3% to 5% of spine-injured patients, but indicates that the sympathetic nervous system is involved. Absence of the bulbocavernosus reflex in the presence of flaccid paralysis carries a grave prognosis. To elicit the bulbocavernosus reflex, a finger is inserted into the rectum, and then the glans of the penis or the head of the clitoris is squeezed. A normal response is a reflex contraction of the anal sphincter.
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There are also characteristic cord syndromes (Table 24-1). In spinal shock, there is flaccid paralysis below the level of the lesion, absent reflexes, decreased sympathetic tone, and autonomic dysfunction. Sensation may be preserved, but if it is absent, the prognosis for recovery is poor. Central cord syndrome is often associated with extension injuries, which can cause circumferential pinching of the spinal cord by the ligamentum flavum. The anterior cord syndrome is associated with severe flexion injuries, especially teardrop fractures, in which a fragment of the fractured vertebral body is driven posteriorly into the anterior portion of the spinal cord.
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Upper extremity position and function may provide clues not only to the presence of a cervical cord injury but also to the level of injury. With injuries at C5, patients can flex at the elbows, but are unable to extend them; with injuries at C6 to C7, they can flex and extend at the elbows; and injuries at the T1 level allow finger and wrist flexion.
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During trauma evaluation, determine whether the child is at risk for cervical spine injury and warrants cervical spine immobilization and radiographic evaluation. Clinical criteria for “clearing” the cervical spine have been established in adults. The National Emergency X-ray Utilization Study (NEXUS) collaboration identified five clinical screening criteria (posterior midline cervical tenderness, altered alertness, distracting injury, intoxication, and focal neurologic findings), which have nearly 100% sensitivity for cervical spine injury and had good interrater agreement among emergency physicians.21–24 Alternatively, the Canadian C-spine Rule has been reported to have nearly 100% sensitivity for cervical spine injury in alert and stable adult trauma patients. The Canadian C-spine Rule was based on clinical, epidemiologic, and mechanism of injury variables.25,26 Neither of these studies focused on children. Recently, a large, multicentered study of 540 cervical-spine–injured children was completed and eight variables were identified that predicted who was at risk for cervical spine injury (Table 24-2).27 When one or more of these factors were present, the model was 98% sensitive and 26% specific for detection of cervical spine injury.27 Although this eight-variable model requires prospective refinement, the consistency of the model with smaller pediatric studies and large adult trials allows the clinician to utilize these findings until further evidence is developed.27
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All trauma victims should be unstrapped and removed from the rigid long board, which is used for extrication and patient transfers in the out-of-hospital setting. This aspect of “full spine immobilization” is known to be associated with adverse effects. Ventilation of trauma victims may be encumbered by full spinal immobilization. Studies in healthy adults and children who were fully immobilized demonstrated a mean reduction in forced vital capacity (FVC) to 80% of their unrestrained supine FVC.28,29 Full spinal immobilization has been reported to cause substantial pain, which may last well beyond the immediate period of immobilization.30–34 Furthermore, pain caused by spinal immobilization may be confused with pain caused by injury leading to unnecessary diagnostic evaluations.30 In spine-injured patients, prolonged immobilization on a rigid long board is associated with an increased risk of developing pressure sores during the immediate postinjury period.35,36 The cervical collar can be discontinued once it has been determined either clinically or radiographically that the victim is free of cervical spine injury.
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If a child may be at risk for cervical spine injury, take steps to maintain neutral cervical spine positioning. In this position, the cervical spine is in lordosis, and there is maximal spinal canal diameter. Achieving this position in children can be difficult. Studies evaluating spine positioning during immobilization indicate that patients, depending on habitus, are often immobilized in nonphysiologic positions. In children younger than 8 years, supine positioning without shoulder padding results in cervical kyphosis due to a relatively large head (Fig. 24-3).37,38 In adults, however, supine positioning causes relative cervical lordosis.39,40 The normal variation in the ratio of head to body among children results in a range of cervical spine positioning of up to 27-degree flexion or extension from neutral during immobilization for trauma transport.41 Thus, as a child grows, padding may be required in either the shoulder or occipital regions to provide neutral positioning.
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Children attended to in the prehospital setting often arrive at the emergency department with immobilization of the cervical spine. Rigid collars are available for infants and children; however, the availability of these devices is limited in the prehospital setting. Cloth tape or straps across the forehead and external orthoses, including a rigid backboard, are usually employed to complete the immobilization. The decision regarding the type of orthosis needed depends on the age of the patient, the affected levels, and the restriction of movement needed (flexion, extension, rotation, etc.). Studies have demonstrated that the commonly available rigid cervical collars, such as Aspen, Miami J, and Philadelphia, all provide significant restriction in neck movement but have subtle variations and the final choice of cervical collar is often based on availability and the recommendations of a spine surgeon.42
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Corticosteroid use in the management of confirmed spinal cord injury in children remains controversial. The investigators of the second National Acute Spinal Cord Injury Study reported that high-dose methylprednisolone (30 mg/kg) followed by 5.4 mg/kg/h for 23 hours, if given within 8 hours of acute spinal cord injury, improved the neurologic recovery as compared with placebo or naloxone.43,44 Children younger than 13 years were excluded from the study. The putative mechanism of action is the ability of the steroid at these doses to inhibit oxygen free radical–induced lipid peroxidation. Lipid peroxidation is thought to mediate cell membrane degeneration and to explain other documented tissue-protective effects of steroids: support of energy metabolism, prevention of posttraumatic ischemia, reversal of intracellular calcium accumulation, prevention of neurofilament degradation, inhibition of vasoactive prostaglandin F2 and thromboxane generation, and retardation of axonal degeneration. Still, there are no clinical trials confirming the efficacy of this regimen in children, but it remains an acceptable option.45 Follow your local or regional trauma center recommendations.