Pediatric emergency medicine trisk 3590 3590
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Patients often arrive in the ED with full or partial cervical spine immobilization
already in place. An immediate assessment of this immobilization is imperative.
Several important issues should be considered: (i) Is the patient appropriately and
fully immobilized? (ii) Is the cervical collar of the correct size and type for the
patient? (iii) Is the patient’s neck in a neutral position? (iv) Is the patient securely
strapped to a long spine board? (v) Has there been a shift in the patient or the
immobilization during the prehospital or interfacility transport that might diminish
effective immobilization, cause hyperflexion or hyperextension of the cervical
spine, or compromise excursion of the chest with respiration? and (vi) Does the
immobilization interfere with the assessment or management of the ABCs? If
these or other immobilization difficulties are identified, they should be
immediately addressed.
If the patient requires initiation of full spinal stabilization and use of a long
spine board, he or she should be secured to the board using tape or straps that
cross the forehead and chin area of the cervical collar. Appropriate straps should
be used to secure the patient to the board at the bony prominences of the
shoulders, pelvis, and lower extremities. Incorrect immobilization may impede
respiration by obstructing chest rise or contributing to secondary spinal injury by
hyperextending the neck. When a child is immobilized on a spine board, the
clinician must remember that the child’s head is disproportionately large
compared with that of the adult. This disparate growth of the head and trunk
causes the neck to be forced into relative kyphotic position when a child is placed
on a hard spine board ( Fig. 112.12 ). This is distinctly different from the adult
patient whose neck is in 30 degrees of lordosis, the neutral position, when
immobilized on a hard spine board. Figure 112.13 demonstrates how cervical
spine alignment can be greatly affected and improved with proper positioning of
the pediatric patient on the spine board. Finally, remove the spine board as soon as
practicable to avoid complications such as pressure sores, pain, or respiratory
compromise.
Consideration of cervical spine radiographic evaluation is the next step in
assessment. The cervical spine has anterior (vertebral bodies, intervertebral discs,
ligaments) and posterior (lamina, pedicles, neural foramen, spinous processes,
ligaments) components ( Fig. 112.14 ) which require evaluation. The provider
should be familiar with criteria to potentially clear a child’s cervical spine
clinically ( Fig. 112.15 ), but recall that regardless of the clearing algorithm
embraced or imaging studies performed, they should never clear the cervical spine
in an unconscious or obtunded patient in the ED. If one is unable to determine
whether an injury (and associated pain) are indeed distracting, or if neck pain or
