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Cervical Spine Injury

  Introduction 

  Flow chart 

Immobilisation  

Radiology 

  Clearing c-spine 

Proven c-spine injury or c-spine cannot be cleared 

  Ongoing care 

Pressure area care 

See also:  Radiology guideline- Acute indications 

Introduction

Traumatic injuries of the cervical spine are uncommon in children. However in many

circumstances it is prudent to assume there is a cervical spine injury until examination and x-

rays prove otherwise.

It is often challenging to assess and immobilise children when a cervical spine injury is

suspected. Constant reassurance is required to help keep the child still and reduce their

anxiety levels. Depending on the age of the child and their level of anxiety, cooperation may

 be reduced. If the child is uncooperative and a thorough examination is not possible, the

collar must stay on and further assessment completed when cooperation has been established.

This document provides a framework for the management of a child with a possible cervical

spine injury at the R.C.H.

Flow Chart

Click to see flow chart 

Immobilisation

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Patients with suspected or possible cervical spine injury must have their cervical spine

 properly immobilised until formal assessment occurs.

Who to immobilise:

The unconscious patient with a history of possible trauma must be immobilised.Theconscious patient with any of the following:

  A mechanism of injury that may indicate risk of spinal injury: o 

Pedestrian / cyclist hit > 30km/hr.

o 

Passenger - collision > 60km/hr.

o 

Fall - more than 3 meters.

o  Kicked / fall from a horse.

o 

Backed over by a car.

o  Thrown from vehicle.

o 

Thrown over handlebars of bike.

o 

Severe electric shock.

  Multiple trauma

Significant injury above clavicles

  Trauma & Unexplained hypotension

  History of neck trauma

  Neck tenderness

  Limitations of neck movement due to pain

  Neurological deficit

  Other major injuries (e.g. fractured limbs, abdominal injury)

How to immobilise the cervical spine:

  Fit a once-piece hard collar (see sizing below)

  Children <3yo are especially difficult. Rigid cervical collars do not usually fit. They

should be immobilised with parents or staff holding the head and body, or sandbags or

towels in situ and, if cooperative, the head taped to the board.

  If uncooperative, avoid rigidly fixing head to trolley or spinal board unless body also

strapped to board as more damage can be done by a child who is thrashing their body

around while their head is strapped to the board.

If the patient's head is attached to the bed, be particularly aware of vomiting and risk

of aspiration - someone must be with the patient at all times.

In the acute phase there is no place for sedation without intubation to aid cervicalspine immobilisation. However analgesia is an important consideration in trauma

 patients.

Sizing a One piece Hard collar ("Stiffneck" collar is used at the RCH):

A one piece hard collar is used in the initial stage (image 3)

  Measure the distance from the top of the patient's shoulder to the angle of the jaw

with your hand (image 1)

  On the "Stiffneck" collar, measure from the bottom of the rigid plastic to the

"measuring post". This should correspond to the above measurement (image 2)

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Image 1: Measuring collar 

Image 2: Measuring neck  

Image 3: Appropriately fitting collar 

Patient position, head immobiliser, rolled towels & tapes:

Lie flat on back with staff or parents holding.

If cooperative - consider rolled towels and tape head to spinal board, towels or headimmobiliser (not trolley) to maintain alignment and keep still.

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Spinal boards:

  Can aid spinal immobilisation in early assessment phase of major trauma but should

 be removed as soon as possible. Patients should not leave the emergency department

whilst still on a spinal board.

For patients < 8yo lying on a spinal board, the large occiput causes neck flexion.These patients should have extra padding under the body but not head (eg. folded

 blanket) to keep neck in neutral position.

  Spinal boards cause significant patient discomfort and can result in pressure ulcers.

Once a decision is made to immobilise the patient the hard collar should remain on or until

cervical spine is cleared. (see - Clearing the c-spine of injury).

Radiology

Who to x-ray:

X-ray 

o  Patient has altered conscious state or 

o 

Adequate assessment of neck symptoms not possible due to distracting injury

or intoxication/sedation or 

o 

 Neck tenderness or pain or 

o 

Abnormal neurological signs

Do not x-ray o 

Patient is alert and has normal conscious state and 

o   No distracting injury, intoxication or sedation etc. and No neck pain or

tenderness and 

o   Normal neurological examination

How to x-ray

  A doctor or nurse from Emergency or Intensive Care MUST accompany the patient to

radiology for imaging to ensure maintenance of cervical spine immobilisation and

airway management.

The patient must be transferred onto the XR table using a patient-slide keeping thespine in-line and with the head being held.

  The x-rays are taken on the XR table without lifting or moving the patient's head.

  The patient is transferred off the table with the same precautions used to move them

on.

The hard collar should remain in place during the cervical spine xray series.

What to x-ray

a.  Lateral c-spine (portable) will be taken in ED/ICU for: 

o 

All major trauma patients (along with trauma series - Pelvis on needs only basis)

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o  Other patients who need portable x-ray for other reason (e.g. chest x-rays

o 

This does not exclude an unstable injury.

 b.  Cervical series will be taken in Radiology (Lat. / AP / Odontoid view (>/=5 yo)): 

o 

If the cervicothoracic junction has not been satisfactorily imaged, a swimmer's

view will be obtained. A single attempt should be made

o 

Oblique views will only be done if required by the orthopaedic orneurosurgical unit.

o  Flexion and extension views are inappropriate in the acute stage and will not

 be performed.

Patients requiring c-spine CT scan:

  Must be discussed with the emergency consultant or unit registrar

  All intubated patients requiring CT brain should have CT c-spine performed at the

same time

  Patients in whom the cranio-cervical or cervico-thoracic junction remain obscured

after a single extra view should not have repeated attempts at plain imaging but have a

CT of the relevant area

  Patients with abnormalities on plain c-spine xrays should have a CT of the relevant

area

 Note: If imaging is necessary, a full c-spine series or CT scan must still be completed prior to

removal of the collar.

Clearing the c-spine of injury

Who can clear the c-spine?

If the patient is to be discharged from the ED, the Registrar from the following units may

clear the c-spine after discussion with the ED Consultant on duty:

  Emergency

  Intensive Care

  Orthopaedic

 Neurosurgery  General Surgery

The Registrar making the decision should be EMST / APLS (or equivalent) trained. If the

 patient is an inpatient or potentially an inpatient the c-spine can only be cleared after

consultation with the Neurosurgical or Orthopaedic Consultant, or the Emergency consultant

if the patient is still in the ED.

How to clear the c-spine:

Clearing the c-spine on clinical grounds:

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Examine the patient: Collar is removed and, while a senior staff member maintains the head

alignment, the examining doctor checks for the following points in sequential order:

1.  Can pain and tenderness be assessed?

2.  Are there other distracting injuries? (Another injury in this patient that distracts from

 possible spinal injury)3.  Is there midline neck pain?

4. 

Is there tenderness over the cervical spine?

5.  Are there any motor or sensory abnormalities?

6. 

Is there limitation of active neck movement?

7.  Is there limitation to head control?

If these are all absent the collar may be removed.

If any of these are present imaging is warranted

Clearing the c-spine after radiology:

It is imperative that the person making the decision has both examined the patient and viewed

the films.

1. View the films: The examining Doctor must view the films. If there is any doubt about the

'normality' of the films a second opinion should be sought.

2. Re-examine the patient: Collar is removed and, while a senior staff member maintains the

head alignment, the examining doctor checks for the above points in sequential order: (see

above) 

If either the films or examination cannot be adequately cleared the cervical collar should

remain insitu. (See - Ongoing care) 

Documenting the c-spine clearance:

Spinal clearance (or inability to clear the c-spine) MUST be documented by the examining

doctor in either the 'Major Trauma management record - Medical' or in the patient's history as

soon as a decision is made so all staff are aware and appropriate care provided. If the spine is

not cleared a plan for further assessment of the spine must also be documented, and a two

 piece hard collar should be fitted.

It is imperative that this decision is made quickly so that, if cleared, the collar can be

removed.

Proven cervical spine injury or cervical spine cannot be

cleared

  Careful neurological examination

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  Refer patients with isolated bony injury to Orthopaedics

  Refer patients with any neurological deficit to Neurosurgery.

Admit all major trauma patients under general surgery.

  Imaging of the spine should include plain films plus CT of the affected area, with

MRI for imaging of the spinal cord.

Ongoing Care

Guidelines for timing of fitting long term hard (Aspen) collars:

(a) For patients being discharged:

If imaging is normal and there is ongoing tenderness of the posterior c-spine but the

 patient is well enough to be discharged, a two piece Aspen (or Philadelphia) collar

should be applied.

  The patient should be brought back to Fracture clinic within 2 weeks for review

(discuss with orthopaedic registrar).

(b) For admitted patients:

By 6 hours, a c-spine injury decision should be made & ideally the one-piece hard

collar is changed to a two piece Aspen (or Philadelphia) collar within 6 hrs if the c-

spine cannot be cleared. The patient must not go any longer than 12 hours in a one-

 piece hard collar. If at 12 hours the decision has still not been finalised a two-piececollar must be fitted regardless; Contact Orthotics department (x5870).

Pressure area care (PAC)

Children <3 years old - greatest area for pressure ulcer is the occiput.

  Children >/=3 years old - greatest area for pressure ulcer is sacrum & heels.

Children must be removed from spinal board as soon as possible.

  Pressure area care must be considered throughout the resuscitation phase.

Every 2 hours (pressure must be relieved from all bony prominence at least every 2hours):

  Collar must be removed: 2 people, one holding head in alignment the other

removing the collar, cleaning under collar area observing for areas of redness or

 breakdown. Clean the collar.

Log roll: Depending on size of patient: 2-4 people to log roll (supporting head,

shoulder and torso, hips and legs)

o 

Log rolling must be done with the one or two piece hard collar on. Observing

in particular heels, hips, and occiput for pressure areas.

  Feet and legs: Passive range of motion and PAC with particular attention to heels.

Orthotics may be required to keep feet in alignment.

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Positioning:

Ideal positioning:

  Flat on back

Hourly PAC

Bed tilting - (if the head is to be elevated for neurological reasons):

  If none of the spine has been cleared the bed should be tilted maintaining body

alignment- trendelenburg tilting.

If everything but the c-spine has been cleared then the bed can be tilted from the hips.

Side to side:

Only once c-spine cleared or fused or at the direction of neurosurgical or orthopaedic

consultant.

   No other injuries that contraindicate side to side positioning (e.g. # pelvis).

  Consider use of spinal bed.

Air mattresses:

  Should not be used for patients that have not had their cervical spine cleared.

May be used once the c-spine has been cleared or spinal fusion has taken place.

  If cervical spine cannot be cleared but the mattress is required for pressure area care,

these individual cases must be taken up with the Orthopaedic and/or Neurosurgical

team looking after the patient.