Pain In The Neck? C- Spine Immobilization. Jamie Sklar, RN, BSN, MS, CCRN Pediatric Intensive Care Unit The Children s Hospital of Philadelphia

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1 Pain In The Neck? C- Spine Immobilization Jamie Sklar, RN, BSN, MS, CCRN Pediatric Intensive Care Unit The Children s Hospital of Philadelphia Objectives Discuss developmental differences in children and its affect on cervical spine injuries Review mechanisms of neck injury Patterns of injury seen in pediatric population Principles of spinal immobilization Nursing care of patients requiring spinal immobilization Incidence Spinal injury only accounts for 1%- 2% of pediatric trauma 60-80% of vertebral injuries in children are in cervical region Associated with significant mortality and morbidity Higher rates of upper cervical spinal injuries in the younger child due to anatomy Cervical Spine Anatomy Cervical spine consists of 7 vertebrae C1 connects to bottom of skull Cervical spine curves slightly inward C7 joins the top of the thoracic spine Neck Range of Motion Adults vs Peds Level of cervical fulcrum changes C2/C3 in infancy C3/C4 at 5-6 y/o C5/C6 at 8 y/o through adult Pediatric Anatomical Differences Weaker ligaments and surrounding musculature Causes greater mobility and elasticity of cervical spine which allows stretching Underdeveloped protective reflexes Incompletely calcified, wedge- shaped vertebrae Mechanisms of Neck Injury Hyperextension Backward somersaults or fall supine onto an object Distraction Breech delivery Whiplash Dragged by moving vehicle Flexion Blow to occipital head Wrestling match Axial Loading Common football injury Mechanisms of Neck Injury Age Based Patterns of Injury

2 Infants and Toddlers Atlanto- occipital dislocation C2- C3 injuries MVC/car seat Non- accidental trauma Misuse of Child Restraint Systems National Highway Traffic Safety Administration 2004 report 3,442 CRS s observed with 72.6% displaying one or more types of critical misuses Most common misuses Loose connection of restraint to vehicle Loose harness straps securing child to restraint Cervical Seat Belt Syndrome Classification of Pediatric Spinal Injuries Bone injury? Disruption of the osseous structures Ligamentous injury? Injury to cervical spine support system Cord injury? Injury to spinal cord Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) Not commonly used in Pediatrics anymore Spinal cord injury that is not seen on normal radiographic studies (pre- MRI) Plain films CT scan SCIWORA was thought to be more common in children under 8 years old due to elasticity and flexibility of the ligaments Cervical Injury - Treatment Immobilization Fusion Unstable bony abnormality at any level Halo Unstable injury to bridge to surgery or instead of fusion Steroids Penetrating Trauma No steroids Blunt Trauma (most pediatric spinal injuries) Steroids controversial Common in adult world To Immobilize or Not to Immobilize? If the child has a history of Head or facial trauma Loss of consciousness High speed motor vehicle crash Unwitnessed trauma They should have cervical immobilization!

3 Spinal immobilization and placement of a rigid collar should begin in the field, continue to the Emergency Department, and then on to the Intensive Care Unit until it has been determined by physical examination and radiographic studies that there is no injury. Broselow- Luten Color Coding Color- coded pediatric equipment Coded by age/weight Effective for both pre- hospital and inpatient use Extrication collars Philly one- piece Laerdal Stifneck Ambu Perfit Pediatric Sizing Gather age appropriate collar (for children 12 and under) If patient is between sizes, have both available Start with the smaller size first Every child is different! Alternative Sizing Use fingers to measure chin to shoulder distance This should then correlate to top of Velcro to bottom edge of plastic on appropriate sized collar Newborns and Infants Present a challenge due to small necks and large head Preparing for Collar Application Gather personnel 2 to 3 people are necessary for initial application and collar care Person at head of bed is responsible to hold manual c- spine immobilization Gather equipment New collar vs. clean pads Padding for children less than 12 years old Mild soap and water Duoderm Sedation/medications Collar Application Assess skin and clean all areas of neck and shoulders Document all injuries or breakdown Clean with mild soap and water and dry completely Start by sliding posterior side of collar behind neck and shoulders Collar should be centered with padding extending beyond all plastic edges The anterior portion of the collar should be flared and then slide up the chest wall scooping it into place under the chin Verify that the ears are free, and the collar sits above the trapezius muscle Hold the ends of the anterior collar snugly against child s neck prior to application of Velcro straps Velcro straps should be secured at equal lengths to ensure immobilization and comfort

4 Collar Care Care varies by institution Assess fit of collar and skin integrity every 12 hours Change pads and perform complete collar care every 24 hours and as needed Skin should be cleaned with mild soap and water and dried completely Collar pads can be washed with soap and water, plastic should be cleaned as well Halo Care Assess pin sites Clean with normal saline or ½ strength peroxide every 12 hours Assess skin integrity under brace Note breakdown or rash Nursing Assessment Neurologic Examination Skin Integrity If skin reddened, document and apply duoderm May need to reposition or resize collar Monitor for other complications of collar placement Complications of Cervical Immobilization Airway compromise Obstruction from incorrectly sized collar Intubation challenges Vascular compromise Increased ICP Risk of aspiration Skin breakdown Increased agitation, especially infant/toddler Airway Management Current ATLS guidelines recommend manual 2- person in- line cervical spine immobilization technique in both pediatric and adult patients Nursing Documentation Collar type, model and size Date and time collar placed Vital signs and neurologic exam pre and post collar placement Skin integrity and any areas of breakdown Patient and family education Patient & Family Education Provide information to family and patient about collar application process prior to beginning If developmentally appropriate, explain to the child the importance of not moving during the procedure Involve the family by showing them the correct application, assessment and care, and encourage questions as they arise Pediatric Cervical Spine Clearance History & Physical Secondary survey Clinical Clearance (CGS 15)

5 Contraindications Age or developmental concerns Altered mental status Altered level of alertness from ETOH or drugs Neurologic deficits Mechanism of injury Radiographic Clearance Bone AP and lateral films, Odontoid films for children who tolerate CT C1- C2 Ligaments Flexion/Extension MRI Qualified Providers Discharge Activity restrictions Quiet activities such as crafts, reading & video games No head- turning, running, jumping, contact sports or other activities where your child could fall Bathing Change collar to Stifneck or other waterproof version Collar Care Daily, every other day or as needed Soap and watee Follow up appointment Discharge When to call the doctor or nurse practitioner If child has increased pain, numbness or tingling If child re- injures neck If collar is not keeping the head in correct position If the skin under the collar stays red for more than 20 minutes If they need more replacement pads References Cervical Collar: Applying (AP) (Pediatric) Mosby s Nursing Skills. AACN Procedure Manual for Pediatric Acute and Critical Care, American Association of Critical- Care Nurses, edited by Judy Trivits Verger, PhD, MSN, RN, CCRN; and Ruth M. Lebet, MSN, CCNS, CCRN, St. Louis: Elsevier/Saunders, Cervical Collar: Management (AP) (Pediatric) Mosby s Nursing Skills. AACN Procedure Manual for Pediatric Acute and Critical Care, American Association of Critical- Care Nurses, edited by Judy Trivits Verger, PhD, MSN, RN, CCRN; and Ruth M. Lebet, MSN, CCNS, CCRN, St. Louis: Elsevier/Saunders, Cook, B. S., Fanta, K., & Schweer, L. (2003, August). Pediatric Cervical Spine Clearance: Implications for Nursing Practice. (M. Harrahill, Ed.) Journal of Emergency Nursing, Gleisher, Gary, Ludwig, Stephen, Ed. (2010) Neck Trauma. Textbook of Pediatric Emergency Medicine. Chapter 115, p th Edition. Patel 2001

6 Hutchings, L. & Willett, K. (2009). Cervical Spine Clearance in Pediatric Trauma: A Review of Current Literature. The Journal of Trauma Injury, Infection and Critical Care, 67(4) Launay, F., Leet, A., & Sponseller, P. (2005). Pediatric Spinal Cord Injury without Radiographic Abnormality: A Meta- analysis. Clinical Orthopaedics and Related Research, 433, Lustrin, et al. (2003, May). Pediatric Cervical Spine: Normal Anatomy, Variants and Trauma. Radiographics, 23, Marinier, M., Rodts, M., & Connolly, M. (1997). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Orthopaedic Nursing, 16 (5). Muzumdar D, Ventureyra EC. Spinal cord injuries in children. J Pediatr Neurosci 2006;1:43-8 Nishisaki, A. et al (2008). Effect of Cervical Spine Immobilization Technique on Pediatric Advanced Airway Management: A High Fidelity Infant Simulation Model. Pediatric Emergency Care, 24 (11), Reilly, C. (2007). Pediatric Spine Trauma. The Journal of Bone and Joint Surgery, Incorporated, Transportation, U. D. (2004). Misuse of Child Restraints. DOT HS , National Highway Traffic Safety Administration, Springfield. Pictures as noted in presentation