This issue includes 4 hours of ACEP/AMA category 1 CME credit.
Authors: Julie A. Haizlip, MD, RPh and Patricia D. Scherrer, MD
Peer Reviewers: Lisa Freeman-Grossheim, MD, FAAM and Paula J. Whiteman, MD, FACEP, FAAP
Publication Date: July 1, 2008
Excerpt from the issue… The Friday night shift brings a variety of traumatic injuries. First, a 15-year-old football player tackled the opposing quarterback while leading with his helmet. At the end of the play, he could not stand and stated his arms were tingling and both his legs were numb. Next, a 3-year-old fell down a flight of stairs after tripping on a toy. She is alert and crying but will not allow anyone other than her parents near her. Finally, an 8-year-old is brought in as a trauma alert, following a motor vehicle crash where another passenger was killed at the scene. This boy is unresponsive and is being bag-mask ventilated by the emergency response team.
Each of these children arrives to the emergency department with a cervical-spine-immobilizing collar in place. Despite very different mechanisms, each will require a complete cervical spine evaluation. What is required to safely remove the collar? Could any of these children be clinically cleared? What radiographic studies are indicated? When is expert consultation required?
Conclusion to the above case study... Each of the three patients had a mechanism of injury that required cervical spine evaluation. Neurosurgery was consulted to see the 15 year-old football player. A cervical spine CT demonstrated no bony injury. An urgent MRI demonstrated soft tissue and spinal cord edema. Cervical spine immobilization was continued, and he was admitted for neurological monitoring. At the time he was trans¬ported to his room, the tingling in his arms was subsid¬ing, but his lower extremity deficits persisted.
After some time, the three year old became less distressed and more active. Despite her cervical collar, she was playful and walked to the soda machine with her mom. At that point she cooperated with a physical exam, during which she had no neck tenderness and she demon¬strated a full active range of motion. Her cervical spine was cleared clinically and she was discharged to home.
The 8 year old was admitted to the Pediatric Inten¬sive Care Unit, where an intracranial pressure monitor revealed severe intracranial hypertension. Despite no obvious bony abnormality on plain films, his clinical course prevented MRI evaluation for ligamentous injury within 72 hours of his accident. Therefore, he remained in a cervical collar at the time of transfer to a rehabilitation facility. He was scheduled to follow up with Orthopedics for further evaluation in 6 weeks.
About this article: Simple management algorithms that can be used to treat adults are not readily applicable to children because of the unique patterns of injury. Because failure to recognize a CSI can prove to be disastrous, prompt stabilization at the scene and accurate diagnostic evaluation in the emergency department are imperative.
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