In this section
All children under 16 years of age with major trauma (including confirmed or highly suspected spinal cord injury) should have ongoing management at Royal Children's Hospital. See
State Trauma Guidelines
In Victoria, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service is available to retrieve critically injured children from referral hospitals and provide safe, expert, emergency inter-hospital retrieval. The earlier contact is made with PIPER, the earlier assistance can be dispatched to the hospital.
Major paediatric trauma – The primary survey
Traumatic injuries of the cervical spine (C-spine) are uncommon in children. However, it is typical to assume there is a cervical spine injury until examination and/or radiological investigation demonstrate otherwise. It is often challenging to assess and immobilise children when a C-spine injury is
Any patient with a history of trauma requires C-spine immobilisation, if the patient:
Note: ‘Distracting Injury’ is not a contraindication for removal of the cervical collar. Any injury below the upper torso should not be regarded as a distracting injury for the purpose of C-spine assessment.
Mechanism is more relevant in patients who are unable to be adequately assessed ie preverbal, disoriented/confused, developmental delay etc. Any patient who cannot be adequately assessed
for clinical signs AND could have any of the following mechanisms of injury
should be immobilised:
Patients with suspected or
possible C-spine injury must have their neck immobilised until formal
Sand bags and tape are NOT recommended in the hospital setting
Spinal boards: all children should be taken off spinal board at time of transfer from ambulance trolley.
Thoracic Elevation Device
(TED): Children have a head which is disproportionately larger than their neck and bodies. When placed flat on a firm surface the size of the head tends to force the neck into flexion losing the desired neutral spine position and potentially obstructing the airway. Children less than 8 years should be placed on a TED.
If abnormal neurology – contact neurosurgery immediately
To be able to adequately assess the patient, he/she must:
C-spine assessment, clearance and X-ray interpretation ought to be conducted in consultation with a senior clinician with sufficient experience in the assessment of the paediatric C-spine.
If patient is unable to be assessed, immobilisation should be maintained.
Patients with signs and symptoms suggestive of possible C-spine injury or those with suspicious mechanism who cannot be reliably assessed, require plain x-rays.
It is imperative that the senior person making the clinical decision regarding clearing the c-spine has both examined the patient and viewed the films.
All patient transfers (on/off x-ray tables, CT scan etc.) must be done using a patient-slide, with clinical staff maintaining in-line immobilisation.
The collar and TED pad should remain in place with the patient during the cervical spine x-ray series.
SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is an outdated term, but refers to a patient sustaining significant injury without bony fractures. Therefore, a “normal” xray and CT does not exclude spinal injury. This occurs in children, predominantly less than eight years of age, and may be the result of lax ligamentous support and immature bony structures or cord ischemia due to vascular injury or hypoperfusion. The presence of neurological symptoms, even if there is a normal x-ray and normal CT, requires consultation with a senior Emergency Department doctor initially, and neurosurgery if required.
Patients with normal
x-rays should be reassessed clinically for:
If there is no tenderness and a full range of motion is preserved then
the collar may be removed.
Patients with persistent posterior midline tenderness, or unable to be clinically assessed, but with normal x-rays of the cervical spine can be classified as below:
Otherwise Well Patient with Midline Tenderness +/- Decreased Range of Movement:
- 2-piece collars should only be fitted by those staff trained to do so
handout should be provided to the family
Patients with Other
Significant Injuries and Decreased Range of Motion/Midline Tenderness:
- The cervical spine cannot be safely cleared in a patient with midline
tenderness/decreased range of motion
and other significant injuries.
The following should be documented following discussion with the managing unit:
Pressure area care is important for all patients requiring immobilisation, and should be considered from initial presentation. Air mattresses are not recommended until c-spine has been cleared.
When to consider transfer to
Documentation: Use the Major Trauma management record for documentation of spinal assessment and plan
Further imaging (including CT, MRI) must be discussed with the Emergency Consultant or Orthopaedic/Neurosurgery Registrar, and the Medical Imaging Fellow/Consultant.
Intubated patients requiring CT brain should be discussed with Neurosurgery.
Patients with multiple injuries are admitted under General Surgery with Neurosurgical and/or Orthopaedic input.
Patients with isolated spinal cord injury are admitted under Neurosurgery.
The Neurosurgery Unit at Monash Children’s provides a service for assessment of paediatric patients with brain and spinal injuries. All patients with suspected injury should be discussed with the Neurosurgery Unit (03 9594 6666).