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PED-EM-L  September 2002

PED-EM-L September 2002

Subject:

Re: minor c-spine trauma

From:

Rob Ojala <[log in to unmask]>

Reply-To:

Rob Ojala <[log in to unmask]>

Date:

Mon, 23 Sep 2002 08:39:31 +1200

Content-Type:

text/plain

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Parts/Attachments

text/plain (83 lines)

The use of sedation in this group of patients as a general rule is one that I would be reluctant to support. The obvious difficulty is with subsequent assessment of any potential head injury.
I must admit that the few real C-spine skeletal injuries I have seen in this age group [as we know they are rare] behave much like any other broken bone - ie they lie incredibly still to minimise pain.  Patients who wriggle++ generally won't have a skeletal injury [I would argue that in SCIWORA, immobilisation is not such an issue] OR they are cerebrely irritated and sedation is a very tricky issue.
In terms of restraint [in little ol' New Zealand] our general approach is to make use of something that is usually always available [difficult foe EMS to stock all sizes etc] and familiar to the patient - their infant/child safety seat, with head supports added. Purists might argue this is not adequate - we would suggest it is a pragmatic compromise that minimises patient aggitation.
Is this Heretical enough to spark a juicy response from the list?  Show me good evidence that pedi-boards et al. are superior!



Dr R.A.Ojala
 Emergency Physician
The Emergency Department
Christchurch Hospital
Christchurch, NZ
Ph(03)3640270
[log in to unmask]
www.cdhb.govt.nz/ed/


>>> Jason Cerovac <[log in to unmask]> 21/09/02 18:13:33 >>>
Hi,

I have found it exceptionally difficult to properly immobilize any infant, toddler, and certain preschoolers.

There are three management possibilities that have worked in 911/EMS and critical-care transport.

One is the use of mom or dad and hushing techniques.  Get mom or dad to help you immobilize the child and then have them stay close, often holding the child's hand, loose hugs, etc.

Two is the use of a short-acting sedative to place the equipment in place, with additional PRN doses to maintain the peace.

And lastly, and most controversial, is having mom or dad hold the child in a position of comfort.  This raises issues of improper spine control, improper restraint use in the ambulance, etc; and caution must be exercised.

The problem is that once the child is placed onto the pedi-board and strapped down, they don't like it, and they fight.  Kicking, screaming, and jerking every which way.  This could lead to exacerbation of any injury.

Prehospitally, it would be played by ear.  If the child was combative, and I can get an order for sedation (low dose diazepam PR or midazolam IM, just enough to make him lethargic but arousable).  I would want PR or IM because of the quickness it can be given with only little discomfort.  Starting an IV would probably be as bad as trying to put him on the board without sedation.

I had a similar case.  Mom and her toddler son fell from the top of the stairs (mom, carrying the child, took "a bad step").  Both mom and baby had said they hurt, and she said she rolled over him in the fall.

Both were put into immobilizers, both were kept right next to each other the whole time, but I had to hover over the child singing nursery rhymes to keep him reasonable calm.  Medical command would not allow me to sedate, arguing that "a proper neuro exam" could not be performed if he was sedated.

Cest la vie.

Jace

On 9/20/2002 at 9:45 PM Chris + Mandy Cresswell wrote:

:Greetings learned colleagues.  Can I have your ideas about the management
:of the following case?  A 2 year old fell off his father's shoulders and
:landed head first onto hard packed snow.  He screamed with apparent pain
:in his neck.  He had bony tenderness in his mid c-spine.  He was moving
:all limbs vigorously and resisting attempts to immobilise him on a spine
:board.
:
:Should he have been immobilised?  If so how?  Is there a place for
:sedation in this case.  Should he have been left to calm down for a while?
:How would you manage this case in the field?

--
Jason Cerovac, NREMT-Paramedic <O> [log in to unmask]
 "He who gives up essential liberty to obtain a little temporary
    safety deserves neither liberty nor safety" - Ben Franklin

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