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CE ARTICLE FIGURE 3 Top: Inadequate padding; bottom: adequate padding for a pediatric patient. symptoms because the nerves that affect them are concentrated in the central column of the cervical cord. Brown-Séquard syndrome is observed following hemisection of the spinal cord by penetrating trauma. It is fortunately quite rare.5 This syndrome manifests Spinal cord injuries are defined as primary or secondary. Primary cord inju- ries occur at the moment of trauma or impact and may include tearing, lacera- tions, patients is identical to any other spinal cord-injured patient. 4$*803" JT NPTU DPNNPO JO DIJMESFO punctures and compressions. Secondary injuries develop over time and often result from bleeding, ischemia and swelling. Additionally, spinal cord injuries are considered either complete or incom- plete. Complete injuries result in the total loss of both motor and sensory function below the injury site, while incomplete injuries result in some degree of cord impairment. Pediatric patients may have one of several types of incomplete spinal cord injuries, including injuries without radiological abnormalities; central cord syndrome; cord contusion; and Brown- Séquard syndrome.4 When a patient presents with the symptoms and signs of spinal cord injury but boney injury cannot be found, the patient is said to have a spinal cord injury without radiological abnormali- UJFT 4$*803" 4$*803" JOKVSJFT PDDVS nearly exclusively in children because pediatric patients have elastic spinal columns with immature ligaments and muscles that permit cord injury without obvious column injury from hyperexten- sion and hyperflexion. While prehospital providers will be able to detect motor/ sensory deficit suggesting spinal cord injury, do not plan on being able to differ- entiate patients with boney injury from UIPTF XJUI 4$*803" )PXFWFS QSPWJEFST who perform interfacility transports may be asked to transport these patients to trauma centers. Management of these 56 AUGUST 2012 | EMSWORLD.com under 8; in fact, one study found it only occurred in patients younger than 8.9 The authors of this study, led by physi- DJBO 1BUSJDL 1MBU[FS EP CFMJFWF 4$*803" is possible in older children. Mechanisms BTTPDJBUFE XJUI 4$*803" BSF UZQJDBMMZ high-energy impacts with hinging forces that produce extreme stretching and whip- ping of the child's head and neck. There BSF OP EFmOJOH TZNQUPNT GPS 4$*803" other than that the patient will have some type of motor or sensory deficit but x-rays and CT scans will fail to show spinal column injury. Central cord syndrome is an incom- plete spinal cord injury that occurs from hyperextension of the cervical spine. When cervical spinal cord hyperextension occurs, one of two injuries may result, both of which present as central cord syndrome. The more common comes from tearing and/or stretching of the central portion of the cervical spinal cord. Alternatively, central cord syndrome can result if the spinal artery is injured and inadequate blood flow to the central portion of the spinal cord leads to ischemia and then central cord necrosis. Distinguishing these two injuries in the field is impossible. The symptoms of central cord syndrome are hallmarked by a dispropor- tionately greater loss of motor strength in the upper extremities compared to the lower extremities. Additionally some degree of sensory loss is common. The upper extremities experience greater with ipsilateral (same side as the injury) motor loss, the generalized loss of sense of position, and contralateral (opposite side from the injury) sensation loss for pain and temperature. Spinal cord contusions are bruises to the spinal cord, and their presentation is determined on the location of the contu- sion. Typically cord contusions present with some varying degree of sensory or motor deficit in the extremities. Completely flaccid extremities are not consistent with spinal cord contusions. Immobilization Techniques When a patient has a mechanism suggesting a potential spine injury and is not reliable for a spine assessment, immobilization is indicated. The threshold for identifying a mechanism as able to cause a spine injury needs to be lower in children than in adults, particularly since no studies have focused on prehospital pediatric spine clearance.10 There are two goals during immobili- zation: Limit current damage and prevent secondary injury. Immobilization with a cervical collar does not effectively stabi- lize the entire spine. Spine stabilization is achieved with the patient's spine and the weight centers (head, shoulders, pelvis) and legs all in an inline neutral position.10 Pediatric cervical collars are designed for children, and their use is essential as a part of proper immobilization. Be sure to apply the properly sized cervical collar, as using one that's too small will provide no stabilization and may obstruct the airway, while one that's too large may allow the cervical spine to flex. The principles of immobilizing chil- dren are simple: 1. Maintain the spine in a neutral and inline position; 2. Control the weight centers: head, shoulders and pelvis; 3. Controlled spine movement toward Fran Milner, www.franimation.com