Renal/ airway/ paediatrics

Question 1

A previously well 65 year old female presents to your ED with the concern that she has a UTI

1. Provide definitions for each of the following categories of urinary tract abnormality and state the significance
2. She has a 3 day history of dysuria, flank pain and rigors. She weighs 70kg and has previous anaphylaxis to cephalosporins and penicillins. Her observations are:

HR: 120
BP: 85/43
Sats: 93%
RR: 26
Temp: 38.9
GCS: 14

Urine analysis is consistent with a UTI

2. What antibiotic treatment does she require?
3. Fluid regime

i. What resuscitation fluid has been shown to cause harm and should not be administered in this patient?

ii. What is the minimum fluid volume you would aim to deliver within one hour if clinically appropriate?

iii. List 4 clinical endpoints you would use to guide ongoing fluid resuscitation in this patient?

4. Using bedside ultrasound what findings would suggest inadequate fluid resuscitation?
5. Vasopressor agents

i. List one clinical indication for commencing a vasopressor after adequate fluid resuscitation

ii. Please list your first line and second line vasopressor agents and there dose range

Answer 1

1. See table

IV antibiotics

1st line
-Gentamicin 7mg/kg IV
-Then PO ciprofloxacin 500mg BD for 7 days

2nd line
-Meropenem 1g IV q8h

i) Synthetic colloid hetastarch

ii) Aim for at least 10ml/kg in first hour and 30ml/kg in first 3 hours

iii) MAP > 65, HR < 100, UO > 1ml/kg/hr, CRT 2s

4. IVC collapsing > 50% on inspiration, hyperdynamic LV function

i) If clinical endpoints have not been meet, lactate > 4

ii)
1st line: Noradrenaline 0.05-0.25mcg/kg/min
2nd line: Vasopressin 0.01-0.06 units/ minute

Question 2

A 5 year old child of mixed aboriginal and caucasian descent presents to ED with lethargy over 6 days. His mother states he is no longer eating or drinking due to vomiting and he is no longer urinating as of 24 hours ago. He has the following appearance:

His vital signs at triage are:
-RR: 45
-HR: 145
-Sats: 91%
-BP: 125/85
-Temp: 38
-GCS: 15

1. State 4 important differential diagnosis to consider in this patient. For each differential state 4 important differentiating features on clinical or investigative assessment.
2. Hist urine dipstick shows the following:

-Protein 4 +
-Nitrites negative
-Epithelials negative
-RBC’s negative

His biochemistry results include
-pH: 7.25 -PaCO2 60 -Na: 135 -K: 6.5 -Cl: 109
-HCO3: 15 -Urea: 23 -Cr: 158 -Glucose 2.8
-ALT: 22 (27 -55) -AST: 33 (38-48) -ALP: 22 (40-129)
-Albumin: 2.8 (3.5-5.0) -Total protein 5.5 (6.3-7.9)
-Bilirubin: 0.2 (0.1-1.2) -GGT: 60 (58-61)
-LDH: 566 (122-222)

Provide an interpretation of findings with rationale

3. Outline your management of this patient
4. State 5 important complications that may ensue in this patient

Answer 2

Nephrotic syndrome - minimal change disease

—> Oedema, proteinuria ≥ 3+, hypoalbuminaemia < 25, hyperlipidaemia

-Nephrotic syndrome can be complicated by:
-Spontaneous bacterial peritonitis –> fever
-Thrombosis

Nephritic syndrome
-Acute poststreptococcal glomerulonephritis

—> Oliguria, hypertension, haematuria, proteinuria, AKI

-Preceding GAS infection (2 weeks)
-Volume overload –> heart failure, pulmonary oedema
-Hypertensive encephalopathy –> seizure

-Leukocytes and RBC casts in urine
-Proteinuria ≤ 2+
-Decreased C3

Treat with fluid restriction

Haemolytic uraemic syndrome

–> Preceding (7-10 days) diarrhoeal illness (bloody) E.coli 0157 –> shiga like toxin

–> Present with oedema, lethargy, oliguria, abdominal pain and vomiting

–> Microangiopathic haemolytic anaemia, thrombocytopenia, AKI

HSP

Congestive heart failure

Urinalysis: 4+ protein consistent with nephrotic syndrome

-AG = 135 - 109 - 15 = 11
-HCO3 15 (low)
-NAGMA likely secondary to renal insufficiency
-Expected CO2 = 30

Respiratory acidosis with PaCO2 of 60 secondary to increased dead space ventilation from pulmonary oedema or effusions

Urea/Cr = 23/0.158 = 23/1/6 = 138 = pre renal AKI

Hyperkalaemia secondary to pre renal AKI
Needs an ECG to assess for signs of hyperkalaemia

Hypoglycaemia secondary to substrate deficiency
–> needs 2ml/kg of 10% dextrose and maintenance fluid of 5% dextrose and normal saline

Nephrotic syndrome leading to:
-Hypoalbuminaemia
-Pre renal AKI and hyperkalaemia
-NAGMA from AKI
-Pulmonary oedema and effusion leading to type II respiratory failure

Nephrotic syndrome

-Prednisolone 1-2mg/kg in discussion with paediatrics

-Oxygen HFNC 2L/Kg

-20% albumin 5ml/kg (1g/kg) IV over 4 hours

-Furosemide 1mg/kg over 20 minutes IV

-Ceftriaxone 50mg/kg IV

-2ml/kg of 10% dextrose

-Discuss with paediatric nephrology / ICU re haemodialysis

-Infections: spontaneous bacterial peritonitis, cellulitis (oedema)

-Thrombosis: DVT, cerebral venous sinus thrombosis, renal vein thrombosis (loin pain)

-Hypovolaemia

Question 3

What are features of post streptococcal glomerulonephritis?

Answer 3

Sequelae of streptococcal pharyngitis and less commonly streptococcal skin infections - deposition of immune complexes in the kidney

Children aged 3-7 with history of fever or pharyngitis 2 weeks prior

Haematuria, flank pain, lethargy, oedema

Can present with
-Pulmonary oedema, cardiac arrhythmias, hypertension
-Renal failure in 2%

Diagnosis
-Urinalysis: blood and protein
-RBC casts in 60%
-Pyuria, granular or hyaline casts
-AKI
-Hyponatremia, hyperkaliemia
-Decreased C4 and C3

Differential diagnosis
-IgA nephropathy - simultaneous upper respiratory tract infection
-Goodpasture’s
-Wegener’s
-HSP
-HUS
-SLE

Management
-Fluid and salt restriction
-Diuretics - thiazides
-Beta blockers for hypertension

Question 4

A 4 boy is brought to your ED having sustained a 4cm eyebrow laceration following a fall at a playground. He is accompanied by his mother.

You plan to suture the wound under procedural sedation using ketamine

1. List 8 contraindications in this setting
2. List 4 potential side effects/ complications associated with ketamine use in this setting
3. Complete the following table regarding ketamine usage in paediatric procedural sedation by route of delivery

The procedure has commenced and ketamine has been given. The nurse notices the waveform capnography has been lost ant the patient is apnoeic

4. List 4 possible causes for this patient apnoeic episode
5. List and explain in detail your 7 steps in the management of the above situation
6. After the above clinical crisis has been resolved and the patient has left your department list and detail 3 steps that need to be addressed from the above case

Answer 4

-Parental refusal
-Previous adverse reaction to ketamine
-Inadequate staffing/ area/ equipment
-Procedure required unsuitable to ketamine sedation
-Raised intraocular pressure - globe injury
-Altered LOC with herniation syndrome
-Active pulmonary infection or disease including asthma/URTI/LRTI
-Full meal within 3 hours (relative contraindication)
-Unstable patient - seizures, vomiting, hypotension
-Cardiovascular disease - e.g. heart failure, CHD, HTN
-Procedures involving stimulation of posterior pharynx
-Known difficult airway or tracheal abnormality
-Thyroid disorder
-Psychosis
-Porphyria

-Airway obstruction/ laryngospasm
-Apnoea
-Emergence phenomena
-Random movements (can resemble seizure activity)
-Hypersalivation
-Vomiting (during or after procedure)
-Nystagmus

3. See table

-Laryngospasm
-Respiratory depression from ketamine
-Anaphylaxis
-Airway obstruction from vomit/ hypersalivation
-Patient illness - e.g. raisied ICP

Request more help urgently - emergency alert and prepare for possible intubation

Assess and manage patients airway
-Airway maneuvers - neutral position, jaw thrust, head tilt, suction, look for FB

Assess breathing and confirm apnoea
-Look for rise and fall of chest, auscultate, confirm position and connection of ETCO2, ensure sats monitoring

PPV with BVM and PEEP valve 5cmH20 (15L/min)

Assess and manage circulation
-Confirm pulse and rate, commence CPR if absent
-Establish or confirm IV access

Midazolam 0.1mg/kg IV

-Final step is RSI
-Succinylcholine 2mg/kg IV (4mg/kg IM)

Open disclosure with parents
-Explain there has been a complication and how it was managed.
-Provide support from a patient advocate.

Debrief with registrar and nurse and offer support
-Identify knowledge gaps
-Opportunity for education
-May require disciplinary action if serious concern

Departmental implications
-Morbidity and mortality meeting
-Review policies and procedures for procedural sedation
-May have to deal with complaint from parents
-Supervision and staffing
-Credentialing

Notes
-IV ketamine: Maximum dose 4.5 mg/kg (though this would be rarely required). IV doses of >2.5 mg/kg are associated with increased risk of adverse events.
If doses higher than 2.5 mg/kg are required, consider aborting procedure / explore alternative sedation options.

Question 5

A 65 year old male presents following a fall. He complains of a painful swollen left wrist. An X-ray of his wrist is shown below:

1. Describe his XR
2. List 4 options for achieving suitable anaesthetic or analgesic conditions for reduction of his fracture
3. List 6 contraindications to performing a Bier’s block
4. List 8 key steps in performing a Bier’s block
5. You decide to perform a regional nerve block to achieve suitable conditions for reduction. Explain the technique for axillary block.
6. List the nerves involved in this procedure
7. How would you ascertain if they are suitably anaethetised?

Ultrasound image for axillary block

8. Label the key landmarks on the diagram provided
9. List 5 complications due to regional nerve block procedures

Answer 5

1. Intra-articular fracture of the distal radius with dorsal angulation

2.

Procedural sedation

Biers Block

Axillary nerve block

Haematoma block

General anaesthesia in theatre

-Refusal of patient
-Uncooperative patient
-Compromised limb circulation
-Compartment syndrome of affected limb
-Peripheral vascular disease/ raynauds
-Systolic BP > 200
-Unable to gain bilateral IV access
-Sickle cell disease
-Ipsilateral humerus fracture
-Local anaesthetic sensitivity/ allergy
-Staff/ area/ equipment unavailable
-Soft tissue injury at torniquet site
-Age < 10/ paediatric patient
-Severe liver disease
-Unstable epilepsy

-Consent - ideally written
-Ensure procedure is in a resus bay with appropriate staff and monitoring.
-Check equipment working.
-IV access in dorsum of ipsilateral hand and AC fossa of contralateral arm
-Elevate the injured arm to exsanguinate the limb
-Inflate cuff - > 100mmHg above systolic BP
-Check for absence of radial pulse
-Injection of local anaesthetic - prolocaine 0.5% 3mg/kg
-Remove the canula in the dorsum of injured arm and apply pressure
-Perform procedure
-Deflate cuff after a minimum of 20 mins and post procedural monitoring for toxicity etc.

-Written consent
-Ultrasound machine with high frequency linear transducer
-Syringe with 2% lidnocaine and 22g needle
-Position patient - abduct arm to 90 degrees
-Gown, sterile gloves, clean and drape
-Place probe immediately distal to wear pectoralis major inserts on the humerus on the medial aspect of arm
-Identify the axillary artery and nerves
-Insert needle in plane from anterior aspect and deposit aliquots of local anaesthetic around the axillary artery (2-3 injections) and the muculocutaneous nerve

-Median, ulnar, radial, musculocutaneous

Median (C5,6,7,8,T1)
-Flexion of wrist and digits, forearm pronation, wrist abduction, thumb abduction, flexion and opposition
-Sensation over thenar eminence

Radial (C5,6,7,8,T1)
-Extension at elbow, wrist and fingers
-Sensation over 1st dorsal web space

Ulnar (C8/T1)
-Wrist flexion and adduction, digit flexion, adduction and abduction, little finger opposition
-Sensation over 5th finger

9. Median nerve
10. Ulnar nerve
11. Axillary artery
12. Axillary vein
13. Radial nerve
14. Musculocutaneous nerve

9.

-Local anaesthetic toxicity
-Block failure
-Vascular injury
-Bleeding/ haematoma
-Neurological injury
-Infection

Question 6

What is the maximum lidocaine dose?

What is the maximum ropivocaine dose?

What is the maximum bupivocaine dose?

Answer 6

Lidocaine 2%
-Duration of anaesthesia 2-5 hours
-4.5mg/kg
-7mg/kg with adrenaline

Ropivocaine 0.5%
-Duration of anaesthesia 4-12 hours
-3mg/kg
-3.5mg/kg with adrenaline

Bupivacaine 0.5%
-Duration of anaesthesia 5-15 hours
-2.5mg/kg
-3mg/kg with adrenaline

Question 7

How do you do a femoral nerve or fascia iliaca block?

Question 8

How do you do an ankle block?

Question 9

Propofol dosing for procedural sedation?

Answer 9

1-2mg/kg IV

0.5mg/kg doses as needed

Onset seconds
Duration minutes

Question 10

Techniques to reduce pain of local anaesthetic injection?

Answer 10

Topical agent prior to injection

Smallest gauge needle possible (27-30g)

Inject slowly

Inject subcutaneous space, not dermis

Minimise number of punctures

Question 11

What are features of local anaesthetic toxicity?

Answer 11

Circumoral tingling

Dizziness

Tinnitus

Visual disturbance

Muscular twitching

Confusion

Convulsions

Coma

Apnoea

Cardiovascular collapse

Question 12

Adverse reactions to local anaesthetics other than systemic toxicity?

Answer 12

Allergy

Catecholamine effects from added adrenaline

Vasovagal

Malignant hyperthermia

Methaemoglobinaemia - prilocaine, benzocaine

Question 13

You are notified by the ambulance service that an 11 year old girl is on her way to your regional ED after a high speed MVA.

1. State the important aspects of organisation you will undertake in ED to prepare for her arrival with specific attention to:

Staffing/ teams

Protocols/ procedures

Equipment

Medications

2. State 10 important anatomical and physiological factors that need to be considered when dealing with paediatric trauma
3. List the potential indications you would consider for intubation in the setting of multi-trauma in children
4. State 5 mechanisms that may affect ventilation in paediatric multitrauma (do not list individual pathologies)
5. Her vital signs on arrival are:

HR: 120
Temp: 35.6
BP: 70/50
Sats: 90% on RA
GCS: 14/15
Her trauma CXR is normal and her pelvic XR is shown below

Classify the radiological abnormality and state the findings that support this.

6. List 5 possible complications of this injury. State how you would assess for these in ED.
7. List 2 alternate options for further management of this patients pelvic injury
8. List 5 factors which may affect your choice in the above management options

Answer 13

Staffing/ Teams
-Team leader assemble teams
-Airway doctor and nurse
-Circulation and procedures doctor

Protocols/ procedures
-Make trauma call to trauma surgeons, ICU, anaesthetics, paediatrics
-Alert radiology for plain film and CT
-Activate blood bank

Equipment
-Weight age + 4 x 2 = 30kg
-Airway equipment: size 6.5 ETT (age/4 + 4)
-Depth of ETT: tube size (mm) x 3
-Fentanyl 1mcg/kg, ketamine 1-2mg/kg
-IV/IO equipment
-Warmed normal saline 20ml/kg
-ICC: largest diameter is 4 x the ET tube size
-Orogastric, nasogastric or foley size is 2 x the ETT size

Large head and brain less myelinated, cranial bones thinner
-Leads to more serious head injury

Cervical spine
-Fulcrum is at a different level - C3 above
-Increased rates of SCIWORA - more tenuous spinal cord and blood supply and more flexibility of spinal column

Airway - surgical airway not possible, early obstruction - needle cricothyrotomy

Chest
-Ribs pliable - no rib fractures - pulmonary contusions
-If rib fractures sign of high velocity trauma

Abdominal organs - liver and spleen not as covered by rib cage and are more anterior and less protected by musculature and subcutaneous tissue mass. Kidney less protected and more mobile making it susceptible to deceleration injury.

CVS
-CO primarily due to HR and SVR, limited ability to increase contractility
-Can compensate for 30% of blood loss by increasing HR and SVR
-Focus on CRT and HR rather than blood pressure in determining severity of shock

Temperature/ body surface area
-Larger body surface area leading to greater potential for heat loss
-Hypothermia contributes to acidosis, negative inotropy, platelet function and catecholamine responsiveness

Growth plates
-Not closed leading to salter harris type fractures

Maintenance fluids, oxygen extraction and consumption, glucose utilisation are much higher per kg in children

Obstructed airway
-Unable to BVM

Type I respiratory failure - inadequate oxygenation

Type II respiratory failure - inadequate ventilation

Raised ICP - GCS < 9 - unable to protect airway, need to lower CO2

Severe decompensated shock resistant to fluid resuscitation
-Remove work of breathing

Anticipation of airway obstruction - severe burns

Management of agitation or severe distress

To facilitate safe transport

-Airway obstruction
-Reduced LOC- hypoventilation
-Pain - hypoventilation
-V/Q mismatch - pulmonary contusions
-Impairment of bellows action of chest wall - flail segment

Young and burgess classification
-Lateral compression fracture type III
-Superior and inferior pubic rami fractures, fracture of left iliac wing

Vascular injury
-Arterial or sacral venous plexus
-Signs of shock
-Blush on CTA

Urethral injury
-Blood at meatus
-Perineal bruising
-Inability to insert IDUC

Bladder injury
-Retrograde urethrogram with contrast extravasation

Lumbosacral plexus nerve injury
-Cauda equina, parasthesias, weakness of lower limb

Rectal injury - compound fracture
-PR bleeding, bony fragments on PR exam

Genitalia injury
-PV bleeding, perineal haematoma

-Interventional radiology - embolisation of potential arterial injury

-Operating theatre for surgical management/ pelvic packing/ external fixation

-Availability of interventional radiology resources and staff vs theatre resources and staff
-Haemodynamic stability of patient - best to go to OT if ongoing instability
-Associated injuries of patient - better to go to OT if associated chest or abdominal injuries
-Results of FAST scan - positive FAST for intra abdominal bleeding should go to OT
-Presence of blush on CTA of pelvis - may benefit from interventional radiology and embolisation

Question 14

A 4 year old boy arrives at your urban district emergency department one hour after falling from a playground slide. The nearest neurosurgical service is twenty minutes away by road ambulance.

1. State 5 important anatomical or physiological factors to consider in the setting of paediatric head injury
2. State 10 important clinical factors to consider during the assessment of this child in determining his further management in ED

His vital signs are:

GCS: 13 (opens eyes to speech, appears confused, obeys commands)
HR: 100
BP: 90/60
Sats: 98% on RA

An image from his CT head is shown

3. List 4 important findings on the above CT image
4. State the important clinical features you would assess for raised intracranial pressure
5. State your management of this patient
6. What are the differences between epidural haematoma and subdural haematoma?

Answer 14

-The cranial vault is larger and heavier in proportion to the total body mass. Predisposes to high degrees of torque that are generated by forces along the cervical spine axis.
-Sutures within the padiatric are skull are both protective and detrimental to the outcome of head injury. Although the cranium may be more pliable relative to the traumatic insult the forces generated internally predispose the paediatric patient to parenchymal injury in the absence of skull fractures.
-The paediatric brain is less myelinated with higher water content predisposing it to shearing forces, further injury and post traumatic seizures
-Paediatric brain is sensitive to decreases in oxygen, perfusion, glucose. Maintenance reduces further brain insult and optimises chance of recovery. CPP = MAP - ICP. Goal MAP > 60 (age 2-6).

-Primary survey assessing for life threatening injuries

CHALICE rule

History
-Witnessed LOC > 5 mins
-Amnesia > 5 mins (retrograde or anterograde)
-Abnormal drowsiness
-≥ 3 vomits after head injury
-Suspicion of NAI
-Seizure after head injury

Examination
-GCS: < 14
-Suspicion of penetrating or depressed skull fracture, or tense fontenelle
-Signs of basal skull fracture
-Focal neurological sign
-Bruise, swelling or laceration > 5cm (if < 1 year old)

Mechanism
-High speed MVA as pedestrian, cyclist or occupant (> 64km/hr)
-Fall > 3m in height
-High speed injury from projectile or an object

PECARN rule age > 2
-GCS < 15 or signs basal skull fracture or AMS –> CT
-History of, vomiting, LOC, severe headache, severe mechanism –> observation vs CT scan (shared decision making)

PECARN rule age < 2
-GCS < 15, palpable skull fracture, AMS –> CT
-History of scalp haematoma (excluding frontal), LOC > 5s, not acting normally, severe mechanism –> observation

Large left sided extradural haematoma

-Heterogenous - ‘swril sign’ consistent with ongoing bleeding
-Subfalcine herniation
-Midline shift
-Effacement of ventricles and sulci

-Papilloedema
-Reduced LOC
-Focal neurological deficits
-3rd nerve palsy, 6th nerve palsy
-Abnormal posturing (decorticate or decerebrate)
-Cushings triad
-Headache and vomiting

5.

-Needs airway secured to facilitate transfer, lowering of intracranial pressure
-Requires urgent neurosurgical intervention
-Arrange urgent transfer

RSI
-Size 5 ETT (4.5 and 5.5 available), bougie, CMAC2, LMA size 2
-Weight: 16Kg

Preoxygenate
-Assisted BVM ventilation with PEEP valve 5cmH20 for 3 mins
-Target sats > 95%, end tidal CO2 30-35mmHg

Optimise haemodynamics
-Target MAP > 60, HR 100-120, CRT 2s
-20ml/kg fluid bolus normal saline
-Noradrenaline 0.05mcg/kg/min

Neuroprotective measures
-HOB up 30 degrees, head in midline
-Hypertonic 3% saline, 3ml/kg
-Mannitol 20% 1g/kg

BVM through period of apnoea to prevent worsening acidosis

Maintain normothermia, normoglycaemia, adequate oxygenation

Epidural haematoma
-Caused by bleeding from meningeal vessels and often associated with overlying fractures
-History of head injury followed by a lucid interval followed by rapid deterioration as ICH worsens

Subdural haematoma
-Secondary to rupture of bridging veins
-Less than half of paediatric cases have overlying fractures
-Occur most commonly in patients < 2 years of age
-Subdural haematomas at multiple sites over areas other than the convexities should suggest the possibility of NAI

Question 15

A 5 year old boy was jumping on a trampoline and fell off awkwardly landing ‘head first’ according to the mother, who admits she did not see the moment of impact with the grass surface. He was not knocked out, did not have a seizure post fall and was able to get up spontaneously afterwards. He continued to complain about neck pain and an ambulance was called; he was immobilised in a rigid collar and brought to ED. A small bruise is present on his forehead. His vital signs are normal and his GCS is 15. He is smiling in ED and conversing with his mother.

1. Discuss the relevance of mechanism of injury in this case; provide rationale
2. Explain your approach to assessment of this child with a potential C-spine injury and outline your approach to C-spine clearance
3. Discuss your approach to C spine immobilisation in young children in ED
4. You decide the child requires initial plane film imaging, discuss the anatomical and physiological differences in the paediatric C-spine of this child and the impact on imaging. Explain your solutions to these challenges.
5. The childs xrays are shown. State the key aspects on lateral neck and AP xrays that need to be assessed and checked. Provide an interpretation.

Answer 15

Axial compression –> burst fracture C1 (very unstable)

Hyperextension injury –> extension teardrop (unstable), hangman’s fracture C2 (unstable)

Hyperflexion injury –> anterior wedge fracture (stable), flexion tear drop fracture (unstable), bilateral facet joint dislocation (unstable), displaced odontoid fracture (unstable), clay shovelers fracture (very stable)

Rotation
-Unilateral facet joint dislocation (stable)

-Primary survey to exclude life threatening injury

-If the patient is cooperative and has no major distracting injury can assess for posterior neck pain, radiological deficit, undo collar, maintain head alignment, assess for posterior midline tenderness and if absent test for limitation in movement (45 degrees left and right) if normal can leave collar off and not Xray
-If any abnormality then do a cervical spine series and if this is abnormal then a CT scan (focus on area of abnormality and after consultation with neuro/ortho)
-If the XR is normal then reassess and if normal can remove collar and reassess, if abnormality discuss with orthopaedics or neurosurgery

-If the patient is unconscious or uncooperative or has a major distracting injury then apply a semi-rigid collar and immobilise the C-spine
-If the the patient is intubated and having a CT brain urgently then also do a CT of the cervical spine
-If the patient is not intubated then can do a cervical spine series and if this is abnormal then perform a CT
-If the X ray is normal and the patient has is uncooperative or has a major distracting injury then needs CT
-If cooperative can assess for midline tenderness and limitation in movement, if normal then leave collar off

Indications for immobilisation
-Reduced LOC
-Inability to give history of pain
-Neck or back pain
-Neurological signs or symptoms
-Multiple system trauma
-History of significant trauma (fall > 3m, pedestrian or cyclist hit by car, unrestrained passenger in MVA, diving accident)

Options

Rigid collar spinal immobilisation on a spinal board with a head immobiliser can cause harm so need to have a high pretest probablity

-Can reduce tidal volume and respiratory excursion
-Flexes neck which can cause movement at site of injury (need a spinal board with a recess for the head or padding that elevates the torso if < 8)
-Ill fitting collars may cause airway obstruction
-Increase intracranial pressure
-Distress and anxiety
-Pressure sores

Rigid spinal collar without spinal board

Philadelphia (two piece collar)

Consider no immobilisation prior to imaging if low pretest probability

-Cervical spine fulcrum changes from C2 to C3 in toddlers to C5 to C6 by 8-12 years of age
-Larger size head leading to more flexion and extension injuries
-Pseudosubluxation of C2 on C3 (in up to 25% of children)
-Exaggerated atlanto-dens distance (20% of children < 8)
-Variable soft tissue width (alters with head positioning and crying)
-Incomplete ossification making making interpretation of bony alignment difficult
-Radiolucent synchondrosis between the odontoid and C2
-Anterior ring apophyses of the vertebral bodies
-Anterior wedging of vertebral bodies

Jefferson fracture

Lateral
-Widening of predental space (> 5mm)
-Prevertebral swelling (> 1/2 vertebral body at C2)

PEG view
-Displacement of lateral masses