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Thread: infants with sci

  1. #1

    infants with sci

    i am a rehab nurse and i have just admitted a 10 month old infant with sci. i am looking for information on caring for such a child. i have questions regarding bladder and bowel routine and so on. do you have any ideas for where to find resources??

  2. #2

    I don't have any personal experience caring for babies with spinal cord injury but suggest that you can find a great deal information about their care in books describing the care of babies with spina bifida and head injury, two more common causes of paralysis in babies.

    In general, severe spinal cord injuries are rare in babies. The vast majority of spinal cord injuries in babies tend to be incomplete spinal cord injury and substantial recovery is the rule rather than the exception. You can find a huge number of recent papers on the subject of pediatric spinal cord injury in the medical literature.

    Two centers that I have a great deal of respect for, particularly for their care of children with spinal cord injury are the Shriner's Hospital in Philadelphia and the University of Washington in Seattle. They have doctors and nurses who are experienced with care of babies of spinal cord injury.

    I attach a couple of very recent articles on pediatric SCI as starting point for your literature search.


    Viccellio, P., H. Simon, et al. (2001). "A prospective multicenter study of cervical spine injury in children." Pediatrics 108(2): E20.
    OBJECTIVE: Pediatric victims of blunt trauma have developmental and anatomic characteristics that can make it difficult to assess their risk of cervical spine injury (CSI). Previous reports, all retrospective in nature, have not identified any cases of CSI in either children or adults in the absence of neck pain, neurologic symptoms, distracting injury, or altered mental status. The objective of this study was to examine the incidence and spectrum of spine injury in patients who are younger than 18 years and to evaluate the efficacy of the National Emergency X-Radiography Utilization Study (NEXUS) decision instrument for obtaining cervical spine radiography in pediatric trauma victims. METHODS: We performed a prospective, multicenter study to evaluate pediatric blunt trauma victims. All patients who presented to participating emergency departments underwent clinical evaluation before radiographic imaging. The presence or absence of the following criteria was noted: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of painful distracting injury. Presence or absence of each individual criterion was documented for each patient before radiographic imaging, unless the patient was judged to be too unstable to complete the clinical evaluation before radiographs. The decision to radiograph a patient was entirely at the physician's discretion and not driven by the NEXUS questionnaire. The presence or absence of CSI was based on the final interpretation of all radiographic studies. Data on all patients who were younger than 18 years were sequestered from the main database for separate analysis. RESULTS: There were 3065 patients (9.0% of all NEXUS patients) who were younger than 18 years in this cohort, 30 of whom (0.98%) sustained a CSI. Included in the study were 88 children who were younger than 2, 817 who were between 2 and 8, and 2160 who were 8 to 17. Fractures of the lower cervical vertebrae (C5- C7) accounted for 45.9% of pediatric CSIs. No case of spinal cord injury without radiographic abnormality was reported in any child in this study, although 22 cases were reported in adults. Only 4 of the 30 injured children were younger than 9 years, and none was younger than 2 years. Tenderness and distracting injury were the 2 most common abnormalities noted in patients with and without CSI. The decision rule correctly identified all pediatric CSI victims (sensitivity: 100.0%; 95% confidence interval: 87.8%-100.0%) and correctly designated 603 patients as low risk for CSI (negative predictive value: 100.0%; 95% confidence interval: 99.4%-100.0%). CONCLUSIONS: The lower cervical spine is the most common site of CSI in children, and fractures are the most common type of injury. CSI is rare among patients aged 8 years or younger. The NEXUS decision instrument performed well in children, and its use could reduce pediatric cervical spine imaging by nearly 20%. However, the small number of infants and toddlers in the study suggests caution in applying the NEXUS criteria to this particular age group.

    Kenter, K., G. Worley, et al. (2001). "Pediatric traumatic atlanto-occipital dislocation: five cases and a review." J Pediatr Orthop 21(5): 585-9.
    Traumatic atlanto-occipital dislocation (AOD) has been thought to be a rare and fatal injury. Recently, more survivors, especially children, have been reported. During a 10-year period, the authors have encountered five children with traumatic AOD. A retrospective review of traumatic AOD in children from 1985 to 1995 was performed. Clinical presentation, initial radiologic findings, and final outcome were emphasized. Distance from the dens to the basion and the ratio of Powers were measured from initial lateral cervical spine radiographs. The average distance from the dens to the basion was 9.8 mm. The average ratio of Powers was 1.38. There were three survivors, two having a concomitant spinal cord injury. All survivors underwent a posterior occipitovertebral fusion. Three cases initially went undiagnosed. The diagnosis of AOD by lateral cervical spine radiographs can be difficult. The authors recommend detailed measurements of the initial cervical spine radiographs in pediatric patients at risk for traumatic AOD.

    Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center." J Pediatr Surg 36(8): 1107-14.
    PURPOSE: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. METHODS: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9(1/2)-year period (January 1991 through August 2000) was performed. RESULTS: The mean age was 10.3 +/- 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle- related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. CONCLUSIONS: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C- spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse.

    Kumaresan, S., N. Yoganandan, et al. (2001). "Pediatric neck injury scale factors and tolerance." Biomed Sci Instrum 37: 435-40.
    Although significant research efforts have been made to determine the tolerance for the adult neck, relatively little research has been conducted to derive the pediatric neck injury parameters. The existing approach to determine injury for the one, three and six year old pediatric populations is based on extrapolations from the adult male and calcaneal tendon tensile data. This study addresses the scale factors for pediatric age groups using data obtained from spinal components and neck geometry. The analysis included the determination of scale factors under extension, tension, compression and flexion loading modes as a function of age. The variations in biomechanical properties of each spinal component were determined from human cadaver studies. Active spinal components were identified under each loading mode and relationships were established for each component to obtain material-based scale factors. The scale factors and resulting injury tolerance values based on spine component material properties are more appropriate than values extrapolated from the calcaneal tendon.

    Patel, J. C., J. J. Tepas, 3rd, et al. (2001). "Pediatric cervical spine injuries: defining the disease." J Pediatr Surg 36(2): 373-6.
    BACKGROUND/PURPOSE: Pediatric cervical spine injuries are uncommon. Most previous studies have been hampered by the small number of patients available for evaluation. The purpose of this study is to determine the incidence and characteristics of pediatric cervical spine injury utilizing a multiinstitutional pediatric trauma database, and to assess the impact of age and level of spine injury on mortality rate. METHODS: All children with cervical spine injury entered into the National Pediatric Trauma Registry over a consecutive 10-year period were identified. Patients were stratified by age, mortality, presence or absence of bony injury, level of cervical spine injury, and presence of neurologic deficit. Data were analyzed utilizing Student's t test for continuous variables and chi(2) analysis for categorical variables. Statistical significance was accepted at the P less than .05 level. RESULTS: From a database of 75,172 injured children, 1,098 were identified with cervical spine injury, overall incidence 1.5%. The mean age of the study group was 11 +/- 5 years, and 61% were boys. Nine hundred eight children (83%) had bony spine injury. Distribution of bony injury among upper cervical spine, lower cervical spine, or both was 52%, 28%, and 7%, respectively. The remaining 13% comprised unspecified levels of injury. Upper cervical spine injuries were prevalent among all age groups (42%, age < or = 8; 58%, age > 8), whereas lower spine injuries predominated in older children (85%, age > 8). One third of children in the study group had neurologic injury, and half of these had no radiographic evidence of bony injury. Ninety-four children (24%) had a complete cord injury, and the remaining 76% had an incomplete spinal cord injury. One hundred eleven children (23%) with upper spine injury died compared with 11 children (4%) with lower spine injury. Mortality rate was highest (48%) in those with atlanto- occipital dislocation. CONCLUSIONS: From this, the largest experience with pediatric cervical spine injury, several conclusions can be drawn. (1) Cervical spine injury occurs in 1.5% of injured children. (2) Upper cervical spine injuries are not limited to younger children but are equally prevalent in both age groups. (3) Associated mortality rate is nearly 6-fold higher in patients with upper cervical injury. (4) Seventeen percent of children with cervical spine trauma show no radiologic anomaly, yet 50% of children with cervical spinal cord injury have no initial radiologic abnormalities. (5) Of those in whom cervical spine injury is associated with a neurologic deficit, the deficit is complete in 24% of children.

    Kokoska, E. R., M. S. Keller, et al. (2001). "Characteristics of pediatric cervical spine injuries." J Pediatr Surg 36(1): 100-5.
    PURPOSE: The objective of this study was to assess the mechanisms and patterns of injury and outcome in children with cervical (C) spine trauma. METHODS: We reviewed the National Pediatric Trauma Registry between April 1994 and March 1999 and identified (by ICD-9 criteria) all cases of blunt trauma victims with cervical fractures, dislocations, and spinal cord injuries without radiographic abnormality (SCIWORA). Data are shown as mean +/- SEM. RESULTS: During the 5-year period, the incidence of blunt C-spine injury was 1.6% (n = 408 of 24,740 total entries). Mean age was 10.5+/-0.3 (1 to 20) years, and 59% were boys. Leading mechanisms were motor vehicle accidents (n = 179; 44%), sports (n = 66; 16%), and pedestrian injuries (n = 57, 14%). Younger (< or =10 years) children more often sustained high [C1 to C4) vs low [C5 to C7) injuries [85% v 57%; P<.01) and also had a higher incidence of dislocations [31% v 20%; P<.01) and cord injuries [26% v 14%; P<.01), whereas older children had more C-spine fractures [66% v 43%; P<0.01). Mortality rates [overall, 17%) were higher in younger children [n = 180) when compared with older children [n = 228; 30% v 7%; P<.01). Overall, the majority of deaths [93%) were associated with brain injuries. No children with cervical dislocations had neurologic sequelae. The preponderance of children with fractures [83%) also were without neurologic injury, whereas those associated with SCIWORA usually were [80%) partial. Overall, complete cord lesions were infrequent [4%). CONCLUSIONS: These data, representing the largest series to date, confirm that blunt C-spine injuries in children are rare. Patterns of injury vary significantly according to child age. Major neurologic sequelae in survivors is uncommon, does not correlate well with cord level, and rarely is complete.

    Alva, N. S. (2000). "Traumatic spinal epidural hematoma of a 10-month-old male: a clinical note." Pediatr Neurol 23(1): 88-9.
    Traumatic spinal epidural hematoma (TSEH) is rare in children. Only three cases of TSEH were documented in the pediatric literature. This clinical note presents an infant with TSEH but no risk factors. Without magnetic resonance imaging examination, children with TSEH and minor symptoms may be missed and under reported. Signs such as irritability and neck pain should alert the clinician to consider TSEH and the need for urgent magnetic resonance imaging of the spine for early diagnosis and treatment to minimize morbidity.

    McCollough, N. C., 3rd (2000). "The evolution of Shriners Hospitals for Children in North America." Clin Orthop(374): 187-94.
    Shriners Hospitals for Children have been providing totally free care to children with neuromusculoskeletal disabilities since 1922. This mission expanded in 1962 to include the care of children with burn injuries and expanded in 1978 to include children with spinal cord injuries. Today, Shriners Hospitals for Children include 19 hospitals that provide pediatric orthopaedic care, four hospitals that provide acute and reconstructive burn care, and three hospitals in which spinal cord injury rehabilitation centers are located. During the past 20 years, case acuity and complexity have increased, comprehensiveness of care has been emphasized, members of the medical staff have increasingly become full-time, and sponsored intramural research has increased to a budget of $22 million annually. Annually, more than 250 orthopaedic residents receive pediatric orthopaedic training and more than 150 surgical residents are trained in pediatric burn care in Shriners Hospitals. In 1998, approximately 25,000 children were admitted for care, more than 22,000 operations were performed, and 236,000 children were treated as outpatients. In 1999, the annual operating budget for Shriners Hospitals for Children was $397 million.


    Here are some additional articles:

    CT: To evaluate and review their experience with pediatric cervical injuries and factors affecting outcome, the authors conducted a retrospective clinical study of 102 cases (65% boys, 35% girls) of pediatric cervical spine injuries treated in the last decade. This study is an extension of and comparison with their earlier experience. METHODS: Patients were divided into two age groups-birth to 9 years (Group I) and 10 to 16 years of age (Group 2)- and managed according to status at presentation and type of injury. Thirty patients were managed surgically and 72 non-surgically (42 wore a halo brace and 30 wore hard collars or custom-molded braces). Motor vehicle accidents were the most common cause of injury, and 40% were associated with head injury. Patients in the younger-age group (Group 1) sustained more neurological injuries than the older patients in Group 2, and most injuries were in the upper cervical spine. Of the 38 children in Group 1, in 39% a subluxation was present and in 29% a fracture or fracture/subluxation was demonstrated. Of the patients in Group 2, 80% had sustained fractures or fracture/subluxations. Vertebral fractures were the most common radiological findings (32%). At late follow-up review (mean 5 years), solid fusions were demonstrated in all patients. Neurological deterioration did not occur in any patient. The mortality rate was 16%. Compared with the authors' earlier report, the incidence of cases with pediatric cervical injuries increased, as did the number managed surgically. Various fusion techniques were used, and neurological and fusion outcomes improved as compared with the previous report. CONCLUSIONS: The prognosis of neurological recovery from pediatric cervical spine injuries is related to the severity of the initial neurological injury. Management must be tailored to the patient's age, neurological status, and type and level of injury. Compared with our earlier experience, fusion and instrumentation procedures were used more frequently. Different types of fusion and instrumentation procedures can be performed safely in children and produce good outcomes.

    Van Hala, S., V. S. Nelson, et al. (1997). "Bladder management in patients with pediatric onset neurogenic bladders." J Spinal Cord Med 20(4): 410-5.
    Our objective was to determine which clean intermittent catheterization (CIC) methods and supplies were used by patients with pediatric onset neurogenic bladders and to relate methodology and materials to reported urinary tract infections. Data were collected via questionnaires distributed by mail and at clinic visits at our university tertiary care outpatient pediatric rehabilitation clinic. Questionnaires were given to 165 patients. Fifty-nine percent were returned (68 patients with myelomeningocele, 27 with pediatric onset spinal cord injury (SCI) and two with other diagnoses). Mean age was 12 years (range 1-27). Fifty-four percent of patients participated in their own CIC. Only two percent used sterile catheterization technique, whereas 98 percent used CIC. A sterile catheter was employed with clean technique by 22 percent. Catheters were reused by 76 percent. Subjects used a wide ranging number of catheters per month, with a median of 5.3. There was no correlation between the number of urinary tract infections (UTIs) per year and the type of catheter used or the use of prophylactic antibiotics. Compared with patients with myelomeningocele, subjects with SCI were significantly more likely to use sterile catheters (p = 0.04), > 10 catheters per month (p = 0.01) and gloves (p < 0.001). Subjects who used gloves or more catheters were more likely to experience UTI. These data suggest that clean reused supplies are not related to an increased likelihood of UTI and should be considered a way to lower costs in these populations.

    Mulcahey, M. J. (1997). "Unique management needs of pediatric spinal cord injury patients: rehabilitation." J Spinal Cord Med 20(1): 25-30.

    Anderson, C. J. (1997). "Unique management needs of pediatric spinal cord injury patients: psychosocial issues." J Spinal Cord Med 20(1): 21-4.

    Vogel, L. C. (1997). "Unique management needs of pediatric spinal cord injury patients: medical issues." J Spinal Cord Med 20(1): 17-20.

    Betz, R. R. (1997). "Unique management needs of pediatric spinal cord injury patients: orthopedic problems in the child with spinal cord injury." J Spinal Cord Med 20(1): 14-6.

    Vogel, L. C. (1997). "Unique management needs of pediatric spinal cord injury patients: etiology and pathophysiology." J Spinal Cord Med 20(1): 10-3.

    Vogel, L. C. (1997). "Unique management needs of pediatric spinal cord injury patients: introduction." J Spinal Cord Med 20(1): 9.

    Chao, R. and M. E. Mayo (1994). "Long-term urodynamic follow up in pediatric spinal cord injury." Paraplegia 32(12): 806-9.
    Less than 5% of all spinal cord injuries occur in children under 16 years of age. We have followed up 40 children with spinal cord injury at our medical center. The patients have an average age at presentation of 9.0 years (range newborn to 17 years) and have a mean follow up of 46.1 months (range 1 to 240 months). Twenty-two patients have cervical injuries, 13 thoracic and five have lumbar injuries. Bladder management in this group includes 11 patients with reflex voiding and 29 patients combining anticholinergic medication with intermittent catheterization. Twenty-eight patients have a follow up for more than 1 year. Review of the video urodynamics in this group has shown good function and preservation of the urinary tract in 25 of 28 patients. Treatment failures can be attributed to noncompliance with recommended voiding regimens. Upper tract surveillance using intravenous pyelogram or renal ultrasound has shown preservation of the upper tracts in all patients with anatomically normal lower tracts. We recommend aggressive follow up in this group of patients with yearly renal ultrasound and video urodynamics every 1-2 years to monitor urinary tract function.

    Todres, I. D. (1993). "Pediatric airway control and ventilation." Ann Emerg Med 22(2 Pt 2): 440-4.
    Emphasis on a clear airway is a primary requisite for effective CPR. Airway control in the trauma victim needs special consideration of the possibility of associated cervical vertebrae and spinal cord injury; thus, modification of the patient positioning for transport is essential. Emphasis on visualization of chest movement is the most important factor in assessing adequacy of ventilation. Experience in the use of bag-valve-mask devices requires appropriate instruction and on-going practice. Small bag volume devices limit the ability to provide adequate tidal volumes and prolong inspiratory times. Tracheal intubation provides optimal airway management. In-field use of this procedure will depend upon the skill and experience of the operator. Validation of correctness of tracheal tube placement is critical; seeing the tube pass the glottic opening on laryngoscopy, bilateral and equal chest movement, auscultation of breath sounds in the chest. Methods to measure end-tidal CO2 as a valuable check for tube position is a useful adjunct but must not be relied upon. Foreign body management continues to be controversial and remains unchanged for the present; ie, the infant < 1 year of age the recommendations are back blows followed by chest thrusts. Above 1 year of age, abdominal thrusts [Heimlich maneuver) is recommended.

    Hamilton, M. G. and S. T. Myles (1992). "Pediatric spinal injury: review of 61 deaths." J Neurosurg 77(5): 705-8.
    Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. The authors present a unique review of 61 pediatric deaths associated with spinal injury. This group represented 28% of the total pediatric spine-injured population and 45% of the total pediatric spinal cord-injured group studied. The ratio of pediatric to adult spinal injury mortality was 2.5:1. Of the 61 children, 54 (89%) died at the accident scene. Thirty patients underwent a complete autopsy, 19 of whom had an Abbreviated Injury Scale Grade 6 injury (maximum score, untreatable). Spinal cord injury was found to be the cause of death in only eight children and was associated with injury to the high cervical cord and cardiorespiratory arrest. These children typically sustained severe multiple trauma. In this population, there appears to be little room for improved outcome through changes in treatment strategy.

    Hamilton, M. G. and S. T. Myles (1992). "Pediatric spinal injury: review of 174 hospital admissions." J Neurosurg 77(5): 700-4.
    Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. A review of 174 pediatric patients is presented, representing 5.4% of all patients admitted with spinal injury. Spinal cord injury was present in 45% of patients. A distinct injury profile, explained by anatomical and biomechanical features, distinguishes the young patient with an immature spine from older adolescents with a more mature, adult-like spine. The younger patients, while less likely to have spinal injury, had a higher incidence of neurological injury, in addition to a higher frequency of both spinal cord injury without radiological abnormality and upper cervical cord injury. In addition, younger patients with spinal cord injury and no radiological abnormality were more likely to have complete or severe cord injury. Prognosis was determined by the severity of spinal cord injury. Patients with complete cord injuries showed little improvement, while patients with incomplete injuries generally fared much better, with 74% showing significant improvement and 59% experiencing a complete recovery of neurological functions. There were six deaths, but none was attributed solely to spinal injury. The authors conclude that outcome is quite good after pediatric spinal cord injury that does not produce a physiologically complete cord deficit.

    Joy, C. (1990). "Pediatric spinal cord injury." Crit Care Nurs Clin North Am 2(3): 415-9.
    Although the incidence of spinal cord injury in childhood is lower than in adults, the impact is significant when the number of years with resulting severe limitations are considered. Prevention is the key to spinal cord management in all age groups, but takes on a stronger, more emphasized sense of urgency with children. If methods of prevention fail, successful early management of a child with spinal cord injury is the best hope for a future filled with accomplishments.

    Keen, T. P. (1990). "Nursing care of the pediatric multitrauma patient." Nurs Clin North Am 25(1): 131-41.
    Pediatric multitrauma causes more deaths and injuries each year in children than any other cause of death. Most of the multitrauma cases involve a motor vehicle accident. Blunt trauma and head injuries constitute the majority of injuries in pediatric multitrauma. Blunt trauma leaves minimal evidence of the underlying injury and is difficult to assess in the unconscious child. The initial assessment in children is in some ways more complex than in an adult. The airway is a more critical concern in the child. Airway obstruction is a more frequent cause of ventilatory insufficiency in pediatric trauma. Hypothermia is a vital concern because children lack the ability to maintain their temperature when they are compromised. Assessment of circulation and shock in children is complicated because the signs of shock are subtle in the child. The plan of care and the approach to the child must incorporate the child's fears and coping mechanisms based on the child's age and developmental level. Nursing diagnoses should reflect the plan of care not only for the child, but for his or her family. The proper approach to the child can positively influence the quality of the assessment, the level of cooperation, and the long-term outcome of care.

    [This message was edited by Wise Young on November 05, 2001 at 09:41 AM.]

  3. #3


    Here is a textbook you may want to get:

    There is also a Peds special interest group in ARN that you can contact through their list-serve (check out the ARN website for info).

    I would also recommend any of the Shriner's Children's Hospitals that have SCI units as invaluable resources for any child with a SCI.


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