How will you evaluate him for other injuries?

What is the significance of the neurologic exam?

Which laboratory tests are important prior to going to the OR?

Is there a role for the immediate administration of steroids?

This child should have a head-to-toe evaluation for other injuries [1]. In this case, there is not a neurosurgical emergency necessitating an immediate trip to the OR. There is time to complete a thorough evaluation for other injuries to the child. The hard collar must not be removed, but nevertheless a physical exam looking for signs of other injuries can be done. With major pediatric trauma, the head is the most frequently injured body area. The neurologic exam should assign a Glasgow coma scale score and evaluate the child for the presence or absence of raised intracranial pressure. The presence of raised ICP will have important impact on the overall management of the child as well as the conduct of an anesthetic [2]. The Glasgow coma scale was initially developed to provide an organized, uniform measure to the level of consciousness [3]. Using the scale, CNS injuries are categorized as mild (13–15), moderate (9–12), or severe (<8). In addition, cranial nerve function should be assessed and focal signs in the motor exam noted. During the evaluation of the cranial nerves, signs of basilar skull fractures such as hemotympanum and “raccoon eyes” should be noted.

The Glasgow coma scale is used to assess cortical and brainstem function.

It is encouraging that the child is awake and alert. The GCS score of the child as described would likely be at least 13 (eye opening: spontaneous, 4; verbal, oriented, 5; motor withdraws to pain, 4). With a higher score on the motor portion of the scale, the GCS could be as high as 15. The fact the child is moving his fingers and toes is an indication that there is some neurologic function below the level of the cervical spine fracture, but the residual function appears to be incomplete.

Additional radiologic studies are indicated unless the child requires emergent surgical intervention. In addition to scans of the head, chest, abdomen, and pelvis, several additional tests are indicated prior to going to the OR. The X-rays taken that showed the spine fracture should be reviewed. It may be that additional studies are needed to rule out additional fractures including a limited CT of the neck. Blood should be sent for a CBC, type and cross, and coagulation studies.

A prospective study done in the 1990s demonstrated that spine-injured patients given large doses of methylprednisolone very soon after the injury had a slightly improved neurologic deficit. The study was not designed to assess long-term neurologic function. The doses of methylprednisolone used in the investigation were 30 mg/kg IV followed by 5.4 mg/kg/h for 23 h. There have been three trials of this drug and dose, one conducted in North America (NASCIS), one in Japan, and one in France. A meta-analysis of these trials indicated that significant recovery of motor function occurred when the therapy outline began within 8 h of the injury. A more recent trial showed that continuing the therapy for an additional 24 h led to additional improvement in motor function particularly if the therapy is not begun within the 8-h period. Significant controversy still exists regarding the use of high dose steroids for spinal cord injury [4].

Which monitors and vascular access are necessary for this case?

How should general anesthesia be induced? Which muscle relaxant should be used to facilitate laryngoscopy?

Are there particular concerns regarding prone positioning for the repair of the cervical spine fracture?

Are there particular maintenance agents best suited in cases where neuroprotection is important? What is the optimal BP for this procedure?

During the procedure, the patient has bradycardia, with HR decreasing to the 60s. What might be the etiology? Your response?

The surgeon expects that the case will be 45–60 min. Would you plan to extubate the child at the end of the procedure?

Prior to the administration of any medication, the child should have at least one well-functioning IV and should have had fluid resuscitation with normal saline. If additional injuries had been uncovered in the workup, the location of IV placement may be affected. If there is also significant abdominal or lower extremity trauma with potential for hemorrhage, IVs should be placed in the upper extremities. The usual ASA monitors should be used. In addition, once induction is completed and the airway secured, an arterial line and central venous pressure line should be placed. If the preoperative evaluation revealed any signs of raised ICP, consideration should be given to placement of an intracranial pressure monitor. Since the child will be in the prone position for the approach to the fractured spine, placement of a precordial Doppler and/or monitoring end-tidal nitrogen will be important for detection of venous air emboli.

Given the X-ray findings and clinical exam, it is imperative that the child not move his neck during induction and when the airway is secured. An IV antisialagogue such as glycopyrrolate should be given prior to any airway manipulations. It should be assumed that the child has a full stomach during the induction even though a complete RSI would not be indicated in this situation. The child has retractions with respirations. If the CXR does not reveal any possible etiology, it is possible that the child has traumatic damage to the airway. The child may have aspirated during the traumatic event and the CXR has not yet shown abnormalities. There could be partial or complete paralysis of the vocal cords or edema or hematoma formation within the airway. Given these considerations, securing the airway with fiber-optic bronchoscopy is a prudent choice. Following administration of a drying agent, the child is gradually anesthetized with an IV agent such that spontaneous respiratory effort is maintained. Topical lidocaine, in the proper dose and concentration, is applied to the nasal and pharyngeal mucosa prior to instrumentation of the airway.