Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Medical College of Georgia

Pearl: It is rare that by a single maneuver on a patient we can accomplish two therapeutic interventions simultaneously. Placing padding under the shoulders of a supine child both opens the airway and provides a neutral cervical spine.

Presentation: Pediatric patients frequently present to the emergency room on a backboard. Other children undergo procedural sedation in the emergency department and remain in a supine position for long periods of time. In both scenarios, the disproportionately large heads of the supine younger pediatric patients invariably will cause significant flexion of the neck, causing an associated risk of airway compromise.

Discussion It has long been recognized that the heads of children are disproportionately large compared to their bodies. The head proportions and body relationships have previously and appropriately been described as "Charlie Brown-like" in reference to the cartoon character.¹ When placed in a supine position on a backboard or a gurney, the relatively larger head causes forward flexion of the neck on the body. (Figure 1) This forward flexion is suspected of causing movement and anterior translation of cervical spine elements in patients with cervical fractures.² Furthermore, the potential exists for this flexion posture of the head on the body to cause compromise of the patient's airway. If during bag-valve-mask ventilation of pediatric patients the face is not pulled upward into the mask, the unacceptable airway position and cervical spine flexion can be aggravated further. Neutral cervical spine positioning in children has been studied by Nypaver et al.³ Neutral position was defined in that study as using enough padding under the shoulders to bring the long axis of the cervical spine perpendicular to the transverse axis of the head. Additionally, eye gaze was directly perpendicular to the horizontal plane of the backboard. Pediatric Advanced Life Support (PALS) training recommends placement of padding sufficient to bring the apex of the patient's shoulders into horizontal alignment with the external auditory meatus or tragus of the ear, which results in improved patency and positioning for bag-valve-mask ventilation of the patient's airway.⁴ (Figure 2) However, a study using defined Cobb angle measurements of the cervical spine suggested that the visual assessment of neutral didn't correlate well with their ideal measurement, despite excellent correlation between observers.⁵ Nevertheless, there is no question that a greater compliance in the placement of padding under the shoulders of pediatric patients either on backboards or gurneys improves cervical spine neutrality and provides a more open airway.

References:

1. Mellick LB, van Stralen D, Perkin R. Letter. Emergency transport and positioning of young children who have an injury of the cervical spine. Pediatr Emerg Care 1993;9:128.
2. Herzenberg JE, Hensinger RN, Dedrick OK, et al. Emergency transport and positioning of young children who have an injury of the cervical spine. J Bone Joint Surg 1989;71-A( I): 15-22.
3. Nypaver M, Treloar D. Neutral cervical spine positioning in children. Ann Emerg Med 1994;23:208-11.
4. Hazinski MF, editor. PALS Provider Manual. American Heart Association, Inc.;2002:48,95.
5. Boswell HB, Dietrich A, Shiels WE, et al. Accuracy of visual determination of neutral position of the immobilized pediatric cervical spine. Pediatr Emerg Care 2001;17:10-4..

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