Pediatric emergency medicine trisk 3625 3625

of sympathetic input to the vascular system. The physical examination may be
misleading in that these patients are bradycardic (unable to mount tachycardic
response to relative hypovolemia) and demonstrate warm, flushed skin in the
setting of hypotension (loss of vasomotor tone). These symptoms may also be
superimposed on traumatic (hypovolemic) shock. These patients need fluid
resuscitation and may require inotropic (alpha agonist) support, such as
norepinephrine or phenylephrine, to maintain adequate perfusion and avoid fluid
overload. Appropriate fluid management is important in preventing hypoperfusion
of the already injured spinal cord. The use of steroids for blunt cervical injury is
not routinely recommended. Several authors suggest that steroid administration
increases potential risk to the patient and does not lead to meaningful neurologic
recovery and that its use as a standard of care is not justified. Steroid use for the
pediatric patient with a clear or potential blunt cervical cord injury is not well
supported by available evidence and should be discussed in consultation with the
treating orthopedic and neurosurgical physicians bearing in mind that it is not
approved by the Federal Drug Administration for this purpose.
Methylprednisolone is not recommended in conjunction with penetrating neck
injuries.

FIGURE 112.36 Normal ossiculum terminale at the tip of the dens (arrow ). (Reprinted with
permission from Swischuk L. Emergency Radiology of the Acutely Ill or Injured Child . 2nd ed.
Baltimore, MD: Williams & Wilkins; 1986:717.)