Hit by car with injuries to the neck and chest


• Scene – C-spine precautions, long backboard (LBB).
• En route – 16g IV, IV normal saline 0.9% fluids ~250ml bolus; primary and secondary physical exams; oxygen; fentanyl 25mcg twice, total of 50mcg.
• Hospital trauma team evaluation; X-ray and CT scans; pediatric neurologist consult.


• Response to treatment – pain went from 10 down to 6/10 after pain medication.
• Disposition – seen by trauma team; diagnosed with C7 fx. Mom called later, reported that patient was starting to bruise up and feel worse, received some more pain medications in the emergency department.


• Mark Shelton Paramedic Woodburn Ambulance
• David Sheridan, MD Associate Professor Oregon Health and Science University
• Matthew Hansen, MD Associate Professor Oregon Health & Science University


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Toni Grimes, EMT-P Woodburn Ambulance

• Fracture of cervical spine
• C-7 fracture
• Traumatic injury
• Car accident

Differential Diagnosis

• Trauma
• Trauma entry
• Head trauma (TBI)
• C-spine injury
• Internal bleeding
• Rib fx
• Left ankle fx
• Hemo/pneumothorax
• Hypovolemic shock
• Lacerations
• Abrasions

Patient Workup

• Patient was riding his bike with a friend and was hit and run over by SUV, both front and back tires. Patient was wearing helmet. Appears that the car ran over his head/helmet with at least 1 wheel. Patient got up and walked out of the street and into parking lot after event. States chest and neck pain. Denies nausea. Denies loss of consciousness.

Physical Exam

• GCS – 15
• CBG – 101
• Patient awake, alert
• No significant bleeding or deformities.
• Facial trauma (abrasion, laceration) to chin, left cheek area; no trauma to teeth or tongue. Pupils PERRL. Denies headache.
• Neck pain prior to c-spine, no obvious deformities.
• Airway patent, some pain with respirations, mild shortness of breath, bbs cl =, no flail chest. Left chest has large abrasion, bleeding controlled.
• Abdomen soft, small abrasion near umbilicus. Pelvis stable.
• Back has abrasions (road rash) on left sides more lateral towards ribs, light ecchymosis noted.
• Left deltoid abrasion, left forearm abrasion.
• Small lacerations on each knee
• Moves all extremities, sensation motor and circulation good in all extremities.
• Skin – core pink and warm, cool extremities, patient diaphoretic. Good cap refill on fingers.

Suggested Approach

• Identify and treat life threatening injuries in any trauma patient.
• Although children have much more pliable skeletons, they remain at high risk of traumatic injuries in a mechanism with auto vs. pedestrian.
• The most common traumatic injury in the pediatric population is a head injury and the goal prior to hospital arrival is to assess airway, GCS status and avoid hypotension.
• If a patient is alert and talking, taking a brief history with the mnemonic SAMPLE is helpful; S-situation, A-allergies, M-medications taken, P-past medical history, L-last meal eaten, E-events surrounding current situation. The evaluation consists of a primary and secondary evaluation.
• Although this patient has a stable blood pressure, obtaining IV access is important as he most likely will need pain medications and possibly fluid resuscitation.
• After ensuring their airway is intact and the patient does not need to be intubated, move to the secondary survey, which is an overall exam to identify other injuries. With this mechanism of injury, regardless if the patient has neck pain/tenderness or not, they should be placed in a C-collar and on a backboard to immobilize their spine. Similar to elderly trauma patients, there are few studies which examine the accuracy of clinical spine clearance protocols in children. In general, providers should practice caution when clinical clearing the spine in children.
• Make sure to obtain a baseline GCS to evaluate during transport if there are any objective changes in the patient’s mental status. The GCS has been modified to be applicable to young children. In this patient, he notes difficulty breathing and has an oxygen saturation of 96%, indicating possible lung or chest wall injury; oxygen may be helpful en route. Any pediatric patient with significant signs of injury and mechanism should be transported to a trauma center and entered into the trauma system.

Suggested references

Advances in prehospital trauma care


• Gender: Male
• Age: 15 years
• Height: Not Available
• Weight: Not Available


• Temperature: Not Available
• Blood Pressure: 113/66
• Heart Rate: 100
• Respiratory Rate: 20
• Pulse Oximetry: 96% RA
Signs and Symptoms
Chest and neck pain; lacerations; abrasions.


• PMH: ADHD, hay fever
• Dispatch info: 15-year-old down, bike vs. vehicle; run over by car.
• Parents were on scene before EMS arrived.
• Lives with parents; student.


• Adderall XR

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