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Medicine by numbers

did not initiate immobilisation of the cervical spine in 8 of 54 (15%) patients transported to hospital by ambulance, 24% of patients (14 of 58) in the emergency departments, and 10% (6 of 58) of those transferred to a tertiary care centre. The reasons for this are unclear but may include lack of awareness of healthcare workers of those at risk, paucity of suitable immobilising devices for small children, and an inability to maintain immobilisation in young, uncooperative patients. Children with isolated head injuries or who had had falls were more likely to be overlooked for immobilisation than those in road crashes. All of these groups are defined as at risk in paramedic training and paediatric life support courses. 4 9 The proportion of frontline staff who had received such training is, however, unknown. Patients who were not immobilised were younger than those immobilised. This has important clinical implications in that the proportion of injuries to the upper cervical spine (vertebrae C1-C4) is higher in patients less than 12 years of age, and this carries a higher mortality than injuries to the lower cervical spine (23% v 4%). This may partially reflect a perceived lack of immobilising options, as rigid collars are not available for infants less than 6 months of age. Spinal boards, sandbags, and tapes are a recommended alternative by paramedic training and paediatric life support courses. 4 A combination of two or more devices is recommended in unconscious patients; however, only hard collars are recommended for agitated patients. 4 10 These recommendations potentially leave infants less than 6 months unprotected but is unlikely to be a major factor in our non-immobilised patients, given their median Glasgow coma score of 7 on presentation.