traumatic atlantooccipital dislocation injury in children

OCTOBER 1994, VOL 60, NO 4 Nichols 9 West

Traumatic Atlan toocciDi tal Dislocation Injury in children m rauma has been identified as one of the major

health problems in this century. The leading cause of death among children less than 15 years of age is trauma (eg, motor vehicle acci- 1 dents, falls, child abuse, gunshot wounds).

Children between the ages of two and seven years are at the highest risk. Severe trauma injuries (ie, immediately life threatening) represent 5% of all injuries but 50% of all deaths from trauma.' The best care for children involved in severe trauma is provid- ed by the specialty team approach at level I trauma centers. This article discusses one of the most chal- lenging of neurological traumas, atlantooccipital dislocation (AOD) injury, and the role of the perioperative nurse in providing optimal care for these trauma victims.

the skull. The usual outcome of traumatic AOD injury is death from transection of the brain stem. If trauma victims survive AOD injury, they exhibit a variety of cranial nerve or upper spinal cord deficit symptoms (eg, rotatory nystagmus, ocular bobbing, decerebrate posturing).3

Respiratory arrest occurs frequently due to brain stem compression as well as diaphragmatic paralysis or lower cranial nerve palsies causing airway obstruction. Hypertension can occur in these patients because of their bilateral glossopharyngeal nerve lesions, whereas complete spinal cord transection can cause hypotension in victims. Medullary compression can lead to bradycardia and apneic spell^.^ More survivors have been reported in the past decade due to improvements in prehospital trauma resuscitation techniques and shorter transportation

ATLAWTOOCCIPITAL DISLOCA- TlON INJURY

The first survivor of traumatic AOD injury was reported in 1908. The patient was a sailor who fell while aboard ship. The surgeon's examination revealed that the patient had sustained complete quadriplegia. His neurological condition failed to improve after an exploratory Cl-C2 decompres- sion laminectomy, and he only lived 32 hours with artificial ventilatory support. Since that time, traumatic AOD survivals have been reported in only 34 cases, most of them children.2

Pathophysiology. Traumatic AOD is caused by the avulsion of the first cervical vertebra (ie, the atlas) from the occipital bone of

A B S T R A C T The tragedy of trauma turns

into triumph when the surgery team members' efforts result in victory for the patient. Nowhere is this more true than in suc- cessful pediatric trauma care. Giving a child a second chance at life and the family an oppor- tunity for a new beginning is the highest reward for the trauma team's years of professional training and practice. Traumatic atlantoocipital dislocation injury usually results in death, but recent neurosurgery trauma advances are increasing pediatric survival rates. AORN J 60 (OCt 1994) 544-558.

times to trauma centers? Pediatric patient profile.

Young children are especially vulnerable to traumatic AOD injuries because their craniovertebral junctions (ie, the point where the head joins the spine) are less stable than those of adults. Children's occipital condyles are smaller, their heads are larger relative to their bodies, the atlantooccipital ligaments are more lax, and the articulating planes of the craniovertebral junctions are more horizontal as compared to adults. In addition, cervical spine injuries occur more frequently in automobile/pedestrian accidents than in collision accidents, and children are involved in automobile/pedestrian accidents more often than adults. Children

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Thnsporting children

to trauma centers within 30

minutes afkr injury is crucial

for optimal patient outcomes.

not only have unstable anatomy at their cranioverte- bra1 junctions, but they are more predisposed to the inciting accidents than adults.6 There have been only 25 documented, long-term survivors who were able to be discharged from hospitals following AOD injuries.’

Pediatric anatomy. The craniovertebral junction and the occipital condyles function as a single unit and provide the head and neck with a “ball-in-socket” type of motion. The atlas, named for the Greek mythology god who carried the world on his shoul- ders, serves as an interposing “ball bearing” in the head and neck junction. With advancing age, this joint becomes more vertical and begins to seat more deeply and f i i l y in the articulating body of the atlas. The atlas is only loosely connected to the occiput by weak anterior, posterior, and lateral membranes. Sta- bility of this joint is dependent on surrounding ligaments (eg, tectorial, cruciate, apical, alar). Extreme hyperextension, together with a distraction force applied to the head (eg, as seen in automobile/pedestrian accidents), can lead to craniovertebral ligament rupture and traumatic anterior or posterior AOD injuries. Lateral AOD is rare.8

Pediatric physical findings. The physical findings of children with AOD who survive automobile accidents to reach the emergency departments (EDs) may be quite varied (eg, cranial nerve palsies, brainstem lesions, hemiparesis, respiratory arrest). Vertebrobasilar strokes from direct injury to the vertebral arteries in the craniovertebral junction and spinal cord transection at the cervicomedullary junction have been documented in these injuries.’ Many cases of AOD are associated with facial or multiple organ system trauma. Invariably, there are associated head or lower cervical spine injuries with traumatic AOD injuries, which may interfere with

accurate AOD diagnoses.I0 Pediatric neurological symptoms. These chil-

dren’s neurological symptoms may range from no deficits to quadriplegia with ventilatory dependency. Discomfort, stiffness, or severe neck pain may be the only indication that an AOD injury has occurred. Neu- rological extremity dysfunctions can be manifested by spasticity, sensory deficits, motor paralysis, or hemiparesis. Reported clinical features associated with this injury are loss of consciousness, hemiparesis or tetra- paresis, cranial nerve palsy, and submental laceration or fracture of the mandible.1’

MEDICAL AND SURGICAL TREATMIM Most trauma specialists agree the earlier a child

can be definitively treated, the better his or her outcome. With children, the first 30 minutes after injury are thought to be crucial.12

Prehospital treatment. Prehospital management consists of the immediate resuscitation, stabilization, and immobilization of the AOD injury victim. Stand- ing orders and communication by shortwave radio are often used to manage the pediatric trauma patient at the injury site and during transport. Improvements in airway management, fluid replacement, and head and neck immobilization methods and rapid transportation by land and air have significantly reduced AOD injury mortality in the last two decades.l3

Emergency department treatment. When the patient arrives in the ED, the patient’s airway, breathing, and circulation (ie, the ABCs); external stabilization of the cervical spine; and establishment of a detailed history of the trauma incident are priorities for the ED trauma team members. After adequate ven- tilation and tissue perfusion have been ensured, the trauma team members’ immediate attention is given to the patient’s neurological condition. A rapid, initial neurological assessment includes

level of consciousness (eg, alert, lethargic, disori- ented, comatose, responsive or unresponsive to

motor activity and tactile sensation (eg, lateraliza- tion, posturing, bilateral extremity strength, asym- metry or flaccidity), obvious head trauma (eg, depressed skull fracture, gunshot wound, leaking cerebrospinal fluid), pupil size and response to light (eg, equal, bilateral pupil response, unilateral, fixed pupil, widely dilat- ed and fixed pupils), vision and oculocephalogyric reflexes (eg, roving eye movements, “doll’s eye” reflex, limitations

pain),

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Figure 2 John Nichols, MD, PhD, uses a model to demonstrate the 1 - to 1 1/2-inch gap between Tommy’s skull and cervical spine. (Reprinted with permission from The Denver Post, Jerry Cleveland, photogrupher)

children and families coping with lengthy, major posttrauma rehabilitation. Disabilities resulting from trauma accidents can be financially exhausting as a result of physical therapy, specialized equipment, and care by rehabilitation specialists.2O

Early rehabilitation is a major goal for children with head injuries. The expertise of many interdisciplinary health care pro- fessionals (eg, nurses; physical, speech, occupational therapists; psychiatrists; urologists; neuropsy- chologists; neuroophthalmologists) is necessary to assess and address specific patient problems. Com- mon problems include

approach is preferable because it preserves anterior structures, such as the anterior atlantooccipital mem- brane, and it provides greater cervical stability. Inter- nal fixation with spinal fusion limits flexion/extension of the patient’s head, and if extensive C2 fusion is performed, rotation of the patient’s head also is severely reduced.

Rehabilitation. The postacute or rehabilitation phase of care begins when the patient is medically and surgically stable and can be transferred from the criti- cal care setting. Recovery from AOD injuries can have great personal, social, and economic impact on children, families, and the health care system. Rehabilita- tion requirements are complex in children for many reasons.

The physical and cognitive rehabilitation process is longer in children than adults. The process is complicated by the problems of pediatric growth and development. There are numerous psychosocial stresses for both

paresis and/or paralysis, communication abnormalities, feeding or swallowing difficul- ties, vision problems, cognitive deficits, bladder and/or bowel dysfunction, behavioral problems, and difficulty adjusting to daily liv- ing activities (eg, eating, hold-

ing items, combing hair, dressing).21 Patients with AOD injuries who remain in chronic

nonresponsive states are placed in long-term care facil- ities or nursing homes.

CASE HISTORY Tommy, a three-year-old male, had been stand-

ing up in the back seat of his mother’s automobile. As his mother’s car rounded a corner, his door swung open, and Tommy was propelled out of the moving vehicle. His head snagged on the shoulder strap of the driver’s safety belt, causing severe trauma to the ligaments holding his skull and cervical spine together. The atlantooccipital dislocation was severe enough to leave more than 1 inch of his spinal cord unprotected and vulnerable to permanent damage (Figure 2).

Tommy’s mother lifted her son into her arms and took him several blocks to the rural town’s only medical center. The mother gave the EMS care providers a

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Figure 3 Lateral radiograph showing the 1 - to 1 1/2- inch gap between Tommy‘s head and cervical spine.

quick trauma history to alert them to her son’s possible injuries.

Tommy was in cardiac arrest when he arrived at the medical center, so EMS care providers initiated cardiopulmonary resuscitation. An EMS care provider placed his hands around Tommy’s neck to provide manual, in-line stabilization to the cervical spine. Tommy was nasally intubated, and his heart resumed beating after the first dose of cardiac drugs was administered. Tommy’s cervical spine was immobilized in a pediatric-size cervical collar, and his head and body were taped to an unpadded spine board. Tommy was responsive to pain only, and the first cervical x-rays obtained were obscured by a pair of hands around Tommy’s neck.

The EMS physician referred Tommy to a regional trauma center for appropriate treatment after confer- ring with level I trauma center physicians in Denver. Tommy was airlifted to the regional trauma center within an hour of his arrival at the rural medical center.

Initial trauma care. An unconscious and intubated Tommy was transported directly to the pediatric ICU and placed on a ventilator. Initial patient care

Figure 4 Lateral view of the 1- to 1 1/2-inch gap between Tommy‘s head and cervical spine.

included assessment of Tommy’s airway, breathing, circulation, spinal injury, level of consciousness, and left pulmonary contusion. The attending neurosurgeon supervised Tommy’s transfer onto a padded spine board to prevent decubitus formation during the wait for the pediatric halo brace.

Tommy began receiving 24-hour infusions of high-dose methylprednisolone within six hours of his trauma injury according to the neurotrauma protocol. Statistics reveal significant increases in motor and sensory function in patients with spinal cord injuries if high-doses of methylprednisolone are started within eight hours of the neurological

The next day, the neurosurgeon placed Tommy in the halo brace. A local anesthetic was used to decrease Tommy’s discomfort. The halo (ie, metal ring) was attached to Tommy’s skull by inserting four pins (eg, two posterior and two anterior) into the external bony table of his cranium. The halo ring was connected to adjustable steel rods that attached to a plastic body jacket lined with fleece material.

After x-rays confirmed that Tommy’s cervical spine was stable, he was untaped from the padded spine board and placed on an alternating pressure bed. Two days after admission, Tommy was taken to the OR for a tracheostomy and gastric feeding tube placement. Tommy was taken off the ventilator and placed on humdified oxygen after surgery. Additional ICU management during the acute phase of care consisted of nutritional support, skin care, and physical therapy.

Neurological symptoms. Tommy’s initial neurological examination by the attending neurosurgeon revealed palsies of both the right and left sixth cranial nerves. His gaze was directed to the left, and his pupils

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were 2 cm in diameter and slug- gishly reactive to light. Tommy could move all four extremities, and he would withdraw from painful stimulation of these limbs. His left extremities were weaker than his right extremities. Deep tendon reflexes of the lower extremities initially were absent.

Diagnostic confirmation. Diagnostic radiographic studies confirmed the neurosurgeon’s diagnosis of traumatic AOD injury (Figures 3 and 4). Radiographs of his cervical spine showed a posten-

Figure 5 9 Photograph of Tommy In his halo brace on the day of surgery for surgical fixation of his head to his neck.

or, type I1 AOD with a 1- to 1 1/2- inch separation between Tommy’s occiput and atlas coupled with increased swelling of the prevertebral soft tissues. The attending neurosurgeon decided to perform surgery when Tommy’s over- all condition was stable. Two weeks after sustaining the AOD injury, Tommy underwent a posterior Cl-C2 fusion to his occiput.

Operating room preparation. A surgical fusion of Tommy’s AOD injury required instruments for exposure of his cervical spine, bone grafting, and decortication of the spinous process. General instm- ments needed for the posterior Cl-C2 fusion to his occiput included 18-inch strands of 22-gauge stainless steel wire, wire twisters, heavy needle holders, and implant-specific instrumentation (eg, 3/16-inch diameter, serrated Steinmann pin). The circulating nurse gathered the preoperative radiographic studies and made them available in the OR for the neurosurgeons.

Intraoperative hypothermia is common in children with cervical spine injuries; therefore, the circulating nurse set up equipment to monitor temperature and maintain normothermia before Tommy arrived in the OR. The circulating nurse increased the OR air temperature to 75” F (24” C) one hour before surgery, placed a temperature regulating blanket on the OR bed, and assembled a forced warm air systemblanket to place on top of Tommy’s lower extremities after positioning. Warmed irrigation and IV solutions were made ready for the case.

Additional necessary equipment and supplies (eg, Mayfield headrest, anterior halo adapter to the May- field headrest, drills, Michel wound clips, antiembolism compression machine, electrosurgical unit [ESU], fluoroscopy unit, x-ray shields, somatosensory evoked potential [SSEP] unit, pillows, foam pads) were

assembled by the circulating and scrub nurses before the patient was transferred to the OR.

Somatosensory evoked potential monitoring. Somatosensory evoked potentials are used intraopera- tively to measure the patient’s neural transmissions during surgical manipulation of the spinal cord. Evoked potentials are produced by repetitively stimu- lating the patient’s peripheral nerves (ie, wrist median nerve, posterior ankle tibia1 nerve) with electrical impulses. The evoked potentials are monitored at vari- ous levels of the sensory pathway that ascends from the peripheral nerve to the dorsal spinal column and up to the thalamus and cortex. The SSEP signal is measured both in amplitude and latency (ie, time required for an impulse to travel from the point of stimulation to the recording point) by a computer.23 On-site interpretation of SSEP data by a certified tech- nician helps identify acute spinal cord neurological deterioration during surgical procedures before irre- versible injury may occur to the patient.

Preoperative patient interview. When the OR was ready to receive Tommy, the circulating nurse proceeded to the pediatric ICU to introduce herself to Tommy and his parents. The circulating nurse conducted her assessment and chart review at the bedside to decrease Tommy’s anxiety and allow the parents to ask questions. The circulating nurse checked the accu- racy of Tommy’s identification bracelet and reviewed his chart for laboratory results, a signed surgical con- sent, a history and physical examination notation, and an anesthesia care provider’s interview notation.

Tommy’s halo brace (with attached wrench) (Figure 5) , tracheostomy tubing, gastric feeding tube, Foley catheter, antiembolism compression stockings,

552 AORN JOURNAL.


and IV tubing were inspected by the circulating nurse for any problems before Tommy was taken into the OR. The circulating nurse realized Tommy’s anxiety would heighten considerably if equipment problems delayed his induction under general anesthesia.

Verbal communication signals were established between Tommy and the circulating nurse to help decrease Tommy’s anxiety and increase his feeling of control of the situation. Tommy was assured that there would be only a short separation from his parents. The circulating nurse asked Tommy’s parents to accompa- ny him to the entrance of the sterile comdor. The surgical team members (eg, neurosurgeon, anesthesia care provider, circulating nurse) transported Tommy to the OR only after all preparations were finished.

Induction and positioning. The instability of Tommy’s AOD injury and the complexity of moving him in his halo brace made induction in his ICU bed a necessity. The OR team members were familiar with the mechanics of halo brace removal for CPR because patients with AOD injuries are susceptible to frequent hemodynamic changes. Tommy was taken into the OR, and the circulating nurse assisted the pediatric anesthesia care provider with placement of cardiac monitors. Tommy was induced under general inhala- tional anesthesia via his tracheostomy tube. A techni- cian placed SSEP leads on Tommy after induction and before he was moved to the Mayfield headrest. The anesthesia care provider inserted a radial arterial line.

After baseline SSEPs were recorded, five neurosurgery team members lifted and carefully turned Tommy to a prone position on the OR bed. The chief neurosurgeon maintained traction on Tommy’s halo ring to keep his neck in a neutral postion during transfer. After transfer, the anesthesia care provider reat- tached the respirator tubing to Tommy’s tracheostomy tube and reapplied the hemodynamic monitors. The second neurosurgeon removed the back of Tommy’s halo ring and secured his head in an anterior halo adapter device attached to the Mayfield headrest (Fig- ures 6 and 7). No changes in SSEPs were noted during this positioning. A lateral cervical spine x-ray film was taken to ensure the atlantooccipital dislocation had not increased during Tommy’s positioning.

After positioning, the circulating nurse padded Tommy’s knees and feet with pillows to prevent pressure necrosis. All pressure points were padded, the patient’s arms are secured with a draw sheet, and both arms were placed at his side.

The circulating nurse checked the positioning of the Foley catheter and attached the antiembolism

Figure 6 . Lateral view of Tommy prone and prepped in a Mayfield headrest after a difficult five-person lift from a supine position to the OR bed.

Figure 7 . Tommy‘s incision site just before the application of the sterile surgical drapes.

Figure 8 lntraoperative photograph showing internal fixation of Tommy‘s occiput to C1 -C2 with a combina- tion of a serrated Steinmann pin, 22-gauge stainless steel wire, and autologous bone.

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compression stockings to the compression machine for the prevention of venous thromboembolization. An ESU dispersive pad was placed on Tommy’s lower posterior thigh. The anesthesia care provider covered the top portion of Tommy’s head with a towel to prevent heat loss. A humidified anesthesia circuit was attached between Tommy’s tracheostomy tube and the ventilator to help maintain his body temperature during surgery. An esophageal temperature probe was placed by the anesthesia care provider.

Prepping and draping. One of the three neurosurgeons shaved the back of Tommy’s head and prepped the occiput and cervical spine for 10 minutes with povidone-iodine solution. The anterior portion of Tommy’s halo vest was protected from prep solution pooling with waterproof pads. Another neurosurgeon prepped Tommy’s right superior iliac crest for bone harvesting. Each prepped area was infused with 10 mL of 0.5% xylocaine with 1:2OO,OOO epinephrine to aid in hemostasis. The two incision sites were draped with pediatric-size surgical drapes that ensured adequate exposure for the procedures.

Surgical procedure. The chief neurosurgeon made a midline longitudinal incision from the occiput through C7. He applied Michel wound clips along the skin edges for hemostasis and then incised the dorsal fascia using monopolar electrosurgical cautery down to the spinous processes of C2 through C7. Gentle dissection was used by the neurosurgeon to free the muscle from the overly- ing Cl-C2 laminae and the occiput. The neurosurgeons noted a 3-cm distraction between the occiput and C1 and another 3/4-cm distraction between C1 and C2. A previously constructed occipitocervical metal brace (ie, 3/16- inch diameter, serrated Steinmann pin) was fashioned by the chief neurosurgeon in the angle between the occiput and Cl-C2 areas with the open end of the U-shaped brace placed caudally (Figure 8).

The second neurosurgeon drilled small burr holes (ie, two holes on the left of the foramen magnum, two holes on the right). The neurosurgeon performed a sublaminar dissection and placed 0-silk sutures through the burr holes and underneath the C1, C2, and C3 laminae. The scrub nurse braided two strands of 18-inch length, 22-gauge stainless steel wire, and the neurosurgeon placed the strands through the four burr holes in the occiput and underneath the cervical laminae. The two neurosurgeons used fluoroscopy to wire the Steinmann pin into place. The atlantooccipital dislocation was reduced by pulling the occiput in both posterior and caudal directions. Fluoroscopy showed no geographical movement of the C1, C2, or occiput.

Figure 9 A postoperative lateral x-ray of the permanent surglcal fixation of Tommy‘s head to his cervical spine using a serrated Steinmann pin, 22-gauge stainless steel wire, and autologous bone.

An intraoperative lateral cervical spine x-ray con- f m e d realignment of Tommy’s atlantooccipital joint.

The neurosurgery resident prepared Tommy’s right superior iliac crest for bone harvesting during the realignment procedure. The resident made a skin incision above the right superior iliac crest and carried it down the iliac crest with monopolar electrosurgical cautery. The exterior aspect of the right pelvis was stripped of cortical and cancellous bone. The bone was inlaid into the previously debrided C1, C2, C3, and occipital posterior laminae elements. At the end of surgery, x-rays revealed the atlantooccipital internal fx- ation construct to be intact and holding well (Figure 9).

Wound closure. The surgical wounds were irri- gated with copious amounts of warm irrigation solution (ie, 1 g cefazolin in 1,000 mL normal saline). The patient’s dorsal cervical fascia was closed using con- tinuous absorbable suture, and the subcutaneous tissue was closed using inverted, interrupted absorbable suture. The head and neck skin incision was closed using a subcuticular stitch. The right iliac crest incision was closed using inverted, interrupted 2-0 absorbable suture. The subcutaneous tissue was closed using inverted, interrupted 3-0 absorbable suture, and the skin was closed using a running, subcuticular 4-0 absorbable stitch. The sponge and needle counts were correct at the end of the procedure, and there were no apparent intraoperative complications.

Postoperative summary. The patient’s SSEP

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improved during the surgery and his postoperative clinical examination was neurologically unchanged. Tommy did not receive blood products, and he tolerat- ed the surgical procedure without complications. Tommy’s halo brace was resecured in place before the team lifted him onto his alternating pressure bed for transport to the pediatric ICU by the trauma team members (eg, chief neurosurgeon, anesthesia care provider, circulating nurse). Postoperatively, Tommy did well and progressed rapidly in therapy.

Rehabilitation. Rehabilitation consisted of daily speech, physical, and occupational therapy. A neu- roophthalmologist treated Tommy for temporaq left eye nerve damage (Figure 10). Within two weeks, Tommy’s motor functions improved and his bilateral sixth nerve palsies resolved completely. A month after the occiput-to-cervical spine fusion surgery, Tommy developed hydrocephalus that required another surgery for placement of a ventriculoperitoneal shunt. Tommy’s halo brace was removed by the chief neurosurgeon four months after Tommy’s admission to the trauma center. Tommy’s tracheostomy was closed approximately four weeks after he recovered his vocal cord function.

Tommy was discharged approximately four months after his accident. He continues outpatient therapy twice a week in his rural home town in Col- orado. Tommy is almost seven years old now, and he

~

Figure 11 Tommy standlng with assistance from his father three years after his trauma injUry.

attends the second grade. His cognitive and communication skills are normal for his age group. Tommy recently took his first steps without assistance. He has adequate strength for standing and has limited independent ambula- tion. Residual spasticity is present in his extremities, but he has gross and f i e motor movement in both hands. Tommy’s range of motion in his neck is less than 45 degrees. He leads an independent life at home, plays on the floor with his two brothers, and has shown a tal- ent for art construction projects.

Tommy and his father travel to Denver every three months for follow-up care (Figure 11). Radi- ographic films are taken monthly to evaluate the surgical construct, and

Figure 10 Tommy with temporary len eye nerve damage responding to Dr Nichols‘ neurological examination three days after surgery.

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the x-rays have shown no increase in the 3/4-inch gap still present between Tommy’s occiput and C1 vertebra. At his recent third anniversary outpatient visit, Tommy was neurologically normal and had developed a solid fusion from the occiput to the axis. The need for future surgery is unknown because no child has reached puberty following traumatic AOD injury.

SUMMARY Traumatic AOD injury can be compatible with

survival and recovery if an aggressive treatment plan is chosen. Even patients with severe deficits from their cervical spine injuries can recover significant normal function with proper treatment. Perioperative nurses should suspect this type of injury in patients with respiratory instability and head injuries sustained in high-energy collisions (eg, motor vehicle versus pedestrian). Children seem to be particularly vulnerable to AOD injury because of their anatomical characteristics.

Complaints of discomfort or stiffness may be the only clue that an AOD injury has occurred. This is especially troubling when dealing with pediatric surgical patients who cannot always verbalize their symptoms. Careful evaluation of the initial bedside lateral cervical spine x-ray should be conducted for accurate diagnosis because of variable patient presentations.

A patient diagnosed with AOD injury should be immobilized with a halo brace for initial stabilization

N O T E S

Accident Facts 1993 (Itasca, Ill: The National Safety Council, 1993).

2 . 0 Harmanli, Y Koyfrnan, “Traumatic atlanto-occipital dislocation with survival: A case report and review of the literature,” Surgical Neurology 39 (April 1993) 324-330.

3. A J Belzberg, B I Tranmer, “Stabilization of traumatic atlantooccipital dislocation: Case report,” Journal of Neurosurgery 75 (Sep- tember 1991) 478-482.

1. The National Safety Council,

4. Ibid. 5. M J Matava, T E Whitesides, P

C Davis, “Traumatic atlanto-occipital dislocation with survival. Serial com- puterized tomography as an aid to diagnosis and reduction: A report of three cases,” Spine 18 (October

6. D G McLone, Y S Hahn, 1993) 1897-1903.

as soon after the injury as possible. As sole treatment, the halo brace is inadequate to attain long-term stability of AOD injury. Early surgical intervention for internal fixation of the occiput to the cervical spine is crucial for survival and optimal patient outcomes.

Survival after traumatic AOD injury, though rare, is increasing with improved EMS response and rapid transport of patients to regional trauma centers. Neu- rological deficits among survivors range from mini- mal dysfunction to ventilator-dependent quadriplegia. We have presented a case of a child who survived traumatic AOD injury and now lives a quality life three years after his trauma injury. His survival and recovery are due to the interdisciplinary expertise of a level I trauma team of physicians, nurses, therapists, and specialty technicians and the success of a trauma network that expeditiously transferred this pediatric trauma patient to the appropriate care facility. A

John Nichols, M D , PhD, is a staff neurosurgeon at Provenant St Anthony Hospital Central, Denver. At the time this article was written, he was chief of trauma neurosurgery, Denver General Hospital.

Janet S . West, RN, BSN, CNOR, is the clinical editor of the AORN Journal. She was the neurosurgery team leader at the time this patient underwent surgery at Denver General Hospital.

“Head and spinal cord injuries in children,” in Swenson’s Pediatric Surgery, ed J G Raffensperger (Nor- walk, COM: Appleton & Lange, 1990) 261-275.

7. Harmanli, “Traumatic atlantooccipital dislocation with survival: A case report and review of the literature,” 326.

8. R Bucholz, W Burkhead, “The pathological anatomy of fatal atlantooccipital dislocations,” Journal of Bone and Joint Surgery 61A (1979)

9. A Cohen et al, “Traumatic atlanto-occipital dislocation in children: Review and report of five cases,” Pediatric Emergency Care 7 (February 1991) 24-27.

10. A B Dublin et al, “Traumatic dislocation of the atlanto-occipital articulation (AOA) with short-term survival,” Journal of Neurosurgery

248-250.

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52 (1980) 541-546; H H Bohlman, “Acute fractures and dislocations of the cervical spine: An analysis of three hundred hospitalized patients and review of the literature,” Journal of Bone and Joint Surgery 61A (1979) 11 19-1 142.

11. A H Van Den Bout, G F Dom- misse, “Traumatic atlanto-occipital dislocation,” Spine 11 (1986) 174-176.

12. N Hosono et al, “Traumatic anterior atlanto-occipital dislocation: A case report with survival,” Spine 18 (May 1993) 786-790.

13. Harmanli, “Traumatic atlantooccipital dislocation with survival: A case report and review of the literature,” 326.

14. W Donellan, “Pediatric trauma,” in Emergency Nursing: A Phys- iologic and Clinical Perspective, ed S Kitt, J Kaiser (Philadelphia: W B Saunders Co, 1990) 545-574.

OCTOBER 1994, VOL 60, NO 4 Nichols West 8

15, Ibid. 16. D I Bulas, C R Fitz, D L John-

son, ‘Traumatic atlanto-occipital dislocation in children,” Radiology 188

17. V C Traynelis et al, “Traumat- ic atlanto-occipital dislocation: Case report,” Journal of Neurosurgeiy 65

18. J V Hickey, The Clinical

(July 1993) 155-158.

(1986) 863-870.

Practice of Neurological and Neuro- surgical Nursing, third ed (Philadel- phia: J B Lippincott Co, 1992) 370- 372.

19. R A Kaufman et al, “Traumat- ic longitudinal atlantooccipital dis-

traction injuries in children,” Ameri- can Journal of Neuroradiology 3 (1982) 415-419.

20. B A Knezevich, Trauma Nurs- ing: Principles and Practice (Nor- walk, Conn: Appleton-Century- Crofts, 1986) 270.

of Neurological and Neurosurgical Nursing, 34546.

22. M B Bracken et al, “A ran- domized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury,” The New England Journal of Medi- cine 322 (May 17,1990) 1405-1411.

2 1. Hickey, The Clinical Practice

23. D D Rose et al, “Cervical spine injury: Perioperative patient care,” AORN Journal 57 (April 1993) 830-850.

SUGGESTED READING American College of Surgeons

Committee on Trauma. Resources for Optimal Care of the Injured Patient: 1993. Chicago: American College of Surgeons, 1993.

Mangum, S; Sunderland, P M. “A comprehensive guide to the halo brace: Application, care, patient teaching.” AORN Journal 58 (Sep- tember 1993) 534-546.

Providing Unbiased Care to Culturally Diverse Patients The American health care system generally reflects the values and beliefs of “mainstream” America as well as values defied in the health care profession. According to an article in the June 1994 issue of Pediatric Nursing, nurses should be aware of the cultural biases of the American health care system and know how to avoid those biases during patient communications.

Ethnic and cultural differences often affect a family’s approach to medical care. For example, compared to white people, black and Hispanic people are more likely to use emergency rooms as their usual sources of health care and are less likely to have health insurance. Different cultures also have different perceived mean- ings of illness. In cultures that consider illness divine punishment or evidence of impurity, families may be less willing to seek medical attention.

ent from their health care providers may feel disre spected, uncared for, or looked down upon by their providers. Consequently, they may not keep follow-up appointments or comply with medical care plans. By incorporating cultural awareness and sensitivity, mutual respect, and cross-cultural communication into patient dialogue, nurses may help improve communication and the provision of care.

When language is a barrier, the health care provider should use a translator (eg, bilingual family members, hospital employees) during patient communications and should look at the patient rather than the translator when communicating.

Families who are ethnically and culturally differ-

Even if the patient speaks English, health care providers should avoid using jargon when caring for patients from different cultures. Families may have different beliefs, values, and ways of responding to illness, and health care providers may want to learn about the family’s culture and ask questions without judging.

Health care providers need to consider the family’s preferences and priorities when developing a care plan and attempt to explain treatments using the family’s frame of reference. For example, when caring for someone who believes that fever is caused by imbalance, the health care provider could tell the patient that large amounts of cool fluids will correct the imbalance that has caused too much heat. Also, health care providers can encourage families to use culture- related illness practices (eg, using religious artifacts to eliminate evil spirits) if they do not impede healing.

The article states that nurses are key to the provision of culturally competent health care. They need to consider possible cultural differences when caring for patients while remembering that individual beliefs also may vary among families from the same ethnic or cultural backgrounds. General knowledge of medical- related beliefs and values of other cultures is the basis for individualized care that promotes understanding and healing.

E Ahmann, “‘Chunky stew‘: Appreciating cultural diversity while providing healfi care for children, ‘ Pediatric Nursing 20 (May/Jne 1994) 320-324.

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traumatic atlantooccipital dislocation injury in children

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