First Aid

Cardiac Emergency Response Plan

The American Heart Association has created tools to help schools develop a comprehensive Cardiac Emergency Response (CER) Plan. Visit the American Heart Association website where you can find implementation letters to parents, sample action steps for school improvement plans, sample timelines for schools, and a guide on how to develop a CER team.

Cervical Spine Injury

First Aid for Cervical Spine Injury


  1. Safety First! Make sure the environment is safe for both rescuer and victim before providing any first aid. Always practice universal precautions and use personal protective equipment whenever you may come in contact with blood or body fluids.
  2. Make sure that the victim is breathing. Breathing is obviously necessary for life, and thus is more important than immobilizing the cervical spine. Check to see if the victim is breathing. If they are breathing then you can begin to attend to the cervical spine injury. If the victim is not breathing, you may be facing a serious emergency, and you should contact 911 immediately.
  3. Even if you suspect a C-spine injury, it is imperative to make sure that is the issue. All suspected cervical spine injuries must be assessed by an x-ray. Call 911 to summon an ambulance. Make sure you know the differences between mobile phones and regular phones before calling 911 on a cell phone.
  4. If the victim is unconscious, protect the victim's airway by placing the victim in the recovery position. Place padding, such as a pillow, under the head of the victim in order to help keep the neck straight.
  5. If the victim is awake, place both hands on either side of the victim's head to steady it. Hold the victim's head gently but firmly to keep it from moving. Any movement of the cervical spine may make a C-spine injury worse. Only release the head to help with the victim's airway, breathing or circulation, or if the scene becomes unsafe.
  6. Continue to immobilize the victim's head until medical help arrives and remind the victim not to move. Remember, any extra movement of the already-injured cervical spine could cause additional damage, and make an injury worse. That is why it is so important to keep the victim's head immobilized and their body as still as possible

By Rod Brouhard, EMT-P
Updated April 27, 2016

Who to immobilize

Determining the risk for spinal cord injury in the pediatric trauma patient requires synthesizing the history, presentation, and physical examination. Risk factors for cervical spine injury are shown in Table 1. Any child demonstrating any of these risk factors should be considered for cervical spine immobilization and radiographic evaluation.

Table 1. Risk Factors for Cervical Injury

Mechanism of injury

High-speed MVA


Bicycle or pedestrian hit by car

Forced hyperextension injury

Acceleration-deceleration injury of head

History of neurologic symptoms including transient symptoms

Weakness, paraesthesia, burning sensation related to neck movement


Unconscious patient


Significant trauma to head or face


Midline cervical pain

Midline cervical tenderness, deformity

Abnormal peripheral neurologic findings

Unreliable examination

Major distracting injury


Drug or alcohol intoxication

Developmentally young child

Inconsolable child

How to immobilize

  • The amount of immobilization depends on the amount of cooperation there is from the patient. Older children often need only neck immobilization. Younger children may need their body immobilized at shoulder and hip level.
  • If a child is thrashing around, start with manual immobilization of the head and neck, shoulders and the hips. Sometimes holding an agitated child can be calming. In a larger child consider whether attempted immobilization is likely to increase cervical spine movement. If this is the case immobilization does not occur until the situation is under control. Calming the child in a quiet voice, presence of a parent and treatment of pain are often effective.
  • Initial immobilization includes:
  1. A rigid cervical collar –initially a Stiff neck collar is used, this is fitted to the child based on length of neck and circumference. (See section on sizing and fitting collars)
  2. If the child continues to move this is supplemented with:
  3. In line manual immobilization
  4. Sand or fluid bags or foam blocks attached to a board behind the head
  5. Velcro tape between the foam blocks increases immobilization if needed. The child is never taped to the mattress as if the child vomits they cannot be placed on their side to clear their airway.
  6. Spine board if the child is unconscious or is uncooperative.
  7. This board comes in three sizes infant, pre-school child and older child. Younger children have a large head and relatively small chest which force the neck into a position of kyphosis and anterior angulation on a flat board. Therefore the boards for younger ages have an occipital dip to keep the spine in a neutral position. Alternatively a pad should be used under the body.
  8. The plastic spine boards are of a uniform material and do not cause interference in the CT scanner. Laminated wooden boards do cause interference (Fig 1).
  9. Extrication boards and scoops from the ambulance service may restrict access to the child and cannot be used in the CT scanner. Therefore the child with major trauma should be transferred from these on arrival.
  10. Transfer from one bed to another of patients at high risk of a spinal injury needs to take place carefully to minimize spinal movement.

Sizing and Fitting Neck Collars and StifNeck Collar

Several different manufacturers make semi-rigid collars. Some are adjustable. The most commonly seen in the CHW Emergency Department is the Laerdal Stifneck extrication collar, which comes in a range of shapes and sizes. The most appropriate should be chosen before fitting as follows.

Measure (roughly as finger-breadths) the distance between the angle of the jaw and the clavicle with the head in the correct degree of flexion/extension in the midline and the shoulders relaxed (Figure 1). This measurement corresponds to the distance between the black measuring “post” on the right of the collar (look inside and see how it matches up with the angle of the jaw) and the bottom of the rigid part of the collar, not the foam liner (Figure 2).

Measuring for a neck collar on child
Figure 1. Measure the Patient

Measuring for a neck collar on child
Figure 2. Measuring the Collar

Different widths exist to accommodate different neck circumferences but there are few choices for children and most babies will end up in the (pink) infant collar, and smaller children in the (blue) pediatric collar.

* Be prepared to get it wrong with your first estimate and try a different size.
* If the collar is flat-packed, assemble it before attempting to size it.

With the patient’s head held by another person in secure manual in-line immobilization, slide the flat back portion of the collar behind the head and neck (Figure 3).

manikin waiting for neck collar
Figure 3. Slide Back Portion Behind Head

Then swing the front of the collar down and across the front of the chest so that it fits beneath the chin before closing the Velcro.

manikin with neck collar on
Figure 5. Swing Front Portion Into Place

Apply sandbags or head blocks and tape before allowing release of the manual immobilization.

Reference list

  1. Mower WR, Hoffman JR, Pollack CV Jr, et al: Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med 2001;38:1-7.
  2. Eubanks,Jd, Gilmore,A, Bess, S and Cooperman,D.R. (2006). Clearing the Pediatric Cervical Spine Following Injury. Journal of the American Academy of Orthopedic Surgeons. 14:552-564.
  3. Copley,LA, Dormans,JP(1998). Cervical spine disorders in infants and children. Journal of the American Academy of Orthopaedic Surgeons, 6:204-214.
  4. Aspen collar fitting – Western Sydney guide.
  5. Log Roll Guide NSW ITIM.

Copyright notice and disclaimer:
The use of this document outside Sydney Children's Hospitals Network (SCHN), or its reproduction in whole or in part, is subject to acknowledgement that it is the property of SCHN. SCHN has done everything practicable to make this document accurate, up-to-date and in accordance with accepted legislation and standards at the date of publication. SCHN is not responsible for consequences arising from the use of this document outside SCHN. A current version of this document is only available electronically from the Hospitals. If this document is printed, it is only valid to the date of printing.

Medical Reviewers:

  • MMI board-certified, academically affiliated clinician
  • Turley, Ray, BSN, MSN

Emergency Use of Epinephrine


Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Unlike common allergy, anaphylaxis onset may be sudden and requires instant action to prevent fatality.

Common Causes of Anaphylaxis:

  • Food
  • Insect sting
  • Medication or immunization

Signs and Symptoms of Anaphylaxis:

  • Throat tightness, difficulty speaking or swallowing
  • Itching, including hives and/or itching of the mouth, throat, or tongue
  • Shortness of breath, wheezing, coughing, chest tightness, blue skin color
  • Swelling of body parts, especially face and mouth
  • Vomiting, diarrhea, abdominal cramps
  • Feeling of apprehension, loss of consciousness

Emergency Response

  • Call 911
  • Retrieve epinephrine Auto-injector (EpiPen or Auvi-Q) from the following location _______________________in this building
  • Administer Epinephrine auto-injector at the first sign or symptom of a known or suspected anaphylactic reaction.
  • K, 1st, 2nd grade- use green EpiPen Junior or blue Auvi-Q 0.15 mg
  • 3rd grade or older- use yellow EpiPen Adult or orange Auvi-Q  0.3 mg
  • May administer oral Benadryl per standing order if victim is alert and breathing normally
  • Notify emergency contact person, school nurse, and administer as soon as possible
  • If reaction continues or worsens, a second dose of epinephrine may be given in 15 minutes.
  • Remain with the victim at all times, note signs, symptoms, and time of epinephrine administration. Send used Epinephrine auto-injector with victim leaving the school.
  • De-brief team response, complete incident report.

Maintenance of Epinephrine Auto-Injector

  • Great Falls Public Schools will provide four (4) epinephrine auto-injectors for each student-occupied school building in the District annually. The elementary buildings will have two (2) pediatric epinephrine auto-injectors and two (2) adult epinephrine auto-injectors, the middle and high schools will have four (4) adult epinephrine auto-injectors
  • The epinephrine auto-injector will be stored in a secure and easily-accessible location chosen by the building administrator and school nurse.
  • The school nurse will be responsible for performing regular checks, on the epinephrine auto-injectors and for requesting replacement auto injectors for those that have been used or expired.

Training of School Personnel

Training in the use of the epinephrine auto-injectors and anaphylaxis protocol will be offered to school staff on an annual basis, or more frequently if the school nurse assesses a need for such. The school nurse will recruit volunteers among school staff who will receive the training.   

The training shall include causes for anaphylaxis, recognition of signs and symptoms of anaphylaxis, indications for administration of epinephrine, administration technique, and the need for immediate access to a certified emergency responder.
Training is to be provided by a school nurse, certified emergency responder, or other health care professional.