Patient Care, Training, Trauma

EMS Instructors Teach Pediatric Immobilization

Issue 10 and Volume 36.

Treating pediatric patients can be complex for EMS providers, primarily due to low pediatric call volumes and a lack of available education. The National Registry of Emergency Medical Technicians (NREMT) has recognized the need for pediatric evaluation during its past practice analysis, which is why it changed the design of the test to include pediatric questions for 15% of each category, except operations.

Several courses, such as Prehospital Trauma Life Support, International Trauma Life Support, and Assessment and Treatment of Trauma, address pediatric immobilization and may include a pediatric immobilization skills station.

In reality, only a few minutes of these 10- to 16-hour courses are focused on pediatrics. This isn’t because the topic is completely discussed in a half hour; an EMS training department could easily spend several hours reviewing case studies and practicing pediatric spinal immobilization.

The module discussed in this article should take approximately 2.5 hours with two EMT instructors and 12 students. Necessary equipment includes a Kendrick Extrication Device (KED) (or pediatric immobilization board, depending on your protocols and equipment), a rear-facing infant car seat, towels, cervical-immobilization devices (CIDs), pediatric C-collars, an infant doll (or manikin, if available) and a pediatric manikin (or a live pediatric “patient,” if available and willing). Successfully completing this module will satisfy 2.5 hours of the mandatory OB-GYN/Pediatrics section for NREMT continuing education (CE) requirements.

The Theory
EMS students should understand the associated cognitive abilities of patients at every age. And instructors should also review cognitive abilities by age because improving communication and minimizing frustration can reduce noncompliance on scene. Research suggests that clinicians routinely underestimate the age of older patients while overestimating the age of younger patients.1 If providers assume that a child is older than their actual age, they may provide directions the patient is unable to comprehend, causing frustration to both the provider and the patient. Lifespan development is not one of the “exciting” points of initial certification courses, and there’s little CE devoted to it.

Although you can and should use many different pediatric immobilization devices in the classroom, the most important factor to consider is that the pediatric patient’s torso usually has to be elevated 2–3 cm so the head is in an inline, neutral position while supporting the occiput.2 Instructors who use a standard adult device for immobilization should remind the student to place blankets or towels where the child’s torso will lie to create the necessary elevation that will allow the pediatric spine to be on a level plane.

Padding voids is also a critical (and often overlooked) component of pediatric immobilization. Remember, when immobilizing an extremity or the spine, the idea is to ensure there’s limited movement. EMS providers should pad the torso from the head and neck down to the pelvis. They should also place lateral padding under the strap voids to ensure limited lateral, anterior and posterior movement. Padding under the knees will aid in patient comfort. Instructors should also remind their students to ensure no padding obstructs patient ventilations or constricts circulation.

Car Seats
Immobilizing an infant or child in a car seat is perfectly acceptable in many situations, and it often provides many benefits.3 The child’s own car seat is familiar to them, which may be comforting in a frightening situation. Also, children can breathe better in an upright position. However, if the provider suspects the patient may decline en route to the hospital, then it may be in their best interest to immobilize them in another manner.

Another consideration is the family’s perception of the car seat. Car seats must be replaced after involvement in a crash, and the patient’s family may believe that because EMS has transported the patient with the car seat, it’s still operational. Remind students to talk to the family about replacing the car seat. If the student is unable to talk to the family on scene, then the student should attempt to talk to the family at the hospital or instruct the emergency department staff to do so.

When immobilizing an infant or child in a car seat, it’s still important to pad all voids to limit movement. Although a CID may be difficult to place in a car seat, providers can improvise one using towels. Horizontally roll a towel and wrap it around the patient’s head.

Another option is to roll two smaller towels and place them on both sides of the patient’s head. Either method is acceptable when taped securely to the car seat.

The Practice
Teaching to the affective domain shapes the attitudes and behaviors of students.4 Good communication will help students develop a positive attitude while interacting with pediatric patients. This task can be accomplished in different ways, depending on the structure of the course.

The following activities are designed to provide an opportunity for students to better understand how children normally respond, because students should understand the norms before interpreting any deviation.

Consider adding a community service component to the curriculum of initial certification courses, such as volunteering for or developing safety education programs at day-care centers, elementary schools or after-school programs. This allows students to simultaneously learn and give back to their community. Here, students will have a chance to interact with children in a non-emergency setting.

Another option is to invite some children to tour an agency’s station. Ideal groups to invite are Scout troops, day-care groups or children whose parents work for the service.

Students should learn these basic principles about communicating with children:
1. Speak on their level, eye to eye.
2. Never be too busy to answer a child’s question.
3. Children don’t always pay attention to what’s said, but they’ll notice what actions are taken.
4. Think about what it’s like to be in their shoes.
5. Pay attention to their actions and feelings.5

Instructors will know their students have grasped the affective components of pediatric education when they’re able to easily and comfortably interact with children of various ages and the children are engaged and enjoying their time with the providers.

Critical Thinking
Absolutes are few and far between in EMS, and spinal immobilization of the pediatric patient is by no means an absolute. As we transition from technician to clinician, it’s imperative that we step out of the algorithmic box and use critical thinking skills to interpret each situation. This component is designed to be an in-class discussion; however, designing a PowerPoint or handout may be useful in conveying this information to students who use visual or read/write styles of learning.6 Kinesthetic learners may learn best by incorporating this discussion into scenarios.

Point out to students that immobilization of some pediatric patients may exacerbate existing injuries. Have students list situations in which immobilization may be detrimental. Ask them about barriers they may encounter and ways to possibly overcome them. After they’ve responded, discuss how pediatric patients may be noncompliant and how their noncompliance may affect clinical care. Soliciting feedback is crucial to improve retention.

Also discuss the relevance of spinal clearance protocols for pediatrics.7 Although these protocols are becoming more common in the prehospital setting, many exclude children under the age of 12. This isn’t necessarily because of potential harm, but rather from a lack of research to substantiate the practice. Some studies indicate that children younger than 3 may be able to undergo a spinal clearance without an X-ray with the use of a small subset of criteria.8 These studies used a physical assessment and such clinical predictors as GCS and mechanism of injury. However, there’s still inadequate research to encourage the development of a spinal clearance protocol for pediatric patients.

After discussing reasons for not immobilizing pediatric patients, EMS instructors should discuss the importance of documentation. Emphasize that it’s necessary to thoroughly document the reason for the decision not to immobilize, along with risks of immobilization and benefits of non-immobilization.

Student Learning Styles
It’s important to teach to all learning styles.

Students who learn by reading and writing will benefit from having skill sheets in-hand before the skills practice begins. Some essential components of every skill sheet include:
1. Checking scene safety and BSI;
2. Maintaining manual C-spine immobilization while communicating with the patient;
3. Keeping the head in an inline and neutral position;
4. Padding the torso 2–3 cm (as necessary);
5. Providing lateral padding; and
6. Assessing pulse, motor and sensory functions at several points.
Critical fail criteria:
a. Did not check scene safety or use BSI;
b. Did not maintain C-spine control or released manual C-spine control prior to full immobilization;
c. Did not pad the torso;
d. Allowed for excessive movement;
e. Did not do pulse, motor and sensory assessment after immobilization; and
f. Did not assess ventilatory status after immobilization.

Give students a skill sheet at the beginning of class so they can follow along during the demonstration. Create a skill sheet for immobilizing a child on a KED or pediatric board and one for immobilizing a child in a car seat.

Visual and aural/auditory learners will generally benefit from using the whole-part-whole model, in which the instructors demonstrate skills while students watch.9 When using this technique, instructors must thoroughly verbalize everything that’s done.

When the first “whole” demonstration is done, the instructors should perform the skill from beginning to end. This section is just an introduction, which allows students to understand the basic concept. There’s no need to describe each step in detail, but it’s still important to verbalize actions.

The “part” section breaks down each step on the skill sheet; this is where the instructor takes the time to discuss each step in detail. Instructors should describe what they’re doing and why they’re doing it. This not only focuses on the specific act of each step, but it also reinforces the importance of performing it properly.

After demonstrating each step individually, use two demonstrating instructors to perform the whole skill again. This gives students an opportunity to see the skill and to mentally incorporate their new understanding of each step. Again, each step should be described aloud so auditory learners can benefit.

Kinesthetic learners will benefit from an opportunity to practice the skill. They may not grasp the concept until practicing it themselves. Divide a class of 12 students into two groups of six, which will allow for a 6:1 student/teacher ratio. This section should take about 30 minutes per skill, for a total of 60 minutes.

Assign one instructor to each skill (board immobilization and car seat immobilization) to ensure that feedback is consistent. Allow students to perform the skill in groups of two or three, depending on staffing at your service.

The instructors should follow along with a skill sheet. Immediately correct any errors during practice. Remember to do so in an appropriate manner, without demeaning or berating the students. If possible and appropriate, ask them what they did wrong, rather than telling them. Everyone should go through each station at least twice.

Spinal immobilization is a skill that’s regularly performed by EMS providers. However, pediatric immobilization isn’t as common and presents its own set of problems, from anatomy to compliance. This skill should be practiced regularly to maintain competency.

While training providers on any skill, it’s important to teach in ways that encourage affective, cognitive and psychomotor learning to ensure students are competent in all areas. Be sure to incorporate critical thinking exercises into physical technique practices to improve retention of the skill. Finally, make sure that you’re teaching for all your students by using the visual, aural/auditory, read/write and kinesthetic learning styles. JEMS

1. Perrin EC, Perrin JM. Clinicians’ assessments of children’s understanding of illness. Am J Dis Child. 1983;137(9):874–878.
2. National Association of Emergency Medical Technicians. Prehospital Trauma Life Support, Seventh Edition. Elsevier: St. Louis. 2011.
3. DeBoer SL, Seaver M. Pediatric spinal immobilization: C-spines, car seats and color-coded collars. J Emerg Nurs. 2004;30(5):481–484.
4. National Association of EMS Educators. 2002. 2002 National Guidelines For Educating EMS Instructors. In National Highway Traffic Safety Administration. Retrieved Aug. 1, 2011, from
5. Heather Knopefli. Communicating with children. Ottowa Valley Co-operative Preschoolers Association Conference. April 1982.
6. Flemming N. (2001). VARK: A guide to learning styles. VARK. Retrieved Aug. 1, 2011, from
7. Domeier RM. Indications for prehospital spinal immobilization: National Association of EMS Physicians standards and clinical practice committee. Prehosp Emerg Care. 1999;3(3):251–253.
8. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the American Association for the Surgery of Trauma. J Trauma. 2009;67(3):543–550.
9. Knowles M, Holton E, Swanson R. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. Elsevier: United Kingdom. 2011.

This article originally appeared in October 2011 JEMS as “Hold Still: Teaching pediatric immobilization techniques.”