ECAT appendix

In-line immobilisation or foam collar (paediatric)

Published: December 2023 Printed on 19 May 2024

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C-spine immobilisation precautions and notes

  • Stabilising the C-spine with a foam collar is preferred however should not be used if the patient is uncooperative or too small (baby or infant).
  • The following should be left in a position of preference — do not reposition the neck:
    • children who use their hands to support the head
    • children with traumatic torticollis
    • concerning abnormal neurology on examination.
  • If a foam collar is not used, movement should be minimised, as best as possible, and it should be made clear to all staff and family that the cervical spine is not clear.
  • In young children, a collar may cause agitation and potential harm. Distracting the child and a hands-off technique, e.g. using a child's car seat or in parents' arms, may be superior to maintaining the neck in a position of comfort.
  • Hard collars are not recommended. Potential harm associated with hard collar use:
    • raised intracranial pressure
    • respiratory disturbance
    • patient agitation
    • soft tissue ulceration.
  • Spinal boards: all children should be removed from spinal boards at the time of transfer from an ambulance trolley.
  • Sandbags or foam blocks can be used but should not be taped.
  • Thoracic elevation device (TED) should be used in children under 8 years:
    • The TED is a mat used to provide an appropriate offset between the supine paediatric patient’s head and torso ensuring the neck is not placed in a flexed position and an open airway is maintained.
    • If the Thoracic Elevation Device is not available, a neutral position can be achieved in infants (up to one year old) by placing 1-2 folded towels under the trunk, from buttocks to shoulders. This allows the occiput to be 1-2 cm lower than the back, and allows the head to rest in a neutral position.
    • A rolled towel can be placed under the shoulders of older children to achieve a neutral position of the head and neck.

Applying a soft (foam) collar

  • Where possible, patients should have movement of the cervical spine minimised using a foam collar labelled with "C-spine not cleared" until cervical spine injury (CSI) has been excluded.
  • Patients with a pre-hospital collar should be labelled "C-spine not cleared".
  1. Gently align the patient's head to a neutral anatomical position or position of greatest comfort.
  2. Measure the distance between the base of the chin and the suprasternal notch.

  1. Select the appropriate size collar using a tape measure or by comparing patient's neck measurement to the width of the soft collar's chin support.
  2. The lower edge of the foam collar can be cut to ensure it fits snugly below the chin.

  1. Slide the collar under the patient's neck (right to left) until the adhesive Velcro strap is clearly visible.

  1. Mould the soft collar around patient's neck and secure the Velcro tabs.
  2. Ensure the patient's chin rests on top of the collar and they are able to open their mouth.

The lower edge of the foam collar can be cut to ensure it fits snugly below the chin.

Illustrations adapted, with permission, from: Queensland Ambulance Services (QAS).

Photo used, with permission, from: Queensland Emergency Paediatric Care.

Information adapted, with permission, from: The Royal Children’s Hospital Melbourne. Clinical practice guidelines: Cervical spine assessment. Melbourne (Vic): 2023.

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Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/appendices/in-line-immobilisation-paediatric

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