of sympathetic input to the vascular system The physical examination may be misleading in that these patients are bradycardic (unable to mount tachycardic response to relative hypovolemia) and demonstrate warm, flushed skin in the setting of hypotension (loss of vasomotor tone) These symptoms may also be superimposed on traumatic (hypovolemic) shock These patients need fluid resuscitation and may require inotropic (alpha agonist) support, such as norepinephrine or phenylephrine, to maintain adequate perfusion and avoid fluid overload Appropriate fluid management is important in preventing hypoperfusion of the already injured spinal cord The use of steroids for blunt cervical injury is not routinely recommended Several authors suggest that steroid administration increases potential risk to the patient and does not lead to meaningful neurologic recovery and that its use as a standard of care is not justified Steroid use for the pediatric patient with a clear or potential blunt cervical cord injury is not well supported by available evidence and should be discussed in consultation with the treating orthopedic and neurosurgical physicians bearing in mind that it is not approved by the Federal Drug Administration for this purpose Methylprednisolone is not recommended in conjunction with penetrating neck injuries FIGURE 112.36 Normal ossiculum terminale at the tip of the dens (arrow ) (Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:717.)