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Respiratory failure may occur as a direct result of high (>C5) spinal-cord injury. Apnea or hypoxia are common symptoms at presentation. However, insidious onset of hypercarbia from relative hypoventilation may occur hours to days after injury, and can best be diagnosed by bedside spirometry or arterial blood-gas analysis. Intubation of the airway in a patient with a possible cervical-spine injury should be undertaken with an assistant maintaining neutral cervical posture and holding in-line traction. Children with suspected atlanto-occipital dislocation or other severely unstable injury may require cricothyroidotomy or tracheostomy. Hypoxia should be rigorously avoided because of its contribution to secondary spinal-cord injury.

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