Pediatric emergency medicine trisk 3553 3553
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. Updated July 8, 2019. Accessed
June 14, 2020. Originally published in: Spitzer VM, Whitlock DG. National Library of
Medicine Atlas of the Visible Human Male: Reverse Engineering of the Human Body . 1st ed.
University of Colorado/Jones & Bartlett, 1998.)
Triage Considerations
These patients require close monitoring, may have difficult airway management,
and may require massive transfusion support for severe blood loss. All penetrating
objects protruding from a child’s neck should be stabilized and not removed in the
emergency department (ED) unless under direct supervision by appropriate
specialist after complete evaluation. Early transfer to a pediatric trauma center
should be considered if appropriate surgical or critical care staff is not available as
the majority of patients require hospitalization or operative intervention.
Clinical Assessment
Rapid assessment of the patient’s physiologic status should take precedence and
will largely determine the ensuing management or further clinical evaluation. For
patients who have “hard signs” of injury (cardiovascular shock, pulsatile bleeding
or expanding hematoma, audible airway compromise, bubbling wound, extensive
subcutaneous air, signs of intracerebral ischemia, hemiparesis, hematemesis),
surgical evaluation and intervention will likely ensue. Patients with “soft signs” of
injury (bruit, voice change, stridor, laceration larger than 2 cm, nonexpanding
hematoma, chest tube, air leak, dysphagia, dyspnea, hemoptysis, paresthesia,
venous oozing) require further clinical and/or radiographic evaluation. Hard signs
are associated with a sensitivity of 100% and specificity of 94% for vascular,
tracheal or esophageal injury, and soft signs with a sensitivity of 100% and
specificity of 76%. Combined hard and soft examination signs demonstrate good
NPV but poor PPV.
The history of the event is important in the evaluation of penetrating neck
trauma. Inquiries about the mechanism of injury, time of incident, events before
arrival in the ED, amount of blood loss, history of pulsatile lesions, neurologic
dysfunction including transient ischemic attack, limb paresthesias, hemiplegia,
blindness, Horner syndrome (ptosis, miosis, enophthalmos, anhidrosis on the
ipsilateral side of the face), and aphasia; and airway compromise should all be
noted. In particular, knowledge of the mechanism and associated risks of injury
can help direct the management of both the stable and unstable patient.
The symptoms and signs suggestive of vascular and other neck injuries are
presented in Table 112.3 . Completely transected arteries often retract and
contract with minimal bleeding. Vessels that are partially severed may continue to
bleed significantly with normal pulses because blood flow may not be totally
