Pediatric emergency medicine trisk 3554 3554
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interrupted. Vascular abnormalities can be assessed partially by evaluating the
carotid (external), superficial temporal, and brachial pulses, although pulses are
not easily accessible to evaluate the internal carotid or vertebral arteries.
Abnormal pulses suggest vascular injury, whereas normal pulses do not guarantee
vascular integrity.
Auscultation of the neck is useful to identify bruits. Although a carotid bruit
may be normal in children, a continuous bruit suggests a traumatic arteriovenous
fistula whereas a systolic bruit suggests a partial arterial tear. Bleeding from a
posterior neck wound, neurologic deficits in areas supplied by the vertebral
arteries (brainstem, cerebellum), bleeding not controlled by carotid compression, a
posterior bruit, or bleeding that accompanies a cervical spine transverse process
fracture suggests a vertebral artery injury. Carotid artery trauma should be
suspected if presentation involves an anterior triangle hematoma, Horner
syndrome, transient ischemic attack, loss of consciousness after a lucid interval, or
hemiplegia.
Neck vessels may be injured indirectly as a result of shock waves from a
penetrating object or bullet. These patients may have clinically unrecognized
vascular intimal damage that can progress to vascular thrombus or occlusion.
Venous or lymphatic (thoracic duct) injuries also occur with penetrating trauma.
These injuries are rarely severe and usually present as an expanding hematoma or
less often with a venous air embolism. If venous air embolism is suspected
because of an unexplained decrease in cardiac output and blood pressure, increase
in central venous pressure, cyanosis, arrhythmias, or air in the heart on chest
radiograph, the patient should be placed in the left lateral decubitus and
Trendelenburg positions.
Injuries to the aerodigestive tract (pharynx, larynx, trachea, and esophagus) also
occur in cases of penetrating trauma, although these relatively mobile structures
are often spared. The esophagus is somewhat protected in that it is usually
collapsed as it courses through the neck but it may be injured by direct penetrating
objects, usually a stab or gunshot wound. These injuries can present initially in a
subtle fashion, but delays in diagnosis can lead to significant increase in observed
morbidity and mortality.
Direct nervous system injury (brachial plexus, spinal cord, cervical nerves) is
possible with penetrating neck trauma and the evaluation of the patient should
assess these structures and their function. A thorough neurologic examination
should be completed and abnormal findings should correspond to the injured
structure ( Fig. 112.5 ). Primary injury to the cervical cord often results from bony
or foreign-body penetration or impingement or cord distraction. Secondary cord
