Pediatric emergency medicine trisk 3555 3555
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injury can occur from vascular compromise, edema, lipid peroxidation, ischemia,
and ligamentous damage.
Management
The goals of management are to ensure airway patency and adequate respiration,
control hemorrhage, maintain osseous stability, and identify and prevent
progression of all injuries. Methodical and timely acquisition of historical and
physical findings is mandatory. The patient must be managed with strict
adherence to the ABCs, with consideration of potential rapid or gradual
deterioration. Penetrating objects that are lodged in the neck should remain in
place until removed under surgical care, preferably in an operating room. All
patients, other than those with minor injuries such as contusions, abrasions, or
superficial lacerations (not through the platysma muscle), should receive
supplemental humidified oxygen, cervical spine stabilization if indicated, correct
airway positioning, suctioning, close observation, and monitoring. The patient
should be maintained in a supine or Trendelenburg position to avoid the
possibility of venous air embolism. A decision tree for the evaluation of direct
blunt and penetrating neck trauma is presented in Figure 112.6 . Patients with
“hard signs” of injury should be immediately evaluated for surgical intervention.
Airway assessment is the initial step in the evaluation of all patients with
trauma. Any airway manipulation should be accomplished with consideration and
prevention of possible cervical spine injury. Potential indications for an artificial
airway with neck trauma include stridor, dyspnea, hypoxia, rapidly expanding
hematoma, expanding crepitus, pneumothorax, hemothorax, tracheal deviation,
altered mental status, quadriplegia, hemiparesis, and other signs of vascular or
airway insufficiency. If the airway is unstable, intubation should be considered.
Orotracheal intubation is the preferred method in children. Intubation should be
attempted only after preparation for the placement of a surgical airway, if time
allows. Fiberoptic intubation via the nasal route, performed by a skilled provider,
may be useful. The physician must be especially careful with the use of blind
nasotracheal intubation in the patient with blunt or penetrating neck or facial
trauma because the airway anatomy may be distorted. Passage of the nasotracheal
or orotracheal tube into a false or blind passage may make subsequent airway
control attempts difficult, if not impossible. Therefore, considering the difficulty
of emergent surgical airway placement in children, elective intubation is not
recommended outside a setting where a surgical airway can be efficiently and
skillfully placed.
