Pediatric emergency medicine trisk 3566 3566
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Tetanus status should be assessed in all patients with penetrating trauma. The
clinician should consider a broad-spectrum antibiotic for a patient with evidence
of neck trauma, especially if esophageal or pharyngeal injury seems likely.
Placement of a nasogastric or an orogastric tube is controversial for the patient
with cervical injury because it may worsen a pre-existing esophageal injury or
dislodge clots in zone I of the neck. When placed, these tubes should be well
lubricated, inserted gently and slowly, and withdrawn if difficulty in passage or
evidence of obstruction occurs.
Superficial abrasions, lacerations, and puncture wounds are common in
children. Wounds superficial to the platysma can be cleaned and sutured under
local anesthesia in the ED. Clean wounds can be sutured as late as 12 to 18 hours
after the injury because of the excellent blood flow in the neck. Closure after 72
hours is not recommended. Penetration of the platysma is an indication for
surgical referral and, in some cases, surgical exploration. When neck wounds that
penetrate the platysma are evaluated, exploration in the ED is discouraged
because of the risks of clot dislodgment and venous air embolism. Rapid surgical
exploration and repair are indicated in patients struck by a high-velocity missile,
those with unstable vital signs, uncontrollable bleeding, rapidly expanding
hematomas, progressive airway compromise, worsening neurologic symptoms,
increasing subcutaneous emphysema, or bubbling wounds ( Table 112.4 ).
