Pediatric emergency medicine trisk 3568 3568
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cardiovascular status, an intact airway, and mechanisms of injury with a lowvelocity bullet or single knife wound may be managed expectantly with the use of
ancillary diagnostic tests and close observation, preferably for at least 48 hours.
These decisions should be made in conjunction with experienced surgical staff.
Adjuncts to the history and physical examination are given in Table 112.5 .
Initial evaluation should include cervical spine radiographs to detect bony or
structural abnormalities, as well as a soft tissue lateral neck radiograph to assess
for blood, edema, subcutaneous air, foreign bodies, and airway impingement or
disruption. A chest radiograph should be evaluated for evidence of hemothorax or
pneumothorax, mediastinal emphysema or widening, and heart size. If a serious
injury is likely, radiographs should be obtained in the ED or the patient should be
accompanied to the radiology department by someone skilled in airway
management. If the patient is stable and a vascular injury is suspected, a CTA or
arteriogram should be performed ( Fig. 112.8 ). Contrast laryngography,
tomography, and xeroradiography have been used for further evaluation; however,
these methods have generally been replaced by the CT scan. CT may not be
accurate for detection of mucosal degloving injuries, mucosal perforation in the
presence of subcutaneous emphysema, endolaryngeal edema or hematoma, and
partial laryngotracheal separation. Noninvasive Doppler studies and
oculoplethysmography may also be useful in evaluating vascular injuries.
TABLE 112.5
ADJUNCTS TO HISTORY AND PHYSICAL EXAMINATION
Cervical spine radiographs
Soft tissue neck radiograph
Chest radiograph
Computed tomographic scan
Arteriography
Doppler
Esophagram
Contrast laryngotracheography
Indirect (mirror) laryngoscopy
Direct laryngoscopy
Flexible bronchoscopy
Direct bronchoesophagoscopy
Surgical exploration
