of sympathetic input to the vascular system The physical examination may be misleading in that these patients are bradycardic (unable to mount tachycardic response to relative hypovolemia) and demonstrate warm, flushed skin in the setting of hypotension (loss of vasomotor tone) These symptoms may also be superimposed on traumatic (hypovolemic) shock These patients need fluid resuscitation and may require inotropic (alpha agonist) support, such as norepinephrine or phenylephrine, to maintain adequate perfusion and avoid fluid overload Appropriate fluid management is important in preventing hypoperfusion of the already injured spinal cord The use of steroids for blunt cervical injury is not routinely recommended Several authors suggest that steroid administration increases potential risk to the patient and does not lead to meaningful neurologic recovery and that its use as a standard of care is not justified Steroid use for the pediatric patient with a clear or potential blunt cervical cord injury is not well supported by available evidence and should be discussed in consultation with the treating orthopedic and neurosurgical physicians bearing in mind that it is not approved by the Federal Drug Administration for this purpose Methylprednisolone is not recommended in conjunction with penetrating neck injuries FIGURE 112.36 Normal ossiculum terminale at the tip of the dens (arrow ) (Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:717.) FIGURE 112.37 Magnetic resonance imaging (MRI) of cervical spine demonstrating epidural hematoma (arrow ) from C5 to T1 Note excellent soft tissue, intervertebral disc, and fluid detail afforded by the MRI scan Suggested Readings and Key References Blunt and Penetrating Neck Trauma Abujamra L, Joseph MM Penetrating neck injuries in children: a retrospective review Pediatr Emerg Care 2003;19:308–313 Bell RB, Osborn T, Dierks EJ, et al Management of penetrating neck injuries: a new paradigm for civilian trauma J Oral Maxillofac Surg 2007;65:691–705 Chatterjee D, Agarwal R, Bajaj L, et al Airway management in laryngotracheal injuries from blunt neck trauma in children Paediatr Anaesth 2016;26(2):132– 138 Cheng J, Cooper M, Tracy E Clinical consideration for blunt laryngotracheal trauma in children J Pediatr Surg 2017;52(5):874–880 Dandu K, Carniol E, Sanghvi S, et al A 10-year analysis of head and neck injuries involving nonpowder firearms Otolaryngol Head Neck Surg 2017;156(5):853– 856 Desai N, Kang J, Chokshi F Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seatbelt sign.” AJNR Am J Neuroradiol 2014;35(9):1836–1840 Feldman KW, Avellino AM, Sugar NF, et al Cervical spinal cord injury in abused children Pediatr Emerg Care 2008;24:222–227 Gee AC, Salter KD, McConnell DB, et al Injuries to the neck In: Flint L, Meredith J, Schwab CW, et al., eds Trauma Contemporary Principles and Therapy Philadelphia, PA: Lippincott Williams & Wilkins; 2008:335–349 Gonzalez RP, Falimirski M, Holevar MR, et al Penetrating zone II injury: does dynamic computed tomography scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study J Trauma 2003;54:61–64; discussion 64–65 Graham J, Dick R, Parnell D, et al Clothesline injury mechanism associated with all-terrain vehicle use by children Pediatr Emerg Care 2006;22:45–47 Hanson CA, Smith JA Penetrating neck injuries in children J Trauma Nurs 2007;14:12–16; quiz 17–18 Inaba K, Munera F, McKenney M, et al Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries J Trauma 2006;61:144–149 Insull P, Adams D, Segar A, et al Is exploration mandatory in penetrating zone II neck injuries? ANZ J Surg 2007;77:261–264 Klinkner DB, Arca MJ, Lewis BD, et al Pediatric vascular injuries: patterns of injury, morbidity, and mortality J Pediatr Surg 2007;42:178–182; discussion 182–183 Losek JD, Tecklenburg FW, White DR Blunt laryngeal trauma in children: case report and review of initial airway management Pediatr Emerg Care 2008;24:370–373 Low GM, Inaba K, Chouliaras K, et al The use of the anatomic ‘zones’ of the neck in the assessment of penetrating neck injury Am Surg 2014;80(10):970– 974 Madsen A, Oosthuizen G, Laing G, et al The role of computed tomography angiography in the detection of aerodigestive tract injury following penetrating neck injury J Surg Res 2016;205(2):490–498 Marathe US, Tran LP Pediatric neck trauma causing massive subcutaneous emphysema J Trauma 2006;61:440–443 Markus-Rodden MM, Bojko T, Hauck LC Traumatic tracheal laceration in a pediatric patient medically managed with high-frequency oscillatory ventilation Pediatr Emerg Care 2008;24:236–237 Marom T, Russo E, Ben-Yehuda Y, et al Oropharyngeal injuries in children Pediatr Emerg Care 2007;23:914–918 Mezhir JJ, Glynn L, Liu DC, et al Handlebar injuries in children: should we raise the bar of suspicion? Am Surg 2007;73:807–810 Navsaria P, Thoma M, Nicol A Foley catheter balloon tamponade for lifethreatening hemorrhage in penetrating neck trauma World J Surg 2006;30:1265–1268 Oliver J, Avraham J, Frangos S, et al The epidemiology of inpatient pediatric trauma in United States hospitals 2000 to 2011 J Pediatr Surg 2018;53(4):758– 764 Stone M, Farber B, Olorunfemi O, et al Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank J Trauma Acute Care Surg 2016;80(4):604–609 Tallon JM, Ahmed JM, Sealy B Airway management in penetrating neck trauma at a Canadian tertiary trauma centre J Can Assoc Emerg Phys 2007;9:101–104 Tessler R, Nguyen H, Newton C, et al Pediatric penetrating neck trauma: hard signs of injury and selective neck exploration J Trauma Acute Care Surg 2017;82(6):989–994 Verschueren DS, Bell RB, Bagheri SC, et al Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma J Oral Maxillofac Surg 2006;64:203–214 Vohra S, Johnston BC, Cramer K, et al Adverse events associated with pediatric spinal manipulation: a systematic review Pediatrics 2007;119:e275–e283 ... Marathe US, Tran LP Pediatric neck trauma causing massive subcutaneous emphysema J Trauma 2006;61:440–443 Markus-Rodden MM, Bojko T, Hauck LC Traumatic tracheal laceration in a pediatric patient... 2006;64:203–214 Vohra S, Johnston BC, Cramer K, et al Adverse events associated with pediatric spinal manipulation: a systematic review Pediatrics 2007;119:e275–e283 ... Otolaryngol Head Neck Surg 2017;156(5):853– 856 Desai N, Kang J, Chokshi F Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seatbelt sign.” AJNR Am J