FIGURE 112.7 Tracheal injury Seven-year-old male patient with extensive gas in the neck after motor vehicle collision Gas seen tracking through a laceration at the junction of the cartilaginous and membranous portions of the trachea on the left (arrow ) In addition to the usual assessment for hypovolemia, the patient should be examined for expanding hematomas or other obvious external bleeding External bleeding should be treated with gentle compression Attempts to clamp bleeding vessels in the neck can injure the vessels and surrounding structures, as well as jeopardize subsequent repair attempts Two large-bore intravenous (IV) catheters should be inserted, ideally on the side opposite to the injury if an obvious vascular abnormality is identified If a subclavian vein injury is suspected and there are no contraindications, one of the IV catheters should be placed in the lower extremity A neurologic examination for signs of cerebral injury secondary to vascular insufficiency, direct spinal cord, cranial or cervical nerve, or brachial plexus injury should be completed An abnormal or changing neurologic examination may indicate progressive vascular insufficiency and the need for rapid surgical evaluation Rapid assessment by CT or magnetic resonance imaging (MRI), followed by surgical intervention, will provide opportunity for optimal outcome Direct nerve injuries may not necessitate surgical repair 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clots in zone I of the neck When placed, these tubes should be well lubricated, inserted gently and slowly, and withdrawn if difficulty in passage or evidence of obstruction occurs Superficial abrasions, lacerations, and puncture wounds are common in children Wounds superficial to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 ) TABLE 112.4 INDICATIONS SUGGESTING SURGICAL EVALUATION IN PATIENTS WITH NECK TRAUMA Unstable vital signs Expanding or massive hematoma Pulsatile or active bleeding Hemorrhagic shock Vascular deficits in the upper extremities Abnormal distal pulses (brachial, superficial temporal, ophthalmologic, fundi) Hematemesis, hemoptysis, epistaxis Hemothorax Progressive respiratory distress Airway obstruction Expanding subcutaneous emphysema Bubbling or sucking wound Pneumothorax Progressive neurologic deficits Hemiparesis Horner syndrome Cranial or cervical nerve dysfunction Diaphragm paralysis Decreased sensorium Neurologic deficits in upper extremity Increasing dysphagia Odynophagia or dysphonia Hoarseness Severe neck pain or tenderness High-velocity wounds (rifles, explosions) Multiple low-velocity wounds Ancillary radiographic studies not available Experienced observation personnel not available Surgical evaluation may yield false-negative results with esophageal lacerations, small vessel lacerations, pharyngeal lacerations, or tracheal injuries The patient who has stable vital signs, no symptoms of impaired neurologic or 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