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