Chapter 24

### IMMEDIATE MANAGEMENT OF LIFE-THREATENING CONDITIONS

Evaluation of the pediatric patient with maxillofacial and neck trauma begins with the primary trauma assessment. Depending on the injuries present, airway management may be difficult due to distortion of normal landmarks or blood present in the path of visualization. It is often difficult to determine the severity of an injury by external examination alone, and complete evaluation may require the use of advanced imaging techniques or consultation with a trauma surgeon.

The complexity and intricacies of the structures of these regions require a thorough examination. Airway management may be difficult in patients with traumatic injuries to the face or neck, and the airway should be secured whenever compromise is present or felt to be imminent.

A number of imaging modalities may be employed to evaluate potential injuries. Computed tomography (CT) scans are commonly used in the emergency department to evaluate for traumatic injuries. Magnetic resonance imaging (MRI) and swallow studies may be used to identify or exclude injury. The emergency department physician should maintain diligence in identifying the patient who may be a victim of non-accidental trauma.

### AIRWAY MANAGEMENT

Continuous monitoring of the airway is crucial. A thorough evaluation of the airway should be made while maintaining cervical spine immobilization with a cervical collar. Patients may initially display little to no external evidence of tracheal injury.

#### LARYNGEAL & TRACHEAL INJURIES

Monitor for changes in phonation, presence of subcutaneous emphysema, development or worsening of edema, expanding hematoma, as well as deviation of the trachea from its midline position. These signs all suggest a potential laryngeal injury and possibly worsening airway compromise.

Tracheal injuries are suggested by mediastinal air on chest radiograph, development of subcutaneous emphysema, or development of a simple or tension pneumothorax.

Endotracheal intubation should be attempted to secure the airway when laryngeal or tracheal injury is suggested. Simultaneous preparation for surgical airway is advised. Cricothyroidotomy or tracheostomy may be necessary if intubation fails.

#### FACIAL & NECK INJURIES

Traumatic injuries to the face or jaw may present with airway obstruction resulting from the displacement of tissue, or from a significant amount of bleeding, which prevents the patient from being able to ventilate or oxygenate effectively. Perform a jaw thrust maneuver when injuries allow, and utilize suctioning to clear blood or secretions that may be complicating ventilation. Neck injuries may include damage to the cervical spinal cord with a reduction in effective spontaneous respirations. In these patients, endotracheal intubation or other airway management should be performed, while maintaining cervical spine alignment. Rapid sequence induction followed by orotracheal intubation is the preferred method for securing an airway. Consider avoidance of paralytics if facial deformity is likely to prevent successful bag-valve-mask ventilation during the procedure. Airway adjuncts may be employed to perform this procedure successfully (see Chapter ...

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