Get in the Zone: Penetrating Neck Trauma Part 2

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The Pre-brief

I know what zone the neck injury is in…now what?

As a recap: Trauma to the neck is bad. There are 3 zones (see previous neck trauma post). In fact, the zones don’t really matter. What matters is how your patient is doing.

Stable penetrating trauma?

  • You don’t know the trajectory of penetrating trauma, so it is always best to assume and evaluate for all possible injuries. 
  • Know what anatomical structures can be affected. 
  • Sclafani et al. found that physical examination for neck trauma has a sensitivity of 61% and specificity of 80%.1 Which means you should consider imaging even in a stable patient. 
  • Lack of obvious platysma violation should not deter a complete evaluation.

Unstable penetrating trauma?

While all roads lead to the operating room, there are a few steps to get through first.

You don’t want your patient to continue to bleed in front of you.

  1. Take a deep breath, then make sure the patient can too; if not, intubate (either person) 
  2. Take down the dressing and put a gloved finger over the bleed or an entire palm if necessary
  3. You can insert a foley catheter and inflate the balloon to tamponade bleeding (this works for cardiac puncture trauma as well)2
    – DO NOT PROBE wounds with active bleeding as this can dislodge a clot  (for that matter, you should not probe any of these wounds if your surgical colleague is not next to you)
  4. If there is respiratory distress, stridor, hemoptysis, or air bubbling from the neck wound assume there is an airway injury and consider early intubation.
    – Intubate with first pass success in mind. You can give RSI meds the way you normally would, but awake intubation might be more beneficial if the situation allows.
    – Use a smaller ET tube if tracheal injury is suspected.
  5. Consider careful* cricothyrotomy if the airway is obscured by copious blood
    – The anatomy may be distorted
    – Cricothyrotomy is relatively contraindicated if an anterior neck hematoma exists or a laryngeal injury is suspected but may be the only viable option in some patients
  6. Consider chest tube placement for pneumothorax for lower neck wounds with decreased breath sounds or lack of pleural movement on bedside EFAST or worsening subcutaneous air.

Once A and C are controlled, remember that there is a whole patient to assess. Start your trauma survey from the top to make sure you don’t miss any injuries.

The Debrief

  • With penetrating neck trauma, determine in what zone your patient is injured
  • Then determine if your patient is stable or unstable
  • Take control of the airway if needed
  • Determine what kind of imaging is needed based on the location of the injury and which structures could potentially be damaged


  1. Sclafani SJ, Cavaliere G, Atweh N, et al. The role of angiography in penetrating neck trauma. J Trauma. 1991;31:557-562. PMID: 2020041.
  2. Navsaria P, Thoma M, Nicol A. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma. World J Surg. 2006 Jul;30(7):1265-8. doi: 10.1007/s00268-005-0538-3. PMID: 16830215.
  3. Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000; 35:221. PMID: 10692187.
  4. Kendall JL, Anglin D, Demetriades D: Penetrating neck trauma. Emerg Med Clin North Am 1998; 16(1): 85-105. PMID: 9496316.
  5. Tisherman, Samuel A. MD; Bokhari, Faran MD; Collier, Bryan DO; Cumming, John MD; Ebert, James MD; Holevar, Michele MD; Kurek, Stanley DO; Leon, Stuart MD; Rhee, Peter MD Clinical Practice Guideline: Penetrating Zone II Neck Trauma, The Journal of Trauma: Injury, Infection, and Critical Care: May 2008 – Volume 64 – Issue 5 – p 1392-1405  doi: 10.1097/TA.0b013e3181692116. PMID: 18469667.


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