• Airway compromise can happen fast.
• Consider pneumothorax, hemothorax in zone I injuries.
• Look for expanding hematoma, stridor, shock signify high likelihood of vascular injury.

• Trauma breaching the platysma muscle of the neck.
• Life threatening through injury to unprotected underlying vascular, aerodigestive and neurological structures.
• Classified by separating the neck into zones:
  • Zone I – sternal notch/clavicle to cricoid cartilage.
  • Zone II – cricoid cartilage to angle of mandible.
  • Zone III – angle of mandible to base of skull.

• Assess airway, breathing, circulation. Obtain surgical consultation as soon as possible.
• Airway:
  • Immediate intubation in patients with significant injury and any signs of respiratory difficulty (significant bleeding or hematoma, stridor, expanding hematoma, subcutaneous air, large volume hemoptysis).
  • Rapid sequence intubation (RSI) is a safe, effective approach in these patients.
  • Fiberoptic intubation can be used if anatomy is distorted or airway is predicted to be difficult for other reasons.
  • Surgical airway with cricothyotomy (ERP/trauma team) or tracheotomy (ENT/trauma team) is used when prior attempts of typical orotracheal intubation are unsuccessful.
• Breathing:
  • Assess for presence of pneumothorax, hemothorax by auscultating the lungs; palpate for crepitous.
  • POC ultrasound can also be used to supplement physical exam findings.
• Circulation:
  • Assess pulses, vitals.
  • Apply direct pressure to bleeding wounds.
  • Generally, exploration of wound in the emergency department is not warranted.
  • Life threatening bleeding can be managed with balloon tamponade, or if bleeding is uncontrolled and no definitive management in OR is available, exploration in ED and application of clamps or other devices can be used.

• Management depends on stability of the patient and presence of hard signs suggesting need for urgent surgical exploration.
• Hard signs include:
  • Large, expanding hematoma.
  • Presence of thrills or bruits.
  • Absent or diminished peripheral pulses.
  • Respiratory distress.
  • Massive hemoptysis or hematemesis.
  • Shock.
  • Neurologic deficit suggestive of cerebral ischemia.
• Any unstable patients or those with hard signs suggestive of severe injury should be prepared for transfer to the operating room for surgical exploration.
• Stable patients with “soft” signs of injury should be further evaluated with imaging.
• Soft signs include:
  • Minor hemorrhage.
  • Mild hypotension responsive to IV fluids.
  • Dysphonia.
  • Non-pulsatile, expanding hematoma.
  • Dysphagia.
• First line imaging is multidetector computed tomography with angiography (MDCT-A).
• Plain chest radiograph should also be completed as part of work up.
• It is generally recommended to assess stable, asymptomatic patients with CT-Angiography, as the reliability of physical exam to rule out underlying injury is still debated.
• Findings on CT-A guide further treatment and workup.
• Low sensitivity at detecting pharyngo-osophageal injury.
• Additional workup including bronchoscopy, contrast swallow/flexible esophagoscopy or surgical exploration may be required.

All patients with evidence of disruption of the platysma muscle should be admitted for observation.

• All patients with evidence of violation of the platysma muscle should be transferred to a trauma centre for further treatment and management.
• Stable patients exhibiting soft signs should be transferred to a facility with capabilities to perform necessary imaging and surgical management.
• It may be appropriate to monitor stable, asymptomatic patients at centres lacking CT-A, angiography and/or surgical capability for a 24 hour period. Transfer to higher level of care is warranted if any signs of injury develop or patient deteriorates.

• All patients should undergo rapid assessment by surgical specialist.
• As above, asymptomatic patients may be appropriate for close observation with transfer to higher level care if warranted.

1. Nowicki J, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl. 2018 Jan;100(1):6–11.

   
   

2. Penetrating neck injuries: Initial evaluation and management – UpToDate [Internet]. [cited 2023 Dec 12]. Available from: https://www.uptodate.com/contents/penetrating-neck-injuries-initial-evaluation-and-management?search=penetrating%20neck%20trauma&source=search_result&selectedTitle=1~34&usage_type=default&display_rank=1#H17

   
   

3. Alao T, Waseem M. Neck Trauma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Dec 12]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470422/