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Penetrating neck trauma
When a neck wound penetrates through the platysma, decide by "hard" and "soft" signs: a hard sign (active bleeding, expanding haematoma, air bubbling from the wound, shock) — theatre; a soft sign — CT angiography; no signs — observation; and above all secure the airway early.
Why it matters in the exam
Questions describe a stab or fragment wound to the neck and test the next step. The modern approach no longer relies only on the "neck zones" (I, II, III) but on clinical signs: a stable patient without hard signs has CT angiography, and its findings guide what follows. A patient with a hard sign goes to theatre without imaging.
Immediate management principles are also tested: do not probe the wound with a finger or instrument beyond the platysma, do not insert a gastric tube, apply direct pressure to bleeding, and a Foley catheter balloon can be inflated in the wound for tamponade. With a large-vein injury there is a risk of air embolism, so cover with an occlusive dressing and lie the patient slightly head-down. A cervical collar is not routine in penetrating injury without a neurological deficit, because it hides an expanding haematoma.
The airway is the most dangerous part: an expanding haematoma, voice change, stridor or subcutaneous air demand early intubation by the most experienced operator, with a surgical airway prepared. Oesophageal injury is often diagnosed late, so when it is suspected CT with oral contrast or endoscopy is done. Strangulation with loss of consciousness or new neck signs also requires CT angiography to look for carotid or vertebral injury.
Key points
- Airway first — early intubation when danger signs appear.
- Hard signs — theatre.
- Soft signs — CT angiography.
- Do not probe the wound, no gastric tube; direct pressure or a Foley balloon.
- Think of oesophageal injury and air embolism.
Summary table
| Group | Signs | Meaning | Action |
|---|---|---|---|
| Hard signs | Active bleeding, expanding or pulsatile haematoma, bruit, shock, air bubbling from the wound, airway obstruction | Definite vascular or aerodigestive injury | Theatre at once |
| Soft signs | Stable haematoma, dysphagia, voice change, subcutaneous air, blood in saliva | Suspected injury | CT angiography |
| No signs | Wound only breaching the platysma | Low risk | Observation or CT by judgement |
| Suspected oesophageal injury | Dysphagia, subcutaneous air, blood in saliva | Late diagnosis is dangerous | CT with oral contrast or endoscopy |
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Sources
- Western Trauma Association Critical Decisions in Trauma: Penetrating neck trauma, 2013 (with later updates) — No-zone approach
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Airway; Neck trauma
- EAST Practice Management Guideline: Penetrating zone II neck trauma, 2008 — Selective management
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.