Penetrating Neck Trauma
Objective: Treat a penetrating neck wound as an airway and bleeding problem. Hold direct pressure, and do not probe the wound. Leave early for a trauma center. If the neck is swelling, plan for cannot-intubate, cannot-oxygenate.
Why this matters
The wound can look small. Crews look inside, pull a clot, and then cannot stop the bleeding. First, hold direct pressure and protect the airway. Check for hard signs, and leave for a trauma center. Do not probe the wound.
Hard signs mean leave now. Those signs are airway compromise, an expanding hematoma, bubbling, pulsatile bleeding, and stroke-like findings. A hematoma is a growing collection of blood. Soft signs still need a trauma center. Neck zones I, II, and III matter to the surgeon. They do not change your field plan.
- Hold direct pressure with a gloved hand, or pack in a way that still lets you watch the airway. Do not clamp blindly.
- Sit the patient up if they can protect their own airway. Suction, and be ready to lose the airway to a hematoma.
- The cervical spine is a mechanism question. A failing airway still comes first. Helmet and spinal-motion-restriction care still apply when the patient is stable enough for them.
- This is a penetrating neck wound. I will hold pressure, and I will not probe.
- If the neck is swelling, the airway can close.
- These are hard signs. We will keep the scene short and go to a trauma center.
- If the voice changes, I will use the cannot-intubate, cannot-oxygenate plan.
Clinical sequence
- Run MARCH: massive hemorrhage, airway, respirations, circulation, then hypothermia and head injury. Stop massive external bleeding with pressure first. Then manage the airway.
- Do not probe the wound. Do not pull an impaled object. Do not remove a clot to see what is under it.
- Hard signs are airway trouble, an expanding hematoma, bubbling, or shock from the neck. Keep the scene short, go to a trauma center, and notify early.
- If the airway is closing, use a supraglottic airway or trained front-of-neck access per protocol. This is a predicted difficult airway. Repeated direct-laryngoscopy attempts use up the oxygen the patient has left.
- Get two large intravenous lines or an intraosseous line during transport. Do not delay transport for a full neurologic exam while the patient is bleeding into the neck.
Teaching points
- Hard signs: airway compromise, an expanding hematoma, pulsatile or brisk bleeding, a bubbling wound, or a focal neurologic deficit. These patients leave now.
- Do not explore the wound. You cannot tie off a carotid artery in the field. Hold pressure and choose the right hospital.
- Airway: a hematoma distorts landmarks. Pausing to look is how a cannot-intubate, cannot-oxygenate emergency happens. See the front-of-neck and attempt-limit lessons.
- Zones I, II, and III are for surgeons. Your destination is a trauma center that can operate on the neck, not the closest clinic.
Common errors
- Putting a finger in the wound to see how deep it is.
- Clamping blindly in a pool of blood.
- Making three intubation attempts while the other side of the neck swells.
Practice
One-minute check
A zone II stab wound has an expanding hematoma. The voice is hoarse. Oxygen saturation is 96% while the patient is sitting. Say the first three actions and the radio sentence. Say what you will not do to the wound.
Related: Front-of-Neck Access, Massive Hemorrhage First.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — penetrating trauma and hemorrhage control; protocol owns procedures
- ACS COT trauma resources / ATLS tradition — hard signs of neck injury — airway and hemorrhage, not wound exploration
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.