Snapshot A 27-year-old male is brought in to the ED after being found down in front of his apartment. The neighbors report that the patient was a stabbing victim, and a small knife was found on the left neck by EMS and left in place. En route, the patient’s blood pressure is 91/53 mmHg, pulse is 110/min, respirations are 21/min, and oxygen saturation is 95% on room air with GCS of 15. On exam, there is a small knife on the lateral left neck above the sternal notch with a large hematoma that feels pulsatile. There are decreased breath sounds on the left apical lung. There are also multiple stab wounds and lacerations on his back. Introduction Neck trauma can be described neck zones zone I: base of neck (thoracic inlet to cricoid cartilage) zone II: midportion of neck (cricoid to angle of mandible) zone III: superior aspect of neck Mechanism of injury can determine zones and layers of neck involved Presentation Airway injury larynx history: strangulation, direct blow, blunt trauma, any penetrating injury involving platysma triad: hoarseness, subcutaneous emphysema, palpable fracture crepitus other symptoms: hemoptysis, dyspnea, dysphonia trachea/bronchus history: deceleration, penetration, increased intrathoracic pressure symptoms: dyspnea, hemoptysis exam: subcutaneous emphysema, Hamman's sign (crunching sound synchronized to heart beat) Pharynx/esophageal injury hematemesis, difficulty swallowing, saliva exiting out of the wound, pneumomediastinum Vascular injury most common injury with penetrating neck trauma hematoma, absent carotid pulse, bruit, shock Nerve injury vagus, spinal accessory, hypoglossal, phrenic nerves are at risk symptoms associated with the specific nerve damaged Management General approach patient should be transported to a trauma center. Meanwhile, immobilize neck to prevent further injury primary survey if penetrating neck trauma present, do NOT: clamp structures (high risk of nerve damage) probe with finger insert nasogastric tube (risk of perforation/bleeding) remove weapon/impaled object in the ED presence of hemodynamic instability or “hard signs” of tissue injury prompt surgical intervention hard signs include vascular injury pulsatile bleeding, expanding hematoma, bruit, signs of cerebral ischemia, absent carotid pulse aerodigestive injury bubbling from the wound, hoarseness, stridor, subcutaneous emphysema, respiratory distress secondary survey imaging CXR and CT scan asymptomatic patients may have time for CT angiogram, esophagoscopy or bronchoscopy to fully characterize extent of injury and dictate further management