Penetrating neck injuries in children are rare—but when they happen, the stakes are high. In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore the clinical pearls behind “no-zone” management, how to distinguish hard and soft signs, when to image versus operate, and why airway always comes first. Get ready for a focused, evidence-based deep dive into pediatric neck trauma.

Learning Objectives

Understand the shift from zone-based to “no-zone” management in pediatric penetrating neck injuries and describe the rationale behind this transition.
Apply ATLS principles to the initial assessment and stabilization of children with penetrating neck injuries, including decisions regarding imaging and airway management.
Evaluate clinical findings to determine the need for operative intervention versus observation in stable pediatric patients with soft versus hard signs of vascular or aerodigestive injury.

Connect with Brad Sobolewski

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References

Stone ME Jr, Christensen P, Craig S, Rosengart M. Management of penetrating neck injury in children: A review of the National Trauma Data Bank. Red Cross Annals. 2017;32(4):171–177. doi:10.1016/j.rcsann.2017.04.003

Callcut RA, Inaba K. Penetrating neck injuries: Initial evaluation and management. UpToDate. Waltham, MA: UpToDate Inc. [Accessed June 24, 2025]. Available from: https://www.uptodate.com

Transcript

Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and in this episode we are diving into a high-stakes but fortunately rare topic in pediatric trauma — penetrating neck injuries. Now these injuries make up less than 1% of all pediatric trauma, but when they occur, they demand precision and vigilance in terms of diagnosis and management.

As you know, the neck packs some vital organs, vessels, the airway, esophagus, and nerves into a tiny little area, so even a seemingly minor wound can injure multiple structures.

Now you remember — way back when — where you learned about the zones of the neck, and this is the traditional teaching, which chopped the neck up into three zones.

You’ve got Zone I, which is the area between the clavicle and cricoid. You’ve got the subclavian arteries and vein, the carotid, and the apices of the lungs.
Zone II, the cricoid to the angle of the mandible — this includes the carotids, jugulars, the vagus nerve, the trachea, and the esophagus.
And then you have Zone III, which is the angle of the mandible to the base of the skull — you’ve got the distal carotid, the vertebral artery, and cranial nerves IX through XII.

Now, you may recall some teaching that you got in medical school or residency where the management was dictated by which zone was injured. And admittedly, a lot of this evidence is in adults, and more penetrating trauma is seen in adults as well.

But now practice is leaning towards the “no zone” approach, where imaginary lines on the skin surface are not dictating management as much as presentation, symptoms, and deciding when to go to the OR versus using CT angiography.

So let’s talk about mechanisms of injury for a minute.

Toddlers can injure their neck when they fall with something in their mouth, like pencils or chopsticks.
School-age kids may take a bike handlebar to the neck, or they’re trying to run or jump over a fence and they get impaled on that — that sounds painful.
Adolescents, unfortunately, are subject to assaults, stabbings, and gunshot wounds, as well as clothesline-type injuries or other high-velocity injury where the neck is injured as they’re riding a bike.

So low-velocity mechanisms dominate pediatric penetrating neck injuries. Force matters, because depth and tissue cavitation decide the overall injury pattern.

In terms of assessing the patient with a penetrating neck injury, it all starts with the ABCs.

Is the patient’s airway patent? Are they protecting and maintaining it?
Look for signs such as hoarseness, stridor, aphonia (they can’t talk at all), a bubbling wound, or an expanding hematoma.

For breathing, patients should be breathing comfortably with no distress.
Look for any signs of asymmetry on chest rise, feeling of crepitus or subcutaneous air, or diminished breath sounds — obviously the latter two indicating a pneumothorax or even hemothorax.

For circulation, if the wound is bleeding, apply direct pressure. Some surgeons will use a Foley balloon tamponade method if they need to stop bleeding before going to the operating room.

Patients will need large bore IVs and fluids — and especially blood product resuscitation.

Only immobilize the C-spine if a patient has neurologic deficits or a high injury mechanism.
Think — somebody that was riding their bike and clotheslined the fence.
Neck collars hide neck wounds and hamper airway management unless they’re strictly needed.

You may have also heard of hard signs and soft signs in terms of the parlance of managing penetrating neck injury.

In general, hard signs mean go to the operating room.
Soft signs need a CT angiogram and observation.

So here are some hard signs:
• Active arterial bleeding — blood spurting out of the patient
• Expanding or pulsatile hematoma
• Airway compromise, stridor, or other signs
• Air bubbling from the neck wound
• Shock that is unresponsive to fluids
• Any focal neurologic deficit

Soft signs include:
• Minor oozing
• A small and stable hematoma
• Mild dysphonia or dysphagia
• Subcutaneous air without any respiratory distress
• Mild voice changes
• Just a little bit of hemoptysis

A large pediatric series showed that 50 to 70% of children with hard signs did need operative repair.
Most with only soft signs were managed safely with imaging and serial exams.

So I alluded to this paradigm at the beginning of the episode — the “no zone” strategy.

For stable children with no hard signs, CT angiography is the gold standard.
It has a sensitivity of 95 to 99% for major vascular injury.
You’re able to visualize the trachea, esophagus, spine, and any foreign bodies.

Make sure you always get a chest X-ray as well, since penetrating neck injuries can injure the apices of the lungs or thoracic structures.

Also, if the CTA is negative but you still have suspicion for injury to the aerodigestive tract, you can do a water-soluble contrast esophagram or flexible endoscopy.

Plain films — yes, you can assess the C-spine and look for radiopaque foreign bodies, but again, if you truly have a child that is stable and has no hard signs, CTA is the gold standard.

If you follow this, you can cut non-therapeutic neck explorations in half without missing any injuries.
So this should be part of your protocol.

If you do have a neck wound that you have to manage before the surgeons can get to it: direct pressure first.

The Foley balloon tamponade method is where you take an 18 to 20 French catheter, place it into the wound, inflate the balloon with 10 to 15 milliliters of water, and then clamp it.

I wouldn’t necessarily do this in a Level 1 trauma center — I have surgeons available — but it might be useful if you have to transport a kid quickly to a trauma center.

Never, ever, ever pull an impaled object out of the neck in the emergency department.
These should be removed in the operating room.

Now, superficial injuries with the platysma intact get routine closure.
Anything deeper deserves imaging.

So here’s some pediatric-specific pearls, again, because these are really rare.

Kids have a small airway, and soft tissues swell quickly, so there’s a low threshold for securing the airway.
If you’re concerned about the airway, make a plan to do it right now.

Kids have low blood volume and don’t tolerate hemorrhage as well.
They’ll underreport pain, especially younger ones — so rely on the exam and parental observations.
Definitely use Child Life to help keep them calm.

And unfortunately, some neck wounds are self-inflicted, so make sure you address mental health concerns after the child is stabilized.

Alright. So let’s bring it all home. What are some key take-home points?
1. Penetrating neck trauma is fortunately rare in kids — far less than 1% of all pediatric trauma — but still high-risk.
2. Males predominate. The younger the child, the higher the risk of aerodigestive injury.
3. Hard signs → go straight to the OR.
4. Soft signs → CT angiography and observation.
5. Hard vs soft signs reliably stratify risk.
6. CTA + chest X-ray is first-line in stable, hard-sign-negative children, which limits unnecessar...