Field Guide to Managing Penetrating Neck Injuries: A Practical Approach for Paramedicsin the Saudi red crescent authority

Abstract

Penetrating neck injuries (PNIs) are complex and life-threatening traumas that pose significant challenges for pre-hospital care providers. Despite accounting for only 1% of all trauma cases, PNIs are associated with mortality rates ranging from 3% to 6%. While hospital-based guidelines exist, there is currently no universally accepted consensus or standardized recommendations for the pre-hospital management of PNIs. This review aims to address this critical knowledge gap by outlining management principles to inform a standardized approach for paramedics, aligning with their scope of practice and operational guidelines. The neck's anatomy is divided into three zones, each housing vital structures vulnerable to injury. The most frequently injured structures are vascular elements, followed by the respiratory and digestive tracts. Initial assessment categorizes findings into "hard" and "soft" signs, guiding the evaluation of injury severity. Uncontrolled hemorrhage is a leading cause of morbidity and mortality, and hemostatic dressings have demonstrated effectiveness in achieving hemostasis in pre-hospital settings. Airway management decisions should be made on a case-by-case basis, with rapid sequence intubation being the preferred method when indicated. Front of neck access may be necessary in "cannot intubate, cannot ventilate" scenarios. Circulation management focuses on hemorrhage control, hemostatic volume resuscitation, and preventing trauma-induced coagulopathy. Neurological injuries are rare but can cause severe deficits, and routine spinal immobilization is not recommended in isolated PNIs. A proposed management algorithm synthesizes current knowledge and provides a structured approach to assessment and intervention in pre-hospital environments. Future research should focus on refining best practices, comparing intubation techniques, evaluating hemostatic agents, and exploring the impact of interventions on secondary brain injury. Incorporating a shared, structured mental model into clinical protocols may enhance the rapid and effective management of PNIs, improving patient outcomes during transfer to definitive care.