Initial management of the patient with penetrating trauma proceeds in accordance with the general principles articulated by the American College of Surgeons Advanced Trauma Life Support (ATLS) course. Airway, breathing, and circulation are evaluated, and immediate life threats addressed. Current assessment of a patient with penetrating neck trauma integrates clinical findings with additional results, in clinically stable patients, from selective diagnostic investigation. Clinical findings have been traditionally classified as “hard” or “soft,” depending on whether obvious evidence of vascular or aerodigestive injury is present. “Hard” signs include active hemorrhage, shock unresponsive to initial fluid therapy, a pulsatile or expanding hematoma, bruit, or thrill, massive hemoptysis or hematemesis, or air bubbling through the wound. Patients presenting with “hard” signs require emergent operative exploration. “Soft” signs include venous oozing, non-expanding or non-pulsatile hematoma, minor hemoptysis, dysphonia, dysphagia, and subcutaneous emphysema. These patients, if they remain clinically stable, are suitable for further investigation. The site of anatomic injury, classified by dividing the neck into three distinct “zones,” has also traditionally been used to determine the need for operative exploration or selective diagnostic investigation. Zone 1 extends from the clavicles to the cricoid cartilage; zone 2, from the cricoid cartilage to the angle of the mandible; and zone 3, from the angle of the mandible to the base of the skull. A presumptive direct relationship between the superficial site of trauma and underlying injury to deeper structures underlies this approach. Zone 2 injuries are the most accessible to direct surgical exploration, whereas wounds in zone 1 and zone 3 are often challenging or inaccessible for surgical intervention and are best served by less-invasive diagnostic and therapeutic approaches. Although commonly utilized, this anatomic distinction can be problematic as an entry wound in zone 2 could easily affect structures in zone 1 or zone 3 without this being immediately apparent from the superficial wound site.