Neck Trauma
                                ===========
þ Penetrating Neck Injury
 - anything that penetrates the platysma is a penetrating neck injury
 - management depends on zone, and definition of Zones have changed in recent
   years:
    Zone I: clavicles to cricoid:
     stable = angio+ esophogram or endoscope (also laryngoscopy/bronch if sx)
    Zone II: cricoid to angle of the jaw:
     explore in OR or angio, esphogram/endoscopy
     (also laryngoscopy/bronch if sx)
    Zone III:  angle of the jaw to base of skull: stable = angio
   This is the system proposed by Roon and Christensen back in 1979 [Roon
   AJ, Christensen N. Evaluation and treatment of penetrating cervical
   injuries. J Trauma 1979; 19:391-7.]
 - Zone I and Zone III penetration: angio prior to IR is standard
 - Zone II penetration: standard used to be to operate for all (started in WW
   II) but some recommend angio first, sometimes with selective embolization
   (big controversy), also often esophageal studies.  Some also recommend
   observation for Zone II injury (also controversial as may miss significant
   injury.
 - immediate OR if penetrating neck trauma and:
  + shock
  + high-velocity missle
  + deterioration during diagnostic testing
  + close-range (<5 meters) shotgun injury
  + massive or expanding hematoma
  + airway compromise
  + stroke
 - may have diagnostic tests prior to OR if:
  + stable nonmassive hematoma
  + continued hemorrhage without shock
  + hemoptysis
  + dysphonia
  + SQ air
  + hematemesis
  + dysphagia
  + peripheral neuro deficit
  (Harwood-Nuss 3e p 493

 - When to intubate and how:
  + earlier intubation is easier
  + early prophylactic RSI is a good idea (per Ron Walls) if
   - stab wound that violates platysma and clinical
     evidence of vascular or direct airway injury, such as pharyngeal bleeding
   - GSW even without any airway involvement
  + Jeff Schaider (Cook County) also recommends RSI if long transport or
    transfer or diagnostic testing.
  + Retrospective study of 114 patients with penetrating trauma found
    29/69 direct intubation attempts failed; 6 required alternate to
    intubation.
    [Eggen JT, Jorden RC. Airway management, penetrating neck trauma. J Emerg
    Med 1993;11:381-385.]
  + Retrospective review of 107 patients with penetrating neck trauma found
    RSI 98% successful (2 required cric), awake fiberoptic 100% (but slow),
    surgical necessary in 6 and all successful, and of the 4 attempts at BNTI
    only 3 succeeded.
    [Shearer VE, Giesecke AH. Airway management for patient with penetrating
    neck trauma: a retrospective study. Anesth Analg 1993;77:1135-8.]
  + Retrospective review of 748 consecutive patients with penetrating neck
    injury: 82 required intubation, 24 of which prehospital, 58 in ED.  39/58
    successful RSI intubations in ED, 6 required 2 or more attempts, 5/58
    successful intubations without paralytics.  Of 12 fiberoptic tried, only
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þ Blunt Neck Trauma
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