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161. What are the clinical characteristics and presentations of an epidural
hematoma?
• Lossofconsciousstatefollowedbyaninterveninglucidinterval
• Secondarydepressionofconsciousness
• Developmentofhemiparesisonthecontralateralside
• Afixedanddilatedpupilontheipsilateralsideoftheimpactarea
162. What is the Glasgow Coma Scale (GCS)?
The Glasgow Coma Scale provides a quantitative measure of the patient’s level of consciousness.
The GCS is scored between 3 and 15, with 3 being the worst and 15 the best. This scale is composed
of three parameters: eye response, verbal response, and motor response.
Best Eye Response:
No eye opening: one point
Eye opening to pain: two points
Eye opening to verbal command: three points
Eyes open spontaneously: four points
Best Verbal Response:
No verbal response: one point
Incomprehensible sounds: two points
Inappropriate words: three points
Confused, but able to answer questions: four points
Orientated: five points
Best Motor Response:
No motor response: one point
Extension to pain: two points
Flexion to pain: three points
Withdrawal from pain: four points
Localizing pain: five points
Obeys commands: six points
163. How is GCS used to classify the severity of the brain-injured patient?
• Mildheadinjury:GCSof14to15
• Moderateheadinjury:GCSof9to13
• Severeheadinjury:GCSscoreofeightorless
164. What is focused assessment sonography (FAST) and its indications?
FAST is a rapid bedside ultrasound exam performed to identify intraperitoneal hemorrhage or
pericardial tamponade. FAST examines four areas for free fluid: perihepatic and hepatorenal space,
perisplenic, pelvis, and pericardium. FAST assessment is indicated in trauma patients who have a
history of abdominal trauma, are hypotensive, or are unable to provide a reliable history because of
impaired consciousness resulting from head injury or drugs. FAST is an adjunct to the ATLS primary
survey and therefore follows the performance of the ABCs.
165. What is diagnostic peritoneal lavage (DPL) and its indications?
DPL involves passing a small catheter into the peritoneal cavity, usually at the umbilicus just inferior
to it (3 to 4 cm). If blood can be aspirated through this catheter, this is referred to as a diagnostic
positive aspiration (DPA). If no blood can be aspirated, a liter of warm crystalloid solution is run into
the peritoneal cavity and then allowed to drain out by gravity after sitting for 5 to 10 min. This lavage
fluid is then sent to the lab for analysis of red blood cell count, white blood cell count, and any bowel
contents. A rule of thumb for a positive DPL is the inability to read newsprint through the lavage fluid.
Further surgical intervention is required if lab results of the submitted specimen indicate that the
presence of 100,000 RBCs/mm3 or more, and > WBCs/mm3. DPL is used as an alternative to the
FAST scan to identify intraperitoneal hemorrhage in blunt abdominal trauma. The role of DPL in the
hemodynamically normal patient with penetrating abdominal injury is to identify hollow viscus injury
(stomach, small bowel, or colon) or diaphragmatic injury. The primary disadvantages of the DPL are
that it is invasive, does not evaluate the retroperitoneum, and has a significant false positive rate.
166. What is spinal shock?
Loss of reflexes and flaccidity, seen after spinal cord injury. Owing to shock, the injured cord may
appear completely functionless, although all areas are not necessarily destroyed.
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167. What are the classifications of spinal cord injuries?
1. Level
2. Severity of neurologic deficit
3. Spinal cord syndrome
4. Morphology
168. What are the most common spinal cord syndromes?
• Central cord syndrome: identified by greater loss of motor function in the upper extremities
than the lower extremities, with varying sensory loss
• Anterior cord syndrome: identified by paraplegia with loss of temperature and pain sensation
169. What are three proper ways for assessment of the trauma patient’s extremities?
1. Primary survey: identification of life-threatening injury
2. Secondary survey: identification of limb-threatening injuries
3. Continuous reevaluation: systematic review to decrease the chances of missing any other
musculoskeletal injury
170. What is the most common cause of cardiac arrest in the pediatric patient?
Hypoxia is the most common cause of cardiac arrest in the pediatric patient. Before cardiac arrest,
hypoventilation causes a respiratory acidosis, which is the most common acid–base abnormality
during resuscitation of the pediatric trauma patient.
171. What are the different degrees of thermal burns?
• First-degree burn: It is identified by erythema with absence of blisters.
• Second-degree burn (partial-thickness burn): It is identified by a mottled or erythematous ap-
pearance with swelling and blister formation. The surface may be wet and weeping; it is painful
and hypersensitive.
• Third-degree burn (full-thickness burn): It is identified by skin that appears dark, translucent,
leathery, and mottled. The surface does not blanch with pressure. The skin is dry, painless, and red.
It is important to ascertain the depth of a burn to properly plan for wound care and predict cosmetic
and functional outcome.
BiBliography
Basic Life Support
Berg RA, Hemphill R, et al.: Part 5: Adult Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmo-
nary Resuscitation and Emergency Cardiovascular Care, Circulation122:S685–S705,2010.
Hazinki MF, Hunter-Wilson SL, editors: BLS for healthcare providers manual, Dallas, TX. American Heart Association, 2011.
Hellevo H: Deeper chest compression: more complications for cardiac arrest patients? Resuscitation84:760–765,2013.
Highlights of the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardio-
vascular Care, Dallas, TX, American Heart Association, 2010.
Ohgali MA: Basic Life Support. In Abubaker O, Benson K, editors: Oral and maxillofacial surgery secrets,ed2,Philadelphia,2007.
Advanced Cardiac Life Support
Arrich J, Holzer M, Havel C, et al.: Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation, Cochrane
Database Syst Rev 9:CD004128, 2012.
Brindley PG, Markland DM, Mayers I, et al.: Predictors of survival following in-hospital adult cardiopulmonary resuscitation,
Can Med Assoc J167:343–348,2002.
Chan PS, Krumholz HM, Nichol G, et al.: Delayed time to defibrillation after in-hospital cardiac arrest, N Engl J Med
358:9–17,2008.
Danciu SC, Klein L, Hosseini MM, et al.: A predictive model for survival after in-hospital cardiopulmonary arrest, Resuscita-
tion 62:35–42, 2004.
Dager WE, Sanoski CA, Wiggins BS, et al.: Pharmacotherapy considerations in advanced cardiac life support, Pharmaco-
therapy12:1703–1729,2006.
Girotra S, Nallamothu DK, Spertus JA, et al.: Trends in survival after in-hospital cardiac arrest, N Engl J Med367:1912–1920,
2012.
McEvoy MD, Field LC, Moore HE, et al.: The effect of adherence to ACLS protocols on survival of event in the setting of
in-hospital cardiac arrest, Resuscitation85:82–87,2013.
Paradis NA, Harken AH: Cardiopulmonary resuscitation. In Harken AH, Moore EE, editors: Abernathy’s surgical secrets, ed 5,
Philadelphia, 2005, Mosby.
Rajab BM, Banks KA: Advanced cardiac life support. In Abubaker O, Benson KJ, editors: Oral and maxillofacial surgery
secrets,Philadelphia,2007,Mosby/Elsevier.
Sinz E, Navarro K, Soderberg E, et al.: Advanced cardiovascular life support provider manual, Dallas, American Heart
Association, 2011.
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Advanced Trauma Life Support
Advanced Trauma Life Support Student Course Manual, ed 9, American College of Surgeons, 2012.
Kozlovsky E, Aziz SR: Advanced trauma life support. In Abubaker O, Benson KJ, editors: Oral and maxillofacial surgery
secrets,Philadelphia,2007,Mosby/Elsevier.
Kress TD, et al.: Cricothyroidotomy, Ann Emerg Med11:197,1982.
Mattox KL, Feliciano DV, Moore EE: Trauma,ed7,McGraw-Hill,2012.
TRACHEOSTOMY
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AND CRICOTHYROTOMY
Andrew Yampolsky, Shahid R. Aziz, A. Omar Abubaker
1. What are the different methods of achieving and securing an airway in an
emergency?
Securing the airway is of paramount importance in both emergencies and critically ill patients. A
simple chin lift and jaw thrust will relieve airway obstruction in most patients. If a patient is unable to
generate adequate respiratory effort on his or her own, bag mask ventilation is attempted first. Oral
and nasal airways may be used in conjunction with these techniques to assist in providing adequate
ventilation. To definitively secure an airway, endotracheal intubation is performed. In certain situations,
oral intubation is unsuccessful or contraindicated, such as in severe panfacial trauma, massive upper
airway bleeding, spasm of facial muscles, and laryngeal stenosis or deformities of the oronasopharynx. A surgical airway (whether by needle or surgical technique) must be performed, thus bypassing
any possible area of obstruction.
2. What are the advantages of cricothyrotomy?
Cricothyrotomy should be viewed as the method of choice in procuring a patent airway in patients
with acute airway obstruction that fail traditional intubation. It is faster and is technically easier to
perform with minimal instrumentation in an emergency setting and with low incidence of operative
and postoperative complications.
3. What anatomy is pertinent to cricothyrotomy?
The thyroid cartilage consists of two quadrilateral laminae of hyaline cartilage that fuse anteriorly.
The anterosuperior edge of the thyroid cartilage, the laryngeal prominence, is known as the Adam’s
apple. The angle at which these laminae converge is more acute in men than women and therefore is
more easily located in men. The thyroid prominence is the most important landmark in the neck when
performing a cricothyrotomy. The next cartilaginous ring below the larynx (and the only complete
ring) is the cricoid cartilage. It helps to maintain the laryngeal lumen and forms the inferior border
of the cricothyroid membrane. This membrane, another important landmark, is a dense fibroelastic
membrane located between the thyroid cartilage superiorly and the cricoid cartilage inferiorly and
bounded laterally by the cricothyroid muscles. It is approximately 22 to 30 mm wide, 9 to 10 mm high,
and 13 mm inferior to the vocal cords. This membrane can be identified by palpating a notch (a slight
indentation or dip) in the skin inferior to the laryngeal prominence in an adult. Although the right and
left cricothyroid arteries (branches of the right and left superior thyroid arteries, respectively) traverse
the superior part of the cricothyroid membrane, these vessels are not of clinical significance or the
cause of problems when performing a cricothyrotomy.
The tissue layers involved in cricothyrotomy include the subcutaneous tissue, cervical fascia,
cricothyroid membrane, and tracheal mucosa. The distance from skin to tracheal lumen is only 10 mm
in most adult patients. In contrast to the main body of the trachea, the posterior wall at this level of
the upper airway is rigidly separated from the esophagus by the tall posterior cricoid cartilage shield,
making esophageal perforation unlikely during cricothyrotomy. The highly vascular thyroid gland lies
over the trachea at the level of the second and third tracheal rings. If the tracheal rings or the thyroid
gland is encountered when performing a cricothyrotomy, the incision is too low in the neck and must
be redirected more superiorly.
4. What is the cricothyrotomy technique?
If there are no known or suspected cervical spine injuries, the patient’s head may be hyperextended.
Identify and palpate the notch or dip in the neck below the laryngeal prominence. Once the pertinent
landmarks are identified, the right-handed surgeon then stabilizes the thyroid cartilage between the
thumb and middle finger of his left hand and identifies the cricothyroid space with his left index finger.
If local anesthetic is used, it should also be injected into the tracheal lumen to diminish the cough
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reflex during tube placement. A 3- to 4-cm transverse or vertical skin incision is made. A vertical
incision is preferred in an emergency situation because if the skin incision is too high or too low, it
may be extended easily, saving time and avoiding a second incision. A short, horizontal stab incision
(about 1 cm long) is made with a No. 11 blade in the lower part of the cricothyroid membrane (nearer
the cricoid ring) to avoid the cricothyroid arteries. Mayo scissors are spread horizontally in the incision
to widen the space. Alternatively, the handle of the scalpel may be inserted and twisted 90 degrees.
Next, the opening is enlarged with Trousseau dilators or a curved hemostat. After stabilization of the
larynx, the tracheostomy tube is inserted, the dilator or hemostat is removed, and the cuff of the
tracheostomy tube is inflated (Fig. 15-1).
5. What is percutaneous transtracheal jet ventilation (PTJV)?
PTJV is an option to provide temporary ventilation for a patient in situations when the equipment for a
formal airway or skilled personnel are not available. A needle cricothyrotomy must first be performed.
A large bore needle with an IV catheter (14 gauge) is attached to a small syringe with sterile saline
and advanced through skin, subcutaneous tissues, and the cricothyroid membrane at a 45-degree
Cricothyroid lig.
A
Pyramidal lobe
Cricothyroid lig.
Cricothyroid m.
Cricoid cart.
First tracheal cart.
B
Figure 15-1. A and B, Surface anatomy and landmarks for cricothyroidotomy. C, A horizontal stab incision is made
through the ligament. (From Morris WM: Cricothyroidotomy. In Loré JM, Medina JE, editors: An atlas of head and neck
surgery, ed 4, Philadelphia, 2005, Saunders.)
C
CHAPTER 15 TRACHEOSTOMY AND CRICOTHYROTOMY 157
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angle until air is aspirated. The syringe and needle are then removed, and the IV catheter is left in
place. A manual jet ventilator device is then attached and 100% oxygen is administered intermittently.
This technique does not allow for adequate exhalation, as such CO2 and airway pressure eventually
builds up. Therefore, this should only be used as a temporizing measure until a definitive airway is
established.
6. When is a tracheostomy the preferred emergency surgical airway?
In pediatric patients younger than ages 10 to 12. The pediatric airway is described as funnel shaped
with the narrowest part below the cords as such entrance through the cricothyroid membrane may
not bypass the airway obstruction. Furthermore, the small 3-mm-wide cricothyroid membrane and
poorly defined anatomic landmarks make cricothyrotomy all but impossible in children.
7. What are the surface anatomy landmarks for a tracheostomy?
The most important anatomic landmarks for the tracheostomy procedure are the thyroid notch, cricoid
ring, sternal notch, and innominate artery, which is above the sternal notch in approximately 25%
of patients. The location for skin incision (approximately 4 to 6 cm long) for tracheostomy should be
about 2 cm below the cricoid ring or midway between this ring and the sternal notch.
8. From the skin to the trachea, what are the layers encountered during dissection
for tracheostomy?
• Skin
• Subcutaneousconnectivetissue
• Platysma
• Investingfascia
• Linealbaoftheinfrahyoidmuscles
• Thyroidisthmus
• Pretrachealfascia
• Trachealrings
9. What is the technique for performing a tracheostomy?
A 4- to 6-cm incision is carried through skin, subcutaneous tissue, and platysma. Flaps are retracted
superiorly, and a vertical incision is made in the fascia overlying the strap muscles. After the cricoid
cartilage is identified, the thyroid isthmus may be retracted superiorly or divided and tied off. This
exposes the second, third, and fourth tracheal rings. Using a hypodermic needle and a syringe, aspi-
rateairfromthetracheaandinject1to2mLoflocalanesthetictominimizecoughingwhenentering
the trachea. Make a 1-cm horizontal incision into the trachea above and below the ring of choice.
This ring is cut so that a small rectangular window into the trachea is made. Place sutures in each
side of the trachea to facilitate locating the tracheal stoma should the tube become dislodged. Insert
the tracheostomy tube into the opening, taking care not to tear the cuff and not to insert the tube in
the space anterior or lateral to the trachea. Once the tube is in place, inflate the cuff and check the
chestforbreathsounds.Leavetheskinedgesaroundthetubeopenoronlypartiallyclosedwith
nonresorbable sutures, leaving a small space to minimize the danger of air escape into the subcutaneous tissue. Suture the tube to the skin, and secure it with a tape tied in a square knot around the
neck (Fig. 15-2).
10. What major vessels may be encountered during tracheostomy?
The anterior jugular vein and the jugular venous arch are found in the suprasternal space of Burns.
The infrahyoid vein and artery and thyroid artery all lie in the space between the pretracheal and
infrahyoid fascia.
11. Which tracheal rings are covered by the thyroid isthmus? What do you do if the
thyroid is encountered during your dissection?
The second through fourth rings. If the thyroid isthmus is encountered during dissection, it can be
managed depending on surgeon preference. Some surgeons prefer to gently mobilize it and retract it
caudally or cranially. Others ligate and divide it to prevent postoperative bleeding.
12. What are the possible intraoperative complications associated with
tracheostomy?
• Hemorrhage: The anterior jugular system and its anastomoses, thyroid isthmus, high aortic arch
(elevated into the surgical field by hyperextension of the neck in children and elderly patients),
thyroid veins and arteries, left innominate or brachiocephalic veins.
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• Subcutaneous emphysema: This can result from a wound that has been closed too tightly around
the tracheostomy tube, sutures that are placed after decannulation, or the tracheostomy tube being
placed in a false passage.
• Recurrent laryngeal nerve injury: The laryngeal nerve innervates the trachea, esophagus, and
all the intrinsic muscles of the larynx except the cricothyroid. Damage to this nerve produces vocal
cord paralysis.
Thyroid cart. notch
Cricoid cart.
A
Innominate a.
Ant.
lig. of
thyroid
Platysma
Ant.
jugular v.
Cricoid cart.
Thyroid
isthmus
B C
Isthmus
transected
Isthmus
retracted
ED
Figure 15-2. A, Surface anatomy landmarks for tracheostomy. B, After skin and platysma incisions are completed, a
vertical incision is made in the fascia at midline between the strap muscles. C, The cricoid cartilage and thyroid isthmus
exposed. D-F, The thyroid isthmus transected, retracted, and secured with ligature.
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2% Lidocaine
10%
Cocaine
GF
Cricoid
Cartilage
IH
Figure 15-2, cont’d. G, Using a smaller gauge needle, air is aspirated into the syringe, 2% lidocaine (Xylocaine) is injected
into the lumen of the trachea. H and I, A window is cut into the second, third, or fourth ring of the trachea. Alternatively,
the ring is left pedicle inferiorly and sutured to the skin. J and K, The tracheostomy tube is inserted into the trachea and
secured in place. (From Loré JM: The trachea and mediastinum. In Loré JM, Medina JE, editors: An atlas of head and neck
surgery, ed 4 Philadelphia, 2005, Saunders.)
KJ
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• Pneumothorax or pneumomediastinum: These are more common in pediatrics, in which the lung
apex extends farther into the lower neck. They can also result from false passage of a tracheostomy tube between the anterior tracheal surface and the mediastinal tissues.
• Other complications include: insertion into a false passage, airway fire, laceration of the posterior
tracheal wall, esophageal injury, loss of airway, aspiration, and even death
13. What are the possible postoperative complications associated with
tracheostomy?
• Atelectasis. This is caused if blood or foreign material is aspirated into the tube or if the tracheos-
tomy tube is directed into one mainstem bronchus, resulting in collapse of the opposite lung.
• Tracheoesophageal fistula. This rarely occurs in an orderly tracheostomy. It may accompany an
emergency stab type of tracheotomy, or it may occur if an ill-fitting tracheostomy tube rubs against
the posterior tracheal wall.
• Subglottic edema and tracheal stenosis. These are preventable by entering the trachea below
the second tracheal ring. The most common symptom is increasing stridor.
• Persistent fistula after decannulation. Vertical incisions heal more rapidly than horizontal ones.
This may require operative closure with resection of the tracheotomy tract.
• Tracheo-innominate fistula resulting in devastating hemorrhage
• Other complications include: vocal chord paralysis, dysphagia, tracheal stenosis, pneumonia, and
difficult decannulation
14. What is the postoperative care for a tracheostomy?
Once the tracheostomy procedure is completed, diligent postoperative care and observation are
essential to prevent postoperative complications associated with this procedure. Both the surgeons
and the nursing staff should supply this care, including:
• ObtainingachestX-raywithintheimmediatepostoperativeperiodtocheckthepositionofthetube
and for presence of a pneumothorax
• Usinghumidiedairtokeepthetrachealmucosamoist
• Frequentlysuctioningthetracheostomytube,becausethetracheotomyreducestheefciencyof
coughing, and initially there are more secretions from the trachea and mucous that may plug the
tracheostomy tube and result in respiratory distress
• Performingroutinewoundcareandchanging/cleaningtheinnercannulaorthetubeitself
• Removingthesuturesonceatractisformed
• Ensuringthatthetubeisappropriatelysecuredandthattheventilatortubingisnotabnormally
pulling on the tube
• Downsizingthetracheostomyandweaningthepatient
15. What are the components of a typical tracheostomy tube? What kinds of tracheostomy tubes exist? How do you select a proper tracheostomy tube?
See Figure 15-3 and Table 15-1.
Tracheostomy tubes exist in a variety of styles and materials and are made by multiple manufacturers. Traditionally made from stainless steel, the so-called Jackson tracheostomy tubes are
infrequently used currently. Modern tracheostomy tubes are typically made from polyvinyl chloride or
silicone, which provide some degree of compliance and flexibility, allowing the tube to conform to the
patient’s anatomy.
Tracheostomy tubes have a variety of variables in their construction that must be considered when
selecting the proper tube, including outer diameter (OD), inner diameter (ID), curvature, proximal and
distal length, presence of an inner cannula, presence of a cuff, type of cuff, and fenestration of the tube.
Depending on the manufacturer, the tracheostomy tubes come in a variety of sizes. Table 15-1 is
based off the traditional Jackson tubes and can be used as a rough guide, with the understanding that
there is variation depending on the specific manufacturer.
Proximal and distal length is an important consideration when selecting an appropriate tube.
Longerproximallength“XLT”tubesareusedinpatientswithalargeneckcircumference(i.e.,obese
patients).Longerdistallengthisusedinpatientswithtrachealanomaliessuchastracheomalacia.The
internal diameter is a consideration in terms of facilitating airway clearance and minimizing resistance
through the tube. Outer diameter is determined by the overall diameter of the patient’s airway, taking
into account the importance of being able to pass laryngeal air around the tube as is required for
phonation. Fenestrated tubes are also often used by some clinicians in situations when the patient
will need to phonate with a tracheostomy tube in place. The use of a tube with a cuff is determined
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Cuff Cuff
Cuff
Obturator
Figure 15-3. Components of tracheostomy tube. (Photo courtesy Dr. Andrew Yampolsky.)
Table 15-1. Jackson Tracheostomy Tube Size
JACKSON ID WITH IC ID WITHOUT IC OUTER DIAMETER
Size (mm) (mm) (mm)
4 5 6.7 9.4
6 6.4 8.1 10.8
8 7.6 9.1 12.2
10 8.9 10.7 13.8
by the patient’s age, requirement of mechanical ventilation, and possible affects on aspiration. The
general consensus is that cuffed tubes are contraindicated in the pediatric population because of a
risk of affecting the development of the immature trachea and potential for long-term squalae such
as tracheal stenosis. Cuffed tubes are often used during periods of mechanical ventilation. Generally
speaking, it is easier to maintain proper hygiene of the airway when an interchangeable inner cannula
is used; the inner cannula can be easily replaced when it becomes soiled with airway secretions or if
an obstructive mucus plug develops.
16. What are the indications for a tracheostomy? What are the benefits of an early
tracheostomy?
Commonly cited indications for the placement of a tracheostomy include: facilitating weaning from
positive pressure ventilation in acute respiratory failure or prolonged ventilation, securing the airway
in the upper respiratory tract where obstruction is a risk, facilitating removal of respiratory secretions,
improved pulmonary toilet, decreased sedation requirements, improved patient comfort and mobility,
to allow a patient to be weaned off mechanical ventilation quicker and in a less monitored setting, and
to obtain an airway for patients with head and neck pathology or those undergoing head and neck
surgery.
It was generally accepted that patients who were expected to require mechanical ventilation for
21 days or more have tracheostomies performed.
More recently, however, it is suggested that early tracheostomy (tracheostomy performed before
day 10 of ICU admission) can be beneficial. Such benefits include reduced time of ventilation, hospitalization, and thus hospitalization cost This is likely due to decreased dead space of a tracheostomy,
improved pulmonary toilet, decreased airway resistance, improved patient comfort, and ability to
wean patients outside the critical care setting.
Inner
cannula
Cap
Flange
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