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P. V. Alexander
to the local taxi drivers, accompanied with instruction on safe transfer (Fig.24.9). This has decreased
the incidence of post-accident spinal injuries
being brought to the hospital and protected the
injured spine. We describe simple pre- hospital
alternatives for immobilization and transfer which
could be implemented in low- resource settings.
Pre-Hospital Measures
Different cultures have varied community
responses to the acutely injured patient. In India,
an invariable community response is to pour water
down the throat of the injured patient, douse his
face and simultaneously yank the victim to his or
her feet notwithstanding the degree of injury, with
the intent that if the victim stands up, everything
will be well. These are interventions that are mentioned to be condemned. The EMS medical service is often nonexistent in the third world, more
so in the remote or rural third world. Permitting
the patient to remain recumbent, ensuring an adequate airway and utilizing locally available materials as a backboard can be both life and spine
saving during transfer, as opposed to being transported hammock style in a blanket or slung over
the back or in the arms of a bystander. A door
frame, planks nailed together, or even a “charpai”
or woven bed frame can all serve as safe alternatives to the commercial “backboard.” Two padded
bricks, bunched clothes, or sandbags (if available)
can serve to stabilize the head, being secured with
a cloth sash, or the belt of a gentleman. This level
of health awareness has not as yet trickled down
to the grass roots.
Hospital Measures
The approach to trauma has now been systematized and protocolized, and there should be little
excuse for deviating from it. The approach,
whether ABC or CAB, demands the placement of
a cervical collar of the appropriate size as part of
the “A.” Cervical collars are now easily available
commercially as are backboards. However, we
still utilize our indigenous plywood backboards
which have served us well at a fraction of the cost.
Children involved in motor vehicle accidents
should not be exempt from this treatment, given
the incidence of SCIWORA (spinal cord injury
without radiologic abnormality). The NEXUS
guidelines [11] serve a practical standard for the
requirement of neck stabilization. Radiologic
exclusion of cervical injury can be established by
standard cross-table lateral X-rays or a CT scan if
available. Inebriated and unconscious patients
always need a collar till the spine is cleared.
Cervical injuries are to be classied as stable
and unstable injuries. All of them will need transfer to a service which can stabilize the spine
operatively. This can be difcult, particularly in
instances of Jeffersons fracture or Jones fracture,
or clay shoveler’s fracture. A halo traction device
is not easy to replicate unless available.
Crutcheld tongs and traction are an alternative,
but they make transfer over mountain and uneven
roads difcult. We have found stabilizing the
sides of the head with sandbags and strapping the
forehead onto the backboard effective in the
transport of the acutely injured cervical injury.
Fig. 24.9 Indigenous plywood backboard and cervical
collars
Injuries totheNeck
Vignette
A 32-year-old male was brought to the emergency room with history of having attempted sui-
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cide by slitting his throat with a knife. On
examination he was conscious, with a 7cm laceration on his anterior neck which was bubbling
with blood. The carotids on either side were
intact. He was taken up for surgery and intubated
on the table, and an infrathyroid tracheal laceration was found and repaired with Prolene sutures.
Postop airway was established with a tracheostomy established distal to the laceration. He did
well on postoperative follow-up and was decannulated later (Fig.24.10).
Blunt injury predisposes to large hematomas,
tracheal injury, and soft tissue injury, with bleeding into the spaces of the neck which in turn can
cause respiratory compromise. Most blunt injury
can be treated conservatively after ensuring there
is no airway compromise. Emergent intubation
followed by a tracheostomy may be required if
there is airway compromise. The investing layer
of cervical fascia provides a closed space and
will result in respiratory distress if there is ongoing bleeding into the space. Most hematomas will
settle with conservative management provided
anticoagulants are not on board and there is no
vessel wall transection.
Direct sharp injury will result in dramatic and
profuse bleeding, which has to be controlled surgically. Pre-hospital control may be established
by direct compression if the bleeding is venous
or the placement of hemostats when available if
the bleeding is arterial. Tracheal injuries can
cause bubbling respiration through the injured
segment. It is best to let them bubble and breathe
till they reach the hospital rather than try to
attempt any control of such an injury on the eld,
unless there is occlusion of the airway.
Concurrent spinal injury is to be kept in mind,
both during transport and during early resuscitation. A cervical collar may restrict access to the
bleeding area or may not be practical in such a
setting, when spinal stabilization should be
ensured by alternative means of sandbags and
strapping to a board.
Ideally, all vascular injuries to the neck should
be managed in the operating theater under general anesthesia, with good light, suction, vascular
instruments, and blood at hand. All components
may not always be available. The dictum of
“proximal and distal control” cannot be overemphasized in the management of these vascular
injuries. Lacerations in the vessels can be repaired
with partial isolation of the vessel with a curved
Satinsky clamp. There may not be time to ensure
a continuity of the circle of Willis, but if the
carotid on one side is beyond repair or grafting, a
CT angio should preclude ligation of the carotid
vessels. Extracranial injury can usually be controlled. A Foley catheter introduced into the rent
and gently withdrawn with the bulb inated
serves well to permit visibility and control and
plan a repair in an otherwise bloody eld
(Fig.24.11).
A snugger can be devised (Fig.24.12) with a
length of wire with a loop at its tip retractable
through a cut length of nasogastric tube or infant
feeding tube. A suture or a thin rubber vessel loop
Fig. 24.10 The neck is particularly susceptible to both blunt and sharp injury
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Fig. 24.11 Use of a Foley catheter to staunch arterial
bleeding
is doubly passed around the vessel and then
extracted through the length of nasogastric tube
using the wire loop passer. This can be used to
permit atraumatic occlusion of the vessel for
proximal control. A mosquito clamp secures the
tension at the proximal end of the cut length of
nasogastric tube.
Segmental loss of tissue from the side of a
vessel can be repaired with a vein graft harvested
from the saphenous vein, eminently serviceable
as a vein graft. Arterial repair with loss of tissue
or length will necessitate use of prosthetic graft
material and postoperative anticoagulation.
In remote regions, the access to digital subtraction angiography and embolization and coiling is not usually available. The surgeon bears the
responsibility to control and staunch the bleeding
with what measures he or she has available.
Injury totheTrachea
Tracheal injuries are best repaired primarily,
using nonabsorbable sutures of Prolene,
approximating the tracheal rings. A tracheostomy may be performed proximally or distally
to permit airway access and control. Tissue loss
P. V. Alexander
Fig. 24.12 A snugger made with a segment of a nasogastric tube and wire to control arterial bleeding
from the trachea is challenging, and the rent
may be converted into a tracheostomy if the
rent occurs in second to fourth tracheal rings.
Larger tissue loss may require the use of prosthetic material as Teon, or a vascularized
graft. Healing without stenosis is the ultimate
aim, because tracheal stenosis is quite challenging to deal with, as is tracheomalacia induced
by trauma and the consequence of repair.
Tracheomalacia is particularly challenging in
the pediatric population.
Injury totheThyroid
The thyroid can be salvaged by debriding devascularized tissue and obtaining hemostasis.
Debridement can follow the guidelines for
hemithyroidectomy or lobectomy, ensuring
hemostasis by the ligation of the vessels feeding
the appropriate vascular territory, whether it be
the superior or inferior thyroid arteries. Removal
of the thyroid while protecting the recurrent
laryngeal nerves and the parathyroids may be
very difcult following an injury and should be
avoided if possible.
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Injury totheEsophagus
Injuries to the esophagus are challenging and
usually require primary repair if the rent is
small and the duration from injury to repair is
brief. Repair can be done using nonabsorbable Prolene sutures or Vicryl sutures. A feeding gastrostomy allows the wound to heal
without the interference of the passage of
food. Injuries that have a delayed presentation
or injuries with tissue loss are best temporized by a cervical esophagostomy, feeding
gastrostomy, and subsequent reconstruction
with a gastric pullup using a thoracic or a
retrosternal approach and anastomosis in the
chest or neck, respectively.
Conclusion
We have tried to summarize only the urgent management of a number of emergent problems in
the neck that present with relatively high frequency to a nonspecialist surgeon in the underserved environment. Care of patients under those
conditions sometimes requires ingenuity and
originality, as well as knowledge of basic anatomy and physiology to apply basic surgical skills
to solve or temporize a dangerous medical problem. All the problems mentioned are more difcult to manage in infants and children than in
adults because of frequent lack of appropriate
instruments and of potential physiologic instability. This is partially compensated by more rapid
healing and rehabilitation following injuries.
This chapter addresses a few management
options and “tricks”; it requires the use of ancillary specialist text or digital media for detailed
information regarding specic surgical issues
that may arise.
References
1. Fitzpatrick PC, Guarisco JL.Pediatric airway foreign
bodies. J La State Med Soc. 1998;150(4):138.
2. Committee on Injury, Violence, and Poison
Prevention. Prevention of choking among children.
Pediatrics. 2010;125(3):601.
3. Tan HK, Brown K, McGill T, Kenna MA, Lund DP,
Healy GB. Airway foreign bodies (FB): a 10-year
review. Int J Pediatr Otorhinolaryngol. 2000;56(2):91.
4. Zhijun C, Fugao Z, Niankai Z, Jingjing C.Therapeutic
experience from 1428 patients with pediatric
tracheobronchial foreign body. J Pediatr Surg.
2008;43(4):718.
5. Tang LF, Xu YC, Wang YS, Wang CF, Zhu GH, Bao
XE, Lu MP, Chen LX, Chen ZM. Airway foreign
body removal by exible bronchoscopy: experience with 1027 children during 2000-2008. World J
Pediatr. 2009;5(3):191–5. Epub 2009 Aug 20
6. Limper AH, Prakash UB. Tracheobronchial foreign
bodies in adults. Ann Intern Med. 1990;112(8):604.
7. Uyemura MC. Foreign body ingestion in children.
Am Fam Physician. 2005;72(2):287.
8. Athanassiadi K, Gerazounis M, Metaxas E, Kalantzi
N.Management of esophageal foreign bodies: a retrospective review of 400 cases. Eur J Cardiothorac Surg.
2002;21(4):653.
9. Samsoon GL, Young JR.Difcult tracheal intubation:
a retrospective study. Anaesthesia. 1987;42:487.
10. Dr. Arpit Mathew, Mr. Jeremiah Naveen
Joseph, Madhipura Christian Hospital, Personal
communication.
11. Hoffman JR, Wolfson AB, Todd K, et al. Selective
cervical spine radiography in blunt trauma: methodology of the Na- tional emergency X-radiography
utilization study (NEXUS). Ann Emerg Med.
1998;32(4):461–9.
How toManage Thoracic Surgical
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Problems inLowandMiddle-Income Countries
WarrenD.Widmann
The greatest wealth is health.
– Virgil, 70–19, BCE
25
Abbreviations
HIC High-income countries
LMICs Low- and middle-income countries
RTAs Road trafc accidents
Introduction
The role of thoracic surgical interventions at the
local level in LMICs is very limited because of
the lack of trained personnel, the absence of the
basic infrastructure (clean water, electricity,
oxygen, anesthetists, and staff) to support
advanced interventions, and the lack of nancial
resources to purchase diagnostic and therapeutic
supplies. Accordingly, we will not focus on the
underlying socioeconomic changes needed to
improve global health but rather on what can be
done at the present time using the limited
resources in LMIC [1].
We will address appropriate interventions that
are feasible given limited resources—appropriate
meaning both effective and practical. In the
absence of personnel trained in advanced tho-
W. D. Widmann (*)
Surgical Education, State University of NewYork
Downstate Health Sciences University,
Brooklyn, NY, USA
racic surgical skills, including general surgeons,
in regions lacking advanced diagnostic and therapeutic equipment, what can the basic healthcare
workers and general surgeons do to lessen the
burden of the common thoracic surgical conditions in LMIC?
Trauma
It is widely recognized that trauma is a huge
cause of morbidity and mortality in LMICs.
The deaths from trauma exceed the combined
total of deaths from HIV/AIDS, TB, and
malaria. Most of the world’s trauma deaths
occur in LMICs. What are the treatable thoracic
injuries?
Loss ofConsciousness withLoss
ofAirway/Endoscopy
A common cause of death from trauma is the loss
of the airway with resultant hypoxemia. This
occurs most often in association with road trafc
accidents (RTAs) in LMIC. Traumatic brain
injury with loss of consciousness results in the
tongue falling back obstructing the airway in the
recumbent victim. Hypoxemia and death follow.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_25
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W. D. Widmann
The estimated frequency of death from this
mechanism is about 30% [2].
Diagnosis ofAirway Obstruction
In any patient who does not respond to verbal
stimulation and is not breathing, there may be
gurgling sounds with attempted inspiration or a
total lack of any air exchange. There may be cyanosis on checking the mucous membranes or
skin. There will be no motion of the chest wall
and no breath sounds on auscultation of the chest.
Treatment ofAirway Obstruction
DuetoLoss ofConsciousness
The rescuer must assume airway obstruction, and
after checking for any foreign material in the
mouth with a nger swipe, the airway must be
opened. In the unconscious patient, the tongue
falls backward into the hypopharynx. The headtilt- chin-lift maneuver that is used when loss of
consciousness is due to a medical condition is
shown in Fig.25.1.
Treatment ofAirway Obstruction
DuetoLoss ofConsciousness
inTrauma Patients
In cases where there is any history of trauma and
loss of consciousness, airway obstruction occurs by
the same mechanism as in medical causes of unconsciousness. The oppy tongue falls backward.
However, performing the head-tilt-chin-lift maneuver is fraught with danger. Head trauma and loss of
consciousness is associated with cervical spine
injury in 15% of cases. The rescuer must assume
there is concomitant instability of the cervical spine
and that the head tilt maneuver may convert a partial
spinal cord injury to a complete spinal cord injury.
The proper maneuver in all trauma cases is the jawthrust maneuver as shown in Fig.25.2.
Endoscopy forIntubation
When used appropriately the head-tilt-chin lift or
the jaw-thrust maneuvers may reestablish a patent airway, but for continued maintenance of the
airway in the unconscious patient, endotracheal
intubation is needed. Tracheal intubation in the
Fig. 25.1 By tilting the
head backward and
hyperextending the neck
while simultaneously
using the other hand to
lift the chin upward, the
tongue is pulled forward
and the airway is
opened. This procedure
should not be used in
cases of trauma
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293
unconscious patient does not require administration of drugs. In the eld or in the clinic, this is
best performed using a battery-powered laryngoscope. The operator must know the basics—there
are two types of blades used for laryngoscopy to
expose the larynx and the vocal cords by lifting
the epiglottis anteriorly (ventrally).
When using the curved blade (Macintosh), the
blade is inserted into the vallecula just to the left
side of the epiglottic fold, and the operator lifts
the back of the tongue upward. The fold of tissue
holding the epiglottis to the base of the tongue
thus pulls the epiglottis ventrally exposing the
vocal cords and the operator can pass the endotracheal tube between the vocal cords inserting
the tube beyond the teeth to the 22–26cm markings on the tube. The balloon on the tube is
inated. The tube is secured in place with tape,
and the patient can then be ventilated with the
operator breathing directly into the tube but preferably with use of an AMBU bag connected to
the endotracheal tube. There should be symmetrical chest wall rise with squeezing the AMBU
bag, and the operator can listen to the chest on
each side to hear breath sounds. The luxury of
measuring end-tidal carbon dioxide may not be
available in the eld in LMICs.
When the operator uses the straight blade
(Miller) for laryngoscopy, the tip of the blade is
inserted just under the epiglottis, and then the
epiglottis and tongue are directly lifted anteriorly
(ventrally) to expose the vocal cords. Figure25.3
shows the proper placement of the laryngoscope
blades.
Advanced Endoscopy (Bronchoscopy)
Both in the eld and in the station hospitals/clinics in LMICs, the support for advanced endoscopy is lacking. Clean water, reliable electricity,
expensive instruments, and trained personnel are
usually not available. However, should endotracheal intubation fail, the airway can be established
in emergencies by performing a cricothyroidotomy as described later in this chapter.
Fig. 25.2 In unconscious trauma patients, the rescuer
must keep the head in the neutral position while performing
the jaw-thrust. The steady traction by both thumbs and ring
and little ngers keeps the head in the neutral position while
the index and middle ngers pull upward on the mandible
moving the tongue forward and opening the airway
Fig. 25.3 Notice that when using the curved blade
(Macintosh), the tip is inserted into the vallecula, just to
the side of the epiglottis and that lifting the blade anteriorly (ventrally) will lift the epiglottis (shown in white)
Tension Pneumothorax
A tension pneumothorax is the result of a progressive buildup of air within the chest cavity
giving the operator a view of the vocal cords and trachea.
When using the straight blade, notice that the operator has
lifted the epiglottis directly
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W. D. Widmann
Fig. 25.4 The examiner uses the right-hand index nger
to palpate the space between the trachea and the head of
the clavicle on each side. The ngertip should easily enter
the space on each side. In the presence of tracheal devia-
caused by leakage of air from the lung into the
pleural space (most commonly) or by entry of air
into the chest through an open wound of the chest
wall during inspiration and then the air getting
trapped by closure of the opening during exhalation. In either case, as intrathoracic pressure
builds up, the lung on the side of the injury progressively collapses while the pressure within the
pleural cavity increases. As the intrathoracic
pressure increases, return of blood to the heart
decreases and obstructive shock and death ensue.
How Can youDiagnose aTension
Pneumothorax?
Let’s start with the injured patient with rib fractures. The sharp fractured ribs can lacerate the
lung with resultant leakage of air into the pleural
cavity. The mechanism of injury in LMIC most
commonly would be RTA. The history of RTA,
the presence of pain localized to the chest wall,
shortness of breath, tachycardia, and dyspnea are
clues. In LMIC we do not have readily available
XRAY machines. We do have physical examinations available! Diminished breath sounds are the
hallmark for a pneumothorax—along with a loss
of tactile fremitus. With a tension pneumothorax,
there will be a shift of the mediastinum away
from the injured side. A simple palpation of the
trachea can help secure the diagnosis, as shown
in Fig.25.4.
How Do youTreat aTension
Pneumothorax?
Immediate Decompression Is the First
Step The traditional approach until recently was
needle decompression by puncturing the chest
wall with a needle in the second intercostal space
approaching in the midclavicular line. Recent
tion, there will be an easily felt discrepancy with the trachea shifted away from the side with the tension
pneumothorax. Additionally, the examiner might notice
jugular venous distention in obstructive shock
Fig. 25.5 After cleansing the chest wall, the anterior
puncture site uses the angle of Louis (the junction of the
manubrium with the body of the sternum) and the level of
the second rib as a landmark. The needle can be inserted
in thin individuals at the lower aspect of the second interspace which is easily determined by palpation just below
and lateral to the angle of Louis, making the insertion in
the midclavicular line to avoid hitting the internal thoracic
artery and close to the top of the third rib to avoid hitting
the main intercostal artery, nerve, and vein which run in a
groove close to the inferior border of each rib (as shown in
red dot)
data shows that decompression on the rst needle
pass was not achieved in many patients and that
approaching initially transaxillary in the third,
fourth, or fth interspace anterior axillary line
was more likely to be successful on the rst needle pass. All that is needed is a basic skin prep
and a needle or needle catheter. Two approaches
are shown in Fig.25.5.
Alternatively, in obese and muscular patients,
the preferred approach would be puncture at the
anterior axillary line (which is at the lateral border of the easily felt pectoralis major muscle)
gaining entry through the third, fourth, or fth
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interspace avoiding the axillary hair and again
staying close to the superior edge of the rib to
avoid the main intercostal artery, nerve, and vein
(as shown in green dot).
Once decompression of the pleural cavity has
been achieved, the obstructive shock has been
relieved, but there is now a collapsed lung on the
injured side needing re-expansion.
How Can aCollapsed Lung
bere-Expanded?
The traditional approach for getting the lung reexpanded is for a chest tube to be inserted and put
to a controlled suction device. There may be no
available controlled suction in LMIC.At best, a
packaged sterile chest tube can be inserted, and at
worst one can use a urethral catheter with two
extra holes cut out. Size 28 has been shown to be
as effective as the larger sizes and causes less
pain. In the absence of available controlled suction, an improvised Heimlich valve can be
Fig. 25.6 The safe area for chest tube insertion is outlined below. Going too far cranially risks injury to the subclavian artery, vein, and brachial plexus; in addition, too
far caudally risks injury to the heart, spleen, and stomach
on the left side and injury to the liver on the right side
applied which allows for exit of air from the chest
cavity without reentry as the improvised valve
closes.
295
Procedural Steps inChest Tube
Insertion
Basic supplies needed are antiseptic solution for
cleansing the operative site, some sterile towels
to create an operative eld, sterile gloves for the
operator, local anesthetic, needles, syringes, sterile scalpel, sterile hemostats or Kelly clamps,
sterile chest tube size 28 or a sterile exible
length of plastic tubing of equivalent size, 2–0
silk sutures to close the wound and secure the
chest tube in place, a needle holder, scissors,
gauze pads for dressing, adhesive tape, and an
improvised Heimlich valve which can be made
from the nger of a sterile glove. With the patient
recumbent and the arm tucked behind the head,
the operative eld is prepped (Fig.25.6). After
the prep, local anesthetic is injected (Fig.25.7).
The chest cavity is entered by blunt dissection
with the Kelly clamp angled superiorly to allow
the chest tube to be “tunneled up” to the interspace above the incision. Thus, as shown in
Fig.25.8, two interspaces required numbing, the
lower interspace of the incision and the upper
Fig. 25.7 The main intercostal nerve runs in a groove
behind the lower border of the rib. An additional branch
runs along the upper border of the rib. Both sites require
injection. The interspace below the site for chest tube
insertion is anesthetized because that is where the incision
will be made. The interspace above the incision is anesthetized because that is the interspace through which the
chest tube will be inserted
interspace for tube insertion both require injection of local anesthesia.
The initial dissection is done with the Kelly
clamp, and the tract enlarged sufciently to allow
insertion of the index nger, following which the
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Fig. 25.8 The lower interspace of the incision and the
upper interspace for the tube insertion both require injection of the local anesthetic
W. D. Widmann
chest tube is grasped between the jaws of the
Kelly clamp and inserted into the chest cavity, as
shown in Fig.25.9.
The chest tube insertion site should be closed
medial and lateral to the tube to prevent air from
being sucked into the chest through the incision.
These sutures also serve a “stay” sutures by
anchoring the chest tube to the skin closure, as
shown in Fig.25.10. The stay sutures have an “air
knot” placed about 1cm after tying the suture to
close the skin and then that suture is wrapped
tightly around the chest tube and rmly tied so
that the chest tube cannot be accidentally pulled
out. By placing one suture medially and one
suture laterally and securing them to the chest
tube, they help to make the chest tube “stay” in
place (Figs.25.10 and 25.11).
Without aControlled Suction System,
how Will Air Escape fromthePleural
Cavity andtheCollapsed Lung Get
Re-Expanded?
A Heimlich valve can be made simply by tying a
condom or even the cut-off nger of a used glove
to the end of the chest tube. A slit is cut into the
distal end of the oppy attached “valve.” With
each inspiration the oppy condom/glove nger
collapses on itself preventing air from being
sucked into the chest. With each expiration as air
pressure is increased within the chest, gas will
bubble out. Lung re-expansion can be facilitated
by having the patient cough (Fig.25.12).
There is no agreement among thoracic surgeons about the best way to remove the chest
Fig. 25.9 After the incision is carried down to the fascia of
the intercostal muscles in the interspace below the site of
planned entry into the pleural cavity, a Kelly clamp is used
to bluntly dissect upward, and once the pleural cavity is
entered, the tract is enlarged to allow passage of the operator’s index nger to conrm that there are no local adhesions. The chest tube is grasped by the Kelly clamp and
then the clamp and tube are inserted angled superiorly
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