Upper Airway Obstruction
Classification based on visualization of pharyngeal structures used to predict a difficult airway
What is the Mallampati
Where a tracheostomy should be placed
What is between the second and third tracheal rings
Zones of the neck
What is zone I: sternal notch to cricoid cartilage, II: cricoid cartilage to angle of the mandible, III: angle of the mandible to base of skull
Hard signs of vascular injury to neck (5)
What are rapidly expanding or pulsatile hematoma, severe hemorrhage or uncontrolled bleeding, shock refractory to fluid/blood, decreased or absent radial pulses, vascular thrill, focal neuro deficit
56 yo F 6 hours post thyroidectomy HR 120, RR 20, BP 125/90, O2 92% on 4L, significant swelling of neck. Next step?
What is open the incision at bedside and perform orotracheal intubation
Should be done in a post thyroidectomy patient with hypoxia, hoarseness, and tachypnea
What is open the incision and release the hematoma
Feared complication of a too low tracheostomy
What is tracheo-innominate fistula
Contents of zone 1 (8)
What is subclavian vessels, internal jugular veins, proximal carotid arteries, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, brachial plexus, and thyroid gland
Hard signs of an esophageal injury (3)
What are massive hemoptysis, massive hematemesis, respiratory distress, air bubbling from the wound
20 yo M stabbed with a pocketknife 3cm below angle of mandible. he is stable, protecting airway, and no hard signs of injury. Next step
What is CTA of the neck
Reasons why a trauma patient needs intubation (4)
What is GCS <8, significant facial or neck edema, high c-spine (lost of phrenic nerve), unable to protect airway, inhalation injury
Benefit per SCORE of early tracheostomy
What is shorter length of stay in the ICU
Borders of the anterior triangle of the neck
What is the SCM, lower border of the mandible, and the anterior cervical midline
Soft signs of penetrating neck injury
What is non-expanding hematoma, minor hemoptysis, hematemesis, dysphonia, dysphagia, tachypnea, and subq emphysema
26 yo stabbed 1cm inferior to mastoid process. Vitals normal, no hard signs; zone and management
What is zone 3 and CTA neck
What is a cuffed tube below the vocal cords
Ways to confirm proper placement of a tracheostomy (3)
What is color change, end tidal CO2, breath sounds present bilaterally, bronchoscopy
Position of ICA in relation to CCA and ECA
What is posterior and lateral to ECA, superior to CCA
Work-up for concern for esophageal injury in a stable patient or in a patient CT was non-diagnostic
What is EGD + esophagography with water soluble contrast
27 yo M stabbed just anterior to left SCM. Hemodynamically normal, has a hematoma by the site (though not expanding), clearly violated platysma, anxious, tachypneic, air is seen bubbling from wound. This mandates exploration
What is air bubbling from the wound
Describe a cricothyroidotomy
What is longitudinal incision on the neck over cricothyroid membrane, transverse incision in cricothyroid membrane, dilate, place cric or 6 et tube
Describe a percutaneous tracheostomy
What is under bronchoscopy guidance, needle stick in 2nd and 3rd tracheal ring, advance catheter, back up et tube, place wire, sequential dilation over a wire, eventually place shilley over wire, watching the balloon enter the trachea, inflate balloon, confirm placement, secure
Contents of Zone 3 (6)
What is distal internal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, and cranial nerves IX-XII
Work-up and management for zone 1 penetrating injury in a stable patient
What is CTA of the neck and if positive consider angioembolization vs median sternotomy
26 yo M high speed MCC with significant facial trauma, subq emphysema to neck, respiratory distress and GCS 8, copious amount of blood in oropharynx, unable to see vocal cords on DL. Next step
what is cricothyroidotomy