Cricothyroidotomy:
Patients in whom attempts at intubation have failed or are precluded from intubation due to extensive facial injuries require a surgical airway. Cricothyroidotomy (Pic below) and percutaneous transtracheal ventilation are preferred over tracheostomy in most emergency situations because of their simplicity and safety. One disadvantage of cricothyroidotomy is the inability to place a tube greater than 6 mm in diameter due to the limited aperture of the cricothyroid space. Cricothyroidotomy is also relatively contraindicated in patients younger than 12 years because of the risk of damage to the cricoid cartilage and the subsequent risk of subglottic stenosis.
A. Use of a tracheostomy hook sta bil izes the thyroid carti lage and facil itates tube insertion. B. A 6.0-endotracheal tu be is inserted after digital confirmation of airway access.
Which of the following is NOT a sign of tension pneumothorax?
The diagnosis of tension pneumothorax is presumed in any patient manifesting respiratory distress and hypotension in combination with any of the following physical signs: tracheal deviation away from the affected side, lack of or decreased breath sounds on the affected side, and subcutaneous emphysema on the affected side. Patients may have distended neck veins due to impedance of venous return, but the neck veins may be flat due to concurrent systemic hypovolemia. Tension pneumothorax and simple pneumothorax have similar signs, symptoms, and examination findings, but hypotension qualifies the pneumothorax as a tension pneumothorax.
Which of the following is a cause of cardiogenic shock in a trauma patient?
In trauma patients the differential diagnosis of cardiogenic shock consists of a short list: (1) tension pneumothorax, (2) pericardia! tamponade, (3) myocardial contusion or infarction, and ( 4) air embolism. Tension pneumothorax is the most frequent cause of cardiac failure. Traumatic pericardia! tamponade is most often associated with penetrating injury to the heart. As blood leaks out of the injured heart, it accumulates in the pericardia! sac. Because the pericardium is not acutely distensible, the pressure in the pericardia! sac rises to match that of the injured chamber. Since this pressure is usually greater than that of the right atrium, right atrial filling is impaired and right ventricular preload is reduced. This leads to decreased right ventricular output and increased central venous pressure (CVP). Increased intrapericardial pressure also impedes myocardial blood flow, which leads to subendocardial ischemia and a further reduction in cardiac output. This vicious cycle may progress insidiously with injury of the vena cava or atria, or precipitously with injury of either ventricle. With acute tamponade, as little as 100 mL of blood within the pericardia! sac can produce life-threatening hemodynamic compromise. Patients usually present with a penetrating injury in proximity to the heart, and they are hypotensive and have distended neck veins or an elevated CVP. The classic findings of Beck's triad (hypotension, distended neck, and muffled heart sounds) and pulsus paradoxus are not reliable indicators of acute tamponade. Ultrasonography (US) in the emergency department (ED) using a subxiphoid or parasternal view is extremely helpful if the findings are clearly positive (Fig. below); however, equivocal findings are common. Early in the course of tamponade, blood pressure (BP) and cardiac output will transiently improve with fluid administration. This may lead the surgeon to question the diagnosis or be lulled into a false sense of security.
A. Ad mission chest fi lm may not show the fu ll extent of the patient's pulmonary parenchymal i njury. B. Th is patient's left pulmonary contusion blossomed 12 hours later, and its associated opacity is noted on repeat chest radiograph.
A trauma patient arrives following a stab wound to the left chest with systolic blood pressure (SBP) 85 mm Hg, which improves slightly with intravenous (IV) fluid resuscitation. Chest X-ray demonstrates clear lung fields. What is the most appropriate next step?
During the circulation section of the primary survey, four lifethreatening injuries must be identified promptly: (1) massive hemothorax, (2) cardiac tamponade, (3) massive hemoperitoneum, and ( 4) mechanically unstable pelvic fractures with bleeding. In this patient hemothorax is unlikely given normal chest X-ray; thus, hemoperitoneum and cardiac tamponade should be suspected. Cardiac tamponade occurs most commonly after penetrating thoracic wounds, although occasionally blunt rupture of the heart, particularly the atrial appendage, is seen. Acutely, < 100 mL of pericardia! blood may cause pericardial tamponade. The classic Beck's triad-dilated neck veins, muffled heart tones, and a decline in arterial pressure is usually not appreciated in the trauma bay because of the noisy environment and associated hypovolemia. Diagnosis is best achieved by bedside ultrasound of the pericardium, which is one of the four views of the FAST examination.
Primary repair of the trachea should be carried out with:
Injuries of the trachea are repaired with a running 3-0 absorbable monofilament suture. Tracheostomy is not required in most patients. Esophageal injuries are repaired in a similar fashion. If an esophageal wound is large or if tissue is missing, a sternocleidomastoid muscle pedicle flap is warranted, and a closed suction drain is a reasonable precaution. The drain should be near but not in contact with the esophageal or any other suture line. It can be removed in 7 to 10 days if the suture line remains secure. Care must be taken when exploring the trachea and esophagus to avoid iatrogenic injury to the recurrent laryngeal nerve.
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