WORKSHOP INTRODUCTION

Today Surgical Airway Techniques Tube Thoracostomy Emergency Cricothyrotomy Tube Thoracostomy

Indications primary indication failed airway patient cannot be adequately ventilated or oxygenated with a bag and mask adequately oxygenated, but there is not another available device (e.g., fiberoptic scope, lighted stylet, intubating laryngeal mask airway [LMA])

Indications second indication method of primary airway management in patients for whom intubation is contraindicated or believed to be impossible

EMERGENCY CRICOTHYROTOMY SET

Contraindications children younger than 12 years cricothyrotome is used Relative contraindications pre-existing laryngeal or tracheal pathology such as tumor infections abscess in the area hematoma or other anatomical destruction of the landmarks coagulopathy lack of operator expertise

SHORT Mnemonic for Difficult Cricothyrotomy Surgery (history of neck surgery, presence of surgical scar) Hematoma Obesity Radiation (history or evidence of radiation therapy) Trauma (direct laryngeal trauma with disrupted landmarks)

Anatomy and Landmarks The cricothyroid membrane

Anatomy and Landmarks

Technique The No-drop Technique The Rapid Four-step Technique Cricothyrotome Technique Seldinger Technique Percutaneous Transtracheal Jet Ventilation Technique

The Rapid Four-step Technique (Brofeldt)

Complications Hemorrhage Pneumomediastinum Laryngeal/tracheal injury Cricoid ring laceration Barotrauma (transtracheal jet ventilation) Infection Voice change Subglottic stenosis

Cricothyrotome Technique (Seldinger Technique)

Percutaneous Transtracheal Jet Ventilation Technique

TUBE THORACOSTOMY

Indications for TT PTX (spontaneous, iatrogenic, traumatic) Hemothorax Chylothorax Decreased breath sounds in unstable patient after blunt or penetrating trauma Multiple rib fractures, sucking chest wound, subcutaneous air in intubated trauma patient Complicated pleural effusion, empyema, lung abscess Thoracotomy, decortication Pleural lavage for active rewarming for hypothermia

Guidelines of the American College of Chest Physicians for the Management of Primary and Secondary Spontaneous Pneumothorax Primary Spontaneous Pneumothorax (No Underlying Lung Disease) A clinically stable patient must have all of the following present: respiratory rate, <24 breaths/min; heart rate, >60 beats/min or <120 beats/min; normal blood pressure, room air O2 saturation, >90%; and can speak in whole sentences between breaths. Clinically Stable Patients with Small Pneumothoraces (<3 cm Apex-to-Cupola Distance) Clinically stable patients with small pneumothoraces (PTXs) should be observed in the emergency department (ED) for 3–6 hr and discharged home if a repeat chest radiograph excludes progression of the PTX (good consensus). Patients should be provided with careful instructions for follow-up within 12 hr–2 days, depending on circumstances. A chest radiograph should be obtained at the follow-up appointment to document resolution of the PTX. Patients may be admitted for observation if they live distant from emergency services or follow-up care is considered unreliable (good consensus). Simple aspiration of the PTX or insertion of a chest tube is not appropriate for most patients (good consensus), unless the PTX enlarges. The presence of symptoms for longer than 24 hr does not alter the treatment recommendations. Clinically Stable Patients with Large PTXs (≥3 cm Apex-to-Cupola Distance) Clinically stable patients with large PTXs should undergo a procedure to reexpand the lung and should be hospitalized in most instances (very good consensus). The lung should be reexpanded by using a small-bore catheter (≤14 Fr) or placement of a 16- to 22-Fr chest tube (good consensus). Catheters or tubes may be attached either to a Heimlich valve (good consensus) or to a water-seal device (good consensus) and may be left in place until the lung expands against the chest wall and air leaks have resolved. If the lung fails to reexpand quickly, suction should be applied to a water-seal device. Alternatively, suction may be applied immediately after chest tube placement for all patients managed with a water-seal system (some consensus).Reliable patients who are unwilling to undergo hospitalization may be discharged home from the ED with a small-bore catheter attached to a Heimlich valve if the lung has reexpanded after the removal of pleural air (good consensus). Follow-up should be arranged within 2 days. The presence of symptoms for longer than 24 hr does not alter management recommendations

Guidelines of the American College of Chest Physicians for the Management of Primary and Secondary Spontaneous Pneumothorax Secondary Spontaneous PTX Clinically Stable Patients with Small PTXs should be hospitalized (good consensus). Patients should not be managed in the ED with observation or simple aspiration without hospitalization (very good consensus). Hospitalized patients may be observed (good consensus) or treated with a chest tube (some consensus), depending on the extent of their symptoms and the course of their PTX. Some of the panel members argued against observation alone because of a report of deaths with this approach. Patients should not be referred for thoracoscopy without prior stabilization (very good consensus). The presence of symptoms for longer than 24 hr did not alter the panel members’ recommendations. Clinically Stable Patients with Large PTXs should undergo the placement of a chest tube to reexpand the lung and should be hospitalized (very good consensus). Patients should not be referred for thoracoscopy without prior stabilization with a chest tube (very good consensus). The presence of symptoms for longer than 24 hr did not alter the panel members’ recommendations. From Baumann MH, Strange C, Heffner JE, et al, and the AACP Pneumothorax Consensus Group: Management of spontaneous pneumothorax: An American College of Chest Physicians Delphi consensus statement. Chest 119:590, 2001.

CONTRAINDICATIONS unstable injured patients with a PTX or an HTX no absolute contraindications to a TT stable patient relative contraindications anatomic problems such as the presence of multiple pleural adhesions, emphysematous blebs, or scarring Coagulopathic patients should be evaluated for clotting factor replacement before any invasive procedure

Complications Undrained PTX, hemothorax, or effusion despite TT  clotted hemothorax, empyema, fibrothorax Improper placement +/- iatrogenic injuries (lung, diaphragm, subclavian, right atrium) Recurrent PTX after tube removal Intrapleural collections following tube removal Thoracic empyema

 Indications for Surgery after Tube Thoracostomy Based on the Results of the Thoracostomy Massive hemothorax, >1000–1500 mL initial drainage Continued bleeding>300–500 mL in 1st hr>200 mL/hr for first 3 or more hr Increasing size of hemothorax on chest film Persistent hemothorax after two functioning tubes placed Clotted hemothorax Large air leak preventing effective ventilation Persistent air leak after placement of second tube or inability to fully expand lung This is meant to be a guide, and clinical judgment should always be used

Prophylactic Antibiotics controversial, and no specific standards exist Multicenter trials have demonstrated no benefit

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