1. WORKSHOP INTRODUCTION

2. Today Surgical Airway Techniques Tube Thoracostomy
Emergency Cricothyrotomy
Tube Thoracostomy

3. 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])

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

6. EMERGENCY CRICOTHYROTOMY SET

10. 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

11. 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)

12. Anatomy and Landmarks
The cricothyroid membrane

13. Anatomy and
Landmarks

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

15. The Rapid Four-step Technique (Brofeldt)

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

21. Cricothyrotome Technique (Seldinger Technique)

22. Percutaneous Transtracheal Jet Ventilation Technique

23. TUBE THORACOSTOMY

24. 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

25. 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

26. 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.

27. 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

28. 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

35.  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

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

37. THANK YOU