Rare surgical airway interventions
Cricotrachetomy as emergent surgical airway
Situation: 34 years old male presents to the emergency department by severe laceration to the anterior neck due to blunt trauma (zone 2) by furious horse.
Background: no immediately available medical or surgical history.
Assessment:
Primary survey
- Airway: compromised, partially obstructed, oesophageal intubation en route.
- Breathing: Bilaterally decreased air entry, SAT 36 %
- Circulation: Unrecorded blood pressure, HR 45
- Neurologically: No eye opening, no sounds, flex bilateral.
Resuscitation
- Failed one best trial in orotrachael intubation and crico not attempted due to cricoid fracture
- Incision through cricotracheal ligament and 6.5 endotracheal tube passed through it and after arrival of ENT team low trachestomy was performed.
- Just after ventilation for few breaths the SAT raised to 99 and the heart rate increased to 110
Reassessment after 30 min
Primary survey
- Airway maintained on definitive airway (low trachestomy)
- Breathing bilateral equal air entry, SAT 99 on O2
- Circulation 110/70 and HR 110 after airway management and one bolus of 500 ml of IV normal saline.
- Deficit spontaneous eye opening, follow orders and trachestomised
The patient underwent reconstruction for the larynx trauma and trachestomy closed and discharged home safely.
Successful Infant emergent cricothyrotomy
11 months infant presented to ED in Alexandria main university hospital by impending airway obstruction due to severe angioedema as a result of accidental ingestion of p-Phenylenediamine.
Initial primary survey
- Airway: severe stridor, severe angioedema.
- Breathing: bilaterally equally decreased air entry, diffuse wheezes, subcostal, intercostal and suprasternal retractions, SAT unobtainable , RR 55
- Circulation: HR 110, blood pressure 50/30 and CRT>5 sec
- Deficit: spontaneous eye opening, no sounds, spontaneous movements
Resuscitation:
One best trial for awake oral intubation was attempted by the most experienced attending in managing critical airway situations and failure was the outcome.
Noninvasive ventilation using AMBU and mask was unsuccessful and the patient developed cardiac arrest.
CPR according AHA guidelines was performed and the problem to be solved was the complete airway obstruction as described by the airway person and the failure to ventilate using AMBU made the problem more complicated and even cardiac arrest made the bad worse.
In the situation of unavailable equipment for jet ventilation and almost complete airway obstruction we were forced to act and in this circumstances the surgical airway was the only option.
We proceed directly to surgical airway and it was done successfully and after another one cycle of CPR the patient developed ROSC.
3 MINs later the patient developed RT tension pneumothorax and lateral thoracostomy was performed and then chest tube was inserted.
The ENT team arrived and formal trachestomy was performed.
Reassessment: (after 45 min)
- Airway: trachestomy as definitive airway was in place.
- Breathing: bilateral equal air entry and RT chest tube in place and sat on FIO2 40% = 99%.
- Circulation: BP 90/50 and HR 130
- Deficit: patient open eye spontaneously, moved spontaneously and on trachestomy tube.
The patient then was admitted to ITU maintaining good hemodynamics and the patient passed away after 5 days due to multi-organ failure.
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