Emergency in Head and Neck
Emergency in Head and Neck
Emergency in Head and Neck
Why Am I Here?
Recognize symptoms signs of common H&N emergency. Team work To be decisive Learn to ACT FAST and EFFICIENT
Emergency related to specific disease Emergency related to the procedure Emergency not related to both
Example
Classification
Surgical
Operative Post operative
Medical
PREVENTION
Correction of nutritional status Preop preparation for hyperthyroid patients Review of medication preoperatively Avoid trifurcation on top of the carotid No skeletenizition of the carotid Patient education
Airway obstruction
Congenital Infectious Inflammatory Trauma Tumour
Airway Emergency
A difficult airway is defined as the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both
2) Inability of the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation.
Difficult laryngoscopy
Not being able to see any part of the vocal cords with conventional laryngoscopy
Difficult intubation
Proper insertion with conventional laryngoscopy requires either (1)More than three attempts or (2)More than ten minutes
Dyspnea Stridor
Inspiratory - Usually a supraglottic obstruction being sucked into the glottis with inspiration Expiratory - Usually a subglottic obstruction being blown up into the glottis during expiration Biphasic - Both of the above or a lesion isolated to the glottis (eg, edema)
Voice change Decreased or absent breath sounds Bleeding Drooling Restlessness Hemodynamic instability (late) Loss of consciousness (very late)
The patient should be asked a simple question If he responds appropriately The airway is patent Ventilation is intact The brain is being adequately perfused Agitation is often a sign of hypoxia
Airway Management
OBJECTIVE: Maintain Patent Airway
Open Airway
Head-tilt/chin-lift method
(big tongue, forward jaw displacement critical)
Suction
Artificial Airways
Oropharyngeal Nasopharyngeal
Breathing
Objective: Maintain Gas Exchange
Rescue Breathing
Chest Rise
Intubation
If no cervical spine fracture orotracheal intubation is preferred If cervical spine injury can not be excluded consider nasotracheal intubation The position of the tube should be checked
Complications include: Oesophageal intubation Intubation of right main bronchus Failure of intubation Aspiration
Awake intubation
Awake trache
Cricothyrotomy
Tracheotomy
Needle
Surgical
Contraindication
Needle cricothyrotomy
Cricothyroid membrane is punctured with a 12 or 14 Fr cannula Connected to oxygen supply via a Y connector Oxygen supplied at a rate of 15 l/min Jet insufflation achieved by occlusion of Y connection
Insufflation provided one second on and four seconds off Jet insufflation can result in significant hypercarbia Should only be used for 30 - 40 minutes
Quiz
Tracheoinnominate fistula
the mortality is nearly 100 % without operation& 15-20% if treated incidence of TIF is only 0.6 % it accounts for most deaths resulting from tracheostomy 72% of TIF presenting within the first 3 weeks
Tracheostomies below the third or fourth tracheal ring bring the cuffs closer to the innominate artery
DD
Postoperative wound bleeding usually occurs less than 48 hours after placement of the tracheostomy, Pneumonia is usually associated with increased secretions and fever.
Diagnostic modalities such as chest radiograph or flexible bronchoscopy can be used to confirm these other conditions but cannot rule out TIF
PREVENTION
Tracheostomy should be performed at the second or third tracheal ring Avoiding hyperextension of the neck The pressure in the tracheal cuff should be below 20 mmHg The patient has to be weaned from the ventilator early
Jones et al recommend that patients with tracheostomies longer than 48 hours with bleeding in excess of 10 mL be given the diagnosis of TIF and treated accordingly until proven otherwise
Management
Overinflation of the cuff, which has been successful in temporary control of bleeding in 85 % of cases .
Direct digital compression against the sternum of the innominate artery succeeds in 89 % of patients when overinflation of the cuff fails
Definitive treatment
Median sternotomy with resection of the segment of the innominate artery involved and removal of any inflamed or necrotic segment of the arterial wall
Carotid blowout
Classification
Threatened carotid blowout Sentinel hemorrhage/impending carotid blowout Acute carotid blowout
Group 1 patients have a visibly exposed segment of the carotid artery that invariably will rupture if not promptly covered with healthy, well-vascularized tissue
Group 2 patients present with a short-lived acute hemorrhage that resolves either spontaneously or with simple surgical packing
Do not traumatize the carotid vessel. Adequate handling of the carotid artery and preservation of the adventitia are most important. Avoid suction catheters that lie adjacent to the carotid artery.
If a fistula is present, it is diverted away from the carotid area. Use adequate dressings that retain moisture.
Cover the carotid artery Treat infection aggressively with drainage, culture, and appropriate antibiotics
Apply direct and firm pressure to the affected area. The operating room should be prepared for neck surgery. Suctioning, good illumination, and adequate instrumentation are imperative.
Cannulize a peripheral vein in each of the patient's arms with a largebore catheter for immediate administration of fluids (Ringer lactate or isotonic sodium chloride solution). Controlling blood pressure and blood volume before the ligation is important.
The airway should be adequate and stable. If the patient does not undergo a tracheotomy, orotracheal intubation may be necessary. Type blood and cross-match it for 4-6 units.
Move the patient to the operating room. If the bleeding cannot be controlled by pressure, clamp the common carotid artery as an emergency procedure after the blood pressure and pulse are within the reference range
Ligate the carotid artery. Avoid repair or diversion in an area of infection. Use general endotracheal anesthesia. Have adequate instrumentation ready
12 patients
32 EPISODES
20 RECURRENT
2 surgical
13 PD
12 success
7 TF
2 Surgical 5SUCCESS
1 died
Seven exposed carotids Seven carotid pseudoaneurysms Eight small-branch pseudoaneurysms Five tumor hemorrhages Three hyperemic/ulcerated wounds One aortic arch rupture
Intraoperative emergency
Intraoperative Hemorrhage
Severe blood loss is uncommon Major vessel trauma, laceration, tear, or transection from internal jugular vein, junction of internal jugular vein and subclavian and/or carotid artery .
A small tear or laceration requires primary closure with a 6-0 continuous vascular suture If the lower end of the jugular vein bleeds excessively :
pressure is the first aid followed by adequate visualization and suctioning until the stump is identified, dissected, and ligated uncontrollable may need thoracic surgeon assistance
If the upper end of the vein bleeds and the stump has retracted into the temporal bone :
packing
Surgicel plicating with the posterior belly of the digastric muscle or both are sufficient to solve the problem
dissection at the carotid bifurcation without manipulation, injection of 2 mL of local anesthetic into the adventitia at the carotid bifurcation
Air embolus
Air embolism can occur when a large vein is inadvertently opened A large volume of air enters rapidly into the open vein by negative pressure and passes directly into the right atrium leading to tamponade of the heart and even death
Clinically:
cyanosis hypotension
loud churning noise over the precordial area appear suddenly the peripheral pulse disappears
Treatment
Packing or clamping the offending vein immediately Turning the patient onto the left side with the head down Cardiac arrest may occur, requiring aspiration of the air from the heart, massage, and standard resuscitation procedures.
Embolism
Most patients with cancer are of the age at which CVA is common Careful handling of the carotid in the neck with gentle retraction, and manipulation is the key for prevention.
Medical emergency
Indications:
Hypoventilation
Bradycardia
Hypotension
Thyroid storm
More recent series have yielded fatality rates between 20% and 50% dropped from 100% noted by Lahy It more likely represents improvements in early recognition and the beneficial effects of the serial addition of antithyroid, corticosteroid, and antiadrenergic therapies to the treatment of this disorder
Risk factors
Pregnancy
symptoms
Palpitation
Disorientation
Increased sweating
Weakness
Heart failure
Laboratory findings in thyroid storm are consistent with those of thyrotoxicosis Presently, no specific diagnostic criteria to establish the diagnosis of thyroid storm exist
Elevated
T3 and T4 levels Elevated T3 uptake Suppressed TSH levels Elevated 24-hour radioiodine uptake
TREATMENT
Medical supportive
Blocking Thyroid Hormone Synthesis Blocking Thyroid Hormone Secretion Blocking Peripheral Action of Thyroid Hormone
Supportive Measures
Pressor agents Add glucose central cooling Multivitamins Acetaminophen Cooling blankets Steroid Digitalization
Hypercalcemia
Miscellaneous:
vitamin D intoxication milk-alkali syndrome (calcium carbonate)
Therapy
Restore ECF volume Normal saline rapidly Positive fluid balance >2 liters in first 24 hr Loop diuresis Normal saline 100-200 ml/hr Replace potassium Zoledronic acid 4 mg IV over 15 min ( malignancy) if plasma [Ca] >14 mg/dl or >12 mg/dl after rehydration Monitor plasma calcium QD
Hypocalcemia
Hypoparathyroidism
Surgical Autoimmune Magnesium deficiency
Signs
or Trousseasus
Therapy
IV calcium infusion
Calcium infusion drips should be started at 0.5 mg/kg/h and increased to 2 mg/kg/h as needed Follow plasma Ca & P Q 4-6 hr & adjust rate
Careful preop evaluation Team work Avoid unnecessary moves Apply you basic skills