NAP4 -difficult airway society (national audit project)

trauma- neck.subcut emphysema

(May-2001 Q10) A 17 yo trail bike rider was struck on the neck by a low branch and thrown from his bike. He presents to your casualty with a hoarse voice, stridor and subcutaneous emphysema of the neck. Discuss your plan to secure this patient's airway.

This patient has a history of neck trauma and impending respiratory distress. In view of the history of neck trauma and subcutaneous emphysema, the most important differential will be disruption of the tracheobronchial tree.

I would consult an ENT specialist with view of performing a surgical airway, as it is likely that any upper airway manipulation might be difficult in view of localized trauma, and the disruption might be distal to the glottis.

I would discuss with the patient regarding an awake tracheostomy under local anaesthesia. This would be done with supplemental O2 via facemask and standard college monitoring is in place.This may not be tolerated well by the patient, however sedation may be fraught with danger because he might have respiratory depression that would further compromise the airway.

maintain spont vent

Alternatives would be fibre optic assessment of the trachea but this is not ideal in this situation given that the patient is stridorous and less likely to cooperate with the procedure. Also, any trauma or bleeding from fibre optic intubation may further jeopardise the airway.

any ETT should be cuffed passed distal to the disruption

Tracheostomy -may be able to locate the distal end of the disruption but may still be proximal to the tracheobronchial disruption , may be difficult due to local tissue injury/bleeding/ edema, may not be aseptic.

After securing the airway, secondary survey looking for other causes of subcut emphysema/ other areas of injury

definitive imaging: neck XR/CT thorax

(Sep-2004 Q13) Describe the technique of applying cricoid pressure to prevent regurgitation of gastric contents.

Cricoid pressure is a manouvere done to occlude the upper esophagus by pressure at the cricoid cartilage, which is a complete ring of cartilage caudal to the most prominent cartilage (the thyroid cartilage), against the c5 vertebral body. The cartilage is fixed with the first and second digits and with the application of directly backward with a force of 30N

more evidence needed! ___

http://www.jephc.com/full_article.cfm?content_id=193

LMA in dental surgery

(Sep-2004 Q10) Justify the use of a laryngeal mask airway in a 25 yo, 80kg man having general anaesthesia for removal of 4 molar teeth.


Anaesthetic indications:
Use of a LMA in this case is less invasive than endotracheal intubation. As this surgery is most likely in the setting of ambulatory surgery, this reduces the need of muscle relaxation, reduces morbidity from sorethroat, especially if the patient is obese and is potentially difficult to intubate. The option of a flexible LMA also allows the tube to be manipulated away from the side of surgery.

Provided that the adequacy of spontaneous ventilation can be achieved to maintain adequate depth of anaesthesia.

The surgeon also has to be agreeable to the use of a supragottic device and is vigilant about suctioning of wash and secretions.

supraglottic devices, if used with adequate depth of anaesthesia, causes a lower risk of laryngospasm.

increased turnover time
easier to insert,

contraindications to LMA: patient with reflux.
disadvantages: less secure airway-may dislodge or kink, shared airway and limited access, secretions, leak with higher airway pressures (esp if obese)