Emergency In Head and Neck Surgery

Emergency In Head and Neck Surgery

Dr. Khalid AL-Qahtani MD,MSc,FRCS(c) Assistant Professor Consultant of Otolaryngology Advance Head and Neck Oncology , Thyroid and Parathyroid,Microvascular Reconstruction, Skull Base Surgery

Why Am I Here?

New treatment available .

Know what to do, when to do it, and how

What Should I Learn?

Recognize symptoms signs of common H&N emergency. Team work To be decisive Learn to ACT FAST and EFFICIENT

What Emergency I mean

Emergency related to specific disease Emergency related to the procedure Emergency not related to both

Example

Airway obstruction laryngeal Ca Trauma to carotid in ND Strock

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

Difficult mask ventilation

(1) Inability of unassisted anesthesiologist to maintain SpO2 > 90% using 100% oxygen and positive pressure mask ventilation in a patient whose SpO2 was 90% before anesthetic intervention; or

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

Suspect airway obstruction

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)

Jaw thrust method with possible neck injury

Suction

Artificial Airways
Oropharyngeal Nasopharyngeal

Breathing
Objective: Maintain Gas Exchange
Rescue Breathing

Mouth to mouth/nose-mouth Bag and Mask

Self-inflating Bag-Mask w/o reservoir 30 -80 % O2 with reservoir 60-95 % O2
Do NOT use demand valve

Best Sign of Effective ventilation

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

Slash trache Surgical airway Cricothyrotomy

Needle

Surgical

Contraindication

Known laryngeal pathology

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

Laryngeal ca Bilateral cord palsy Complex facial trauma Ludwig angina

Tracheoinnominate fistula

Prolonged intubation Long term tracheotomy

Respir Care. 2001 Oct;46(10):1012-8

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

factors known to contribute to the formation of TIF

Tracheostomies below the third or fourth tracheal ring bring the cuffs closer to the innominate artery

Overinflated cuffs erode the tracheal cartilage

Sharply bent cannulas Tracheostomy tube with adjustable flange Addition of CPAP Vascular anomalies
Auris Nasus Larynx Volume 32, Issue 2 , June 2005, Pages 195-198

Signs of impending bleeding

Aspiration of blood Pulsating cannula

DD

Tracheitis Wound bleeding Pneumonia Traumatic suctioning

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

Thorac cardiovasc Surg 2002; 50: 249-250

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

Ann Surg. 1976;2:194-204

Management

Airway Control of bleeding Fluid and blood resus CVT + O.R

Overinflation of the cuff, which has been successful in temporary control of bleeding in 85 % of cases .

Ped emerge care Volume 21(11), November 2005, pp 763-766

Direct digital compression against the sternum of the innominate artery succeeds in 89 % of patients when overinflation of the cuff fails

Ped emerge care Volume 21(11), November 2005, pp 763-766

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

Group 3 patients present with an acute, profuse hemorrhage

Prevention of carotid artery rupture

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

Definitive treatment for carotid artery rupture

Ligate the carotid artery. Avoid repair or diversion in an area of infection. Use general endotracheal anesthesia. Have adequate instrumentation ready

Endovascular therapeutic management of CBS by John C et al in 1999

12 patients

32 EPISODES
20 RECURRENT
2 surgical

12 SINGLE EPISODE 10 success

13 PD
12 success

7 TF
2 Surgical 5SUCCESS

1 died

American Journal of Neuroradiology 20:1069-1077

Seven exposed carotids Seven carotid pseudoaneurysms Eight small-branch pseudoaneurysms Five tumor hemorrhages Three hyperemic/ulcerated wounds One aortic arch rupture

Intraoperative emergency

Bleeding Carotid sinus reflux Pneumothorax Air embolus Embolism

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 .

Inernal jugular bleeding

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

the jugular foramen with large pieces of

Surgicel plicating with the posterior belly of the digastric muscle or both are sufficient to solve the problem

Carotid sinus reflux

Hypotension caused by carotid sinus reflux This may be avoided by

careful

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

Embolism may occur and lead to stroke

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

Hyperthyroidism: indications for emergency management

Acute coronary syndrome Heart failure Thyroid storm

fever agitation

or stupor severe concomitant illness

Confirm hyperthyroidism (free T4, TSH)

Propylthiouracil (PTU) 200-300 mg PO Q 6 hr Iodine (SSKI) 2 gtt (80 mg) PO Q 12 hr

Beta- adrenergic antagonist if not in CHF
propranolol 40 mg Q 6 hr adjust dose to HR <100/min

Intensive therapy of concomitant disease

Follow free T4 Q 4-6 days

When free T4 normal, schedule RAI therapy
stop

iodine 2-4 weeks before stop PTU 3-5 days before

Hypothyroidism: emergent therapy

Indications:
Hypoventilation

Bradycardia
Hypotension

Hypothyroidism: emergent therapy

Confirm diagnosis: FT4, TSH T4 50-100 mg IV Q 6 hr x 24 hr, then T4 75-100 mg IV Q 24 hr

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

Ann Surg 1931; 93: 1026-30.

Risk factors

Infections, especially of the lung

Thyroid surgery in patients with overactive thyroid gland

Stopping medications given for hyperthyroidism

Too high of thyroid dose

Treatment with radioactive iodine

Pregnancy

Heart attack or heart emergencies

symptoms

Palpitation

Greatly increased body temperature

Chest pain Shortness of breath

Anxiety and irritability

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

Other abnormal laboratory values

Increased BUN and creatinine kinase Electrolyte imbalance from dehydration, anemia, thrombocytopenia, and leukocytosis Hepatocellular dysfunction as shown by elevated levels of transaminases, lactate dehydrogenase, alkaline phosphatase, and bilirubin Elevated calcium levels Hyperglycemia

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

Primary hyperparathyroidism Malignancy:

Breast carcinoma Squamous lung carcinoma, head & neck carcinoma Myeloma Renal carcinoma

Miscellaneous:
vitamin D intoxication milk-alkali syndrome (calcium carbonate)

Indication of emergent therapy

Severe symptoms of hypercalcemia Plasma [Ca] >12 mg/dl

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

PTH resistance Vitamin D deficiency Vitamin D resistance

Other: renal failure, pancreatitis, tumor lysis

Signs

Paresthesiae Tetany Trousseaus, Chvosteks signs Seizures Chronic: cataracts

Indication for therapy

Symptomatic

or Trousseasus

positive Plasma calcium <8 mg/dl

Therapy

IV calcium infusion

100-300 mg of elemental calcium should be given over 5-10 minutes

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

Oral calcium 1-2 gm BID - TID Oral calcitriol 0.25-2 mcg/day

Take home message

Careful preop evaluation Team work Avoid unnecessary moves Apply you basic skills