emergency in head and neck

7/27/2019 Emergency in Head and Neck

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Emergency In Head and NeckSurgery


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Emergency In Head and Neck

SurgeryDr. Khalid AL-Qahtani

MD,MSc,FRCS(c)

Assistant ProfessorConsultant of Otolaryngology

Advance Head and Neck Oncology , Thyroid and

Parathyroid,Microvascular Reconstruction,

Skull Base Surgery


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Why Am I Here?

New treatment available .

Know whatto do, whento do it, and how


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Recognize symptoms signs ofcommon H&N emergency.

Team work

To be decisive

Learn to ACT FAST and EFFICIENT

What Should I Learn?


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What Emergency I mean

Emergency related to specific

disease

Emergency related to the

procedure

Emergency not related to both


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Example Airway obstruction laryngeal Ca

Trauma to carotid in ND

Strock


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Classification

Surgical Operative

Post operative

Medical


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PREVENTION

Correction of nutritional status

Preop preparation for hyperthyroid

patientsReview of medicationpreoperatively

Avoid trifurcation on top of the

carotidNo skeletenizition of the carotid

Patient education


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Airway obstruction

Congenital

Infectious

Inflammatory

Trauma

Tumour


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Airway Emergency

A difficultairwayis defined as the

clinical situation in which a

conventionally trainedanesthesiologist experiences

difficulty with face mask ventilation

of the upperairway, difficulty with

tracheal intubation, or both
http://www.armstrongmedical.com/ami/item.cfm?sction=3&sbsection=13&category=17&itemid=828


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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


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2) Inability of the unassisted

anesthesiologist to prevent or

reverse signs of inadequateventilation during positive pressure

mask ventilation.


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Difficult laryngoscopy

Not being able to see any part of the

vocal cordswith conventional

laryngoscopy


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Difficult intubation

Proper insertion with conventional

laryngoscopy requires either

(1)More than three attempts or(2)More than ten minutes


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Suspect airwayobstruction 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)
http://www.cpfeifer.org/archives/choking-old.jpg


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Voice change

Decreased or absent breath

sounds Bleeding

Drooling

Restlessness Hemodynamic instability (late)

Loss of consciousness (very late)


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The patient should be asked a

simple question

If he responds appropriatelyThe airway is patent

Ventilation is intact

The brain is being adequatelyperfused

Agitation is often a sign of hypoxia


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Airway Management

OBJECTIVE: Maintain Patent AirwayOpen Airway

Head-tilt/chin-lift method

(big tongue, forward jaw displacementcritical)

Jaw thrust method with possible neckinjury

Suction

Artificial AirwaysOropharyngeal

Nasopharyngeal


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Breathing

Objective: Maintain Gas Exchange

Rescue Breathing

Mouth to mouth/nose-mouth

Bag and MaskSelf-inflating Bag-Mask

w/o reservoir 30 -80 % O2with reservoir 60-95 % O2

Do NOT use demand valve


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Best Sign of Effectiveventilation

Chest Rise


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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


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Complications include:

Oesophageal intubation

Intubation of right main bronchus Failure of intubation

Aspiration


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Awake intubation

Awake trache


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Cricothyrotomy

Tracheotomy


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Surgical airway CricothyrotomySlash trache


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Needle Surgical


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Contraindication

Known laryngeal pathology


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Needlecricothyrotomy 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


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Insufflation provided one second

on and four seconds off

Jet insufflation can result insignificant hypercarbia

Should only be used for 30 - 40

minutes


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Quiz

Laryngeal ca

Bilateral cord palsy

Complex facial trauma Ludwig angina


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Tracheoinnominate fistula


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http://www.bartleby.com/107/142.html


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

Prolonged intubation

Long term tracheotomy


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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


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factors known tocontribute 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 LarynxVolume 32, Issue 2 , June 2005, Pages 195-198
http://www.sciencedirect.com/science?_ob=JournalURL&_cdi=4978&_auth=y&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=b5c5c3de760ea6ff3ddfccde8fce03c7http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%234978%232005%23999679997%23596538%23FLA%23&_auth=y&view=c&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=61d3ee4c0cf37d32b57b94db52b4f057http://www.sciencedirect.com/science?_ob=JournalURL&_cdi=4978&_auth=y&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=b5c5c3de760ea6ff3ddfccde8fce03c7http://www.sciencedirect.com/science?_ob=JournalURL&_cdi=4978&_auth=y&_acct=C000022002&_version=1&_urlVersion=0&_userid=458507&md5=b5c5c3de760ea6ff3ddfccde8fce03c7


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Signs of impending

bleeding Aspiration of blood

Pulsating cannula


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DD

Tracheitis

Wound bleeding

Pneumonia Traumatic suctioning


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Postoperative wound bleeding

usually occurs less than 48 hours

after placement of thetracheostomy,

Pneumonia is usually associated

with increased secretions and

fever.


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Diagnostic modalities such as

chest radiograph or flexible

bronchoscopy can be used toconfirm these other conditions but

cannot rule out TIF


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PREVENTION

Tracheostomy should beperformed at the second or thirdtracheal ring

Avoiding hyperextension of theneck

The pressure in the tracheal cuffshould be below 20 mmHg

The patient has to be weaned fromthe ventilator early

Thorac cardiovasc Surg 2002; 50: 249-250


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Jones et al recommend that

patients with tracheostomies

longer than 48 hours with bleedingin excess of 10 mL be given the

diagnosis of TIF and treated

accordingly until proven otherwise

Ann Surg. 1976;2:194-204


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Management

Airway

Control of bleeding

Fluid and blood resus CVT + O.R


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Overinflation of the cuff, which has

been successful in temporary

control of bleeding in 85 % ofcases .

Ped emerge care Volume 21(11), November 2005, pp 763-766
http://gateway.ut.ovid.com/gw1/ovidweb.cgi?View+Image=00006565-200511000-00012|FF1&S=IDNJHKJOCBBPBN00D&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00006565-200511000-00012


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Direct digital compression against

the sternum of the innominate

artery succeeds in 89 % of patientswhen overinflation of the cuff fails

Ped emerge care Volume 21(11), November 2005, pp 763-766
http://gateway.ut.ovid.com/gw1/ovidweb.cgi?View+Image=00006565-200511000-00012|FF2&S=IDNJHKJOCBBPBN00D&WebLinkReturn=Full+Text%3dL%7cS.sh.15.16%7c0%7c00006565-200511000-00012


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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


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Carotid blowout


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Classification

Threatened carotid blowout

Sentinel hemorrhage/impending

carotid blowout Acute carotid blowout


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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


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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


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Prevention of carotidartery 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.


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If a fistula is present, it is diverted

away from the carotid area.

Use adequate dressings that retainmoisture.


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Cover the carotid artery

Treat infection aggressively with

drainage, culture, and appropriateantibiotics


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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.


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Cannulize a peripheral vein in each

of the patient's arms with a large-

bore catheter for immediate

administration of fluids (Ringer

lactate or isotonic sodium chloride

solution). Controlling blood

pressure and blood volume beforethe ligation is important.


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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.


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Move the patient to the operating

room.

If the bleeding cannot be controlledby pressure, clamp the common

carotid artery as an emergency

procedure after the blood pressure

and pulse are within the referencerange


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Definitive treatment forcarotid artery rupture

Ligate the carotid artery.

Avoid repair or diversion in an area

of infection. Use general endotracheal

anesthesia.

Have adequate instrumentation

ready


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Endovascular therapeutic management of CBS

by John C et al in 1999


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12 patients

20 RECURRENT

13 PD 7 TF

32 EPISODES

5SUCCESS12 success

12 SINGLE

EPISODE

2 Surgical

1 died

10 success2 surgical

American Journal of Neuroradiology20:1069-1077


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Seven exposed carotids

Seven carotid pseudoaneurysms

Eight small-branchpseudoaneurysms

Five tumor hemorrhages

Three hyperemic/ulcerated wounds

One aortic arch rupture


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Intraoperativeemergency

Bleeding

Carotid sinus reflux

Pneumothorax Air embolus

Embolism


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IntraoperativeHemorrhage

Severe blood loss is uncommon

Major vessel trauma, laceration, tear, or

transection frominternal jugular vein,

junction of internal jugular vein and

subclavian

and/or carotid artery .


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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


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If the upper end of the vein bleeds and the stump

has retracted into the temporal bone :

packing the jugular foramen with large pieces ofSurgicel

plicating with the posterior belly of the digastric

muscle

or both are sufficient to solve the problem


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Carotid sinus reflux

Hypotension caused by carotid sinus reflux

This may be avoided by

careful dissection at the carotid bifurcationwithout manipulation,

injection of 2 mL of local anesthetic into the

adventitia at the carotid bifurcation


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Air embolus

Air embolism can occur when a large vein is

inadvertently opened

A large volume of air enters rapidly into the openvein by negative pressure and passes directly

into the right atrium

leading to tamponade of the heart and even

death


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Clinically:

cyanosis

hypotensiona loud churning noise over the precordial area

appear suddenly

the peripheral pulse disappears


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Treatment

Packing or clamping the offending vein

immediately

Turning the patient onto the left side with thehead down

Cardiac arrest may occur, requiring aspiration

of the air from the heart, massage, and

standard resuscitation procedures.


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Embolism

Embolism may occur and lead to stroke

Most patients with cancer are of the age at whichCVA is common

Careful handling of the carotid in the neck with

gentle retraction, and manipulation is the key for

prevention.


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Medical emergency

Hyperthyroidism: indications for


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Hyperthyroidism: indications foremergency management

Acute coronary syndrome

Heart failure

Thyroid storm fever

agitation or stupor

severe concomitant illness


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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


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Intensive therapy of concomitant disease

Follow free T4 Q 4-6 days

When free T4 normal, schedule RAI therapy

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

Hypothyroidism: emergent


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Hypothyroidism: emergenttherapy

Indications:

Hypoventilation

BradycardiaHypotension


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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


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Thyroid storm

More recent series have yielded fatality

rates between 20% and 50% dropped

from 100% noted by Lahy

It more likely represents improvements inearly recognition and the beneficial

effects of the serial addition of

antithyroid, corticosteroid, and

antiadrenergic therapies to the treatmentof this disorder

Ann Surg 1931; 93: 1026-30.


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Risk factors

Infections, especially of the lung

Thyroid surgery in patients withoveractive thyroid gland

Stopping medications given for

hyperthyroidism


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Too high of thyroid dose

Treatment with radioactive iodine

Pregnancy

Heart attack or heart emergencies


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symptoms

Palpitation

Greatly increased body temperature

Chest pain

Shortness of breath


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Anxiety and irritability

Disorientation

Increased sweating

Weakness

Heart failure


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Laboratory findings in thyroid storm

are consistent with those of

thyrotoxicosis

Presently, no specific diagnostic

criteria to establish the diagnosis of

thyroid storm exist


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Elevated T3 and T4 levels

Elevated T3 uptake

Suppressed TSH levels

Elevated 24-hour radioiodine

uptake

Oth b l


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Other abnormallaboratory 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


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TREATMENT

Medical

supportive


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Blocking Thyroid Hormone

Synthesis

Blocking Thyroid HormoneSecretion

Blocking Peripheral Action of

Thyroid Hormone


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Supportive Measures

Pressor agents

Add glucose

central cooling Multivitamins

Acetaminophen

Cooling blankets Steroid

Digitalization


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Hypercalcemia

Primary hyperparathyroidism

Malignancy: Breast carcinoma

Squamous lung carcinoma, head & neckcarcinoma

Myeloma

Renal carcinoma

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

Indication of emergent


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Indication of emergenttherapy

Severe symptoms of

hypercalcemia

Plasma [Ca] >12 mg/dl


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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


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Hypocalcemia

Hypoparathyroidism Surgical

Autoimmune

Magnesium deficiency

PTH resistance

Vitamin D deficiency

Vitamin D resistance

Other: renal failure, pancreatitis, tumorlysis


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Signs

Paresthesiae

Tetany

Trousseaus, Chvosteks signs Seizures

Chronic: cataracts


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Indication for therapy

Symptomatic or Trousseasus

positive

Plasma calcium


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Therapy

IV calcium infusion 100-300 mg of elemental calcium should

be given over 5-10 minutes

Calcium infusion drips should be startedat 0.5 mg/kg/h and increased to 2mg/kg/h as needed

Follow plasma Ca & P Q 4-6 hr & adjustrate

Oral calcium 1-2 gm BID - TID

Oral calcitriol 0.25-2 mcg/day


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Take home message

Careful preop evaluation

Team work

Avoid unnecessary moves Apply you basic skills


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emergency in head and neck

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