NEUROIMAGING IN EMERGENCIES Jitender Saini, Associate Professor, Department of NIIR, NIMHANS

Imaging modalities

CT

MRI

DSA

USG

Contrast

Resolution

CT

Attenuation

Image generation

Detectors and rows

Newer developments

Applications

CT

Attenuation

Density Tissue Hounsfield

Units Visual representation

High White

Mineral/bone +1 to +500 White

Medium Water/fluid 0 Shades of Gray

Air/lung Low –1 to –500 Black

Black

MRI

Contrast mechanism

Relaxation times

Sequences

Spin echo vs Gradient echo

T1W, T2W, FLAIR, Gradient image, SWI, Diffusion weighted imaging, MR spectroscopy

Newer contrast

Digital subtraction angiography Principles

Subtraction

Applications

Newer developments

Contusion

Fractures

Hemorrhage Extradural hemorrhage

Subdural hemorrhage

Diffuse axonal injury

Parenchymal hematoma

Subarachnoid hemorrhage

Infarct

PLAIN

Contrast

Non opacification of SSS

24 yrs female with headache

25 years female

CASE 1

Cerebral herniations

Several different types

1. Subfalcine,

2. Transtentorial -central (ascending and descending) and lateral (anterior-uncal and posterior-parahippocampal)

3. Tonsillar

4. Transphenoidal (ascending and descending)

5. External hernias

Subfalcine Herniations

Transtentorial herniation

Uncus Hippocampus Suprasellar cistern Peduncular cistern CP angle cistern

Transtentorial herniation

Tonsillar herniation

Ascending transtentorial herniation

Trans-sphenoidal herniation

Thank You

External Ventricular Drainage

&

Lumbar Drainage

Procedure and Care.

Amey R. Savardekar

Assistant Professor

Neurosurgery, NIMHANS.

External Ventricular Drain Indications:

Therapeutic (To relieve raised ICP).

Hydrocephalus (communicating and non-communicating)

Surgical Mass lesions.

Infections (pyogenic and tuberculous).

Chiari Malformations.

SAH resulting in acute hydrocephalus

Shunt failure due to mechanical disruption or infection

Brain relaxation in the OT, etc.

ICP monitoring

ICP monitoring and EVD Intraventricular catheters are

considered the gold standard for

measuring ICP.* (Level 3)

An external ventricular device not

only has ICP monitoring

capabilities, but also can assist

with controlling increased ICP by

allowing for therapeutic CSF

drainage.

*Czosnyka, M., & Pickard, J. D. (2004). Monitoring and interpretation of

intracranial pressure. Journal of Neurology, Neurosurgery, and Psychiatry,

75, 813–821.

EVD System

1. Brain Cannula

2. Ventricular Catheter

3. Stylet

4. Connecting tube

5. Collecting Bag

Preparation Written informed consent

Ask for history of bleeding tendency.

Check Coagulogram

All ICP catheters should be inserted using sterile

technique.

Intracranial catheters inserted outside of the OR show a

tendency toward higher infection rates.*

*Arabi,Y., Memish, Z., Balkhy, H., Francis, C., Ferayan, A., Shimemeri, A., et

al. (2005).Ventriculostomy-associated infections: Incidence and risk factors.

American Journal of Infection Control, 33, 137–43

Preparation Position: 300 head end elevation with head in neutral

position.* (Level 2)

Immobilize the head (Saline bottles on either side of

the head).

During insertion, continuously monitor heart rate,

respiratory rate, and O2 saturation

Prepare site by shaving or clipping

Always the non-dominant side.

By rule – right side.

*Fan, J. Y. (2004). Effect of backrest position on intracranial pressure and

cerebral perfusion pressure in individuals with brain injury: A systematic

review. Journal of Neuroscience Nursing, 36 (5), 278–88.

Procedure Markings:

Midline of the scalp by connecting nasion to inion.

Mid-pupillary line.

The coronal suture. Or draw a perpendicular line from mid-point of zygoma.

Mark Kocher’s point 1 cm anterior to coronal suture on mid-pupillary line.

Clean site in circular motion with antiseptic solution.

Thrice with betadine and once with spirit.

Procedure The scalp is infiltrated with lignocaine Adr soln.

Properly administered LA prevents scalp bleeding.

With scalpel, a small (1 cm) bone-deep incision is

made in the scalp

If it starts bleeding torrentially --- apply pressure for 2 min.

Another incision (1 cm) is made 3-5cm behind this

incision and subgaleal tunneling (with artery forceps) is

performed between these incisions.

Procedure Bone is drilled in the direction of the catheter placement

(exactly perpendicular to the scalp).

A guard is essential in preventing plunging of the drill tip.

Approx 1.5 cm of the drill tip should be exposed beyond

the guard.

In our setting, dura is to be punctured along with bone

in a single thrust

Gradual pressure on the dura may lead to stripping of the

adjoining dura resulting in EDH

Twist Drill

Procedure Ventricular puncture

Enter the brain perpendicular to skull at Kocher’s point

Note the distance at which the ventricle is hit

Pre-measure the length of the catheter to be inserted

The catheter is secured using a tunneling method

through a separate incision and sutured

A CT scan must be performed

to confirm catheter placement and

to rule out complications like EDH, SDH, ICH, IVH

Procedure Completion

Dress insertion site by applying sterile dressing

The tubing can be placed in a sterile manner in a

camera cable cover to prevent contamination

Must Dos:

Measure the ICP and document it

Take CSF for analysis

Establish the EVD system & set the level

Document the procedure and complications, if any

EVD Insertion

Complications of EVD EVD Infections.

This is the major complication with EVD.

The mean EVD-associated infection rate is 8%–9%.*

The difficulty is with making the diagnosis

The inflammatory response to blood (aseptic or chemical

meningitis) may mask the response to infection.

EVD-associated infection is defined by a positive CSF

culture.**

*Fichtner, J., Güresir, E., Seifert, V., & Raabe, A. (2010). Efficacy of silver-bearing external

ventricular drainage catheters: A retro- spective analysis. Journal of Neurosurgery, 112(4), 840-

846. **Lozier, A. P., Sciacca, R. R., Romagnoli, M. F., & Connolly, S. E. (2002).Ventriculostomy-related

infections: A critical review of the literature. Neurosurgery, 51, 170–182.

Prevention is the Best Cure Strict adherence to Aseptic Technique

Prophylactic antibiotics remain controversial due to the risk of selection for resistant organisms

Antibiotic-impregnated ventricular catheters have been widely used after a randomized multicenter clinical trial showed evidence of their ability to reduce infections (Zambramski et al., 2002)

Tunneling is a technique frequently used to decrease EVD infection (Dasic Hanna, Bonjanic, & Kerr, 2006; Lozier et al., 2002)

For EVD-associated infection rates greater than 10%, it is recommended the institution should investigate its practices and EVD protocols (Level 3; Lozier et al.).

Complications of EVD

Non-infectious Complications

Aneurysmal re-bleeding and hemispheric shifts from

reduction in ICP

Set the level based on the indication for the EVD

CSF overdrainage

Monitor the CSF drainage (every 4th hourly)

Monitor the ICP frequently.

Set the level as per the ICP value.

Hemorrhage and misplacement complications

CT scan after EVD insertion

Call for help if first tap is dry.

2 taps is the maximum limit.

Points to Remember Written Informed Consent

Strict aseptic precautions

Kocher’s point

Direction – Perpendicular to the skull

Pre-measure length of the catheter to be inserted

Tunnel the catheter

Measure the ICP and document it

Set the level

Document the procedure

Removal of the EVD Close monitoring of the clinical status and the ICP of the

patient.

When the primary pathology has been dealt with.

Slowly raise the height of the level at which the EVD is set for drainage. Monitor GCS and ICP. Periodic CT scans should be done.

If patient responds well – Clamp EVD for 2 hours and then remove EVD in the clamped position.

If ICP rises or patient’s GCS deteriorates – open EVD --- Consider VP shunt.

Lumbar Drainage Indications:

Therapeutic.

CSF rhinorrhea after transsphenoidal surgery

CSF rhinorrhea/otorrhea after craniotomy

CSF leak from wound site

Wound bulge

to manage non-traumatic subarachnoid hemorrhage to prevent vasospasm

Prophylactic.

During transsphenoidal surgery.

During intracranial surgery to decrease brain bulge.

LD – Absolute Contraindications Increased ICP (excludes documented pseudo-tumor cerebri patients)

Unequal pressures between the supratentorial and infratentorial compartments as evidence by the following head CT findings:

midline shift

Loss of suprachiasmatic and basilar cisterns

posterior fossa mass

loss of the superior cerebellar cistern

loss of the quadrigeminal plate cistern

Infected skin over the needle entry site

Spinal epidural abscess

Intracranial mass

Obstructive non-communicating hydrocephalus

Spinal arteriovenous malformation

LD – Relative Contraindications

Coagulopathy, active bleeding, or severe

thrombocytopenia

Brain abscess

History of prior lumbar spine surgery

History of prior lumbar vertebral fracture

Preparation Written Informed Consent

Patient positioning

Preparation

Preparation Identify interspaces and mark the puncture site at the

L4 – L5 interspaces in a perpendicular line from the

iliac crest

Drape the patient with sterile drape.

Recheck the landmarks.

Infiltrate the skin and subcutaneous tissue with

preservative-free 1% lidocaine with a 23-gauge needle.

Procedure Insert the Touhy needle into the midline of the

interspace with bevel up. Direct the needle on a 10-

degree angle toward the umbilicus

Advance the needle slowly, removing the stylet every

2–3 millimeters to check for CSF flow

Procedure Once the dural sac is punctured and CSF flow

established – Turn the needle 90 degree.

Collect CSF for analysis.

Thread the catheter through the needle and then

remove the needle.

Procedure Connect the system.

Set the level. 40mL every 4th hourly.

Secure the LD catheter to the patient.

Secure the system with steri-drape.

Maintenance Steri-drape over the entire area.

Problem is always at the connector.

While making changes to the patient’s positioning, the LDD should be clamped so that overdrainage does not occur.

The lumbar drain should be closed when patient is ambulatory.

The level should be reset every time the patient changes her/his position.

Daily electrolytes to look for imbalances. CSF – electrolyte rich.

Good hydration to be maintained. Consider the CSF drainage in the input-output balance.

Removal of the LD. Once the indication has been taken care of.

Clamp the drain.

Look for CSF leak/wound bulge.

If the problem has settled – remove the LD in the

clamped position.

If not --- consider shunt.

Complications Post-dural puncture headache

Lumbar sacral nerve injury or paresthesias

Cerebrospinal fluid leak

Meningitis

Insertion site infection

Spinal or epidural hematoma

Catheter fracture or catheter retention

Thank you

Cervical traction Creates a longitudinal pull

Reduces deformity

Restores normal alignment

Provides stabilization

Methods

Head halter

Cranial tongs

Halo head ring

Indications Reduction of subluxation /dislocation in cervical spine

Reduction of congenital deformities of cvj

For stabilization in infections and traumatic injuries

Cervical radiculopathy

During surgery for maintaining distraction

To reduce muscle spasm and painful neck conditions

Cranial tongs Crutchfield and Gardner -Wells

Crutchfield Introduced in 1933

Applied at the parietal regions above the widest diameter

More weight could be applied

Disadvantages : easily dislodged

Blunt tips – need of bone holes

Gardner -Wells

Easily applied sharp tips

Applied below the equator

Gardner –Wells appliacation Local anaesthesia Pin location below eqator 2-3 cm above the ears In line with meatus and mastoids consent and explaining the procedure Detailed neurolgical examination Idea is to apply along the long axis in neutral position Hair to be shaved Area prep

Application Pins to be cleaned

Local aneasthesia upto galea

no adrenaline

One assistant to hold the correct position

Pins tightened smoothly till indicator is 1 mm protruded

Pulley at the top of head

Head eleavation 20-30 degrees

Increase of weights gradually 3 lb or ½ kg per vertebra

Two methods continous /intermittent

Xray films at the en dof the procedures

Neurological examination again!

Pin site care

Tightening of screws

Risks and complications Deterioration ? MRI

Infection osteo menin abscess

Occipital decubitus ulcer

Dislodgement

Penetration

Dr K V L Narasinga Rao Associate Professor

NIMHANS BANGALORE

What is “Tracheostomy”

The word “tracheostomy” is derived from the Latin “trachea” and “tomein” (to make an opening).

Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea .

HISTORY Tracheostomy is one of the oldest surgical procedures. A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC. Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC. The first successful tracheostomy was performed by Brasovala in the 15th century.

Chevalier Jackson

Described the principles of trachestomy in early 20th century

Cervical Tracheal Relationships-Anterior

Skin Superficial & Deep fascia. 2nd to the 4th rings are covered by the isthmus of the thyroid.

Tracheotomy Indications To bypass obstruction

Tracheostomy Indications Prolonged intubation

- Need for prolonged respiratory support such as prolonged coma - To reduce anatomic dead space and increase the chance for mechanical ventilation withdrawal

-Easier Tracheal Toilet

Head trauma with consciousness disturbances, uneffective cough Tracheobronchitis with an edema and a lot of secretes Thoracic trauma with uneffective cough Post surgical procedure wtih inadequate cough - Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm

Tracheotomy Indications Miscellaneous

-Congenital abnormalities. (Pierre Robin, Triecher Collins syndromes) - Obstructive Sleep Apnea Syndrome. - Aspirations related to muscle or sensory problems. -Prophylaxis (as preparation for extensive H&N procedures, before radiotherapy for H&N CA) -Cervical spinal cord injuries with respiratory muscles paralysis.

Types of Tracheostomy

1) Open procedure a) High tracheostomy (Cricothyroidectomy)

b) Low tracheostomy 2) Percutaneous procedure

Preoperative workup

Physical assessment also surgical and anesthesiological

CBC

PT, PTT, INR

Low Tracheostomy

Skin Prep with povidine iodine, chlorohexidine(savlon) Draping Good light source and suction machine ready and tested to be functional

Transverse Incision Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Incision length=6cm/ anterior border of SCM msc lateral

Blunt dissection of subcut tissue Transversely Retracted as shown

Strap msc is divided longitudinally at midline Thyroid isthmus is divided at midline by 2 haemostat and cut edge secured by 2/0 vicryl

Depending on the TT size abt 4cm longitudinal opening is made in trachea below 2nd ring

Tube is anchored

Points to ponder!

Good positioning and light source

Mark the incission and don’t compromise on

length

Always take a stich on the tracheal ring so

that you hold the flap

Points to ponder !

Keep tube lubricated and cuff checked prior to the

procedure itself

Never remove the endo-tracheal tube until you are

sure of your position of TT

Protect your eyes and face from patient secretions !

Post-Op Managment

Repeat X-Ray soft tissue neck Strong Analgesia Antibiotics IV fluid until able to tolerate orally

Complications immediate

Apnea due to loss of hypoxic respiratory drive.

This is mainly important in the awake patient. Ventilatory support must be available .

False root

Bleeding

Pneumothorax or pneumomediastinum

Complications immediate

Damage to the vocal cords (direct)

Injury to adjacent structures: recurrent laryngeal nerves, the great vessels, and the esophagus.

Post-obstructive pulmonary edema

Hypotension

Arrhythmia

Complications early

Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia and begins to cough.

Plugging with mucus

Tracheitis

Cellulitis

Tube displacement

Subcutaneous emphysema

Atelectasis

Complications late

Bleeding - tracheoinnominate fistula

Tracheo- and laryngomalacia

Stenosis

Tracheoesophageal fistula

Tracheocutaneous fistula

Granulation

Scarring

Failure to decannulate

TRACHEOSTOMY TUBE

CARE

Tube changes:

Indications: soiled, cuff rupture.

Complications: insertion into a false passage bleeding,

and patient discomfort.

Avoid within 1st week.

First tube change by surgeon.

Difficult cases (obese, short and thick neck), be

prepared for endotracheal intubation.

Use of this content is subject to the Terms and Conditions of the MD Consult web site.

Cummings: Otolaryngology: Head & Neck Surgery, 4th ed., Copyright © 2005 Mosby, Inc.

INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ).

The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for

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tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis.[29] [41] [49] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later.

Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging.

Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation.[21]

Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting.[29] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field.

The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed.[23] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie)[10] [28] ( Figure 106-4 ), or inferiorly retracted (least commonly used method).[28] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture.

Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [15] [29] [47] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated.

Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy.[20]

2445

Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy (left) and cricothyrotomy (right). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin.

Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [46] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%.[20] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure.

The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence

2446

Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus.

Figure 106-3 The thyroid isthmus may be retracted or suture ligated.

of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%.

Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed.

Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery.[36] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire,[1] and surgical injury to adjacent structures.

Intermediate Complications Intermediate complications develop during the first hours to days after surgery.

Again, hemorrhage may be a frequent postoperative complication of tracheotomy.

2447

Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea.

Figure 106-5 A horizontal incision can be made in the intracartilaginous space.

Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs.[27]

Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively.[48]

Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum,

Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea.

and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy, blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [43] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%.[43]

Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction.

Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy, postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps.

Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation

2448

into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies.[14] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a "sentinel" bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination.[26] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%.[7] [8] [37]

Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%.[51] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus.

The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken.[22] [40]

Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis.

Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract.

Contraindications No absolute contraindications exist to open surgical tracheostomy.

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TRACHEOSTOMY TUBE CARE

Tracheostomy tube cuff pressures ---20 to 25 mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.

TRACHEOSTOMY TUBE CARE

Humidification of the inspired gas is a standard of care for tracheostomized patients.

Thermovent

• Secretions in the trach • Suspected aspiration of gastric or upper airway secretions • Increase in peak airway pressures when on ventilator • Increase in respirations or sustained cough or both • Gradual or sudden decrease in ABG • Sudden onset of respiratory distress when airway patency is questioned

Indications For Suctioning

Types of tubes

Cuffed and uncuffed

Fenestrated and unfenestrated

Single and double lumen

Various diameters

Cuffs

To protect airway

To allow ventilation

Uncuffed Cuffed

Fenestrated

Allow patient to ventilate past tube via upper airway

Allow speech