Airway Equipment Stephen Estime, MD; Abdullah Hasan Pratt, MD; Nicholas Ludmer, MD UChicago Medicine
Airway trauma is a critical and potentially life-threatening condition, and timely diagnosis and management is imperative for patient survival, as concomitant injuries and nonspecific symptoms may otherwise lead to fatal outcomes. Efficient airway management is paramount to addressing airway trauma, necessitating a comprehensive approach involving timely diagnosis, appropriate interventions, and the use of specialized equipment to ensure optimal patient outcomes.
Prompt and efficient management not only ensures the patient’s immediate survival but also plays a pivotal role in minimizing the impact on respiratory function and overall quality of life. The main objective is to establish a secure and patent airway, enabling efficient ventilation and later surgical repair. This video delivers a thorough and detailed exposition of the equipment utilized in airway management.
The primary survey of every trauma patient begins with ABC: airway, breathing, circulation. If the patient is deemed to require airway management, endotracheal intubation may be performed utilizing rapid sequence intubation (RSI). In RSI, an induction agent and a rapid-acting neuromuscular blocking agent (NMBA or paralytic) are administered and intubation is performed as soon as unconsciousness and paralysis are achieved. Trauma patients may require intubation for a number of reasons. This video review focuses on the pharmacology, dosing, and other considerations for use of common medications for pretreatment, paralysis with induction, and post-intubation management in trauma patients.
A hemothorax is a collection of blood within the pleural cavity. Blood can accumulate within this space as a sequelae of chest trauma (penetrating or blunt), iatrogenic injury (e.g., vascular access injuries), or spontaneously (e.g., due to malignancy). To treat the condition, a chest tube is inserted into the thoracic cavity on the affected side of the body. In addition to evacuating blood from the pleural cavity, a chest tube can also be used to treat pneumothorax (air in the pleural space) and pleural effusion (e.g., empyema or chylothorax), and to insert medications into the pleural space. Depending on the specific pathology, a tube or catheter may be utilized.
Vacuum-assisted closure (VAC) is a method of wound management commonly employed as an adjunct to surgery that uses negative pressure to accelerate healing. This video is a comprehensive step-by-step demonstration of VAC change for a complex right hip wound. The patient is a male in his fourth decade with a history of paralysis beginning in childhood due to a spinal tumor. He was admitted to the hospital with a right hip joint infection complicated by methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. Given his immobility at baseline, the patient was deemed a suitable candidate for a Girdlestone procedure, which involved resection of the femoral head and proximal aspect of the femur, resulting in a complex wound with exposed bone.
This is the case study of a 17-year-old male Reserve Officers’ Training Corps (ROTC) cadet who suffered a superficial perforating saber wound to the medial part of the right knee during a routine practice session. This video demonstrates the step-by-step patient assessment process and subsequent saber removal.
A diaphragmatic hernia (DH) is characterized by protrusion of abdominal organs into the chest cavity through an opening in the diaphragm. A sliding or paraesophageal hernia is the most prevalent type, characterized by its occurrence near the esophageal hiatus. Typically present since birth, it can also develop later in life, occasionally arising as a result of severe trauma or iatrogenic injury. Less often, congenital DHs protrude through posterolateral or substernal diaphragmatic defects, referred to as Bochdalek and Morgagni hernias, respectively.
DH can remain asymptomatic and is commonly detected as an incidental finding during evaluation for other medical issues. Hiatal hernias differ from abdominal wall hernias in that they are influenced by the constant motion of the diaphragm, which exerts continuous friction and pressure changes on the esophagus and the stomach. As a result, hiatal hernias have a higher likelihood of recurrence following surgical correction in comparison to abdominal hernias.
This is the case of an exploratory laparotomy for bowel obstruction and primary pledgeted repair of two diaphragmatic hernias.
For long-term enteral nutrition, percutaneous endoscopic gastrostomy (PEG) is considered the standard of care; however, it often leads to a number of complications: tube migration, blockage, inadvertent tube slipping and removal, and less often, perforation. PEG involves insertion of a feeding tube through the skin and into the stomach, with the assistance of endoscopic intraluminal visualization of the stomach. PEG is a blind procedure, making it difficult to detect organs interposed between the stomach and the abdominal wall (e.g., colon, small intestine, greater omentum). To avoid these complications, laparoscopic-assisted PEG (LAPEG) was introduced.
LAPEG tube placement stands out as a minimally invasive surgical intervention that combines the techniques of laparoscopy and endoscopy to establish enteral access for nutritional support. The laparoscopic approach provides visualization for the feeding tube insertion and for approximation of the gastric and abdominal walls. This method proves particularly beneficial for individuals who require long-term enteral feeding while having obstacles with conventional approaches to stomach access due to diverse medical conditions.
Intracranial hypertension is a critical concern in traumatic brain injury (TBI), with elevated intracranial pressure (ICP) significantly impacting patient outcomes. ICP monitoring is an essential component in managing patients with various brain pathologies that can lead to dangerously elevated intracranial pressure. In neurosurgical practice, accurate monitoring and timely intervention are critical when dealing with the challenges of intracranial hypertension, and its timely resolution is crucial for preventing severe neurological sequelae and fatal outcomes.
The risk of Infections or hemorrhage of significance associated with ICP devices, which can lead to patient morbidity, usually do not outweigh the benefit of continuous ICP monitoring in TBI. Therefore, these should not deter the decision to monitor ICP.
This video provides step-by-step visual guidance for placing a right frontal Camino bolt to guide optimal patient care. In this clinical case a patient presents without prior opportunity for clinical exam and with reported signs of a cranial hemorrhage, coupled with a right occipital fracture, thereby requiring ICP monitoring to proceed with further neurosurgical care.
Airway injury remains a leading cause of early mortality in patients with trauma. Despite its rarity, direct traumatic airway injury and tracheobronchial injury (TBI) pose significant challenges for emergency clinicians, with an estimated incidence of 0.5–2% among trauma patients. Blunt or penetrating injuries to the head, oropharynx, neck, or upper chest can result in immediate or delayed airway blockage. Trauma can cause airway obstruction by itself or by blood clots, tissue edema, or gastric contents clogging the airway lumen. The added complexity of associated spinal injuries further underscores the need for precise and timely airway assessment.
In the context of trauma patients, a fundamental aspect of care involves prompt airway assessment. The Advanced Trauma Life Support (ATLS) algorithm, a cornerstone in trauma care, outlines a systematic approach focusing on a sequential assessment and management of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE), as part of the initial evaluation of the injured individual. While adapted for battle and disaster environments, the ATLS algorithm consistently emphasizes the timely assessment and treatment of life-threatening airway and breathing issues before shifting focus to circulation problems. The CAB sequence has become more widely embraced in the last ten years, surpassing the airway-breathing-circulation (ABC) model for individuals with serious bleeding injuries. When bleeding is severe or life-threatening, prioritizing control of the bleeding takes precedence over interventions related to airway and breathing․
The spleen is highly vascular, is the largest secondary lymphoid organ, and is the most commonly injured organ in the setting of blunt abdominal trauma. Patients may present asymptomatically or with abdominal pain, nausea and vomiting, or signs of hemodynamic instability. Although many splenic injuries caused by blunt abdominal trauma may be managed conservatively, free intra-abdominal fluid with hemodynamic instability warrant surgical management in the form of exploratory laparotomy and splenectomy.
This video report demonstrates the management of a patient who was assaulted, sustaining blunt abdominal trauma and a hemodynamically significant grade IV splenic laceration. An exploratory laparotomy and splenectomy were performed.
