Surgical Airway Management

Indications & Assessment - Call for the Cut!

Emergency FONA (Front of Neck Access) Indications:

• CICO/CICV: Cannot Intubate, Cannot Oxygenate/Ventilate - the critical trigger.
• Massive trauma: Maxillofacial, laryngeal, neck; precluding other airway methods.
• Acute upper airway obstruction (unmanageable otherwise):
  • Irremovable foreign body, angioedema, hematoma, severe infections (Ludwig's).
• Failed intubation: > 3 attempts or > 10 min by experienced provider.

Rapid Assessment (Cricothyroidotomy):

• Identify Cricothyroid Membrane (CTM): Palpable gap between thyroid/cricoid.
• Key Contraindications:
  • Age < 8-12 yrs (needle cricothyroidotomy preferred).
  • Laryngeal fracture/transection (risk of further damage).
  • CTM obscured by pathology (e.g., tumor).

⭐ In CICO, immediate FONA is crucial. Delay significantly increases risk of hypoxic brain injury & death.

Cricothyroidotomy - Speedy Slice!

• Primary Goal: Rapid emergency airway in "Can't Intubate, Can't Oxygenate" (CICO) scenarios.
• Key Indications: Failed intubation, severe maxillofacial trauma, acute upper airway obstruction (e.g., angioedema, foreign body).
• Contraindications:
  • Absolute: Age < 8-12 years (needle cricothyroidotomy or tracheostomy preferred due to risk of subglottic stenosis).
  • Relative: Laryngeal pathology (fracture, tumor), coagulopathy, overlying infection.
• Anatomy: Incision through cricothyroid membrane (palpable between thyroid & cricoid cartilages).
• Surgical Technique:

• Complications: Bleeding, incorrect tube placement, esophageal/tracheal injury, subcutaneous emphysema, voice changes, late subglottic stenosis.

⭐ Cricothyroidotomy is a temporary airway; plan for conversion to formal tracheostomy within 24-72 hours if continued airway support is needed.

• 📌 "Slice, Insert, Secure!" for rapid execution.

Tracheostomy - Hole Story!

• Surgical stoma in anterior trachea for definitive airway, bypassing upper airway.

• Indications: Prolonged ventilation (>14 days), upper airway obstruction, copious secretions, failed extubation.

• Types:

  • Surgical (ST): Open dissection, OR.
  • Percutaneous Dilatational (PDT): Bedside, Seldinger; e.g., Ciaglia.

• Timing: Early (<7-10 days) vs. Late (>10 days) post-intubation.

• Incision: Midline, between 2nd-3rd (or 3rd-4th) tracheal rings.

• Cuff Pressure: 20-30 cm H₂O; seals airway, prevents ischemia & aspiration.

• Complications:

  • Early: Bleeding, pneumothorax, tube displacement/obstruction.
  • Late: Tracheoinnominate fistula (TIF) ⚠️, tracheal stenosis, tracheomalacia.

• Decannulation: Indication resolved, tolerates capping (≥24h), effective cough.

⭐ Tracheoinnominate Artery Fistula (TIF), a feared late complication, may present with a sentinel bleed.

Complications & Aftercare - Trouble Tube?

Complications:

• Immediate: Bleeding, pneumothorax, esophageal/Recurrent Laryngeal Nerve (RLN) injury, false passage, apnea.
• Early (days): Tube obstruction/displacement, infection (local/systemic), subcutaneous emphysema, hematoma.
• Late (weeks-months): Tracheal stenosis/malacia, tracheo-esophageal fistula (TEF), tracheo-innominate fistula (TIF), granuloma, persistent stoma, difficult decannulation.

  ⭐ Tracheo-innominate artery fistula (TIF): rare, catastrophic bleed (often sentinel bleed first). Mortality >75%.

Aftercare:

• Humidification, regular sterile suctioning.
• Cuff pressure: 20-30 cm H₂O (prevents ischemia/aspiration).
• Stoma care, monitor for infection/bleeding.
• Decannulation: assess airway patency, gradual downsizing, speaking valve trials. Consider swallow assessment.

Troubleshooting (📌 DOPES Mnemonic for sudden deterioration):

• Displacement
• Obstruction (mucus plug, blood clot)
• Pneumothorax
• Equipment failure
• Stacking breaths / Secretions / Stomach

High‑Yield Points - ⚡ Biggest Takeaways

• CICO (Cannot Intubate, Cannot Oxygenate) mandates emergency surgical airway.
• Cricothyroidotomy: Preferred in adult CICO; faster than tracheostomy.
• Needle cricothyroidotomy (14-16G cannula): For oxygenation (TTJV), not full ventilation.
• Surgical cricothyroidotomy: Incision through cricothyroid membrane.
• Tracheostomy: For prolonged airway needs; usually 2nd-3rd tracheal rings.
• Cricothyroidotomy is relatively contraindicated in children < 8-12 years.
• Key late risks: Subglottic stenosis (cricothyroidotomy), tracheal stenosis (tracheostomy).