Surgical Airway—the last strategy in airway management.ppt

Surgical Airway—the last strategy in airway management Presented by Kang, Ting-jui CASE ( I ) Brief History 57 y/o female with NPC s/p radiotherapy Denied any other systemic disease One episode of massive bleeding from nose and oral cavity on 2/7 Vital sign stable, consciousness clear Anterior packing with V-G and posterior packing with Foley catheter for stopping bleeding Intra-operation Tracheostomy and TAE were suggested Emergent tracheostomy was initiated in OR under local anesthesia ENT doctor asked us of setting ventilator after tracheostomy was inserted De-saturation and consciousness loss was noted when we arrived High pressure while resuscitation bagging, capnography showed no end-tidal concentrations of CO2 Intra-operation The suction tube can’t be passing through the tracheostomy tube Tube mal-positioning was suspected and the ENT doctors kept trying to insert the tube Saturation below 60% and downward in seconds Bredycardia ? atropine 1mg was given Trismus ? fiberoptic nasal intubation was performed Standstill ? CPR start, bosmin and cardiac massage ? ROSC in 5 minutes ? send to SICU CXR Normal heart size.Bilateral pneumothorax and diffuse subcutaneous emphysema.Endotracheal tube with the tip above the carina CXR Normal heart size Clear lung field.no significant pneumothorax Diffuse subcutaneous emphysema from the bilateral neck to the abdominal wall Bilateral chest tube Endotracheal tube with the tip above the carina Outcome On arriving SICU, deep coma with loss of light reflex was noted CXR showed diffuse subcutaneous emphysema and bilateral pneumothorax ? bilateral chest tubes were inserted Next day (2/8), pupils returned to 2.0mm with positive light reflex and stable vital signs without any inotropic agent Anisocoria was noted in the early morning of 2/10 Outcome Brain CT showed severe brain swelling, blunting of cortex-white matter junction, cistern and sulci effacement and brain stem compression Hypoxic encephalopathy was impressed. Cushing