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1. ENT Emergencies

2. Layout
• Epistaxis
• Foreign Body nose and ear
• Airway obstruction
• …. Misc, Q & A.

3. Epistaxis
• Hx & Physical (examine throat as well)
– Potential cause?
– Posterior bleed
• Assess severity (mild, moderate, severe)
• Comorbids (HTN), Trauma?
• Hx:
– How many cups or teaspoons?
– Duration?
– Any other bleeding site or hx of anticoagulants?

5. Epistaxis

6. Epistaxis: management
• Depends on severity and patient response
• ABC (hemodynamic status)
• Direct pressure for 5-10 mins
• Cautery: Chemical, electric etc.
• Vasoconstrictor spray (xynosine)
• Nasal packs

9. Care of packs
• Antibiotics
• Examine throat
• Timely removal of packs
• Types of packs

10. Foreign body ear and nose

11. !!!!!

12. Removal
Use of nasal and
ear drops??

13. Choking

14. Tracheostomy &
cricothyroidotomy

15. Layout
Airway emergencies in Military trauma
Intro to tracheostomy
Indications
Functions and care precautions
Complications and management
Decannulation
Overview of cricothyroidotomy and emergency
airway management

16. Military trauma, airway issues
• 293 cases of airway interventions, of which 17
cricothyroidotomies , over a 2 year period
(Adams, B. D., Cuniowski, P. A., Muck, A., & De Lorenzo, R. A. (2008). Registry of Emergency Airways Arriving at Combat Hospitals.
The Journal of Trauma: Injury, Infection, and Critical Care, 64(6), 1548–1554. )
• A compromised airway is the third potentially preventable
cause of death on the battlefield and results in 1% to 2% of all
combat fatalities in modern military conflicts
(Committee on Tactical Combat Casualty Care. Military Medicine. In: Butler FK, Giebner S, eds. Prehospital Trauma Life Support
Manual. 7th ed. (Military Version), St. Louis, MO: Elsevier; 2011:591–750.)
(Schauer SG, Bellamy MA, Mabry RL, et al. A comparison of the incidence of cricothyrotomy in the deployed setting to the
emergency department at a level 1 military trauma center: a descriptive analysis. Mil Med 2015;180:60–3.)

17. Kyle T, le Clerc S, Thomas A, et al. The success of battlefield surgical airway
insertion in severely injured military patients: a UK perspective J R Army Med
Corps 2016;162:460–464.

18. Introduction

19. Functions
• Alternative breathing pathway
• Improves ventilation
• Protection against aspiration
• Removal of secretions

20. Indications & Contraindications
• Upper airway obstruction (multifactorial)
• Removal of secretions
• Respiratory insufficiency
• Prolonged ventilation
• Part of another procedure
• Contraindications (relative)

21. Types
• Emergency
• Elective
• Permanent
• Percutaneous dilational
• Cricothyroidotomy (aka Mini tracheostomy)
• High, mid or low.

23. Technique

26. Post procedure care
• Supervision and monitoring (communication)
• Suctioning
• Prevention of crusting & tracheatis
(humidification)
• Care of tracheostomy tube (preventing
dislodgment, intermittent pressure release)

29. Complications

30. • Immediate (At time of operation, procedure
related)
– Hemmorhage, apnea (sudden relief resulting in loss of O2
drive), pneumothorax, damage to surrounding structures,
blood aspiration, esophageal injury
• Intermediate (First few hours or days.
Maintenance related)
– Bleeding, tube displacement, tube blockage, subcutaneuos
emphysema, Tracheitis (with crusting), atelactasis & lung
infections, POPE, wound infection
• Late (weeks to months)
– Bleeding, laryngeal stenosis (perichonsritis), tracheal
ulceration & infection, TE fistula, Tracheocutaneous fistula,
keloid

31. Decannulation
• Block (progressively) till patient is able to
tolerate 24 hours.
• Using progressively smaller diameter tube

32. Cricothyroidotomy/ emergent
airway management
• “Can’t intubate, can’t ventilate”
Must be converted to Tracheostomy

33. Needle cricothyroidotomy

34. Open/ regular cricothyroidotomy
(scalpel bougie crico)

36. For emergency airway, staff should be
trained in scalpel bougie
cricothyroidotomy
(Pracy JP, Brennan L, Cook TM, et al. Surgical intervention during a can’t intubate can’t oxygenate (CICO) event:
emergency front of neck airway (FONA). Clin Otolaryngol 2016; 41(6): 624–26.)

37. Final advice
• Airway emergencies in Military Trauma are rare, but
are preventable causes of Mortality. First responders
should be well trained in it.
• You won’t know how easy or how tough it is, till you
practice it. (when you’re “tunnel visioned”, you work
on reflexes)
• Don’t get bogged down by the specific steps,
remember the principles of the surgery
• Tracheostomy learning initiative (whatsApp group).
Phone # 0321-8542431.

38. ENT emergencies

39. Any Questions or suggestions?