- NEETMDS- courses

Dautrey Procedure

The Dautrey procedure is a surgical intervention aimed at preventing dislocation of the temporomandibular joint (TMJ) by creating a mechanical obstacle that restricts abnormal forward translation of the condylar head. This technique is particularly beneficial for patients who experience recurrent TMJ dislocations or subluxations, especially when conservative management strategies have proven ineffective.

Indications:
- The Dautrey procedure is indicated for patients with a history of recurrent TMJ dislocations. It is particularly useful when conservative treatments, such as physical therapy or splint therapy, have failed to provide adequate stabilization of the joint.
Surgical Technique:
- Osteotomy of the Zygomatic Arch: The procedure begins with an osteotomy, which involves surgically cutting the zygomatic arch, the bony structure that forms the prominence of the cheek.
- Depressing the Zygomatic Arch: After the osteotomy, the zygomatic arch is depressed in front of the condylar head. This depression creates a physical barrier that acts as an obstacle to the forward movement of the condylar head during jaw opening or excessive movement.
- Stabilization: The newly positioned zygomatic arch limits the range of motion of the condylar head, thereby reducing the risk of dislocation during functional activities such as chewing or speaking.
Mechanism of Action:
- By altering the position of the zygomatic arch, the Dautrey procedure effectively changes the biomechanics of the TMJ. The new position of the zygomatic arch prevents the condylar head from translating too far forward, which is a common cause of dislocation.
Postoperative Care:
- Following the procedure, patients may require a period of recovery and rehabilitation. This may include:
  - Dietary Modifications: Soft diet to minimize stress on the TMJ during the healing process.
  - Pain Management: Use of analgesics to manage postoperative discomfort.
  - Physical Therapy: Exercises to restore normal function and range of motion in the jaw.
Outcomes:
- The Dautrey procedure has been shown to be effective in preventing recurrent TMJ dislocations. Patients often experience improved joint stability and a better quality of life following the surgery. Successful outcomes can lead to reduced pain, improved jaw function, and enhanced overall satisfaction with treatment.

Cricothyroidotomy

Cricothyroidotomy is a surgical procedure that involves making an incision through the skin over the cricothyroid membrane, which is located between the thyroid and cricoid cartilages in the neck. This procedure is performed to establish an emergency airway in situations where intubation is not possible or has failed, such as in cases of severe airway obstruction, facial trauma, or anaphylaxis.

Indications

Cricothyroidotomy is indicated in the following situations:

Acute Airway Obstruction: When there is a complete blockage of the upper airway due to swelling, foreign body, or trauma.
Failed Intubation: When attempts to secure an airway via endotracheal intubation have been unsuccessful.
Facial or Neck Trauma: In cases where traditional airway management is compromised due to injury.
Severe Anaphylaxis: When rapid airway access is needed and other methods are not feasible.

Anatomy

Cricothyroid Membrane: The membrane lies between the thyroid and cricoid cartilages and is a key landmark for the procedure.
Surrounding Structures: Important structures in the vicinity include the carotid arteries, jugular veins, and the recurrent laryngeal nerve, which must be avoided during the procedure.

Procedure

Preparation

Positioning: The patient should be in a supine position with the neck extended to improve access to the cricothyroid membrane.
Sterilization: The area should be cleaned and sterilized to reduce the risk of infection.
Anesthesia: Local anesthesia may be administered, but in emergency situations, this step may be skipped.

Steps

Identify the Cricothyroid Membrane: Palpate the thyroid and cricoid cartilages to locate the membrane, which is typically located about 1-2 cm below the thyroid notch.
Make the Incision: Using a scalpel, make a vertical incision through the skin over the cricothyroid membrane, approximately 2-3 cm in length.
Incise the Membrane: Carefully incise the cricothyroid membrane horizontally to create an opening into the airway.
Insert the Airway Device:
- A tracheostomy tube or a large-bore cannula (e.g., a 14-gauge catheter) is inserted into the opening to establish an airway.
- Ensure that the device is positioned correctly to allow for ventilation.
Secure the Airway: If using a tracheostomy tube, secure it in place to prevent dislodgment.

Post-Procedure Care

Ventilation: Connect the airway device to a bag-valve-mask (BVM) or ventilator to provide oxygenation and ventilation.
Monitoring: Continuously monitor the patient for signs of respiratory distress, oxygen saturation, and overall stability.
Consider Further Intervention: Plan for definitive airway management, such as a formal tracheostomy or endotracheal intubation, once the immediate crisis is resolved.

Complications

While cricothyroidotomy is a life-saving procedure, it can be associated with several complications, including:

Infection: Risk of infection at the incision site.
Hemorrhage: Potential bleeding from surrounding vessels.
Damage to Surrounding Structures: Injury to the recurrent laryngeal nerve, carotid arteries, or jugular veins.
Subcutaneous Emphysema: Air escaping into the subcutaneous tissue.
Tracheal Injury: If the incision is not made correctly, there is a risk of damaging the trachea.

SHOCK

Shock is defined as a pathological state causing inadequate oxygen delivery to the peripheral tissues and resulting in lactic acidosis, cellular hypoxia and disruption of normal metabolic condition.

CLASSIFICATION

Shock is generally classified into three major categories:

1. Hypovolemic shock

2. Cardiogenic shock

3. Distributive shock

Distributive shock is further subdivided into three subgroups:

a. Septic shock

b. Neurogenic shock

c. Anaphylactic shock

Hypovolemic shock is present when marked reduction in oxygen delivery results from diminished cardiac output secondary to inadequate vascular volume. In general, it results from loss of fluid from circulation, either directly or indirectly.
e.g.   ?   Hemorrhage
   •   Loss of plasma due to burns
   •   Loss of water and electrolytes in diarrhea
   •   Third space loss (Internal fluid shift into inflammatory exudates in
       the peritoneum, such as in pancreatitis.)

Cardiogenic shock is present when there is severe reduction in oxygen delivery secondary to impaired cardiac function. Usually it is due to myocardial infarction or pericardial tamponade.

Septic Shock (vasogenic shock) develops as a result of the systemic effect of infection. It is the result of a septicemia with endotoxin and exotoxin release by gram-negative and gram-positive bacteria. Despite normal or increased cardiac output and oxygen delivery, cellular oxygen consumption is less than normal due to impaired extraction as a result of impaired metabolism.

Neurogenic shock results primarily from the disruption of the sympathetic nervous system which may be due to pain or loss of sympathetic tone, as in spinal cord injuries.

PATHO PHYSIOLOGY OF SHOCK

Shock stimulates a physiologic response. This circulatory response to hypotension is to conserve perfusion to the vital organs (heart and brain) at the expense of other tissues. Progressive vasoconstriction of skin, splanchnic and renal vessels leads to renal cortical necrosis and acute renal failure. If not corrected in time, shock leads to organ failure and sets up a vicious circle with hypoxia and acidosis.

CLINICAL FEATURES

The clinical presentation varies according to the cause. But in general patients with hypotension and reduced tissue perfusion presents with:
•   Tachycardia
•   Feeble pulse
•   Narrow pulse pressure
•   Cold extremities (except septic shock)
•   Sweating, anxiety
•   Breathlessness / Hyperventilation
•   Confusion leading to unconscious state