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📖 General Surgery

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Cricothyroidotomy
General Surgery

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

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

Steps

  1. 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.
  2. Make the Incision: Using a scalpel, make a vertical incision through the skin over the cricothyroid membrane, approximately 2-3 cm in length.
  3. Incise the Membrane: Carefully incise the cricothyroid membrane horizontally to create an opening into the airway.
  4. 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.
  5. 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.
Types of Brain Injury
General Surgery

Types of Brain Injury

Brain injuries can be classified into two main categories: primary and secondary injuries. Understanding these types is crucial for effective diagnosis and management.

1. Primary Brain Injury

  • Definition: Primary brain injury occurs at the moment of impact. It results from the initial mechanical forces applied to the brain and can lead to immediate damage.
  • Examples:
    • Contusions: Bruising of brain tissue.
    • Lacerations: Tears in brain tissue.
    • Concussions: A temporary loss of function due to trauma.
    • Diffuse axonal injury: Widespread damage to the brain's white matter.

2. Secondary Brain Injury

  • Definition: Secondary brain injury occurs after the initial impact and is often preventable. It results from a cascade of physiological processes that can exacerbate the initial injury.
  • Principal Causes:
    • Hypoxia: Reduced oxygen supply to the brain, which can worsen brain injury.
    • Hypotension: Low blood pressure can lead to inadequate cerebral perfusion.
    • Raised Intracranial Pressure (ICP): Increased pressure within the skull can compress brain tissue and reduce blood flow.
    • Reduced Cerebral Perfusion Pressure (CPP): Insufficient blood flow to the brain can lead to ischemia.
    • Pyrexia: Elevated body temperature can increase metabolic demands and worsen brain injury.

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale is a clinical tool used to assess a patient's level of consciousness and neurological function. It consists of three components: eye opening, verbal response, and motor response.

Eye Opening (E)

  • Spontaneous: 4
  • To verbal command: 3
  • To pain stimuli: 2
  • No eye opening: 1

Verbal Response (V)

  • Normal, oriented: 5
  • Confused: 4
  • Inappropriate words: 3
  • Sounds only: 2
  • No sounds: 1

Motor Response (M)

  • Obeys commands: 6
  • Localizes to pain: 5
  • Withdrawal flexion: 4
  • Abnormal flexion (decorticate): 3
  • Extension (decerebrate): 2
  • No motor response: 1

Scoring

  • Best Possible Score: 15/15 (fully alert and oriented)
  • Worst Possible Score: 3/15 (deep coma or death)
  • Intubated Cases: For patients who are intubated, the verbal score is recorded as "T."
  • Intubation Indication: Intubation should be performed if the GCS score is less than or equal to 8.

Additional Assessments

Pupil Examination

  • Pupil Reflex: Assess size and light response.
  • Uncal Herniation: In cases of mass effect on the ipsilateral side, partial third nerve dysfunction may be noted, characterized by a larger pupil with sluggish reflex.
  • Hutchinson Pupil: As third nerve compromise increases, the ipsilateral pupil may become fixed and dilated.

Signs of Base of Skull Fracture

  • Raccoon Eyes: Bilateral periorbital hematoma, indicating possible skull base fracture.
  • Battle’s Sign: Bruising over the mastoid process, suggesting a fracture of the temporal bone.
  • CSF Rhinorrhea or Otorrhea: Leakage of cerebrospinal fluid from the nose or ear, indicating a breach in the skull base.
  • Hemotympanum: Blood in the tympanic cavity, often seen with ear bleeding.
Types of Head Injury
General Surgery

Types of Head Injury

1. Extradural Hematoma (EDH)

Overview

  • Demographics: Most common in young male patients.
  • Association: Always associated with skull fractures.
  • Injured Vessel: Middle meningeal artery.
  • Common Site of Injury: Temporal bone at the pterion (the thinnest part of the skull), which overlies the middle meningeal artery.
  • Location of Hematoma: Between the bone and the dura mater.

Other Common Sites

  1. Frontal fossa
  2. Posterior fossa
  3. May occur following disruption of major dural venous sinus.

Classical Presentation

  • Initial Injury: Followed by a lucid interval where the patient may only complain of a headache.
  • Deterioration: After minutes to hours, rapid deterioration occurs, leading to:
    • Contralateral hemiparesis
    • Reduced consciousness level
    • Ipsilateral pupillary dilatation (due to herniation)

Imaging

  • CT Scan: Shows a lentiform (lens-shaped or biconvex) hyperdense lesion between the brain and skull.

Treatment

  • Surgical Intervention: Immediate surgical evacuation via craniotomy.
  • Mortality Rate: Overall mortality is 18% for all cases of EDH, but only 2% for isolated EDH.

2. Acute Subdural Hematoma (ASDH)

Overview

  • Location: Accumulates in the space between the dura and arachnoid.
  • Injury Mechanism: Associated with cortical vessel disruption and brain laceration.
  • Primary Brain Injury: Often associated with primary brain injury.

Presentation

  • Consciousness: Impaired consciousness from the time of impact.

Imaging

  • CT Scan: Appears hyperdense, with hematoma spreading diffusely and having a concavo-convex appearance.

Treatment

  • Surgical Intervention: Evacuation via craniotomy.
  • Mortality Rate: Approximately 40%.

3. Chronic Subdural Hematoma (CSDH)

Overview

  • Demographics: Most common in patients on anticoagulants and antiplatelet agents.
  • History: Often follows a minor head injury weeks to months prior.
  • Pathology: Due to the tear of bridging veins leading to ASDH, which is clinically silent. As the hematoma breaks down, it increases in volume, causing mass effect on the underlying brain.

Clinical Features

  • Symptoms may include:
    • Headache
    • Cognitive decline
    • Focal neurological deficits (FND)
    • Seizures
  • Important to exclude endocrine, hypoxic, and metabolic causes in this group.

Imaging

  • CT Scan Appearance:
    • Acute blood (0–10 days): Hyperdense
    • Subacute blood (10 days to 2 weeks): Isodense
    • Chronic (> 2 weeks): Hypodense

Treatment

  • Surgical Intervention: Bur hole evacuation rather than craniotomy.
  • Anesthesia: Elderly patients can often undergo surgery under local anesthesia, despite comorbidities.

4. Subarachnoid Hemorrhage (SAH)

Overview

  • Causes: Most commonly due to aneurysms for spontaneous SAH, but trauma is the most common cause overall.
  • Management: Conservative treatment is often employed for trauma cases.

5. Cerebral Contusions

Overview

  • Definition: Bruising of the brain tissue due to trauma.
  • Mechanism: Often occurs at the site of impact (coup) and the opposite side (contrecoup).
  • Symptoms: Can range from mild confusion to severe neurological deficits depending on the extent of the injury.

Imaging

  • CT Scan: May show areas of low attenuation (hypodense) or high attenuation (hyperdense) depending on the age of the contusion.

Treatment

  • Management: Depends on the severity and associated injuries; may require surgical intervention if there is significant mass effect.

 INFLAMMATION

General Surgery

Inflammation is the respone of the body to an irritant.

Stages of Inflammation

1. General: Temperature Raised. In severe cases bacteremia or septicemia ,rigors may occur.

2. Local: classical signs of inflammation are due to hyperemia and inflammation exudate

i) Heat:  inflammed area feels warmer than the surrounding tissues.

ii) Redness

iii) Tenderness: Due to pressure of exudate on the surrounding nerves  If the exudate is  under tension, e.g. a furuncle (boil) of the ear, pain is severe.

iv) swelling

v) Loss of function.

The termination of Inflammation

This may be by:1. Resolution 2. Suppuration 3. Ulceration 4. Ganangren s. Fibrosis

Management

i. Increase the patients resistance., Rest,  Relief of pain by analgesics,  Diet: High protein and high calorie diet with vitamins,  Antibiotics,  Prevent further contamination of wound.

Surgical measures

1. Excision: If possible as in appendicectomy.

2. Incision and drainage: If an abscess forms.