Cutting the neck – a final word!

The one area of greatest concern, amongst delegates when I’m giving an airway workshop, is when and how, to do a surgical airway. Why do we fear this so much?

It’s very simple. There are three main reasons:

1. We keep asking ourselves, “When should I really do the surgical airway?” So we aren’t sure of the indications.

2. We keep asking ourselves, “What if I screw it up?”

3. We don’t do this procedure often, in fact very rarely, so we are not as skilled as we would like to be.

Let me go over some of the main points associated with surgical airway, that will clarify all of these issues.

The surgical airway is a last avenue, it is usually the final pathway in the management of the emergency airway.

The indication for the surgical airway is simply cannot ventilate and cannot oxygenate. It is not cannot intubate.

Although our initial aim is to secure the airway, by putting a cuff in the trachea and inflating it, our plans must change, once we cannot obtain access to the trachea, via the cords.

You say, but I can’t intubate and I don’t have a secure airway. I must do the surgical airway.


Stop for a moment and think. The third reason […]

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Electrical injury – who needs to be monitored?

Electrical injury, although not a common occurence can present with significant injury. Often the extent of the injury can be under-estimated as it mostly occurs below the skin, with little more than an entry and exit wound to see.
The very fact that patients with these injuries don’t present often, can result in management challenges. These can range from resuscitation approaches, to decision making as to who needs to be monitored.

The obvious high voltage exposure, with significant burn and injury, is not really a challenge in terms of monitor/non-monitor decision making. The challenge is from that group of patients that are well, with minimal injuries. Who, if any, of these patients do we monitor?

Electrical burns have a trimodal distribution:
1. The first peak is in children. This is primarily due to behaviors such as cord biting.
2. The second peak is in adolescents who engage in risky behaviour and the third group is:
3. Those whose work involves electricity and potential exposure.

Childhood injuries are usually biting injuries, where the child will chew through an electric cord. The result will be a burn to the lips or mouth. These burns are usually bloodless and painless as the vessels have been cauterised and the nerves damaged. One of the main issues in dealing with this kind of elelctrical injury is […]

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