1 00:00:00,040 --> 00:00:03,720 Welcome back to the Deep Dive. Today the vibe in the studio is 2 00:00:03,720 --> 00:00:06,320 a little different. Usually we are relaxed, we are 3 00:00:06,320 --> 00:00:08,400 curious, we are just exploring ideas. 4 00:00:08,920 --> 00:00:13,720 But today, today my palms are sweating just a little bit. 5 00:00:13,960 --> 00:00:16,360 I can feel it. Because today we are simulating 6 00:00:16,360 --> 00:00:20,320 the walk down that long quiet corridor to the exam hall. 7 00:00:21,000 --> 00:00:24,280 We are stepping into the shoes of a final year MD 8 00:00:24,280 --> 00:00:27,600 Anesthesiology student facing the Gujarat University 9 00:00:27,600 --> 00:00:29,840 Examiners. The pressure cooker, I remember 10 00:00:29,840 --> 00:00:31,920 that walk well. And honestly, for anyone 11 00:00:31,920 --> 00:00:35,120 listening who isn't actually taking that specific exam, don't 12 00:00:35,120 --> 00:00:36,680 tune out. No, definitely not. 13 00:00:36,760 --> 00:00:39,480 Because what we are doing today is essentially a master class in 14 00:00:39,480 --> 00:00:42,520 advanced airway management, we are stripping away the fluff and 15 00:00:42,520 --> 00:00:45,320 focusing purely on examiner centric knowledge regarding 16 00:00:45,320 --> 00:00:47,440 tracheostomy. Exactly, I've got my stack of 17 00:00:47,440 --> 00:00:48,840 books here. I'm looking at Millers 18 00:00:48,840 --> 00:00:52,760 Anesthesia, Ocean Intensive care manual, Morgan and Michael, but 19 00:00:52,760 --> 00:00:55,080 I don't have time to read 200 pages right now. 20 00:00:55,120 --> 00:00:57,000 Nobody does. I need the extraction. 21 00:00:57,080 --> 00:00:58,880 I need the examiner centric gold. 22 00:00:59,080 --> 00:01:02,400 Our mission is tracheostomy indications, techniques, 23 00:01:02,560 --> 00:01:06,320 complications and management. And that is a topic that smells 24 00:01:06,320 --> 00:01:10,560 like fear in an exam. It's the ultimate crossover 25 00:01:10,560 --> 00:01:12,720 topic. It's surgical, it's airway, it's 26 00:01:12,720 --> 00:01:15,040 ICU, and it's Emergency Management. 27 00:01:15,280 --> 00:01:16,680 All in one. All in one. 28 00:01:16,840 --> 00:01:19,880 If you're sitting in a Viva and they hand you a tracheostomy 29 00:01:19,880 --> 00:01:22,840 tube, you can either look like a consultant or you can fail the 30 00:01:22,840 --> 00:01:25,320 station in 30 seconds. That is terrifying. 31 00:01:25,320 --> 00:01:27,440 Yeah. So let's structure this exactly 32 00:01:27,440 --> 00:01:29,480 how the exam demands. We need to cover the long 33 00:01:29,480 --> 00:01:32,880 question, that massive 20 mark essay structure. 34 00:01:32,880 --> 00:01:35,400 Yeah, read the short note on PDT. 35 00:01:35,440 --> 00:01:37,120 Yeah. And we need to survive the table 36 00:01:37,120 --> 00:01:39,640 Viva traps. Let's start with part A, 37 00:01:39,640 --> 00:01:42,880 introduction and exam framing. If I open that exam paper and 38 00:01:42,880 --> 00:01:44,800 see tracheostomy is the long question. 39 00:01:45,080 --> 00:01:48,080 How do I start without rambling? You start with the definition 40 00:01:48,280 --> 00:01:50,880 crisp and precise. Do not just say it's a hole in 41 00:01:50,880 --> 00:01:52,200 the neck. Right, that's two basic 42 00:01:52,200 --> 00:01:53,520 undergraduate level. Exactly. 43 00:01:53,520 --> 00:01:56,560 You define it strictly as a surgical procedure creating an 44 00:01:56,560 --> 00:01:59,720 opening, an artificial opening in the anterior aspect of the 45 00:01:59,720 --> 00:02:02,080 neck to access the lower airway through the trachea. 46 00:02:02,080 --> 00:02:04,960 OK, specific. And here is where you grab your 47 00:02:04,960 --> 00:02:08,840 first nuance point from Miller's Anesthesia, the difference 48 00:02:08,840 --> 00:02:11,440 between tracheotomy and tracheostomy. 49 00:02:11,440 --> 00:02:13,400 Oh I saw this in the notes. It's the suffix right? 50 00:02:13,400 --> 00:02:17,160 The Tomi versus Stomi. Exactly, it's etymology and 51 00:02:17,160 --> 00:02:19,680 examiners love it because it shows you respect the language 52 00:02:19,680 --> 00:02:22,800 of medicine. Tomi AT comes from the Greek 53 00:02:22,800 --> 00:02:26,120 tome meaning to cut. OK, so the cut itself. 54 00:02:26,120 --> 00:02:30,000 The act of slicing the skin and trachea, that's the tracheotomy. 55 00:02:30,000 --> 00:02:34,680 So the ACT is the TOMI correct? But stomi STMA means mouth or 56 00:02:34,680 --> 00:02:37,440 opening. So the tracheostomy is the 57 00:02:37,440 --> 00:02:41,800 actual semi permanent opening where the tube lives, the stoma. 58 00:02:41,880 --> 00:02:43,520 The maintained opening? Yes, the. 59 00:02:43,520 --> 00:02:46,160 Skin is sewn to the trachea or held open by the tube. 60 00:02:46,400 --> 00:02:48,440 Clinicians use the words interchangeably. 61 00:02:48,520 --> 00:02:49,640 You know, in day-to-day practice. 62 00:02:49,640 --> 00:02:51,120 Sure, everyone does. But if you write that 63 00:02:51,120 --> 00:02:53,920 distinction down in your exam, tracheotomy is the cut, 64 00:02:53,960 --> 00:02:56,320 tracheostomy is the opening. It shows you've read the big 65 00:02:56,320 --> 00:02:57,400 books. It's an easy mark. 66 00:02:57,400 --> 00:02:59,480 Nice easy points right off the bat, yeah. 67 00:02:59,480 --> 00:03:01,800 Now, context. Why do we do this? 68 00:03:01,800 --> 00:03:04,280 Why not just leave the endotracheal 2IN forever? 69 00:03:04,560 --> 00:03:08,120 It's about the long game. Historically and still today, 70 00:03:08,120 --> 00:03:11,880 it's the definitive substitute for endotracheal intubation. 71 00:03:11,880 --> 00:03:15,240 We'll call it ETT. Yeah, ETT, either to bypass an 72 00:03:15,240 --> 00:03:18,840 upper airway obstruction or you know, much more commonly for 73 00:03:18,840 --> 00:03:20,320 long term ventilation. OK. 74 00:03:20,320 --> 00:03:22,800 So the clinical importance, what are the bullet points for my 75 00:03:22,800 --> 00:03:24,520 intro? OK, four key things and you 76 00:03:24,520 --> 00:03:27,640 should list them just like this. One, it reduces Dead Space. 77 00:03:27,760 --> 00:03:30,720 We'll get into why later. OK, two, it reduces the work of 78 00:03:30,800 --> 00:03:33,960 breathing, hugely important for waning, right? 79 00:03:33,960 --> 00:03:36,840 Three, it improves patient comfort. 80 00:03:37,280 --> 00:03:40,360 They can potentially eat, they can vocalize a bit. 81 00:03:40,600 --> 00:03:42,840 It's much more humane than an ETT. 82 00:03:42,880 --> 00:03:47,080 I'm 4/4 it facilitates pulmonary toilet. 83 00:03:47,080 --> 00:03:49,080 Pulmonary toilet. I always love that turn. 84 00:03:49,080 --> 00:03:51,480 It sounds so undignified, but it's crucial. 85 00:03:51,480 --> 00:03:53,080 It is. It just means you can stick a 86 00:03:53,080 --> 00:03:56,080 suction catheter down there and clean out the lungs easily if a 87 00:03:56,080 --> 00:03:59,200 patient has a weak cough. That ability to suction is the 88 00:03:59,200 --> 00:04:01,280 difference between pneumonia and recovery. 89 00:04:01,280 --> 00:04:03,120 Makes sense. And the other big one, which is 90 00:04:03,120 --> 00:04:05,840 sort of linked to comfort, is sedation holidays. 91 00:04:05,840 --> 00:04:09,520 Oh, with an ETT, the patient usually needs some sedation to 92 00:04:09,520 --> 00:04:12,200 tolerate that big plastic tube in their throat. 93 00:04:12,200 --> 00:04:14,760 It's really uncomfortable. Yeah, you see them gagging on it 94 00:04:14,760 --> 00:04:16,200 all the time. Exactly. 95 00:04:16,279 --> 00:04:18,800 With a track it's much more comfortable so you can often 96 00:04:18,800 --> 00:04:21,720 wake them up completely. You can stop the propofol and 97 00:04:21,720 --> 00:04:23,720 start weaning them from the ventilator much sooner. 98 00:04:24,000 --> 00:04:25,800 It accelerates the whole process. 99 00:04:25,800 --> 00:04:27,440 OK, so that's our intro and framing. 100 00:04:27,760 --> 00:04:30,480 I feel good about that. Now let's move to Part B, 101 00:04:30,480 --> 00:04:34,480 Anatomy and Physiology. The outline marks this as 102 00:04:34,640 --> 00:04:38,040 absolutely essential and exam core. 103 00:04:38,240 --> 00:04:40,760 You cannot bluff the anatomy. You just can't. 104 00:04:40,920 --> 00:04:43,680 If you are discussing the surgical technique in an exam, 105 00:04:43,960 --> 00:04:45,760 you need to visualize the layers. 106 00:04:45,760 --> 00:04:47,520 OK, so let's do that. Picture the neck. 107 00:04:47,560 --> 00:04:49,280 Where do I start? Start with the surface 108 00:04:49,280 --> 00:04:50,840 landmarks. What can you feel? 109 00:04:50,880 --> 00:04:53,600 You have the laryngeal prominence, the Adam's apple got 110 00:04:53,600 --> 00:04:55,720 it. Below that you feel a gap and 111 00:04:55,720 --> 00:04:58,960 then a hard ring that is the cricoid cartilage. 112 00:04:58,960 --> 00:05:01,000 Level C6. Correct C6 level, and the 113 00:05:01,000 --> 00:05:04,480 cricoid is unique because it is the only complete cartilaginous 114 00:05:04,480 --> 00:05:07,200 ring in the entire airway. The only one that goes all the 115 00:05:07,200 --> 00:05:09,000 way around. It's a full circle, like a 116 00:05:09,000 --> 00:05:10,920 signet ring. Everything below it. 117 00:05:10,920 --> 00:05:14,320 The trichial rings are C shaped. Right, the tracheal rings are 118 00:05:14,320 --> 00:05:15,920 open at the back. Exactly. 119 00:05:15,960 --> 00:05:18,880 They are D shaped with the flat part at the back and that flat 120 00:05:18,880 --> 00:05:22,640 part, the membranous posterior wall lies right against the 121 00:05:22,640 --> 00:05:24,360 esophagus. Which is a huge deal. 122 00:05:24,360 --> 00:05:28,000 It's a massive danger zone. If you push too, with a needle 123 00:05:28,000 --> 00:05:31,240 or a dilator during the procedure, you can punch right 124 00:05:31,240 --> 00:05:33,440 through the back of the trachea and into the esophagus. 125 00:05:33,440 --> 00:05:36,640 Creating a TT tracheoesophageal fistula. 126 00:05:36,640 --> 00:05:40,000 Exactly a disaster. Now let's talk numbers. 127 00:05:40,040 --> 00:05:42,840 Exams love numbers. The trachea extends from the 128 00:05:42,840 --> 00:05:46,960 cricoid to the Karina and an adult that length is about 10 to 129 00:05:46,960 --> 00:05:50,440 13 centimeters. OK, the magic number to quote is 130 00:05:50,440 --> 00:05:52,680 that the distance from the cricoid to the Karina is 131 00:05:52,680 --> 00:05:55,800 approximately 11 centimeters. 11 centimeters? 132 00:05:55,800 --> 00:05:57,440 That doesn't seem like a lot of room for error. 133 00:05:57,520 --> 00:05:59,600 It isn't. And that brings us to the danger 134 00:05:59,600 --> 00:06:03,280 zone regarding blood vessels. This is what keeps surgeons and 135 00:06:03,280 --> 00:06:06,120 anesthetists awake at night. OK, let's do a mental 136 00:06:06,120 --> 00:06:08,240 dissection. You are cutting down the 137 00:06:08,240 --> 00:06:10,080 midline. What layers are you passing 138 00:06:10,080 --> 00:06:13,720 through? OK, so skin subcutaneous fat. 139 00:06:14,000 --> 00:06:18,080 Right then the platysma muscle, then you get to the investing 140 00:06:18,080 --> 00:06:21,960 layer of deep cervical fascia. Then you find the strap muscles, 141 00:06:22,080 --> 00:06:24,960 the sternohyoid and sternothyroid, and you separate 142 00:06:24,960 --> 00:06:27,120 them in the midline. You retract them laterally. 143 00:06:27,120 --> 00:06:31,280 Exactly, and then you hit the pre tracheal fascia and sitting 144 00:06:31,280 --> 00:06:34,320 right there usually mocking you is the thyroid is. 145 00:06:34,320 --> 00:06:37,680 Smith and this usually sits over the second, third and fourth 146 00:06:37,680 --> 00:06:40,120 rings. Usually, but anatomy is rude. 147 00:06:40,680 --> 00:06:42,680 It varies. Sometimes it's high, sometimes 148 00:06:42,680 --> 00:06:44,760 it's low, but you have to deal with it. 149 00:06:44,840 --> 00:06:47,000 You can retract it up. You can retract it down. 150 00:06:47,400 --> 00:06:51,600 But Morgan and McHale is very specific here for the exam. 151 00:06:51,600 --> 00:06:53,800 You mentioned division and ligation. 152 00:06:53,800 --> 00:06:56,520 Cut your tie. Yes, because if you just retract 153 00:06:56,520 --> 00:06:59,080 it, it can slip back over the stoma later and cause 154 00:06:59,080 --> 00:07:02,200 obstruction or bleeding. So division and ligation is the 155 00:07:02,200 --> 00:07:03,560 definitive answer. Got it. 156 00:07:03,600 --> 00:07:07,520 But looking deeper, below the isthmus, we enter the real 157 00:07:07,520 --> 00:07:10,760 danger zone, the enominate artery, the brachiocephalic. 158 00:07:10,760 --> 00:07:13,320 There's that exactly. In relation to the trachea, it 159 00:07:13,320 --> 00:07:16,600 crosses the trachea low down in the neck, usually behind the 160 00:07:16,600 --> 00:07:20,920 sternum, but and here's the catching children or in people 161 00:07:20,920 --> 00:07:23,480 with a very narrow necks, it can ride high. 162 00:07:23,480 --> 00:07:26,560 So it's more vulnerable. Much more if you place a 163 00:07:26,560 --> 00:07:31,840 tracheostomy too low, say below the 4th ring, or if the tip of 164 00:07:31,840 --> 00:07:35,600 your curved tube angles forward and erodes over time. 165 00:07:35,680 --> 00:07:37,080 It can eat right into that that artery. 166 00:07:37,080 --> 00:07:39,960 It can erode through the tracheal wall and into that. 167 00:07:39,960 --> 00:07:42,120 Artery A tracheoenominate fistula. 168 00:07:42,120 --> 00:07:45,400 Which is essentially an arterial blowout into the airway. 169 00:07:45,400 --> 00:07:47,760 We will talk about managing that in the emergency section. 170 00:07:47,760 --> 00:07:50,360 But anatomically, you must know it's there, OK? 171 00:07:50,440 --> 00:07:53,000 And don't forget the nerves. What's running on either side? 172 00:07:53,320 --> 00:07:56,560 The recurrent laryngeal nerves. In the tracheoesophageal groove, 173 00:07:56,840 --> 00:08:00,360 stray too far laterally with your dissection and you paralyze 174 00:08:00,360 --> 00:08:02,600 A vocal cord. Unilateral is bad. 175 00:08:02,600 --> 00:08:04,720 Bilateral is a catastrophe. Right. 176 00:08:04,720 --> 00:08:07,280 So midline, midline, midline. That's the mantra. 177 00:08:07,280 --> 00:08:10,160 Stay in the middle. Let's pivot to Physiology. 178 00:08:10,400 --> 00:08:13,320 We mentioned Dead Space earlier. Can you unpack that for me in 179 00:08:13,320 --> 00:08:15,600 exam terms? Sure, let's get a little nerdy 180 00:08:15,600 --> 00:08:18,560 with the physics. Anatomical Dead Space is the 181 00:08:18,560 --> 00:08:23,200 volume of air in your conducting Airways, nose, throat, trachea 182 00:08:23,200 --> 00:08:25,600 that doesn't reach the alveoli for gas exchange. 183 00:08:25,680 --> 00:08:27,440 It's still in the Pikes. Exactly. 184 00:08:27,760 --> 00:08:30,720 When you breathe through your nose and mouth, that path is 185 00:08:30,720 --> 00:08:32,600 long. When you breathe through a 186 00:08:32,600 --> 00:08:36,080 tracheostomy, you are bypassing the entire upper airway. 187 00:08:36,320 --> 00:08:39,000 You are cutting that path in half, sometimes more. 188 00:08:39,280 --> 00:08:43,080 So the ratio of Dead Space to tidal volume, the VDVT ratio, 189 00:08:43,080 --> 00:08:44,600 goes down. Exactly. 190 00:08:44,840 --> 00:08:48,080 For a standard tidal volume, more of that air is actually 191 00:08:48,080 --> 00:08:51,200 participating in gas exchange. This means the patient doesn't 192 00:08:51,200 --> 00:08:54,080 have to breathe as deeply or as frequently to maintain their 193 00:08:54,080 --> 00:08:56,160 blood gases. Which means less energy 194 00:08:56,160 --> 00:08:58,240 expenditure. It all contributes to lowering 195 00:08:58,240 --> 00:09:00,800 the overall work of breathing, but the bigger factor is 196 00:09:00,800 --> 00:09:02,000 resistance. Poiseuille's Law. 197 00:09:02,200 --> 00:09:04,720 That's the one. Resistance is inversely 198 00:09:04,720 --> 00:09:07,840 proportional to the radius to the power of four and directly 199 00:09:07,840 --> 00:09:10,640 proportional to length. So a long thin tube has high 200 00:09:10,640 --> 00:09:11,760 resistance. Right. 201 00:09:12,040 --> 00:09:15,320 An endotracheal tube is long, maybe 30 centimeters. 202 00:09:15,440 --> 00:09:18,960 A tracheostomy tube is short, maybe 8 centimeters. 203 00:09:19,040 --> 00:09:23,760 So simply by short the tube, you drop resistance significantly. 204 00:09:23,840 --> 00:09:27,480 Drastically, which again decreases the work of breathing 205 00:09:27,480 --> 00:09:31,160 or WOB. This is huge for a patient who 206 00:09:31,160 --> 00:09:33,400 is weak and trying to wean off the ventilator. 207 00:09:33,400 --> 00:09:35,000 OK. But is there a catch? 208 00:09:35,200 --> 00:09:37,640 However, and this is a distinction level point for the 209 00:09:37,640 --> 00:09:39,440 exam, remember the radius factor. 210 00:09:39,760 --> 00:09:44,000 A very small tracheostomy tube, say a size 6 point O, can 211 00:09:44,000 --> 00:09:47,040 actually have higher resistance than a normal airway because the 212 00:09:47,040 --> 00:09:48,680 radius is so small. Oh, interesting. 213 00:09:49,000 --> 00:09:51,840 So the benefit really kicks in with appropriate sizing. 214 00:09:51,840 --> 00:09:56,880 Size 8.0 is usually the sweet spot for adult males, 7.0 or 7.5 215 00:09:56,880 --> 00:09:59,680 for females. Is there a downside to bypassing 216 00:09:59,680 --> 00:10:02,080 the nose, physiologically speaking? 217 00:10:02,160 --> 00:10:03,880 Definitely. The nose isn't just a tube. 218 00:10:03,880 --> 00:10:06,480 It's an air conditioner. It warms and humidifies the air 219 00:10:06,480 --> 00:10:08,600 we breathe. It's the mucosiliary escalator, 220 00:10:08,600 --> 00:10:10,440 right? When you bypass it, you lose 221 00:10:10,440 --> 00:10:13,320 that humidification. The secretions in the lungs get 222 00:10:13,320 --> 00:10:16,600 dry, thick and sticky. We call that inspiration. 223 00:10:16,600 --> 00:10:18,720 It's like concrete. That's a huge problem. 224 00:10:18,720 --> 00:10:20,880 And what about the laryngeal breaking mechanism? 225 00:10:20,880 --> 00:10:23,800 I've seen that term. This is a subtle but important 226 00:10:23,800 --> 00:10:27,280 physiological point. Normally when you exhale, your 227 00:10:27,280 --> 00:10:31,120 vocal cords narrow slightly. This creates a tiny back 228 00:10:31,120 --> 00:10:34,920 pressure, a physiological peep. Positive and expiratory 229 00:10:34,920 --> 00:10:37,760 pressure. Right, a natural peep that helps 230 00:10:37,760 --> 00:10:41,360 to keep your alveoli open at the end of expiration. 231 00:10:41,360 --> 00:10:44,040 Under the track, you lose that. You lose that completely, the 232 00:10:44,040 --> 00:10:45,960 air just dumps out of the hole in the neck. 233 00:10:46,240 --> 00:10:50,160 So unless you add some external PEEP or C PAP from the 234 00:10:50,160 --> 00:10:54,480 ventilator, these patients are prone to basal atelectasis. 235 00:10:55,040 --> 00:10:57,800 Their lung bases collapse because they lost that natural 236 00:10:57,800 --> 00:10:59,320 back pressure. Fascinating. 237 00:10:59,480 --> 00:11:01,800 OK, let's move to Part C indications and types. 238 00:11:01,800 --> 00:11:05,520 This is labeled Exam gold. If I'm writing the long answer, 239 00:11:05,520 --> 00:11:07,920 how do I organize the indication so I sound professional? 240 00:11:08,000 --> 00:11:10,400 Don't just list them randomly, categorize them. 241 00:11:10,400 --> 00:11:12,800 It shows organized thinking. OK, what are the categories? 242 00:11:12,800 --> 00:11:14,960 Category 1 Upper airway obstruction. 243 00:11:14,960 --> 00:11:17,040 This is the classic life saving indication. 244 00:11:17,040 --> 00:11:20,000 So things like infections. Yes, sync infections like 245 00:11:20,000 --> 00:11:23,440 Ludwig's angina where the floor of the mouth swells up, or 246 00:11:23,440 --> 00:11:27,400 epiglottitis. Trauma like severe maxillofacial 247 00:11:27,400 --> 00:11:29,320 fractures where you can't intubate orally. 248 00:11:29,720 --> 00:11:32,440 Tumors of the larynx or thyroid that are compressing the airway, 249 00:11:32,840 --> 00:11:35,880 or bilateral vocal cord paralysis where the cords are 250 00:11:35,880 --> 00:11:38,480 stuck closed. Basically anything blocking the 251 00:11:38,480 --> 00:11:39,680 door from above. Got it. 252 00:11:39,880 --> 00:11:42,040 Category 2. Prolonged mechanical 253 00:11:42,040 --> 00:11:44,600 ventilation. This is the most common reason 254 00:11:44,600 --> 00:11:47,880 in the ICU today. The Trackman trial is the famous 255 00:11:47,880 --> 00:11:50,640 study here. Generally, if a patient is going 256 00:11:50,640 --> 00:11:54,120 to be on a ventilator for more than 7 to 14 days, we start 257 00:11:54,120 --> 00:11:56,280 thinking about a track. And why is that? 258 00:11:56,520 --> 00:11:59,680 It prevents laryngeal stenosis from the ETT pressing on the 259 00:11:59,680 --> 00:12:02,480 vocal cords for weeks. And like we said, it makes 260 00:12:02,480 --> 00:12:06,120 weaning much, much easier. Is there a hard rule on the 261 00:12:06,120 --> 00:12:07,960 days? Seven days, 10 days? 262 00:12:08,080 --> 00:12:09,440 I feel like this is always debated. 263 00:12:09,440 --> 00:12:11,600 It is. The Trackman trial showed that 264 00:12:11,600 --> 00:12:15,360 doing a tracheostomy very early, like within four days, didn't 265 00:12:15,360 --> 00:12:18,640 necessarily improve 30 day mortality compared to doing it 266 00:12:18,640 --> 00:12:22,480 later after 10 days. So the consensus is usually to 267 00:12:22,480 --> 00:12:26,120 make a decision around day 7 to 10 based on clinical judgment. 268 00:12:26,120 --> 00:12:28,320 So it's not a race. It's not a race. 269 00:12:28,360 --> 00:12:31,880 If you know the patient isn't waking up anytime soon, say a 270 00:12:31,880 --> 00:12:34,000 severe head injury, you might do it earlier. 271 00:12:34,000 --> 00:12:36,320 If you think they might just turn a corner tomorrow, you 272 00:12:36,320 --> 00:12:38,080 wait. OK, Category 3. 273 00:12:38,400 --> 00:12:41,960 Pulmonary toilet This is for patients who cannot clear their 274 00:12:41,960 --> 00:12:44,960 own secretions. So neurological causes mainly. 275 00:12:45,000 --> 00:12:49,280 Yes, bulbar palsy, a big stroke, Guillain Barre syndrome. 276 00:12:49,280 --> 00:12:53,200 They are literally drowning in their own mucus and the track 277 00:12:53,200 --> 00:12:56,160 gives us a direct route to suction them out effectively 278 00:12:56,160 --> 00:12:57,520 and. What about airway protection? 279 00:12:57,520 --> 00:13:00,520 Is that its own category? I'd put it as #4 prevention of 280 00:13:00,520 --> 00:13:03,640 aspiration in patients with no gag reflex, maybe after a head 281 00:13:03,640 --> 00:13:06,480 injury. But, and this is a crucial exam 282 00:13:06,480 --> 00:13:11,760 nuance, OK, a cuff tracheostomy tube does not guarantee 100% 283 00:13:11,760 --> 00:13:14,880 protection against aspiration. Right, I remember reading that. 284 00:13:14,880 --> 00:13:17,000 Why is that? Liquid can still trickle down 285 00:13:17,000 --> 00:13:18,880 the microscopic channels in the cuff folds. 286 00:13:19,240 --> 00:13:22,200 Microaspiration happens. It's much better than a 287 00:13:22,200 --> 00:13:25,480 completely unprotected airway, but it's not a perfect seal. 288 00:13:25,760 --> 00:13:28,800 You have to mention that to show you understand the limitations. 289 00:13:28,800 --> 00:13:31,120 Are there any absolute contraindications? 290 00:13:31,320 --> 00:13:34,720 Very few absolute ones because it's often a life saving 291 00:13:34,720 --> 00:13:39,080 procedure, but there are strong relative contraindications that 292 00:13:39,080 --> 00:13:42,760 you must mention. One if the patient requires very 293 00:13:42,760 --> 00:13:48,600 high oxygen and FIO 2 / 80% or high PEEP over 10 centimeters of 294 00:13:48,600 --> 00:13:51,000 water. Why is that a contraindication? 295 00:13:51,240 --> 00:13:53,760 It seems like they need a secure airway more than anyone. 296 00:13:53,760 --> 00:13:57,280 Because during the procedure, specifically the percutaneous 1, 297 00:13:57,280 --> 00:14:01,120 you have to disconnect the circuit and stop ventilation to 298 00:14:01,120 --> 00:14:02,960 swap the tubes or dilate the tract. 299 00:14:03,440 --> 00:14:05,440 So they have no reserve. They have 0 reserve. 300 00:14:05,440 --> 00:14:08,200 They will desaturate instantly and potentially have a cardiac 301 00:14:08,200 --> 00:14:10,120 arrest on the table. You have to stabilize them 302 00:14:10,120 --> 00:14:11,520 first. OK, that makes sense. 303 00:14:11,560 --> 00:14:14,720 What else? Two uncorrected Coagulopathy, 304 00:14:15,080 --> 00:14:18,840 especially for a percutaneous tracheostomy, a PDT, you are 305 00:14:18,840 --> 00:14:22,520 poking a hole blindly. If they have an INR of three or 306 00:14:22,520 --> 00:14:25,320 platelets of 20,000, you're going to cause a massive 307 00:14:25,320 --> 00:14:26,960 hematoma that compresses the airway. 308 00:14:27,160 --> 00:14:28,880 So you have to correct the numbers before you start. 309 00:14:28,880 --> 00:14:32,280 You have to or opt for an open surgical procedure where you can 310 00:14:32,280 --> 00:14:34,720 actually see and control the bleeding vessels. 311 00:14:34,880 --> 00:14:37,200 Let's distinguish the types of tracheostomy. 312 00:14:37,560 --> 00:14:39,480 The outline mentions high versus low. 313 00:14:39,480 --> 00:14:42,000 What does that mean? This is an anatomy question. 314 00:14:42,080 --> 00:14:44,680 It's about where you make the hole in the trachea. 315 00:14:45,320 --> 00:14:48,960 A high tracheostomy enters above the thyroid isthmus at the first 316 00:14:48,960 --> 00:14:51,920 or second ring. This is bad practice. 317 00:14:51,920 --> 00:14:53,720 Why? It's too close to the cricoi 318 00:14:53,720 --> 00:14:57,400 cartilage and can cause subglottic stenosis, a scarring 319 00:14:57,400 --> 00:15:00,440 and narrowing of the airway that is very, very hard to fix. 320 00:15:00,440 --> 00:15:02,480 OK, so avoid high, What about low? 321 00:15:02,760 --> 00:15:05,640 A low tracheostomy is below the isthmus. 322 00:15:05,640 --> 00:15:07,160 This is also dangerous. Why? 323 00:15:07,880 --> 00:15:09,920 The inominant artery. The inominant artery we talked 324 00:15:09,920 --> 00:15:12,880 about high risk of erosion and catastrophic bleeding. 325 00:15:12,880 --> 00:15:15,920 So we want to be in the middle. The mid tracheostomy is the 326 00:15:15,920 --> 00:15:19,160 sweet spot behind the isthmus entering at the second, third or 327 00:15:19,160 --> 00:15:21,120 fourth rings. That's the ideal location. 328 00:15:21,280 --> 00:15:24,080 And the other big distinction is surgical versus percutaneous, 329 00:15:24,080 --> 00:15:26,640 the PDT. Correct surgical is done in the 330 00:15:26,640 --> 00:15:29,600 OR open incision direct visualization. 331 00:15:29,880 --> 00:15:32,920 It's better for patients with difficult anatomy, short fat 332 00:15:32,920 --> 00:15:35,160 necks or big goiters. And PDT. 333 00:15:35,160 --> 00:15:38,240 PDT is done at the bedside in the ICU using using the cylinder 334 00:15:38,240 --> 00:15:40,160 technique, guide wires, and dilators. 335 00:15:40,560 --> 00:15:44,360 It's faster, it's cheaper, but it really requires the patient 336 00:15:44,360 --> 00:15:47,160 to have normal neck anatomy. We'll get into the details of 337 00:15:47,160 --> 00:15:48,240 those now. Perfect. 338 00:15:48,440 --> 00:15:49,960 Which brings us to Part D technique. 339 00:15:50,400 --> 00:15:52,520 Let's start with the classic surgical tracheostomy. 340 00:15:52,520 --> 00:15:55,240 This is exam core. Walk me through the steps, 341 00:15:55,400 --> 00:15:59,400 focusing specifically on what I, as the anesthetist, need to be 342 00:15:59,440 --> 00:16:03,120 doing and thinking about. OK, step one is positioning. 343 00:16:03,640 --> 00:16:06,560 You want the trachea to be as superficial and accessible as 344 00:16:06,560 --> 00:16:09,360 possible. So patient is supine and you put 345 00:16:09,360 --> 00:16:12,600 a sandbag or a shoulder roll under their shoulders to extend 346 00:16:12,600 --> 00:16:14,200 the neck. To bring the trachea forward. 347 00:16:14,200 --> 00:16:15,840 Exactly. And a little head up. 348 00:16:15,840 --> 00:16:19,800 Tilt maybe 15 to 20° to drain the veins in the neck and reduce 349 00:16:19,800 --> 00:16:21,880 bleeding. The surgeon makes the incision. 350 00:16:21,920 --> 00:16:25,320 Usually a transverse or collar incision for cosmetic reasons. 351 00:16:25,320 --> 00:16:28,400 About midway between the cricoid and the Super sternal notch. 352 00:16:28,400 --> 00:16:30,040 OK. They dissect down in the 353 00:16:30,040 --> 00:16:32,880 midline, separate the Strat muscles, ligate the thyro, 354 00:16:32,880 --> 00:16:35,360 dismiss. Then they identify the trachea 355 00:16:35,360 --> 00:16:37,160 itself. They might confirm it by 356 00:16:37,160 --> 00:16:39,320 aspirating air with a needle and syringe. 357 00:16:39,600 --> 00:16:41,080 And then the cut into the trachea. 358 00:16:41,080 --> 00:16:45,720 Right, they can make a simple window a cruciate cut, but a key 359 00:16:45,720 --> 00:16:49,160 term to drop in your exam answer is the Bjork flap. 360 00:16:49,560 --> 00:16:51,520 Bjork flap. So I see this in the textbooks. 361 00:16:51,520 --> 00:16:53,880 What is it exactly and why is it important? 362 00:16:53,960 --> 00:16:57,720 It's where the surgeon cuts an inferiorly based flap of the 363 00:16:57,720 --> 00:17:00,240 tracheal wall. So AU shaped cut opening 364 00:17:00,240 --> 00:17:02,520 downwards. Exactly, and they take that 365 00:17:02,520 --> 00:17:04,880 little flap and suture it to the skin of the neck. 366 00:17:04,920 --> 00:17:06,960 It creates a little ramp. I ramp. 367 00:17:07,040 --> 00:17:08,520 Yes. If the tube falls out 368 00:17:08,520 --> 00:17:11,240 accidentally in the first few days before the tract is mature, 369 00:17:11,440 --> 00:17:15,040 that flap keeps the hole open and basically guides the tube 370 00:17:15,119 --> 00:17:17,839 back into the trachea. It's a huge safety feature, 371 00:17:17,839 --> 00:17:20,160 especially for decannulation emergencies. 372 00:17:20,359 --> 00:17:22,280 That's brilliant. OK, now the critical moment. 373 00:17:22,480 --> 00:17:25,720 The airway exchange. I want to slow down here because 374 00:17:25,720 --> 00:17:27,839 this feels like the part where careers can end. 375 00:17:28,400 --> 00:17:30,640 I'm at the head of the bed. The surgeon is ready to put the 376 00:17:30,640 --> 00:17:34,280 track tube in, but my oral ETT is in the way. 377 00:17:34,520 --> 00:17:36,600 What is the dance? This is all about closed loop 378 00:17:36,600 --> 00:17:38,520 communication. It has to be perfect. 379 00:17:38,560 --> 00:17:41,800 The surgeon will say something like trachea is open, I'm ready 380 00:17:41,800 --> 00:17:44,000 to insert. OK, what do I do? 381 00:17:44,200 --> 00:17:46,960 You, the anesthetist, check your monitor. 382 00:17:47,360 --> 00:17:51,240 Is the patient fully paralyzed? Are they 100% oxygenated? 383 00:17:51,680 --> 00:17:54,240 You have to be ready for a period of apnea. 384 00:17:54,240 --> 00:17:57,320 You say ready. OK, the surgeon says withdraw 385 00:17:57,320 --> 00:17:58,600 the ETT. Now. 386 00:17:58,600 --> 00:18:00,800 What's the very first thing you do before you pull? 387 00:18:02,000 --> 00:18:04,720 Deflate the cuff. Even before that, suction the 388 00:18:04,720 --> 00:18:08,360 mouth and pharynx. Of course, so gunk doesn't fall 389 00:18:08,360 --> 00:18:09,840 down into the lungs. Exactly. 390 00:18:09,840 --> 00:18:13,560 So you suction thoroughly, then you deflate the cuff of your 391 00:18:13,560 --> 00:18:17,800 oral ETT completely, and you pull back slowly. 392 00:18:18,040 --> 00:18:20,840 How far do I pull back? You are watching the surgeon. 393 00:18:20,840 --> 00:18:23,560 The surgeon is looking into the hole they just made in the neck. 394 00:18:24,160 --> 00:18:27,640 They want to see the tip of your EPT slide up past their 395 00:18:27,640 --> 00:18:29,520 incision. As soon as they see the cuff 396 00:18:29,520 --> 00:18:31,320 clear the window they'll yell STOP. 397 00:18:31,800 --> 00:18:33,200 And I hold it there. I freeze. 398 00:18:33,200 --> 00:18:35,520 You freeze. The tip of your tube is now 399 00:18:35,520 --> 00:18:39,160 sitting just above the vocal cords or high in the subglottic 400 00:18:39,160 --> 00:18:41,280 space. It is not out of the patient. 401 00:18:41,280 --> 00:18:42,800 Why not just take it out completely? 402 00:18:42,800 --> 00:18:44,640 Get it out of the way. Because what if the surgeon 403 00:18:44,640 --> 00:18:47,560 can't get the trash tube in? What if the hole collapses? 404 00:18:47,560 --> 00:18:49,880 What if there's a massive bleed right at that moment? 405 00:18:50,080 --> 00:18:52,480 Then you've lost the airway. You have completely lost the 406 00:18:52,480 --> 00:18:55,600 airway by leaving the tube tube just above the cords. 407 00:18:55,600 --> 00:18:58,520 If disaster strikes you, just push it back down a few 408 00:18:58,520 --> 00:19:01,400 centimeters, inflate the cuff and you are ventilating again. 409 00:19:01,520 --> 00:19:02,960 It is your lifeboat. OK. 410 00:19:03,000 --> 00:19:05,600 That's a critical safety step. Absolutely critical. 411 00:19:05,600 --> 00:19:09,400 Only when the surgeon says tracks in cuff is up and you've 412 00:19:09,400 --> 00:19:12,120 connected your circuit to the new track tube and see a 413 00:19:12,120 --> 00:19:16,080 beautiful CO2 waveform on your monitor, only then do you remove 414 00:19:16,080 --> 00:19:18,200 the oral ETT completely. Got it. 415 00:19:18,200 --> 00:19:21,640 Confirm placement first. Always end title CO2 is your 416 00:19:21,640 --> 00:19:24,880 confirmation. Now let's talk percutaneous 417 00:19:24,880 --> 00:19:28,920 dilatational tracheostomy PDT. This is listed as very high 418 00:19:28,920 --> 00:19:32,360 yield for short notes. Yes, because PDT is the standard 419 00:19:32,360 --> 00:19:35,040 in most Icus now for elective cases. 420 00:19:35,320 --> 00:19:37,880 It uses the Seldinger technique just like putting in a central 421 00:19:37,880 --> 00:19:39,360 line. OK, walk me through it. 422 00:19:39,480 --> 00:19:43,560 Step one bronchoscopic guidance. This is the gold standard. 423 00:19:43,880 --> 00:19:47,240 You pass a flexible bronchoscope down the existing ETT. 424 00:19:47,440 --> 00:19:49,280 You're watching from the inside. Exactly. 425 00:19:49,600 --> 00:19:52,760 You're watching the anterior wall of the trachea on a screen. 426 00:19:53,080 --> 00:19:55,520 Step 2. The operator punctures the 427 00:19:55,520 --> 00:19:58,080 trachea between the second and third rings with a needle. 428 00:19:58,320 --> 00:20:01,880 You watch the needle indent the wall and then pop into the lumen 429 00:20:01,920 --> 00:20:04,040 right on the screen. That's much safer than doing it 430 00:20:04,040 --> 00:20:05,560 blind. Infinitely safer. 431 00:20:05,960 --> 00:20:09,360 Step three, they pass a guide wire through the needle into the 432 00:20:09,360 --> 00:20:12,320 trachea. Step four they remove the needle 433 00:20:12,320 --> 00:20:14,080 and dilate the tract over the wire. 434 00:20:14,680 --> 00:20:18,040 The Ciaglia Blue Rhino is the most common single tapered 435 00:20:18,040 --> 00:20:20,320 dilator. It looks like a curved rhino 436 00:20:20,320 --> 00:20:21,600 horn. And you just push that in to 437 00:20:21,600 --> 00:20:23,760 stretch the hole. You gently advance it to stretch 438 00:20:23,760 --> 00:20:26,960 the hole to the right size. Step five you slide the 439 00:20:26,960 --> 00:20:30,080 tracheostomy tube over the dilator and into the trachea. 440 00:20:30,440 --> 00:20:32,600 Then you pull the dilator and guide wire out. 441 00:20:32,640 --> 00:20:35,360 Inflate the cuff and confirm with your CO2 trace. 442 00:20:35,480 --> 00:20:37,440 Why is the bronchoscope so important? 443 00:20:37,480 --> 00:20:38,880 What's the main thing it prevents? 444 00:20:39,120 --> 00:20:42,000 Posterior wall puncture. Remember we said the esophagus 445 00:20:42,000 --> 00:20:45,120 is right behind the thin membranous part of the trachea. 446 00:20:45,480 --> 00:20:48,560 If you push that needle too hard without seeing where it's going, 447 00:20:48,720 --> 00:20:50,600 you can easily stab the esophagus. 448 00:20:50,920 --> 00:20:53,480 The scope lets you see the needle enter the lumen of the 449 00:20:53,480 --> 00:20:56,440 trachea safely and stops you from going too far. 450 00:20:56,520 --> 00:20:58,960 OK. And the main advantages of PDT 451 00:20:58,960 --> 00:21:01,240 over surgical? It's a bedside procedure. 452 00:21:01,240 --> 00:21:04,800 You don't have to transport a critically I'll unstable patient 453 00:21:04,800 --> 00:21:07,520 to the operating room. That's a huge plus, right? 454 00:21:07,760 --> 00:21:10,920 Avoids the transport risk. Also a smaller skin incision 455 00:21:10,920 --> 00:21:14,040 which means less infection and better cosmetic result. 456 00:21:14,040 --> 00:21:16,360 It's generally faster and more cost effective. 457 00:21:16,520 --> 00:21:18,720 But the disadvantage is that it's still a semi blind 458 00:21:18,720 --> 00:21:19,840 procedure, right? Correct. 459 00:21:19,880 --> 00:21:22,920 Even with a scope, we don't have the same direct vision of the 460 00:21:22,920 --> 00:21:25,520 surrounding vessels. So it's not for patients with 461 00:21:25,520 --> 00:21:29,240 difficult anatomy, previous neck surgery or as we said, 462 00:21:29,240 --> 00:21:32,560 Coagulopathy. Moving on to part E anesthetic 463 00:21:32,560 --> 00:21:35,560 management pre op prep. We've covered some of this. 464 00:21:35,600 --> 00:21:39,000 You're going to check coagulation PTINR platelets. 465 00:21:39,000 --> 00:21:43,680 You need to optimize FIO 2 to one point O to pre oxygenate 466 00:21:43,680 --> 00:21:45,720 them as much as possible. Build that reserve. 467 00:21:46,200 --> 00:21:49,640 Build that reserve for the apnea period and you must have the 468 00:21:49,640 --> 00:21:54,000 difficult airway cart in the room and ready Plan B, Plan BC 469 00:21:54,000 --> 00:21:57,120 and D. You need smaller ET TS a 470 00:21:57,120 --> 00:22:00,200 laryngeal mass airway cricothyroidotomy kit. 471 00:22:00,680 --> 00:22:03,520 You have to be prepared for total airway loss. 472 00:22:03,560 --> 00:22:06,560 What about anesthesia type GA versus local? 473 00:22:06,560 --> 00:22:09,840 How do you decide? For 99% of cases, especially 474 00:22:09,840 --> 00:22:12,560 elective ones, general anesthesia is standard. 475 00:22:12,760 --> 00:22:15,440 You have a secure airway with the ETT. 476 00:22:15,440 --> 00:22:18,160 You have controlled ventilation. The patient is still 477 00:22:18,160 --> 00:22:21,280 uncomfortable. OK, when would you ever use 478 00:22:21,280 --> 00:22:23,160 local? Consider the patient with a 479 00:22:23,160 --> 00:22:27,320 massive friable upper airway tumor or LED wigs angina where 480 00:22:27,320 --> 00:22:29,520 the neck is rock hard and swollen shut. 481 00:22:29,520 --> 00:22:31,080 The ones you're terrified to induce. 482 00:22:31,080 --> 00:22:32,680 Exactly. If you put them to sleep and 483 00:22:32,680 --> 00:22:35,080 paralyze them, the airway muscles relax. 484 00:22:35,080 --> 00:22:37,680 The tumor might flop over and block everything completely. 485 00:22:37,680 --> 00:22:40,360 You might find yourself in a cannot intubate, cannot 486 00:22:40,360 --> 00:22:42,720 ventilate situation. The ultimate nightmare. 487 00:22:42,720 --> 00:22:46,760 It is in that specific high risk scenario you may opt for an A 488 00:22:46,760 --> 00:22:49,120 weak tracheostomy under local anesthesia. 489 00:22:49,120 --> 00:22:51,680 That sounds incredible, really stressful for everyone involved. 490 00:22:51,880 --> 00:22:54,600 It is the most stressful procedure you will ever be a 491 00:22:54,600 --> 00:22:57,600 part of. You use local infiltration 492 00:22:57,600 --> 00:23:00,120 lidocaine with adrenaline along the incision line. 493 00:23:00,560 --> 00:23:04,520 You might do a superficial cervical plexus block, but you 494 00:23:04,520 --> 00:23:07,800 keep the patient breathing spontaneously the entire time. 495 00:23:07,800 --> 00:23:09,720 You're talking to them. You're talking to them, 496 00:23:09,720 --> 00:23:13,120 reassuring them you give them just enough sedation to tolerate 497 00:23:13,120 --> 00:23:15,600 it, but not so much that they stop breathing. 498 00:23:16,320 --> 00:23:19,360 You do not paralyze them until the surgeon has confirmed the 499 00:23:19,360 --> 00:23:21,920 trachea is open and the tube is in and secure. 500 00:23:22,080 --> 00:23:25,360 Maintain spontaneous ventilation at all costs at all costs. 501 00:23:25,360 --> 00:23:27,520 And there's a note here about fire safety in the 502 00:23:27,520 --> 00:23:31,400 intraoperative considerations. Seems like a classic exam 503 00:23:31,400 --> 00:23:32,760 question. It is a classic. 504 00:23:33,320 --> 00:23:35,920 What is the fire risk during a tracheostomy? 505 00:23:36,000 --> 00:23:38,080 OK, what is it? When the surgeon cuts into the 506 00:23:38,080 --> 00:23:41,680 trachea, there is oxygen rich gas leaking out of the hole from 507 00:23:41,680 --> 00:23:45,400 your ventilator circuit. If they then use diathermy or 508 00:23:45,400 --> 00:23:48,800 cautery to cut the trachea or control bleeding right at the 509 00:23:48,800 --> 00:23:51,200 edge of the opening. Spark plus oxygen. 510 00:23:51,360 --> 00:23:54,240 Equals a fire. You get a blowtorch effect right 511 00:23:54,240 --> 00:23:56,560 in the patient's airway. It is devastating. 512 00:23:56,560 --> 00:23:59,640 So what's the rule? The rule is do not use diathermy 513 00:23:59,640 --> 00:24:02,440 to enter the trachea. The surgeon must use a cold 514 00:24:02,440 --> 00:24:05,480 knife, a scalpel or scissors only for that step. 515 00:24:05,840 --> 00:24:09,160 And as the anesthetist, you should try to reduce the Fio 2 516 00:24:09,160 --> 00:24:12,360 to as low as is safely possible right before they make the 517 00:24:12,360 --> 00:24:14,720 tracheal incision. No cautery on the airway. 518 00:24:14,760 --> 00:24:17,680 Got it. Part F Complications absolutely 519 00:24:17,680 --> 00:24:20,240 essential. Let's break this down into early 520 00:24:20,240 --> 00:24:22,920 and late. OK early complications These 521 00:24:22,920 --> 00:24:27,880 happen immediately in the OR or within the 1st 24 to 48 hours #1 522 00:24:27,960 --> 00:24:29,720 Hemorrhage. This is the most common one. 523 00:24:29,920 --> 00:24:33,160 Usually it's venous bleeding from the anterior jugular veins 524 00:24:33,160 --> 00:24:35,440 or the thyroid isthmus. Usually controllable. 525 00:24:35,640 --> 00:24:41,080 OK #2 pneumothorax, especially in children or in COPD patients 526 00:24:41,080 --> 00:24:44,280 with large boule where the apex of the lung pleura can rise up 527 00:24:44,280 --> 00:24:47,080 high into the neck. If the dissection goes too deep 528 00:24:47,080 --> 00:24:48,920 and too lateral, you can pop the pleura. 529 00:24:49,000 --> 00:24:50,080 How would you know that's happened? 530 00:24:50,200 --> 00:24:53,440 Suddenly High Peak airway pressures drop in saturation and 531 00:24:53,440 --> 00:24:55,200 decreased breath sounds on one side. 532 00:24:55,440 --> 00:24:58,840 You'd need a chest X-ray and a chest string subcutaneous 533 00:24:58,840 --> 00:25:00,880 emphysema. This is dramatic to see. 534 00:25:01,240 --> 00:25:05,200 The patient puffs up like the Michelin Man, their face, neck, 535 00:25:05,400 --> 00:25:08,680 chest, all full of crackly air. When does that happen? 536 00:25:09,080 --> 00:25:12,240 Usually it's because the skin has been sutured too tightly 537 00:25:12,240 --> 00:25:14,960 around the tube. Air leaks out of the tracheal 538 00:25:14,960 --> 00:25:18,600 stoma, but it can't get out of the skin incision, so it tracks 539 00:25:18,600 --> 00:25:21,040 into the subcutaneous tissue. Is it dangerous? 540 00:25:21,240 --> 00:25:23,440 It's alarming, but usually self limiting. 541 00:25:23,440 --> 00:25:26,680 If you loosen or remove a couple of skin sutures to let the air 542 00:25:26,680 --> 00:25:29,800 escape, the bigger worries that it might be a sign of a false 543 00:25:29,800 --> 00:25:31,320 passage. A false passage. 544 00:25:31,320 --> 00:25:33,840 Yes, the tube isn't in the trachea at all. 545 00:25:34,040 --> 00:25:36,000 It's sitting in the pre tracheal tissue. 546 00:25:36,200 --> 00:25:38,200 That's our 4th early complication. 547 00:25:38,480 --> 00:25:41,160 Tube misplacement. A true disaster. 548 00:25:41,160 --> 00:25:42,840 OK. And leak complications. 549 00:25:42,840 --> 00:25:45,360 These are the ones to show up weeks or months later. 550 00:25:45,400 --> 00:25:49,040 Number one is tracheal stenosis, a narrowing of the trachea. 551 00:25:49,040 --> 00:25:51,200 This is usually due to the cuff. Too much pressure. 552 00:25:51,280 --> 00:25:53,240 Exactly. If the cuff pressure is too 553 00:25:53,240 --> 00:25:56,840 high, consistently greater than 25 or 30 centimeters of water, 554 00:25:57,200 --> 00:26:00,040 it exceeds the capillary perfusion pressure of the 555 00:26:00,040 --> 00:26:01,080 tracheal mucosa. It. 556 00:26:01,080 --> 00:26:03,880 Cuts off the blood supply. It cuts off the blood supply, 557 00:26:03,880 --> 00:26:07,400 the mucosa becomes ischemic, it dies, it scars down, and the 558 00:26:07,400 --> 00:26:10,560 trachea narrows at that spot. This is why regular cuff 559 00:26:10,560 --> 00:26:12,160 pressure monitoring is so important. 560 00:26:12,360 --> 00:26:13,320 Right. What's next? 561 00:26:13,800 --> 00:26:18,160 Tracheosophageal fistula or TF We mentioned the risk. 562 00:26:18,160 --> 00:26:21,920 It's due to erosion of the posterior wall, either from the 563 00:26:21,920 --> 00:26:25,040 cuff pressure or the tip of the tube rubbing against it to what 564 00:26:25,120 --> 00:26:26,440 else? Granulation tissue. 565 00:26:26,880 --> 00:26:30,960 Little fleshy cauliflower like growths can form at the stoma 566 00:26:30,960 --> 00:26:34,040 site or at the tip of the tube. They can bleed easily or even 567 00:26:34,040 --> 00:26:35,960 grow large enough to obstruct the tube. 568 00:26:36,120 --> 00:26:40,240 Part G Tracheostomy emergencies. This is Viva gold, the examiner 569 00:26:40,240 --> 00:26:42,600 asks. You are the anesthetist on call 570 00:26:42,600 --> 00:26:44,800 for the hospital. You were called to the ward. 571 00:26:45,120 --> 00:26:47,640 A patient's tracheostomy tube has fallen out. 572 00:26:47,640 --> 00:26:49,960 It was put in yesterday. What do you do? 573 00:26:50,280 --> 00:26:53,040 This is the accidental decannulation scenario. 574 00:26:53,040 --> 00:26:55,360 It is a tract. The entire answer depends on one 575 00:26:55,360 --> 00:26:56,440 question. What's that? 576 00:26:56,440 --> 00:26:58,280 Is it a fresh tract or a mature tract? 577 00:26:58,280 --> 00:27:00,000 And what's the cut off? How do you define that? 578 00:27:00,000 --> 00:27:01,920 Usually seven days. It takes about a week for the 579 00:27:01,920 --> 00:27:04,840 tract to epithelialize to heal into a stable tunnel from the 580 00:27:04,840 --> 00:27:06,440 skin to the trachea. OK. 581 00:27:06,440 --> 00:27:09,320 So in the scenario it was put in yesterday, it's a fresh tract. 582 00:27:09,320 --> 00:27:13,120 It's a fresh tract. The tissue planes, skin, muscle, 583 00:27:13,760 --> 00:27:16,840 trachea are all still soft and mobile. 584 00:27:17,040 --> 00:27:20,280 The second the tube comes out, they will slide over each other 585 00:27:20,280 --> 00:27:22,560 and the hole will disappear. So what's the rule? 586 00:27:22,920 --> 00:27:27,160 The Golden rule Do not blindly poke a tube back into a fresh 587 00:27:27,160 --> 00:27:28,560 stoma. Why not? 588 00:27:28,960 --> 00:27:31,000 I mean if the hole is right there you can see it it. 589 00:27:31,000 --> 00:27:35,080 Looks like it's there, but if you try to force A2 in, you will 590 00:27:35,080 --> 00:27:39,400 almost certainly miss the small collapsed tracheal opening and 591 00:27:39,400 --> 00:27:42,000 slide into the pretracheal space instead. 592 00:27:42,120 --> 00:27:44,640 You create a false passage. You create a false passage. 593 00:27:44,840 --> 00:27:46,760 Then you attach a bag and ventilate. 594 00:27:47,080 --> 00:27:49,840 You pump air into the soft tissues of the neck, which then 595 00:27:49,840 --> 00:27:51,960 compresses the real airway from the outside. 596 00:27:52,160 --> 00:27:55,200 The patient will desaturate and die of hypoxia and you will have 597 00:27:55,200 --> 00:27:58,040 caused it. OK, so for a fresh track, what 598 00:27:58,040 --> 00:27:59,960 is the algorithm? What do I say in the exam? 599 00:28:00,040 --> 00:28:04,760 One, call for help anesthetic senior ENT surgeon crash team. 600 00:28:05,240 --> 00:28:08,800 Two, apply high flow oxygen to the patient's face and over the 601 00:28:08,800 --> 00:28:10,000 stoma. They might be able to get some 602 00:28:10,000 --> 00:28:13,960 gas and through the hole. Three, do not poke the neck. 603 00:28:14,240 --> 00:28:18,000 And four. Four, perform oral intubation. 604 00:28:18,240 --> 00:28:20,240 Treat it like a standard difficult airway. 605 00:28:20,440 --> 00:28:24,280 Secure the airway from above. Once the patient is stable and 606 00:28:24,280 --> 00:28:27,400 intubated, you can then take them back to the OR and have the 607 00:28:27,400 --> 00:28:30,600 surgeons redo the tracheostomy in a controlled setting. 608 00:28:30,720 --> 00:28:32,880 OK, that's a very clear, safe answer. 609 00:28:33,080 --> 00:28:36,040 Now what if it's a mature tract, say 3 weeks old? 610 00:28:36,200 --> 00:28:37,640 Then you have a well formed tunnel. 611 00:28:37,640 --> 00:28:40,000 It's much safer. You can attempt to reinsert the 612 00:28:40,000 --> 00:28:42,840 tube. You use the obturator that comes 613 00:28:42,840 --> 00:28:44,920 with the tube to give it a smooth rounded tip. 614 00:28:44,920 --> 00:28:48,480 You gently try to reinsert it, or even better, you can try a 615 00:28:48,480 --> 00:28:52,640 smaller size tube first, or put a gum elastic bougie into the 616 00:28:52,640 --> 00:28:55,960 stoma feel for the tracheal clicks and then railroad the 617 00:28:55,960 --> 00:28:58,200 tube over it. But what if you meet resistance? 618 00:28:58,200 --> 00:29:00,320 If you meet any resistance, you stop. 619 00:29:00,960 --> 00:29:04,240 Oral intubation is always the ultimate safety net for a fresh 620 00:29:04,240 --> 00:29:06,960 or a mature tract. If you can't secure the airway 621 00:29:06,960 --> 00:29:08,720 from the neck, secure it from the mouth. 622 00:29:08,920 --> 00:29:11,160 Another emergency, the blocked tube. 623 00:29:11,160 --> 00:29:12,680 What are the steps? Very common. 624 00:29:12,680 --> 00:29:15,960 Usually it's a thick mucus plug. Step one is the easiest and 625 00:29:15,960 --> 00:29:18,440 often works. Remove the inner cannula. 626 00:29:18,440 --> 00:29:21,080 Most tubes have an inner tube you can just pull out and clean 627 00:29:21,080 --> 00:29:23,480 or replace. If the plug is in there, you've 628 00:29:23,480 --> 00:29:25,880 solved the problem instantly. And if that doesn't work. 629 00:29:26,280 --> 00:29:29,280 Step 2. Pass a suction catheter down the 630 00:29:29,280 --> 00:29:30,880 tube. If it goes in easily, the tube 631 00:29:30,960 --> 00:29:33,040 tube is patent. If it stops, it's blocked. 632 00:29:33,200 --> 00:29:35,920 OK, Step 3. Deflate the cuff. 633 00:29:36,480 --> 00:29:39,200 Sometimes the cuff can honeyate over the end of the tube and 634 00:29:39,200 --> 00:29:42,240 cause an obstruction. Deflating it might relieve it. 635 00:29:42,480 --> 00:29:45,120 And if you still can't pass a suction catheter after all that? 636 00:29:45,120 --> 00:29:47,000 The two is definitively obstructed. 637 00:29:47,240 --> 00:29:49,760 You must remove it and replace it with a new one, just like in 638 00:29:49,760 --> 00:29:52,560 an accidental depanulation. Now the bleeding emergency. 639 00:29:52,640 --> 00:29:55,520 The big one, we talked about the anomin artery earlier. 640 00:29:55,800 --> 00:29:57,160 Let's talk about the Sentinel bleed. 641 00:29:57,240 --> 00:29:59,920 This is absolutely vital for any exam. 642 00:30:00,280 --> 00:30:03,720 A small amount of bright red pulsatile blood from the stoma, 643 00:30:03,720 --> 00:30:06,680 maybe just a teaspoonful, is often a warning sign. 644 00:30:06,880 --> 00:30:09,160 A warning for what? It's called a Sentinel bleed. 645 00:30:09,320 --> 00:30:12,400 It means the tracheoenominate fistula has formed and is 646 00:30:12,400 --> 00:30:15,400 leaking slightly before the main catastrophic blowout. 647 00:30:15,400 --> 00:30:17,840 You must not ignore it. If a nurse calls you about a 648 00:30:17,840 --> 00:30:20,720 small bleed, you have to go see it immediately and get the 649 00:30:20,720 --> 00:30:24,040 surgeons involved. OK, now the worst case scenario 650 00:30:24,040 --> 00:30:27,640 happens. The massive haemorrhage, blood 651 00:30:27,640 --> 00:30:30,520 is hitting the ceiling. What is the immediate maneuver? 652 00:30:30,520 --> 00:30:31,880 This is the ugly maneuver, right? 653 00:30:32,640 --> 00:30:34,680 You have seconds to act. What's step one? 654 00:30:34,920 --> 00:30:38,640 Step one, hyperinflate the cuff of the tracheostomy tube. 655 00:30:39,320 --> 00:30:41,280 Shove 20-30 mils of air in there. 656 00:30:41,760 --> 00:30:44,720 Sometimes a balloon itself will expand and push against the 657 00:30:44,720 --> 00:30:46,960 artery wall and temporarily stop the flow. 658 00:30:47,120 --> 00:30:49,960 And if that fails. If that fails and blood is still 659 00:30:49,960 --> 00:30:53,160 pouring out, you have to perform digital compression. 660 00:30:53,320 --> 00:30:55,560 Paint the picture for me. What am I physically doing I 661 00:30:55,560 --> 00:30:58,320 need to be able to describe? This You remove the tracheostomy 662 00:30:58,320 --> 00:31:00,640 tube. Yes, you take it out completely. 663 00:31:00,960 --> 00:31:03,760 You insert your index finger directly into the stoma. 664 00:31:04,040 --> 00:31:06,880 You slide it down along the interior surface of the trachea 665 00:31:07,320 --> 00:31:10,040 until you are behind the manubrium, the top of the 666 00:31:10,040 --> 00:31:12,560 breastbone. OK, I'm in the chest, you are in 667 00:31:12,560 --> 00:31:14,480 the chest. Then you hook your finger 668 00:31:14,480 --> 00:31:17,680 forward, pulling up. So I am pinching the artery 669 00:31:17,680 --> 00:31:20,640 between my finger inside the neck and the back of the sternum 670 00:31:20,640 --> 00:31:21,960 outside. Exactly. 671 00:31:22,080 --> 00:31:25,680 You are manually clamping the innominate artery against the 672 00:31:25,680 --> 00:31:27,600 posterior surface of the manubrium. 673 00:31:27,920 --> 00:31:31,240 The bleeding should stop, or at least slow dramatically, and 674 00:31:31,240 --> 00:31:34,440 then you are the clamp. You cannot let go. 675 00:31:34,560 --> 00:31:37,640 You climb onto the Gurney, your finger deep in the patient's 676 00:31:37,640 --> 00:31:41,240 chest, and you ride with them to the operating theater for an 677 00:31:41,240 --> 00:31:44,000 emergency sternotomy. That is the only way they 678 00:31:44,000 --> 00:31:47,240 survive. That is intense, but if you say 679 00:31:47,240 --> 00:31:49,800 digital compression of the innominate artery against the 680 00:31:49,800 --> 00:31:53,000 manubrium in the exam, you've basically passed the station. 681 00:31:53,080 --> 00:31:54,920 Absolutely. It shows you know the anatomy 682 00:31:54,920 --> 00:31:57,400 and you know the desperation of the situation and exactly what 683 00:31:57,400 --> 00:31:59,080 to do. Let's take a breath and move to 684 00:31:59,080 --> 00:32:01,520 Part H post operative and ICU care. 685 00:32:02,000 --> 00:32:05,560 This feels a bit calmer. Once the tube is in and secure, 686 00:32:05,560 --> 00:32:08,440 the care is routine but vital. Number one has to be 687 00:32:08,440 --> 00:32:10,840 humidification. It's non negotiable. 688 00:32:11,760 --> 00:32:14,880 You bypass the nose, so you must replace its function. 689 00:32:15,600 --> 00:32:18,600 You use a heat moisture exchanger or HME, the little 690 00:32:18,600 --> 00:32:22,120 plastic nose, or a heated humidified circuit from the 691 00:32:22,120 --> 00:32:23,520 ventilator. And if you don't? 692 00:32:23,800 --> 00:32:26,040 If you don't, the secretions turn to concrete. 693 00:32:26,040 --> 00:32:29,360 As we said, they form thick plugs that can block the tube or 694 00:32:29,360 --> 00:32:32,240 the smaller Airways. #2 Suctioning. 695 00:32:32,360 --> 00:32:34,360 Yes, it must be a sterile technique. 696 00:32:34,680 --> 00:32:37,920 You pre oxygenate the patient before you suction and you don't 697 00:32:37,920 --> 00:32:41,080 suction for longer than 10 to 15 seconds at a time to avoid 698 00:32:41,080 --> 00:32:43,040 hypoxia and trauma to the mucosa. 699 00:32:43,120 --> 00:32:45,160 And cuff care. You need to monitor the cuff 700 00:32:45,160 --> 00:32:47,120 pressure or regularly with a manometer. 701 00:32:47,360 --> 00:32:50,800 The goal is to keep it between 20 and 25 centimeters of water, 702 00:32:51,160 --> 00:32:54,520 just enough to create a seal for ventilation, but not so much 703 00:32:54,520 --> 00:32:56,200 that it causes tracheal ischemia. 704 00:32:56,200 --> 00:32:59,480 Weaning and decannulation. When do we finally take it out? 705 00:32:59,520 --> 00:33:01,440 We often use special tubes for weaning. 706 00:33:01,920 --> 00:33:04,240 A fenestrated tube is a common one. 707 00:33:04,240 --> 00:33:07,480 What does that mean? It has a hole or a fenestration 708 00:33:07,480 --> 00:33:09,240 in the outer curvature of the tube. 709 00:33:09,760 --> 00:33:12,480 When you remove the inner cannula and deflate the cuff, 710 00:33:12,760 --> 00:33:16,000 air can go up from the lungs through the fenestrations into 711 00:33:16,000 --> 00:33:18,400 the vocal cords. This allows the patient to 712 00:33:18,400 --> 00:33:20,080 speak. And the speaking valve. 713 00:33:20,800 --> 00:33:22,600 I see the passing mirror valve used a lot. 714 00:33:22,680 --> 00:33:25,320 That's a one way valve. It sits on the end of the track 715 00:33:25,320 --> 00:33:28,040 tube. It has a diaphragm that opens to 716 00:33:28,040 --> 00:33:31,760 let air in when the patient inhales, but it closes when they 717 00:33:31,760 --> 00:33:34,280 exhale. So the exhaled air is forced to 718 00:33:34,280 --> 00:33:37,320 go up around the outside of the tube and through the vocal cords 719 00:33:37,440 --> 00:33:39,600 so they can talk in a much more natural voice. 720 00:33:39,600 --> 00:33:41,600 OK, there's a huge safety point here, isn't? 721 00:33:41,600 --> 00:33:43,480 There a critical exam safety point. 722 00:33:43,800 --> 00:33:46,840 If you put a speaking valve on, you must deflate the cuff. 723 00:33:47,160 --> 00:33:49,360 You have to write that in bold in your mind. 724 00:33:49,360 --> 00:33:51,160 Why is that so? Absolutely, but. 725 00:33:51,520 --> 00:33:54,960 Think about the physics. The valve let's air in, but it 726 00:33:54,960 --> 00:33:57,280 blocks air from coming out through the tube. 727 00:33:57,880 --> 00:34:00,920 If the cuff is still inflated, the air can't get up around the 728 00:34:00,920 --> 00:34:02,600 tube either. So the air is trapped. 729 00:34:02,600 --> 00:34:05,960 You have created a one way system that is just filling the 730 00:34:05,960 --> 00:34:08,520 lungs. The patient can breathe in but 731 00:34:08,520 --> 00:34:11,840 cannot breathe out at all. You will cause breath stacking, 732 00:34:12,159 --> 00:34:15,159 a massive tension pneumothorax and cardiac arrest within 733 00:34:15,159 --> 00:34:16,800 minutes. So the mantra is. 734 00:34:16,960 --> 00:34:21,440 Cuff down in Valvarin. Always decanulation criteria. 735 00:34:21,560 --> 00:34:24,080 When is the patient ready? The patient must be able to 736 00:34:24,080 --> 00:34:26,600 protect their own airway. That means they have a good 737 00:34:26,600 --> 00:34:30,280 swallow and a strong, effective cough, the original reason for 738 00:34:30,280 --> 00:34:31,840 the track. Like an upper airway, 739 00:34:31,840 --> 00:34:35,840 obstruction must be resolved and their secretions must be minimal 740 00:34:35,840 --> 00:34:37,679 and thin. And how do you test that? 741 00:34:38,000 --> 00:34:40,960 If they pass those checks, we often downsize to a very small 742 00:34:40,960 --> 00:34:43,320 tube and then cap it for 24 hours. 743 00:34:43,800 --> 00:34:46,480 If they can breathe perfectly fine with the cap on, tolerating 744 00:34:46,480 --> 00:34:48,960 it without any distress, then we know they don't need the track 745 00:34:48,960 --> 00:34:51,320 anymore. We pull the tube and cover the 746 00:34:51,320 --> 00:34:53,080 stoma with an occlusive dressing. 747 00:34:53,280 --> 00:34:55,719 It usually closes on its own in five to seven days. 748 00:34:55,880 --> 00:34:58,160 Finally, Part 1 exam integration. 749 00:34:58,400 --> 00:35:01,160 Let's hit the comparison tables in Viva Traps Tracheostomy 750 00:35:01,160 --> 00:35:03,480 versus ETT Quick Fire Pros and cons. 751 00:35:03,720 --> 00:35:08,280 OK tracheostomy pros Lower Dead Space, lower work of breathing, 752 00:35:08,360 --> 00:35:11,320 better patient tolerance, allows eating and speech. 753 00:35:11,640 --> 00:35:13,600 Very stable airway for a long term care. 754 00:35:13,760 --> 00:35:16,320 ETT Pros. Quick and non invasive to place 755 00:35:16,320 --> 00:35:19,120 in an emergency. Protects against aspiration a 756 00:35:19,120 --> 00:35:21,880 little better initially. No surgical risks. 757 00:35:21,880 --> 00:35:23,560 OK. Tracheostomy Cons. 758 00:35:23,560 --> 00:35:28,560 All the surgical risks leading methorax nerve injury, stoma 759 00:35:28,560 --> 00:35:31,640 scars, risk of late complications like tracheal 760 00:35:31,640 --> 00:35:33,440 stenosis. And ET cons. 761 00:35:33,440 --> 00:35:36,160 High airway resistance, very uncomfortable so it usually 762 00:35:36,160 --> 00:35:39,160 requires sedation and significant risk of laryngeal 763 00:35:39,160 --> 00:35:41,480 and vocal cord trauma if it's left in for too long. 764 00:35:41,800 --> 00:35:42,440 Perfect. Right. 765 00:35:42,600 --> 00:35:45,960 Next comparison surgical tracheostomy versus PDT. 766 00:35:46,160 --> 00:35:48,520 OK PDT Pros. It's faster, it can be done at 767 00:35:48,520 --> 00:35:51,720 the bedside, smaller hole, less bleeding, and it's cost 768 00:35:51,720 --> 00:35:52,920 effective. And the downside? 769 00:35:52,920 --> 00:35:55,880 It's a semi blind procedure. Higher risk of posterior wall 770 00:35:55,880 --> 00:35:57,760 puncture or creating a false passage. 771 00:35:58,160 --> 00:36:00,080 It's not good for patients with difficult anatomy. 772 00:36:00,120 --> 00:36:02,200 And surgical prose. Better for those patients with 773 00:36:02,200 --> 00:36:04,040 difficult anatomy. You have direct vision so 774 00:36:04,040 --> 00:36:07,000 bleeding is better controlled and you can create a Bjork flat 775 00:36:07,000 --> 00:36:09,120 for added security. The downside being. 776 00:36:09,240 --> 00:36:12,720 It requires transport to the OR. It's a bigger procedure and 777 00:36:12,720 --> 00:36:14,440 there's a higher risk of wound infection. 778 00:36:14,760 --> 00:36:17,120 Great. And let's just recap the common 779 00:36:17,120 --> 00:36:19,440 exam questions in Viva Traps one last time. 780 00:36:19,640 --> 00:36:23,640 Trap #1 the examiner asks how do you do a tracheostomy? 781 00:36:23,720 --> 00:36:25,480 And the trap is jumping straight to the. 782 00:36:25,480 --> 00:36:26,320 Knife. Exactly. 783 00:36:26,320 --> 00:36:28,080 The answer is not I pick up a scalpel. 784 00:36:28,200 --> 00:36:31,120 The answer is first I would assess the indications. 785 00:36:31,120 --> 00:36:32,800 I would ensure all contraindications are 786 00:36:32,800 --> 00:36:34,560 considered. I would check the coagulation 787 00:36:34,560 --> 00:36:36,440 and get informed consent. And then I would position the 788 00:36:36,440 --> 00:36:40,840 patient, show them you are a safe, thoughtful Dr. before you 789 00:36:40,840 --> 00:36:45,080 are a technician. Track #2 The patient desaturates 790 00:36:45,080 --> 00:36:47,880 during the procedure. Don't just say give more oxygen, 791 00:36:48,120 --> 00:36:50,720 be systematic. My first thought is an airway 792 00:36:50,720 --> 00:36:52,560 problem. I would immediately check the 793 00:36:52,560 --> 00:36:55,760 position of the ETT. Has it been pushed too deep into 794 00:36:55,760 --> 00:36:59,280 the right main bronchus or has it been withdrawn too far out? 795 00:36:59,440 --> 00:37:00,960 Deco PE. Exactly. 796 00:37:01,040 --> 00:37:04,360 Dislodgement, obstruction, pneumothorax, equipment failure. 797 00:37:04,640 --> 00:37:07,320 Check for pneumothorax, Check for circuit disconnection. 798 00:37:07,320 --> 00:37:10,880 Be an anesthetist. And trap #3 management of 799 00:37:10,880 --> 00:37:13,840 massive hemorrhage. Don't just say call the surgeon. 800 00:37:13,840 --> 00:37:16,040 You are the first responder you say. 801 00:37:16,200 --> 00:37:19,360 My immediate actions would be to hyperinflate the cuff and if 802 00:37:19,360 --> 00:37:22,320 that fails I would perform digital compression of the 803 00:37:22,320 --> 00:37:25,560 enominate artery while calling for urgent surgical help. 804 00:37:25,960 --> 00:37:28,360 Use the keywords. And for the written exam 805 00:37:28,360 --> 00:37:30,920 diagrams, what should I be able to draw? 806 00:37:31,440 --> 00:37:34,880 Practice drawing two things. First, a simple cross section of 807 00:37:34,880 --> 00:37:38,400 the neck showing the relations, trachea in the middle, esophagus 808 00:37:38,400 --> 00:37:42,400 right behind it, thyroid isthmus in front, strap muscles and the 809 00:37:42,400 --> 00:37:44,880 great vessels laterally. It shows you on the anatomy. 810 00:37:44,960 --> 00:37:47,480 And the second one. A schematic of the cylinder 811 00:37:47,480 --> 00:37:51,800 technique for PDT. 4 simple steps Needle wire, dilator tube 812 00:37:52,120 --> 00:37:54,600 Simple line drawing score very high marks because they show you 813 00:37:54,600 --> 00:37:57,080 understand the process. And for the conclusion of the 814 00:37:57,080 --> 00:37:59,640 Big 20 mark essay, how to wrap it all up? 815 00:37:59,880 --> 00:38:01,560 You summarize nicely something like. 816 00:38:01,800 --> 00:38:06,600 In conclusion, tracheostomy is a definitive airway procedure with 817 00:38:06,600 --> 00:38:09,600 significant physiological benefits for long term 818 00:38:09,600 --> 00:38:12,920 ventilation, specifically the reduction in anatomical Dead 819 00:38:12,920 --> 00:38:16,200 Space and work of breathing. However, it is not without 820 00:38:16,200 --> 00:38:18,600 significant risks, both immediate and delayed, 821 00:38:18,600 --> 00:38:22,120 particularly hemorrhage, airway loss and tracheal stenosis. 822 00:38:22,760 --> 00:38:25,480 The role of the anesthetist is therefore crucial and 823 00:38:25,480 --> 00:38:28,840 preoperative optimization, ensuring intraoperative airway 824 00:38:28,840 --> 00:38:31,720 security during the critical exchange and the rapid 825 00:38:31,720 --> 00:38:34,960 recognition and management of life threatening complications. 826 00:38:35,040 --> 00:38:37,600 Fantastic. This has been a true deep dive. 827 00:38:37,600 --> 00:38:39,920 I feel like I can actually visualize the layers of the 828 00:38:39,920 --> 00:38:41,560 neck. Now, and that visualization is 829 00:38:41,560 --> 00:38:43,440 the key. If you can see the anatomy in 830 00:38:43,440 --> 00:38:46,360 your mind's eye, you can reason through any question they throw 831 00:38:46,360 --> 00:38:47,560 at you. To the student listening, 832 00:38:47,760 --> 00:38:49,640 remember the 11 centimeters from Crickoid. 833 00:38:49,640 --> 00:38:53,480 To Karina, remember the Sentinel bleed and Please remember cuff 834 00:38:53,480 --> 00:38:55,440 down valve on. You've got this. 835 00:38:55,680 --> 00:38:57,440 Go ace that Viva. Good luck. 836 00:38:58,200 --> 00:38:59,760 Thanks for listening to the deep dive.