Médecine d'urgence: libre accès
Libre accès
ISSN: 2165-7548
ISSN: 2165-7548
Filippelli O.S, Giglio A.M, Tiburzi S.P, Maglio P, Archinà M.T, Barozzi E
Catanzaro,Italy: Adult man, large burned and in a coma, is initially rescued through placement of the laryngeal mask (LMA). The patient, who was transferred by the ambulance at hub hospital, underwent an emergency tracheostomy. This made it possible to better manage the airways during the subsequent transfer of a helicopter ambulances to the available large burns centers. This is the first regionally documented case of a patient undergoing rapid tracheostomy with a view to an imminent heliambulance transfer.
Quick Tracheostomy
Among the techniques of percutaneous tracheostomy (and among these we remember the most widespread techniques: according to Griggs and according to Ciaglia1 Blue Rhino, suitable for the patient in intensive care who needs long-term ventilation), rapid tracheostomy is certainly the best approach to immediately and safely manage the respiratory tract in critical patients in emergency conditions. It consists of quickly introducing a small caliber cannula into the tracheal space2,3. To this end, it is necessary for the operator to know with extreme confidence the anatomical recovery of the neck region corresponding to the structures of the larynx and trachea. It is essential to identify on the anterior region of the neck of the cranio-caudal thyroid cartilage with its upper and lower margins, below this, the thyroid space and the cricoid, finally the first and second tracheal ring. The cannula used in this case is mounted on a spindle needle at the end of which a syringe connects. The technique consists in the puncture, by the spindle needle, of the skin centrally in the crico-thyroid space or under the lower edge of the cricoid cartilage, between this and the first tracheal ring or between the first and second ring once detected at the digit pressure. Once you have crossed the layer of the skin with the spindle of the needle, proceed until air is sucked through the connected syringe, a sign indicating the entry into the tracheal light. At this point, the cannula slips along the spindle inside the trachea.
Presentation of the patient
November 2019: A 58-year-old man sets himself on fire through gasoline inside the city cemetery. The patient was rescued by the medical staff of 118 of the HEMS base in Locri (Calabria, Italy) who provided the positioning of LMA for rapid airway management; then he was transported to the Hub Hospital in Catanzaro during clinical stabilization and in anticipation of possible transfer to the nearest burns center. The patient, suffering from severe obesity, presented our observation with a state of GCS 3 coma with widespread stiffness, reporting severe burns4 of the 3rd and 4th in about 95% of the body surface, with evident widespread edema, especially on the region of the face. He was assisted by Mapleson circuit connected with LMA in 100% O2; for monitoring the parameters were as follows: NIBP 95/50 mmHg, c.f. 120 bpm, SpO2 92%. Given the high risk of LMA dislocation due to massive edema, particularly evident in the labial region, and the high predictive index of difficult intubation, it would have been rather imprudent to remove the LMA to proceed with orotracheal intubation. Therefore, to ensure access to the airways and the subsequent transport of the patient with heliambulance to the centre with large burns, it was decided to proceed with an emergency tracheostomy by an emergency tracheostomy device with cannula n°4.0 without cuff. The burnous skin in the crico-thyroid region was of hard wooden consistency, while, below the lower margin of the cricoid region, the skin was relatively more elastic.