The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy.

We evaluated the association between the timing of tracheostomy and clinical outcomes in patients with infratentorial lesions. We performed a retrospective observational cohort study in a neurosurgical intensive care unit (ICU) at a tertiary academic medical center from January 2014 to December 2018. Consecutive adult patients admitted to the ICU who underwent resection of infratentorial lesions as well as tracheostomy were included for analysis. Early tracheostomy was defined as performed on postoperative days 1-10 and late tracheostomy on days 10-20 after operation. Univariate and multivariate analyses were used to compare the characteristics and outcomes between both cohorts. A total of 143 patients were identified, and 96 patients received early tracheostomy. Multivariable analysis identified early tracheostomy as an independent variable associated with lower occurrence of pneumonia (odds ratio, 0.25; 95% CI, 0.09-0.73; p = 0.011), shorter stays in ICUs (hazard ratio, 0.4; 95% CI, 0.3-0.6; p = 0.03), and earlier decannulation (hazard ratio, 0.5; 95% CI, 0.4-0.8; p = 0.003). However, no significant differences were observed between the early and late tracheostomy groups regarding hospital mortality (p > 0.999) and the modified Rankin scale after 6 months (p = 0.543). We also identified postoperative brainstem deficits, including cough, swallowing attempts, and extended tongue as well as GCS < 8 at ICU admission as the risk factors independently associated with patients underwent tracheostomy. There is a significant association between early tracheostomy and beneficial clinical outcomes or reduced adverse event occurrence in patients with infratentorial lesions.

Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review.

As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.

Influence of early elective tracheostomy on the incidence of postoperative complications in patients undergoing head and neck surgery.

BACKGROUND: The incidence of postoperative complications after head and neck surgery is high. This study evaluated the influence of early elective tracheostomy on the incidence of postoperative pneumonia and delirium. METHODS: We reviewed the data of all patients who had undergone removal of an oropharyngeal tumor and microsurgical tissue transfer at our department in a two year period. Pearson's Chi-squared test and the Fischer's exact t-test were then used to measure the influence of patients' preexisting conditions and risk factors and of early elective tracheostomy on the incidence of postoperative complications. RESULTS: In total, 47 cases were analyzed. Patients with an endotracheal tube were ventilated for a longer time (3.4 days vs. 1.5 days) and were transferred to the regular ward later (after 6.9 days vs. 4.7 days) than patients with tracheostomy. Only 1 (2.1%) of the patients with a tracheostomy developed pneumonia in contrast to 5 intubated patients (10.6%) and only 2 patients with a tracheostomy developed postoperative delirium (9.5%) in contrast to 8 intubated patients (30.8%). CONCLUSION: Early primary tracheostomy in patients undergoing resection of oropharyngeal cancer seems to have numerous benefits, such as lower complication rates with regard to pneumonia and postoperative delirium and shorter duration of both mechanical ventilation and intensive care unit (ICU) stays. Further studies have to evaluate if these benefits also influence morbidity and mortality rates.

Comparison of outcomes between vertical and transverse skin incisions in percutaneous tracheostomy for critically ill patients: a retrospective cohort study.

BACKGROUND: Percutaneous tracheostomy (PT) is a common procedure in critical care medicine. No definite clinical practice guidelines recommended on the choice of the direction of skin incision, vertical or transverse for tracheostomy in critically ill patients. The objective of this retrospective study was to compare the outcomes associated with vertical and transverse skin incisions in patients undergoing PT. METHODS: Patients who underwent PT between March 2011 and December 2015 in the intensive care unit (ICU) of a tertiary hospital were retrospectively included. PTs were performed by pulmonary intensivists at the ICU bedside using the single tapered dilator technique assisted by flexible bronchoscopy. The primary outcome was the incidence of tracheostomy site ulcers at 7 days after PT. RESULTS: Of the 458 patients who underwent PT, a vertical incision was made in 27.1% and a transverse incision was made in 72.9%. There were no tracheostomy-related mortalities, and no significant difference in the incidence of immediate postoperative complications, including bleeding, tracheal ring fracture, and subcutaneous emphysema. Thirty-five patients (7.6%) developed complications within 7 days after PT, in which tracheostomy-related pressure ulcers were the most frequent. Compared with vertical incisions, transverse incisions were associated with significantly lower incidence of complications (14.1% vs. 5.4%, P = 0.001). CONCLUSIONS: This retrospective study showed that transverse skin incisions in PTs for critically ill patients, resulted in a significant decrease in overall complications, particularly ulcers in the tracheostomy site.

Management trends of infantile hemangioma: A national perspective.

INTRODUCTION: The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown. MATERIALS AND METHODS: The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4. RESULTS: The number of qualified admissions significantly increased over the years (9271 in 2003-12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001). CONCLUSIONS: Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

A New Modified Evans Blue Dye Test as Screening Test for Aspiration in Tracheostomized Patients.

OBJECTIVE: The authors assessed the diagnostic accuracy of a new modified Evans blue dye test (MEBDT) as a screening test for aspiration in tracheostomized patients. DESIGN: Monocentric retrospective study performed between October 2013 and December 2015. SETTING: Anesthesia and Intensive Care Unit, Second University of Naples. PARTICIPANTS: Among 62 eligible patients, 5 were excluded. The authors' study population included 57 patients. INTERVENTIONS: Patients underwent both fiberoptic endoscopic examination of the swallow (FEES) and MEBDT to evaluate swallow. The MEBDT results were compared with those of FEES and the diagnostic accuracy of MEBDT was calculated using the FEES as the gold standard. MEASUREMENTS AND MAIN RESULTS: The authors found that both FEES and MEBDT were positive for aspiration in 40 patients (true-positive MEBDT); FEES and MEBDT were negative in 10 (true-negative MEBDT). On the other hand, FEES was positive with an MEBDT negative in 7 patients (false-negative MEBDT), and there were no FEES negative and MEBDT positive (false-positive MEBDT). MEBDT had a sensitivity, specificity, positive, and negative predicted value of 85%, 100%, 100%, and 58.82%, respectively. CONCLUSIONS: MEBDT could be a supplementary diagnostic test for aspiration. Patients with positive MEBDT should not undergo oral feeding, while patients with negative MEBDT should undergo FEES before starting oral feeding.

Tracheostomy After Operations for Congenital Heart Disease: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database.

BACKGROUND: Information concerning tracheostomy after operations for congenital heart disease has come primarily from single-center reports. We aimed to describe the epidemiology and outcomes associated with postoperative tracheostomy in a multi-institutional registry. METHODS: The Society of Thoracic Surgeons Congenital Heart Database (2000 to 2014) was queried for all index operations with the adverse event "postoperative tracheostomy" or "respiratory failure, requiring tracheostomy." Patients with preoperative tracheostomy or weighing less than 2.5 kg undergoing isolated closure of patent ductus arteriosus were excluded. Trends in tracheostomy incidence over time from January 2000 to June 2014 were analyzed with a Cochran-Armitage test. The patient characteristics associated with operative mortality were analyzed for January 2010 to June 2014, including deaths occurring up to 6 months after transfer of patients to long-term care facilities. RESULTS: From 2000 to 2014, the incidence of tracheostomy after operations for congenital heart disease increased from 0.11% in 2000 to a high of 0.76% in 2012 (p < 0.0001). From 2010 to 2014, 648 patients underwent tracheostomy. The median age at operation was 2.5 months (25th, 75th percentile: 0.4, 7). Prematurity (n = 165, 26%), genetic abnormalities (n = 298, 46%), and preoperative mechanical ventilation (n = 275, 43%) were common. Postoperative adverse events were also common, including cardiac arrest (n = 131, 20%), extracorporeal support (n = 87, 13%), phrenic or laryngeal nerve injury (n = 114, 18%), and neurologic deficit (n = 51, 8%). The operative mortality was 25% (n = 153). CONCLUSIONS: Tracheostomy as an adverse event of operations for congenital heart disease remains rare but has been increasingly used over the past 15 years. This trend and the considerable mortality risk among patients requiring postoperative tracheostomy support the need for further research in this complex population.

Impact of a Palliative Care Program on Tracheostomy Utilization in a Community Hospital.

BACKGROUND: Tracheostomies are typically provided to wean patients off the ventilator. However, in many circumstances tracheostomies are placed in patients who are at the end of their life with little hope of meaningful recovery. Palliative care teams decrease utilization of aggressive medical interventions in patients who are at the end of life. OBJECTIVE: The study objective was to determine the impact of a palliative care team on tracheostomy utilization in a community hospital setting. METHODS: The study was a four-year retrospective analysis of adult patients undergoing elective tracheostomy two years before and after the establishment of a palliative care program. The study in an ethnically diverse community hospital included patients older than 18 years old, with patients undergoing a tracheostomy due to trauma excluded. Before and after comparisons were made of demographics, in-hospital mortality, length of stay, and discharge status of patients undergoing tracheostomy. RESULTS: Seven hundred ninety patients undergoing tracheostomy were identified (n = 406, n = 384 before and after September 10, 2010, respectively). Patients were ethnically diverse (Caucasian 43%, Asian 23%, African American 11%, Hispanic 7%). The number of hospital admissions slightly increased during these two time periods (n = 58,926; n = 60,662, respectively). There were no statistical differences in age (73 versus 72, p = 0.827); gender (n = 218 [54%] versus n = 217 [57%] male, p = 0.426); or race (n = 187 [46%] versus n = 150 [39%] Caucasian, p = 0.073) in the two time periods. Patients who underwent tracheostomy after a palliative care service was established had less incidence of comorbid disease (Charlson Comorbidity Index score [CCIS]: 2 versus 3, p = 0.025); lower inpatient mortality (n = 107 [28%] versus n = 148 [37%], p = 0.009]); greater discharge to home or rehabilitation (n = 262 [68%] versus n = 249 [62%], p = 0.01); and lower rates of palliative weaning from mechanical ventilation (n = 61[16%] versus n = 113 [28%], p < 0.001). CONCLUSIONS: In an ethnically diverse community hospital, the institution of a palliative care program appears to have improved patient selection for tracheostomy with lower rates of inpatient mortality, improved rates of home discharge, and lower rates of palliative weaning from mechanical ventilation.

Tracheostomy After Cardiac Surgery With Median Sternotomy and Risk of Deep Sternal Wound Infections: Is It a Matter of Timing?

OBJECTIVE: To assess the impact of timing of percutaneous dilatational tracheotomy (PDT) on incidence of deep sternal wound infections (DSWI) after cardiac surgery with median sternotomy. DESIGN: Retrospective study between 2003 and 2013. SETTING: Single-center university hospital. PARTICIPANTS: Eight hundred seventy-nine patients after cardiac surgery with extracorporeal circulation and median sternotomy. INTERVENTIONS: PDT using the Ciaglia-technique with direct bronchoscopic guidance. MEASUREMENT AND MAIN RESULTS: Mean time from surgery and (re)intubation to PDT was 6.7±9.9 and 3.8±3.3 days, respectively. Incidence of DSWI was 3.9% (34/879). The incidence of DSWI was comparable between patients with PDT performed before postoperative day (POD) 10 and those with PDT after POD 10 (29/755 [3.8%] v 5/124 [4.0%], p = n.s.). However, the authors observed an association of timing of PDT and DSWI: The incidence of DSWI was significantly higher in patients with PDT performed≤POD 1 compared to those with PDT after POD 2 (12/184 [6.52%] v 22/695 [3.16%], p = 0.046). In multivariate analysis, obesity, use of bilateral internal mammary arteries, ICU stay>30 days and PDT<48 hours after surgery (OR 3.519, 95% CI 1.242-9.976, p = 0.0018) were independent predictors of DSWI. In 15/34 patients (44.1%), similarity of microorganisms between sternotomy site and tracheal cultures was observed, indicating a possible cross-contamination. CONCLUSIONS: PDT within the first 10 postoperative days after cardiac surgery with median sternotomy can be performed safely without an increased risk of DSWI. In contrast, very early PDT within 48 hours after surgery is associated with an increased risk of mediastinitis and should, therefore, be avoided.

Changes in pediatric tracheostomy 1982-2011: a Canadian tertiary children's hospital review.

BACKGROUND: Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period. METHODS: A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time. RESULTS: 251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed. CONCLUSIONS: Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH.

Novel method for laryngotracheal reconstruction: combining single- and double-stage techniques.

OBJECTIVES: Traditional open techniques for laryngotracheal reconstruction are either single- or double-stage procedures. Some patients may benefit from the presence of a long, single-tube stent, such as an endotracheal tube, but their predicted need for a 2-stage procedure and a persistent tracheostomy is high. We describe a novel technique for airway reconstruction that combines the methods of both single- and double-stage procedures. METHODS: We present a retrospective review of 4 patients. All patients underwent laryngotracheal reconstruction by a single surgeon. After the operation, the airway was stented with nasotracheal intubation. A small stent, fashioned from an endotracheal tube, was placed in the tracheostoma to keep it patent. The patients subsequently underwent extubation and replacement of the tracheostomy tube. RESULTS: The study included 1 patient with grade 4 subglottic stenosis, 2 patients with grade 3 subglottic stenosis, and 1 patient with a posterior glottic scar. All were tracheostomy tube-dependent. Serial bronchoscopy was used to follow the patients for a minimum of 9 months after the operation. All 4 patients have since met the criteria for decannulation. CONCLUSIONS: This hybrid reconstruction merges the advantages of both the single- and double-stage procedures. It adds versatility to the surgical toolbox for airway reconstruction.

Pediatric tracheotomy: are the indications changing?

OBJECTIVE: The most common indications for tracheotomy in pediatric patients include upper airway obstruction, prolonged ventilator dependence, and hypotonia secondary to neurologic impairment. In this study we review the indications for tracheotomy within our patient population over the last 11 years. METHODS: We conducted a retrospective chart review of consecutive patients undergoing tracheotomy at a tertiary care pediatric hospital from January 2000 to April 2011. We evaluated patient age, sex, pre-operative and post-operative diagnosis, and direct laryngoscopic and bronchoscopic findings. Patients were divided into six groups based on their indication for tracheotomy. In order to assess changing indications for tracheotomy over time, we compared an early (2000-2005) and a late (2006-2011) patient group. RESULTS: We had complete data available on 158/165 patients (95.8%) who underwent tracheotomy from 2000 to 2011. There was no significant difference in mean age between the early and late groups (4.73 ± 6.0 years vs. 3.6 ± 5.5 years, p=0.26). There was a change in the most common indication for tracheotomy between the early and late groups, with upper airway obstruction becoming more common in the late group and significantly fewer patients undergoing tracheotomy for prolonged ventilation in the late group (33/76 (43%) vs. 23/82 (28%), p=0.05). More patients underwent bronchoscopy at the time of tracheotomy in the late group (52/82 (63%) vs. 28/76 (37%), p=<0.01). CONCLUSION: A review of our pediatric tracheotomy experience demonstrated a change in the most common indication for tracheotomy between 2000 and 2011. In our patient population, there was a significant decline in the number of tracheotomies performed for prolonged intubation and an increasing number of patients who required tracheotomy for upper airway obstruction.

Traqueostomia: uma revisão atualizada / Tracheostomy: an up-to-date review

Nesta revisão, discutimos o tempo ideal para a realização da traqueostomia, além de revisar suas principais indicações e benefícios. Apesar de a traqueostomia ser um dos procedimentos mais realizados em unidades de terapia intensiva (UTI), o tempo para a sua realização ainda é controverso. Geralmente, esse se encontra em torno do sexto e oitavo dia de ventilação mecânica. Porém, em pacientes com doenças neurológicas graves, a traqueostomia pode ser considerada antes desseperíodo. Inúmeras vantagens são descritas ao se realizar a traqueostomia, entre elas, conforto do paciente, facilidade no desmame ventilatório e limpeza de secreções da árvore brônquica. Além disso, a traqueostomia precoce parece reduzir o tempo de internação em UTI e complicações associadas à intubação prolongada.

Traqueostomia pediátrica: relato de uma série de casos / Pediatric tracheostomy: Cases report series

Objetivo: Determinar a faixa etária, indicações e complicações de traqueostomia realizada em crianças até 12 anos de idade. Métodos: Revisão retrospectiva de 26 crianças submetidas à traqueostomia no período de novembro de 1999 a julho de 2003, em hospital geral terciário. Resultados: Aidade média das crianças foi de 32 meses; 17 (65,4%) eram menores de 1 ano. O procedimento foi eletivo em 20 (76,9%) e de emergência 6 (22,1%). As principais indicações foram ventilação mecânica prolongada em 13 (50%), estenose subglótica em 5 (19,3%) e malformações congênitas em 4 (15,4%). As complicações foram tecido de granulação no traqueostoma em 7 (26,9%), hemorragia em 3 (11,5%), obstrução da cânula em 3 (11,5%), enfisema subcutâneo em 2 (7,7%), pneumotórax em 2 (7,7%), decanulaçao acidental em 2 (7,7%), estenose laríngea em 1 (3,8%) e infecção da ferida operatória em 1 (3,8%). Não foram observadas diferenças significativas entre as complicações observadas nos procedimentos eletivos e de urgência. Treze pacientes morreram por complicações não relacionadas à traqueostomia; onze (42,2%) permaneceram com traqueostomia, e 2 (7,7%) foram decanulados. Conclusões: Nos últimos anos ocorreram mudanças nas indicações e faixa etária das crianças submetidas à traqueostomia: ela é mais comumente realizada em crianças menores de um ano, e mais freqüentemente devido à intubação prolongada. A traqueostomia é um procedimento seguro quando é realizada por cirurgião treinado com a técnica cirúrgica e com cuidados pós-operatórios de hospital terciário de referência (AU)

Objective: To determine age of surgery, indications and complications of tracheostomy in children until 12 years old. Method: Retrospective review of 26 children submitted to tracheostomy from November 1999 to July 2003 at a tertiary general hospital. Results: The mean age was 32 months; 17 (65.4%) were under 1 year old. In 20 (76.9%) the procedure was elective, whereas in 6 (22.1%) it was performed as emergency. The main indications of tracheostomy were prolonged mechanical ventilation in 13 patients (50%), subglottic stenosis in 5 (19.3%) and congenital malformations in 4 (15.4%). The most common complications were granulation at the site of the stoma in 7 (26.9%), bleeding in 3 (11.5%) , blockage of the cannula in 3 (11.5%), subcutaneous emphysema in 2 (7.7%) , pneumothorax in 2 (7.7%), accidental decannulation in 2 (7.7%), larynx stenosis in 1 (3.8%), surgical wound infection in 1 (3.8%). Regarding complications , it was not observed any significant difference between elective and emergency procedures. Thirteen patients (50%) died due to complications not related to the tracheostomy; eleven (42.2%) kept the tracheostomy, and 2 (7.7%) were decannulated. Conclusions: In the last few years there were changes in pediatric tracheostomy. It is being indicated more often in children under one year old, and more recently due to prolonged intubation. Tracheostomy is a safe procedure when performed by trained surgeon with appropriate technique and postoperative care at tertiary hospital (AU)

Tracheostomy in preterm infants: current trends.

OBJECTIVE: To study the indications for and outcomes of tracheostomy in a population of preterm infants. DESIGN: Retrospective analysis of case records. SETTING: Two university-affiliated tertiary care children's hospitals. Patients We identified premature infants who required tracheostomies from January 1, 1997, through January 31, 2001. Information on weight, gestational age, comorbid conditions, indication for tracheostomy, and outcomes was collected. Infants were divided by birth weight into group 1 (<1000 g; n = 19 [very low birth weight]) and group 2 (> or =1000 g; n = 14). Comorbid conditions were scored and a total score was calculated for each patient. RESULTS: Group 1 had a higher incidence of patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity. The incidence of congenital or genetic defects was equal in groups 1 and 2 (11 infants [58%] and 8 infants [57%], respectively). Group 1 had a higher average number of failed extubations (5.17 vs 3.18) and a higher oxygen requirement (48.7% vs 30.3%) compared with group 2. Weight at tracheostomy was essentially equal in groups 1 and 2 (3.6 vs 3.7 kg). Subglottic stenosis and laryngotracheomalacia were equally common findings in groups 1 and 2. The average comorbidity score for group 1 was higher than that for group 2 (6.7 vs 2.8). The most common indication for tracheostomy was ventilatory dependence (n = 24 [73%]), compared with airway obstruction (n = 6 [18%]) and pulmonary toilet (n = 3 [9%]). Overall, 6 patients (18%) had a complication related to the tracheostomy. CONCLUSIONS: Severity of pulmonary disease was the most significant factor associated with the need for tracheostomy in preterm infants. A tracheostomy can safely be performed in these infants with minimal morbidity.

Variações da técnica de traqueostomia: uma abordagem atual / Variation of tracheostomy techniques: a new approach

O presente trabalho teve como objetivo fazer uma revisão da literatura sobre traqueostomia, enfocando novas técnicas alternativas, bem como suas vantagens, limitações e complicações

Trauma de Cuello / Neck Trauma

El trauma de esta estructura representa del 5 al 10 por ciento de todos los traumas. La diversidad de lesiones en un área tan pequeña y sus diferentes manejos llevaron a una alta tasa de exploraciones en blanco creando controversia entre el manejo quirúrgico mandatoio y el manejo selectivo. La tendencia actual es que en paciente asintomáticos con heridas en la zona II, el examen físico es seguro para descartar lesiones graves, proponiéndose por esta razón el manejo individualizado. Al colocar en práctica la experiencia militar en la práctica civil se encontraon altos índices de exploraciones en blanco (69-84 por ciento), desarrollándose estudios de manejo selectivo que disminuyeron el número de exploraciones negativas y los costos sin variar la morbimortalidad. La clasificación de Monson y Saletta de las zonas de cuello tiene la importancia clínica de seleccionar a los paicentes según sus posibles lesiones y su estudio. Los mecanismos del trauma se clasifican en penetrante y no penetrante; el primero sucede cuando la lesión atraviesa el plano profundo del músculo cutáneo o platisma del cuello y el segundo mecanismo es producido por procesos de aceleración y desaceleración en accidentes de transito, contusiones, ahorcadura. El manejo del paciente comprende el manejo adecuado de la vía aérea, la inmovilización del cuello y el control por compresión del sangrado buscando disminuir el tiempo de traslado a un centro especializado dentro de los primeros 60 minutos siguientes al trauma; se debe evaluar el mecanismo de lesión, trayecto de la herida, estado general, pérdida de sangre y descartar o confirmar otras lesiones concomitantes realizando una adecuada evaluación de la vía aérea así como del compromiso vascular, neurológico y del tracto digestivo

Traqueítis bacteriana

La traqueítis bacteriana es una entidad potencialmente fatal que ha reaparecido en la última década con inusitado auge. A propósito de su detección en nuestro servicio decidimos realizar un estudio retrospectivo en el Hospital Universitario de la Misericordia de Santa Fe de Bogotá entre enero de 1990 y julio de 1994. Se revisaron 88 historias de pacientes con diagnósticos clínico sugestivo de traqueítis bacteriana pero sólo 13 pacientes cumplieron con el requisito de confirmación endoscópica del diagnóstico para ser considerados en el presente trabajo. La edad osciló entre 1 y 7 años, predominando el sexo masculino. Existió antecedente de infección respiratoria previa en el 54 por ciento, los síntomas más frecuentes fueron fiebre, tos perruna y dificultad respiratoria; los hemogramas mostraron leucocitosis, neutrofilia y aumento de la VSG. En la endoscopia se observó exudado traqueal, membranas purunlentas y úlceras; en solo cultivo se aisló Staphylococcus aureus. El 62 por ciento requirió permeabilizar la vía aérea, 3 con traqueostomía y 5 con tubo orotraqueal. El 46 por ciento se manejó con oxacilina y todos evolucionaron satisfactoriamente.