- Preparation
- Neck extended
- Rotate head away from site of injury
- Prep wide - including Chest
Zone 1 access
- Unstable patient
- For right
- Median sternotomy - exam answer as can get proximal control
-
- Supraclavicular extension
- For Left
- DSCT say anterolateral thoracotomy as subclavian vessels are lower on the left
- But sternotomy and + Supraclavicular extension an option
- Stable
- Trans-clavicular
- Cut skin down on the clavicle
- Remove all muscle of clavicle
- Jiggly saw medial and then rotate lateral (can save) then wire it back
- This can be extended down the arm or sternotomy
- Infra-clavicular
- Supra-clavicular
Zone 2 access
- Incision
- Longitudinal at Anterior border of SCM
- Can extend all the way from the mastoid process down to the clavicle if needed
- Can be extended up and down or into a sternotomy
- Through subcutaneous tissue and platysma to reach muscle.
- Retract sternocleidomastoid laterally
- Omohyoid only strap to cross Carotid Sheath → CCA landmark
- Expose IJV
- Landmark for the carotid bifurcation - facial vein, which dives off the anterior border of the Internal jugular vein
- Divide facial vein to take you on to the common carotid
- Lateral retractiopn of IVJ takes you to common carotid
- Beware of vagus nerve which is running in carotid sheath
- Lateral retraction of Carotid Sheath to access Trachea/Oesophagus/Thyroid
- Need to divide three structures
- Medial retraction to access Prevertebral Fascia and Vertebral Artery
Zone 3 access
- Principles
- Nasotracheal tube if possible
- Neurosurgery
- Temporize by using Fogarty catheters via neck
- Incision
- Longitudinal at Anterior border of SCM
- Divide the sternocleidomastoid muscle at the mastoid if required
- Mindful of the Accessory Nerve, which is going to enter into the sternocleidomastoid about 3 centimetres distal to that
- Retractor on the mandible and pull that anteriorly to open up the space.
- Dislocate the mandible or divide the mandible in order to get you increased access if needed
- Same as zone 2
- Ligate the middle thyroid and the common facial veins, retract the sternocleidomastoid muscle and internal jugular laterally
- Careful of the vagus nerve in the carotid sheath.
- Find carotid artery proximal and follow superiorly
- Can divde posterior belly of diagastric
- Hypoglossal Nerve will run anterior to the artery at this point