Question
A 47-year-old man is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision. On arrival, he is unconscious and unresponsive to painful stimuli. His pulse is 120/min, respirations are 10/min, and his blood pressure is 88/60 mm Hg. Infusion of 0.9% saline is begun, and intubation is attempted without success. Pulse oximetry on 20 L/min of oxygen via bag-mask shows an oxygen saturation of 78%. The next appropriate step in the management of this patient involves passing a tube through an incision in which of the following structures?
| A. |
Buccopharyngeal fascia
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| B. |
Investing layer of deep cervical fascia
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| C. |
Cricotracheal ligament
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| D. |
Prevertebral layer of deep cervical fascia
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Show Answer
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Correct Answer � B
Explanation
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Answer B) Investing layer of deep cervical fascia
Intubation has failed in this increasingly hypoxemic patient. The next step requires establishing a surgical airway.
Investing layer of deep cervical fascia
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Incision of the investing layer of deep cervical fascia is necessary to perform the cricothyroidotomy needed to establish an airway in this patient.
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In emergency situations where a patient cannot be effectively ventilated by the conventional bag and mask ventilation or endotracheal intubation, a cricothyroidotomy is the surgical procedure of choice to restore oxygenation.
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A cricothyroidotomy is performed by vertically incising the skin (superficial cervical fascia, investing layer of deep cervical fascia, and pretracheal fascia) and then horizontally incising the cricothyroid membrane.
Buccopharyngeal fascia
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Incision of the buccopharyngeal fascia, which envelops the superior constrictor muscle of the posterior pharynx, is not part of the procedure to establish an emergency surgical airway that this patient requires.
Cricotracheal ligament
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Incision of the cricotracheal ligament, which connects the cricoid cartilage to the first tracheal ring, is not part of the procedure to establish an emergency surgical airway that this patient requires.
Prevertebral layer of deep cervical fascia
Incision of the prevertebral layer of deep cervical fascia, which runs posterior to the trachea, is not part of the procedure to establish an emergency surgical airway that this patient requires.
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