When attempts at orotracheal intubation or airway rescue techniques (e.g., laryngeal mask airway) have failed in a patient who cannot oxygenate or ventilate, cricothyroidotomy is the emergency surgical airway of choice. It can be performed open or percutaneously. The approach should be dictated by the proceduralist’s preference and experience.

• The indications for shunting after vascular injury include damage control for patients in extremis, the presence of associated fractures requiring fixation, the need for transportation to specialized centers for definitive reconstruction, or injury occurrence in an austere environment with limited resources.

• There are a number of commercially available vascular shunts. Improvised shunts can be constructed out of any plastic tubing that has the adequate diameter to match the corresponding vessel, such as chest tubes, intravenous tubing, and feeding tubes. Improvised shunts must be rigid enough that when they are tied into position, the sutures do not collapse the lumen of the shunt.

• When selecting the shunt size for temporary bypass, the largest size of shunt that fits into the injured vessel without forcing it into place should be selected. This will maximize distal blood flow.

• Commercially made shunts should not be trimmed. The edges of commercially made shunts are smooth and designed to avoid trauma to the intima of the artery.

• Improvised shunts should be left long, with redundant length in both the proximal and distal vessel. This will reduce the risk of inadvertent shunt dislodgement.

• The maximum length of time that a vascular shunt can remain in situ is unknown. It is important to perform definitive repair as soon as the patient’s physiology and other circumstances allow. Most shunts remain patent for 24–48 hours. The patency of the shunt is confirmed by the presence of a distal palpable pulse or dopplerable signal.

• The vertebral artery (VA) is the first cephalad branch of the subclavian artery. From a trauma surgery perspective, the VA is divided into three parts. Part I runs from its origin at the subclavian artery to C6, where it enters the transverse foramen. Part II courses in the bony vertebral canal, formed by the transverse foramen of C6 to C1. Part III runs outside the vertebral canal, from C1 to the base of the skull. The VA enters the skull through the foramen magnum, piercing the dura mater. It joins the contralateral VA to form the basilar artery, which is part of the circle of Willis.

• The first part of the VA can be landmarked externally by the triangle formed by the sternal and clavicular heads of the sternocleidomastoid (SCM) muscle and the clavicle. It runs upward and backward between the anterior scalene and longus colli muscles, before entering the vertebral canal at the C6 level.

• The carotid sheath is anterior and medial to the first part of the VA.

• The external landmark of C6, where the VA enters into the vertebral canal and the second part of the VA begins, is the cricoid cartilage.

• The VA is surrounded by a venous plexus.

• The cartilaginous and bony structures of the larynx include the hyoid bone as well as the thyroid and cricoid cartilages. The trachea begins below the cricoid cartilage.

• The hyoid bone, thyroid cartilage, and tracheal cartilages are incomplete rings, with posterior membranous walls. In contrast, the cricoid cartilage is a complete ring, forming an important structural attachment for muscles and ligaments of the larynx. The cricoid cartilage ensures airway patency by stenting the larynx open.

• The cricothyroid membrane is situated between the thyroid and cricoid cartilages in the midline anteriorly. It is located directly beneath the skin, providing direct and easy access to the airway. This membrane is bordered superiorly by the thyroid cartilage, inferiorly by the cricoid cartilage, and laterally by the paired cricothyroid muscles. In adults, it is approximately 1 cm tall and 2–3 cm wide.

• The vocal cords are enclosed within the thyroid cartilage, approximately 1 cm from the upper border of the cricothyroid membrane.

• The cricothyroid membrane is about four fingerbreadths from the suprasternal notch.

• Trauma laparotomy set

• Fixed abdominal retractor, e.g., Bookwalter

• Adequate lighting including a headlamp

• Temporary abdominal closure devices should be available, if needed