Chapter 45

### Tracheostomy

• Supralaryngeal obstruction.
• Secure airway access.
• Prolonged intubation and mechanical ventilation.
• Inability to control secretions.

### Emergency Cricothyroidotomy

• Inability to obtain an oral or nasopharyngeal airway in a patient who requires emergent intubation.
• Severe facial or head and neck trauma.
• Acute loss of the airway due to supralaryngeal obstruction secondary to tumor, anaphylaxis, foreign body, trauma, or burn injury.

### Tracheostomy

• Significant coagulopathy can be considered a relative contraindication because bleeding into the airway can be catastrophic.

### Emergency Cricothyroidotomy

• There are few contraindications to cricothyroidotomy in the emergent setting with a patient in extremis.

• The emergent circumstances under which cricothyroidotomy are considered typically preclude informed consent.

### Expected Benefits (Tracheostomy)

• Provision of a secure airway and prevention of complications of prolonged oral or nasal intubation.

### Potential Risks (Both Procedures)

• Surgical site infection.
• Bleeding.
• Tracheal stenosis (1.6–6%).
• Vocal cord injury.
• Subglottic stenosis.
• Tracheoesophageal fistula formation.
• Rates of complications and vocal cord injury are higher for emergent cricothyroidotomy as compared with elective tracheostomy.

• No special equipment is required, although a bronchoscope can be useful in some instances.
• Small self-retaining retractors are useful for exposing the operative field.

• If possible, patient preparation should include the use of a folded sheet, sandbag, or other supporting device placed transversely under the shoulders; this helps in extending the neck and exposing the operative area.
• Endotracheal intubation is also extremely useful to maintain the airway during the procedure.
• In emergent situations when the patient is in respiratory distress, there may not be any time for such preparations.

### Anatomic Landmarks

• Figure 45–1: The anatomy of the neck with pertinent landmarks.
• The location of the thyroid cartilage in relation to the cricoid cartilage and the trachea is shown.
• Incision for the tracheostomy is made either transversely or vertically, approximately 2 fingerbreadths above the sternal notch.
• An emergency cricothyroidotomy is performed between the thyroid cartilage and the cricoid cartilage.
• A vertical incision is preferred for emergency cricothyroidotomy to minimize bleeding secondary to venous laceration. Additionally, if the initial incision is off target, it is easier to extend a vertical incision rather than make another transverse incision.

### Open Tracheostomy

• Figure 45–2: After incision (shown here as a transverse incision), dissection is carried down through the subcutaneous tissues.
• Often there is an anterior jugular vein crossing the field which may be tied off and divided.
• A small self-retaining retractor is useful to hold the incision open.
• Once the strap muscles are identified, they are divided vertically in the midline to expose the trachea.
• Often, the thyroid isthmus can be seen in the superior portion of the dissection; it may need to be divided for exposure.
• It is preferable ...

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