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Tracheostomy

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

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Emergency Cricothyroidotomy

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  • 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.

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Tracheostomy

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

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Emergency Cricothyroidotomy

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

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

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Expected Benefits (Tracheostomy)

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

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Potential Risks (Both Procedures)

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  • 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.

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  • 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.

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  • 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.

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Anatomic Landmarks

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  • 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.

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Open Tracheostomy

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  • 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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