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Emergency Tracheotomy

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In surgery, two concepts are distinguished - tracheotomy and tracheostomy.

A tracheotomy is the opening of the trachea and the insertion of a tube into it to allow air to enter the lower respiratory tract during asphyxiation. This is an emergency operation.

A tracheostomy is also an opening of the trachea, but with the hemming of the edges of the resulting incision to the underlying tissues and the formation of an opening for breathing.

A bit of history

This method of emergency care was known in ancient Egypt and India, there is documentary evidence that even Alexander the Great used it to save soldiers in his army. Hippocrates and Gallen wrote about this procedure, but because of its invasiveness and danger to life, they were not recommended to use it often in practice.

The first successful operation was performed by the Italian physician Anthony Brasavol in 1546. This is the first documented evidence that the patient remained alive after the manipulation. Since 1718, this type of surgical intervention has become ordinary and has been used more widely by doctors. Nevertheless, many were still afraid to use it. For example, George Washington’s personal physician preferred his patient to die than dare to perform risky manipulations.

The emergence of aseptic and antiseptic rules somewhat reduced the risk of complications and mortality, but still did not convince the medical community that this method is safe for the patient. Currently, tracheotomy is an emergency way of help, which is used only when all other methods (Heimlich's reception, intubation) are ineffective or there is no time for them.

Indications for surgery

No matter how simple the tracheotomy may seem, the indications for it are quite strict, since the risk to human life during this manipulation exceeds the possible benefit. It:

  1. Foreign bodies located above the trachea that cannot be removed by other means.
  2. Closed injuries narrowing the lumen of the larynx.
  3. Acute stenosis of the larynx with diphtheria croup, whooping cough, measles, typhus, etc.
  4. Overlap of the lumen of the trachea or larynx with a tumor.
  5. Compression of the upper respiratory tract from the outside.
  6. Chemical burns
  7. Allergic stenosis.

Types of airway obstruction

  • Acute, or lightning-fast, develops in just a few seconds. It can be like blockage by foreign bodies, as well as allergic edema.
  • Acute - manifests itself in a matter of minutes, usually associated with diphtheria or foreign bodies.
  • Subacute - closure of the lumen of the respiratory tract can last tens of minutes, or even hours. This condition is typical for false croup, sore throat, chemical burns.
  • Chronic - can grow over the years with pathological processes such as laryngeal cancer, perichondritis, cicatricial narrowing of the trachea.

Instruments

Do not forget that for all its urgency and improvisation, this technique is positioned as an operation. A tracheotomy should be performed with a specific set of instruments, if any. Conventionally, they can be divided into two large groups: these are general surgical instruments and specialized ones.

The first group includes tweezers, a scalpel, clamps for stopping blood, surgical scissors, hooks for diluting tissues, a catheter, syringes and needles. The second group includes the Luer tracheotomy cannula, consisting of two tubes located one in the other, a Chassignac hook designed to hold the trachea without trauma, a trachea expander and a hook to move the thyroid isthmus.

Technique for performing tracheotomy

Before any operation, appropriate preparation is carried out, which helps the doctor to carry out the necessary intervention as quickly and painlessly as possible for the patient. In this case, it is necessary to put the patient on his back and throw his head back as far as possible so that the tracheal cartilage is clearly visible. For this, a roller is sometimes used. After fixation, the person receives anesthesia. It can be either general inhalation or local. It all depends on the conditions in which the operation is performed, the age of the patient, the capabilities of the doctor and the hospital. If the situation is urgent, then the doctor performs the manipulation without anesthesia. After all preparations, a tracheotomy begins directly.

The technique consists in a layered incision of the skin, subcutaneous fat, fascia and fibrous membrane downward from the thyroid cartilage. Then the muscle is exposed, which in a blunt way is bred to the sides. Under it is the cartilage and the isthmus of the thyroid gland. The gland is separated from the trachea and pushed up, another fascia is dissected. The larynx is fixed with a hook and, limiting the scalpel blade with a finger, bandage or adhesive, a small incision is made. The goal is achieved. The air again enters the lungs. At first, respiratory arrest may occur, but then the patient begins to cough and turn pink. Only after the doctor has made sure that the person has started breathing again, cannula is inserted into the wound and fixed with sutures or plaster. The wound is sutured so that it holds the tube tightly.

Conicotomy

This is a small operation preceding a tracheotomy, if there is no possibility and time to conduct a tracheotomy normally. Performing it, no longer make phased cuts. One movement dissects the neck up to the cricoid cartilage and the thyroid cricoid ligament. A clip is inserted into the incision, its branches are bred and they are fixed in this position. If the patient began to breathe, turned pink, he developed a cough, which means that the procedure was successful. Once the danger has passed, the conicotomy can be converted into a tracheostomy to ensure a constant flow of air for the patient.

Possible errors during the manipulation

  1. During the operation:
  • the wrong incision line can cause venous bleeding, air embolism, and sometimes transection of the common carotid artery,
  • blood can enter the lower respiratory tract, causing repeated asphyxiation,
  • the incision should be equal to the diameter of the cannula, otherwise it will have to be sutured and injured the tissue even more,
  • a deep incision can cause injury to the esophagus, so the scalpel blade must be limited to 1 cm.

2. Immediately after surgery:

  • hypoxia
  • fracture of the tracheal ring or its puncture,
  • subcutaneous emphysema
  • pneumothorax.

3. Delayed consequences:

  • tracheobronchitis,
  • stenosis of the trachea and repeated asphyxia,
  • change (hoarseness) of the voice due to transection of the recurrent nerve,
  • cosmetic defects.

All the doctors from their student days remember how tracheotomy is dangerous. This is not an operation that can be performed continuously. Only in emergency, special cases, when the patient is on the verge of life and death, as in a hurry you can harm the patient. And if this manipulation is not carried out in a hospital, but somewhere on the street or at home, then it’s worth a hundred times to think before deciding. Simple at first glance, the technique should be supported by sufficient experience of the surgeon. A tracheotomy at home is not just impossible, it is dangerous. If you do not have a medical education and relevant skills, do not try to repeat it.

A tracheotomy is advisable only to save a person’s life! The risk of death or serious complications is high enough to make the doctor think about alternatives. Even considering the fact that this operation has been known since time immemorial, the medical community has not yet figured out how to make it safe enough.

A tracheotomy is an opportunity to save someone's life, but at the same time the same equivalent opportunity to take it away.

How to do emergency tracheotomy

One of the most common causes of death due to accidents is asphyxiation. In hopeless, critical situations, when the reception of Heimlich has already been carried out, but breathing has not been restored, a tracheotomy can be performed to save a person's life. The procedure for tracheotomy at home or in the field is quite an operation, especially it is difficult for an unprepared person and dangerous, the procedure should only be performed by a medical professional, and only in extreme cases, but most likely will not be able to arrive, the bill goes in a few minutes, delay is inevitable death the victim. So choose you, give the victim a chance to survive, or just watch him suffocate.

Technique and procedure for performing emergency tracheotomy

- Call an ambulance.

- Note the time or ask another person to start counting the time. Choking for more than three minutes leads to irreversible damage to the brain.

- Locate the cricothyroid membrane at the victim. This is a soft space under the larynx where you make an incision. Find Adam's apple or Adam's apple. Put your finger on the Adam's apple and slide down until you feel another bulge, this is a cricoid cartilage. The deepening between the Adam's apple and cricoid cartilage is the cricoid membrane - here you will make an incision.

- Make an incision 1.5 cm long and 1.5 cm deep. Cut the skin and you will see a cricoid membrane. Make an incision in the membrane. The depth of incision should be sufficient to gain access to the airways. To facilitate breathing, place a tube from improvised means in the trachea, the most suitable case is the ballpoint pen case. Hope for the victim’s self-restoration of breathing. Otherwise, you will need to do artificial respiration through this tube.

Tracheotomy is the last thing you can resort to in the absence of other possible techniques and medical personnel.
Use a clean pipe if possible. The infection you bring into the trachea can be a serious complication of tracheotomy.
This is an extremely dangerous procedure. With the wrong technique, it is possible to cause harm to the victim’s health and even death.
Remember also the legal consequences of failure. You may be charged with a person’s death.

Buy paracord bracelet with portable emergency stock

Tracheotomy

This term refers to surgery that is performed in the neck. To ensure proper breathing, a tube is placed in the hole obtained.

With the help of manipulation, it is possible to bypass obstacles that disrupt breathing.

The hole obtained as a result of the procedure is called a stoma or tracheostomy. It may be present temporarily or be permanent.

With the help of the procedure, the doctor opens the airways. It is carried out to normalize breathing in such situations:

  1. Airway blockage at or above the larynx. The provoking factors of this violation include traumatic neck injuries and tumor lesions of the upper respiratory organs.
  2. Respiratory failure, which needs continued support. Pneumonia or traumatic damage to the spinal cord in the neck can be a provoking factor.
  3. Congenital malformations of the larynx or trachea.
  4. Damage to the respiratory tract due to inhalation of smoke or harmful chemical elements.
  5. Complex forms of night apnea.
  6. Ingestion of foreign objects that lead to blockage of the trachea or larynx.

Technique

To perform the procedure, the surgical field is processed in accordance with general surgical rules. Manipulation is carried out under local anesthesia, which involves the use of a 0.5% solution of novocaine with the addition of adrenaline.

In severe hypercapnia in children, anesthesia may not be used, since in such situations the sensitivity decreases sharply, and the surgeon has very little time.

During the procedure, the nose and mouth must not be closed. This will help the patient to breathe better, and the doctor to control the progress of the operation. An incision is made in the neck area and a specific fragment is removed in the trachea. A tracheostomy tube is placed in the hole obtained. It will become a replacement for the respiratory tract. The skin around this device is covered with braces or stitches.

As long as the tube remains in the throat, breathing is carried out through it. To improve ventilation, a special apparatus for artificial respiration is used.

TTracheotomy technique in our video:

Recommendations

Any variant of tracheotomy is a rather complicated intervention, the implementation of which requires appropriate skills and a special set of tools. Compliance with sterile conditions and anesthesia is of no small importance. Therefore, at home, this operation is not performed.

For this purpose, you can use any improvised device. Often use a thick needle or a kitchen knife. In the resulting hole, you need to put some kind of tube - for example, the body of a ballpoint pen. These manipulations can save the victim's life.

Rehabilitation

To avoid complications, special attention should be paid to the recovery period. At the rehabilitation stage, such manipulations may be required:

  1. Maintain a clean stoma. It must be cleaned every day with hydrogen peroxide or water with a mild soap. The dressing should be constantly changed.
  2. Ask a specialist when it is possible to carry out water procedures.
  3. Familiarize yourself with the rules for caring for a tracheostomy tube. It must be cleaned, systematically purged to eliminate secretions, moisten the air. When going out, the pipe should be covered with a scarf so that foreign objects do not get into it.
  4. On the recommendation of a doctor, consult a speech therapist.
  5. If necessary, take antibiotics.
  6. Avoid serious stress for 1.5 months after the intervention.
  7. Follow your doctor’s recommendations.

How to clean the tracheotomy tube. look in our video:

Provided that the operation is performed correctly and all medical recommendations are followed, the prognosis is favorable. However, in some cases, tracheotomy provokes unpleasant complications. These include the following:

  • damage to the vocal cords, nerve fibers or esophagus,
  • infection
  • bleeding,
  • violation of swallowing function,
  • lung tissue damage,
  • cicatricial changes in the neck, which can lead to closure of the tracheostomy,
  • pressure reduction
  • displacement and damage to the tube in the stoma.

The following factors increase the likelihood of complications:

  • children and old age
  • excess weight,
  • malnutrition
  • recent pathologies, especially damage to the upper respiratory system,
  • the use of certain medications
  • smoking,
  • alcoholism.

Tracheotomy is a serious operation, which in some cases can save a person’s life. To achieve the desired results and avoid complications, it is necessary to consult a qualified surgeon and clearly adhere to medical recommendations during the rehabilitation period.

Content

1. Successful or threatening obstruction of the upper respiratory tract

  • The sharpest (lightning fast). Develops in seconds. As a rule, this is obstruction by foreign bodies
  • Sharp. Develops in minutes. Foreign bodies, true croup for diphtheria (obturation with films), Quincke's edema, less often - ligamentous laryngitis
  • Subacute. Develops in tens of minutes, hours. False croup, laryngeal tonsillitis, edema with chemical burns of the esophagus, etc.
  • Chronic. It develops in a day, months, years. Perichondritis, cicatricial narrowing of the trachea, cancer of the larynx

Most often, the following conditions lead to obstruction of the upper respiratory tract:

  • Foreign bodies of the respiratory tract (if it is impossible to remove them with direct laryngoscopy and tracheobronchoscopy),
  • Violation of the airway during injuries and closed injuries of the larynx and trachea,
  • Acute stenosis of the larynx in infectious diseases (diphtheria, influenza, whooping cough, measles, rash or recurrent typhoid, erysipelas),
  • Laryngeal stenosis with specific infectious granulomas (tuberculosis, syphilis, scleroma, etc.),
  • Acute stenosis of the larynx in non-specific inflammatory diseases (abscessed laryngitis, laryngeal tonsillitis, false croup),
  • Laryngeal stenosis caused by malignant and benign tumors (rarely),
  • Compression of the tracheal rings from the outside by the jet, aneurysm, inflammatory neck infiltrates,
  • Stenoses after chemical burns of the mucous membrane of the trachea with acetic essence, caustic soda, fumes of sulfuric or nitric acid, etc.,
  • Allergic stenosis (acute allergic edema),

2. The need for respiratory support in patients undergoing prolonged mechanical ventilation

It is necessary for severe traumatic brain injury, for poisoning with barbiturates, for a burn disease, ALS (amyotrophic lateral sclerosis), etc.

  • According to the level of dissection of the trachea relative to the isthmus of the thyroid gland, upper, middle and lower tracheostomy are distinguished.
  • In the direction of the tracheal incision - longitudinal, transverse, U-shaped (according to Björk) tracheostomy.

Adults have an upper tracheotomy, children have a lower one, since their thyroid gland is located higher. Secondary tracheotomy is extremely rare if it is not possible to produce an upper or lower tracheotomy, for example, with a special anatomical variant of the location of the thyroid gland or with a thyroid tumor.

  • A set of general surgical instruments: hats, anatomical tweezers, surgical tweezers, Billroth and Kocher styptic clamps, a scalpel, straight and Cooper scissors, sharp hooks, blunt hooks, a grooved probe, an elastic catheter for suctioning blood, a syringe suitable for a catheter, or surgical a pillow with oxygen, needle holders, 10-15 needles of various numbers.
  • Special tools for tracheostomy:
Tracheostomy cannulas. The most widely used Luer cannula, which consists of two tubes - external and internal. The modern design consists of metal rings and is arranged like a corrugated tube, Shassignyak sharp single-tooth tracheostomy hook designed to fix the trachea, Dumb hook to move the isthmus of the thyroid gland, Trachea expander to push the edges of the tracheal section before inserting a cannula into its lumen. The most widespread are the tracheo expanders Trousseau (1830) and S.I. Wulfson (1964).

The patient lies on his back, a roller is placed under his shoulders, his head is thrown back. This position of the patient allows you to maximize bring the larynx and trachea to the front of the neck. The operation is performed both under endotracheal anesthesia and under local anesthesia. In children, endotracheal anesthesia is usually used. Local infiltration anesthesia is performed with 0.5-1% novocaine solution or 0.5% trimecaine solution. Under extreme conditions, they operate without anesthesia.

A layer-by-layer incision is made of the skin, subcutaneous tissue, superficial fascia and white line of the neck 4-6 cm long from the thyroid cartilage down, after which the sterno-thyroid muscle (m.sternothyroideus) of the right and left halves of the neck is exposed. Spreading the muscles, they find the cricoid cartilage and the isthmus of the thyroid gland lying under it. Dissect the leaf of the intracervical fascia (f.endocervicalis) in the transverse direction, after which the isthmus is separated from the trachea and pushed it bluntly downward, thus exposing the upper cartilage of the trachea. After that, the larynx is fixed with a single-pointed pointed hook to stop convulsive movements. Taking the pointed scalpel in the hand with the blade up, the operator places the index finger on the side of the blade and, not reaching the tip of 1 cm (in order not to damage the back wall of the trachea, opens the third, and sometimes the fourth, cartilage of the trachea, directing the scalpel from the isthmus to the larynx (up). After air enters the trachea, breathing stops for a while, apnea occurs, followed by a sharp cough, and only after that the tracheodilator is inserted into the tracheotomy wound, and the tracheostomy cannula is removed and placed across the trachea so that the flap is in the sagittal plane, draw into the lumen of the trachea, the expander is removed, the cannula is rotated so that the flap is located in the frontal plane, followed by the cannula moving down and fixing it around the neck.The skin wound is sutured to the tracheostomy tube.

The incision is carried out from the cricoid cartilage to the sternum. Dissect the surface leaf of the own fascia of the neck and penetrate into the suprasternal interaponeurotic space (spatium interaponeuroticum suprasternale). In a blunt way, the cellulose is separated and, moving down the venous jugular arch, a deep leaf of the own fascia of the neck (scapular-clavicular fascia) is cut and the muscles (sternum-hyoid and sternum-thyroid) of the right and left halves of the neck are exposed. Spreading the muscles to the sides, dissect the parietal plate of the intracervical fascia (f. Endocervicalis) and penetrate into the pre-tracheal space. In the fiber of this space, the venous plexus and sometimes the lower thyroid artery (a. Thyroidea ima) are found. The vessels are ligated and transected, and the isthmus of the thyroid gland is pulled up. The trachea is freed from the visceral fascia fascia covering it and the fourth and fifth tracheal cartilages are dissected. The scalpel must be held as described above and directed from the sternum to the isthmus so as not to damage the brachiocephalic trunk. Further methods are no different from those indicated for the upper tracheostomy.

  • Technique of cryoconicotomy.
  1. At one moment, a vertical incision along the midline of the neck below the thyroid cartilage dissects the skin, the arch of the cricoid cartilage and the thyroid cricoid ligament,
  2. Introduce a clamp into the incision and push the branches apart, which ensures air flow into the respiratory tract,
  3. After the disappearance of asphyxia, a cryoconicotomy is replaced by a tracheostomy.

Like any major surgery, a tracheostomy has its own complications. Their severity ranges from cosmetic defects to death. Moreover, the more time has passed after the operation, the less the likelihood of serious complications.

  • Complications that may occur during the operation: in
An incision made not along the midline of the neck can lead to damage to the cervical veins, and sometimes to the carotid artery (one should not forget about the possibility of air embolism in case of damage to the cervical veins). Insufficient hemostasis before opening the trachea can lead to leakage of blood in the bronchi and the development of asphyxiation. If possible, the tracheal incision should correspond to the diameter of the cannula. Injury to the posterior wall of the esophagus. Before the introduction of the cannula, you should make sure that the mucous membrane of the trachea is dissected and its lumen is opened, otherwise you can insert the cannula into the submucosal layer, which will lead to a protrusion of the mucous membrane into the lumen of the trachea and increased asphyxiation.
  • Complications, the occurrence of which is possible immediately after the operation: there is a risk of hypoxia, perforation of the posterior wall of the trachea, fracture of the tracheal ring, wound of the esophagus, subcutaneous emphysema, pneumothorax.
  • In the later postoperative period, purulent tracheobronchitis, tracheal stenosis, tracheal fistula, voice changes, and, due to cosmetic complications, gross scars on the skin in the area of ​​the tracheostomy can occur.

A large number of complications after a tracheostomy occurs as a result of blockage of the tube, mismatch of its size and trachea, incorrect position of the tube in the trachea, its displacement and loss.

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