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Emergency Tracheotomy

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Stabbing of the cricothyroid membrane, or an

attempted stabbing of the trachea, so long taught as an emergency

tracheotomy, is a mistake. The author's two stage, finger guided

method is safer, quicker, more efficient, and not likely to be

followed by stenosis. To execute this promptly, the operator is

required to forget his textbook anatomy and memorize the schema (Fig.

105). The larynx and trachea are steadied by the
humb and middle

finger of the left hand, which at the same time push back the

important nerves and vessels which parallel the trachea, and render

the central safety line more prominent (Fig. 106). A long incision is

now made from the thyroid notch almost to the suprasternal notch, and

deep enough to reach the trachea. This completes the first stage.

[FIG. 107.--Illustrating the author's method of quick tracheotomy.

Second stage. The fingers are drawn ungloved for the sake of

clearness. In operating the whole wound is full of blood, and the

rings of the trachea are felt with the left index which is then moved

slightly to the patient's left, while the knife is slid down along the

left index to exactly the middle line when the trachea is incised.]

Second stage. The entire wound is full of blood and the trachea cannot

be seen, but its corrugations can be very readily felt by the tip of

the free left index finger. The left index finger is now moved a

little to the patient's left in order that the knife shall come

precisely in the midline of the trachea, and three rings of the

trachea are divided from above downward (Fig. 107). The Trousseau

dilator should now be inserted, the head of the table should be

lowered, and the patient should be turned on the side to allow the

blood to run away from the wound. If respiration has ceased, a cannula

is slipped in, and artificial respiration is begun. Oxygen

insufflation will aid in the restoration of respiration, and a pearl

of amyl nitrite should be crushed in gauze and blown in with the

oxygen. In all such cases, excessive pressure of oxygen should be

avoided because of the danger of producing ischemia of the lungs. Hope

of restoring respiration should not be abandoned for half an hour at

least. One of the author's assistants, Dr. Phillip Stout, saved a

patient's life by keeping up artificial respiration for twenty minutes

before the patient could do his own breathing.

The after-care of the tracheotomic wound is of the utmost

importance. A special day and night nurse are required. The inner tube

of the cannula must be removed and cleaned as soon as it contains

secretion. Secretion coughed out must be wiped away quickly, but

gently, before it is again aspirated. The gauze dressing covering the

wound must be changed as soon as soiled with secretions from the wound

and the air-passages. Each fresh pad should be moistened with very

weak bichloride of mercury solution (1:10,000). The outer tube must be

changed every twenty-four hours, and oftener if the bronchial

secretion is abundant. Student-physicians who have been taught my

methods and who have seen the cases in care of our nurses have often

expressed amazement at the neglect unknowingly inflicted on such cases

elsewhere, in the course of ordinary routine surgery. It is not

unusual for a patient to be sent to the Bronchoscopic Clinic who has

worn his cannula without a single changing for one or two years. In

some cases the tube had broken and a portion had been aspirated into

the trachea.

[FIG. 108.--Method of dressing a tracheotomic wound. A broad

quadruple, in-folded pad of gauze is cut to its centre so that it can

be slipped astride of the tube of the cannula back of the shield. No

strings, ravellings or strips of gauze are permissible because of the

risk of their getting down into the trachea.]

If the respiratory rate increases, instead of attributing it to

pulmonary complications, the entire cannula should be removed, the

wound dilated with the Trousseau forceps, the interior of the trachea

inspected, and all secretions cleaned away. Then the tracheal mucosa

below the wound should be gently touched with a sterile bent probe, to

induce cough to rid the lower air passages of accumulated secretions.

In many cases it is a life-saving procedure to insert a sterile long

malleable aspirating tube to remove secretions from the lower

air-passages. When all is clear, a fresh sterile cannula which has

been carefully inspected to see that its lumen has been thoroughly

cleaned, is inserted, and its tapes tied. Good plumbing, that is,

the maintenance at all times of a clear, clean passage in all the

pipes, natural and artificial, is the reason why the mortality in

the Bronchoscopic Clinic has been less than half of one per cent,

while in ordinary routine surgical care in all hospitals collectively

it ranges from 10 to 20 per cent.