Overview
Definition:
Emergency tracheostomy is a life-saving surgical procedure performed urgently to establish an airway when conventional methods of airway management (e.g., intubation) have failed or are not feasible.
Epidemiology:
While not common, emergency tracheostomy is a critical intervention in situations of complete airway obstruction
Incidence varies based on trauma, anaphylaxis, and upper airway emergencies.
Clinical Significance:
This procedure is paramount for preventing irreversible hypoxic brain injury and death in patients with impending or complete airway loss
Prompt recognition and execution are vital.
Indications
Absolute Indications:
Complete upper airway obstruction above the glottis
Failure of endotracheal intubation despite multiple attempts
Severe facial trauma compromising the airway
Upper airway bleeding or edema causing obstruction.
Relative Indications:
Need for prolonged mechanical ventilation in patients who cannot be extubated
Facilitation of secretion clearance in compromised patients
Anticipated difficult airway for prolonged procedures.
Contraindications:
Generally, there are no absolute contraindications in a true life-threatening airway emergency
Relative contraindications may include severe coagulopathy or local infection at the proposed site, but these are often overridden by the need for an airway.
Diagnostic Approach
History Taking:
Rapid assessment focusing on symptoms of airway compromise: stridor, dyspnea, hoarseness, inability to speak, cyanosis
History of trauma, anaphylaxis, foreign body aspiration, or prior airway issues.
Physical Examination:
Assess for inspiratory stridor, accessory muscle use, retractions, cyanosis, accessory muscle use, tracheal deviation, and palpable foreign bodies
Listen for breath sounds, noting absence or diminished air entry
Assess for gag reflex and vocal cord function if possible.
Imaging And Investigations:
Usually not feasible or indicated in an emergency scenario
If time permits and the patient is stable enough, lateral neck X-ray or CT scan can assess the level of obstruction, but definitive airway intervention takes precedence.
Surgical Management
Preoperative Preparation:
Ensure adequate lighting and sterile field if time permits
Position the patient supine with neck extended (unless cervical spine injury is suspected)
Prepare local anesthetic and necessary surgical equipment (scalpel, tracheal hook, dilator, tracheostomy tube, obturator, ties).
Technique Percutaneous Dilation:
This is often preferred in non-emergency settings but can be adapted
Identify cricothyroid membrane
Make stab incision
Insert guidewire
Dilate tract
Insert tracheostomy tube over dilator
Remove dilator and obturator
Secure tube.
Technique Open Cricothyroidotomy:
Preferred in true emergencies
Palpate cricothyroid membrane
Make horizontal incision through skin and membrane
Insert small tracheal hook
Insert blunt-tipped instrument (e.g., Kelly forceps) to dilate
Insert cuffed tracheostomy tube or small endotracheal tube
Secure tube.
Technique Open Tracheostomy:
For lower airway obstruction or when cricothyroidotomy is not feasible
Incise skin over trachea
Dissect strap muscles
Identify trachea
Incise between tracheal rings (typically 2nd-3rd or 3rd-4th)
Insert tracheostomy tube
Secure tube
This is less common as a primary emergency procedure due to time constraints.
Tube Selection:
Choose appropriate size cuffed tracheostomy tube
For cricothyroidotomy, a smaller tube (e.g., 4-6 mm ID) is often used
For open tracheostomy, a standard size is selected.
Postoperative Care
Immediate Monitoring:
Closely monitor vital signs, oxygen saturation, and chest wall movement
Ensure securement of the tracheostomy tube
Auscultate bilateral breath sounds
Connect to humidified oxygen or mechanical ventilation as needed.
Suctioning:
Regular suctioning of secretions is crucial
Use sterile technique
Suction depth should not exceed the length of the tracheostomy tube to avoid tracheal damage
Limit suction attempts to minimize hypoxia and mucosal trauma.
Humidification And Cleaning:
Administer humidified air to prevent secretion drying
Perform regular tracheostomy site care to prevent infection and skin breakdown
Inner cannula changes as per protocol.
Nutrition And Communication:
Initiate appropriate nutritional support
For long-term patients, consider speaking valves once stable to aid communication and swallowing rehabilitation.
Complications
Early Complications:
Hemorrhage (surgical site bleeding)
Pneumothorax
Subcutaneous emphysema
Accidental decannulation
Tube obstruction by blood clots or secretions
Nerve injury (recurrent laryngeal nerve)
Esophageal perforation.
Late Complications:
Tracheal stenosis
Tracheomalacia
Tracheoesophageal fistula
Tracheoinnominate artery fistula (life-threatening hemorrhage)
Granulation tissue formation
Persistent stoma
Wound infection.
Prevention Strategies:
Accurate landmark identification
Careful dissection
Proper tube size selection and securement
Humidification of inspired air
Diligent suctioning
Regular stoma care
Close monitoring for signs of complications.
Key Points
Exam Focus:
Emergency tracheostomy vs
cricothyroidotomy indications and techniques
Management of immediate complications like hemorrhage or pneumothorax
Recognition of life-threatening late complications such as tracheoinnominate fistula.
Clinical Pearls:
In a true airway emergency, do not hesitate to perform a cricothyroidotomy
Timely intervention prevents brain damage
Always have emergency airway equipment readily available
If unsure about intubation, consider early surgical airway
Confirm tube placement with capnography if possible.
Common Mistakes:
Delaying intervention when airway is compromised
Attempting complex dissections in a chaotic emergency
Incorrect landmark identification leading to wrong site access
Failure to secure the airway adequately
Inadequate post-operative suctioning and humidification.