see also: [[jet insufflation]], [[Airway]] see: [Tintinalli - complications of airway devices](x-devonthink-item://FD6F18CE-FB87-49A1-B46B-6EA51187ED3B?page=77) > NB the emergency cricothyroidotomy for CICO to obtain front of neck airway access is different from a tracheostomy. This document covers both because there are two versions of emergencies involving surgical holes in the neck: > 1. CICO and need to place cricothyroidotomy in ED > 2. blocked or bleeding tracheostomy that we need to troubleshoot in ED # equipment ![[Pasted image 20240131065637.png]] ![[Pasted image 20240131065528.png| Close-up of a Shiley tracheostomy tube. Note that only the inner cannula has a 15-mm adapter that will accept an Ambu bag or a ventilator; the outer cannula will not. The inner cannula MUST be in place to ventilate the patient.]] # Procedure ## anatomy pictures ![[Pasted image 20241114171736.png]] ![[Pasted image 20241114172608.png]] ![[Pasted image 20241114171922.png|pic is a bit odd, but emphasises the nearby vasculature to avoid…]] ![[Pasted image 20241114172115.png]] ## surgical cricothyroidotomy | step | explanation | | ----------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Equipment | - scalpel 10 or 20<br>- bougie<br>- size 6 ETT | | preparation | - extend neck<br>- locate cricothyroid membrane (palpate notci + slide finger down) <br>- +/- local anaesthetic | | procedure | - stabilise thyroid cartilage with non-dominant hand<br>- make 2-3 cm vertical incision over cricothyroid junciton<br>- transverse incision across lower half of membrane (ideally don't cut posterior trachea<br>- open menbrane: twist scalpel 90 deg, use artery forceps<br>- dilated with little finger or forceps<br>- pass bougie 10-15cm<br>- insert lubricated size 6 ETT w/ dominant hand<br>- insert only enough length for the cuff to be in trachea<br>- inflate cuff, check position, and secure | ![[Pasted image 20241114172744.png]] ![[Pasted image 20241114172818.png]] ## CICO age <10 See: [paediatric FONA](https://emcrit.org/emcrit/pediatric-tracheotomy/) videos - declare critical situation as CICO - perform cannular cricothyroidotomy - extend neck - stabilise larynx and identify cricothyroid membrane - insert size 14g cannula needle through cricothyroid membrane in caudal direction at 45 deg - confirm position by aspiration of air using syringe filled with saline - advance cannula over needle and support in non-dominant hand - perform [[jet insufflation]] - attach adjustable jet insufflation device set to O2 source # indications - prolonged mechanical ventilation -- to facilitate weaning from resp support - pulmonary toilet -- patients unable to clear excessive secretions (eg bulbar palsy or weak cough) - airway protection -- pts unable to maintain an airway eg assorted neurological conditions or reduced consciousness - part of surgical procedure -- head and neck or ENT surgery (eg laryngectomy) - upper airway obstruction -- facial or laryngeal trauma, burns, anaphylaxis # contraindications # tracheostomy complications **early complications** < 2 weeks - haemorrhage - tube dislodgement or obstruction - false passage can occur from blind forceful attempts at re-insertion if it comes out before a tract has formed <5 days after procedure - s/c emphysema - *infection* (common cause early) - thyroid injury - pneumothorax - equipment failure - tube fracture (usually at the juncture of flange and tube connection) → migrate inferiorly and obstruct the racheal lumen. replace tube and consider bronch if tube fragment has been aspirated - tracheal *cuff complications*: target pressure is 18-25 mmHg > ==tracheoinnominate artery fistula== (TIF) can present within first 3 weeks after tracheostomy. may be preceded by hours to days with small-volume sentinel bleed. ↑ mortality **late complications** > 2 weeks - traceal stenosis or tracheal malacia - tube dislodgement or obstruction - arterial fistula (eg ==TIF==) - tracheo-esophageal fistula - infection - thyroid vessel erosion - granulation tissue ![[Pasted image 20241114173604.png]] # Tracheostomy troubleshooting ## bleeding 1. HF 15L O2 to mouth (unless known laryngectomy) 2. Maintain + clear airway: remove caps+inner tubes of tracheostomy and ==suction== vigourosly 3. ==Hyperinflate tracheostomy cuff== in 5mL alloquots to 50mL to tamponade bleeding 4. Dedicated assistant ==apply pressure to root of neck== in the sternal notch 5. Insert finger into stoma and pull anteriorly to occlude **innominate artery** 6. ==Correct coagulopathy== and replace blood products as required, early activation MTP, aim MAP >65 and normal mentation 7. If above fails withdraw tracheostomy and ==intubate orally or through stoma== placing ETT cuff distally and overinflate 8. Disposition: urgent ENT/anaesthetics +/- thoracics consult for urgent exploration in OT ![[Pasted image 20240728190623.png|Pressure placed by the clinician’s finger through the tracheostomy hole occluding the tracheo-innominate artery]] ![[Pasted image 20241106125857.png]] ## poor ventilation Ddx: obstruction (eg blood or secretions), displacement, stenosis, other causes of resp distress (eg bronchospasm, LRTI, PTx, PE, etc) - get help - Position upright - O2 - Troubleshoot inner tube (remove) and try and pass suction catheter -