Lecture 30. CRICOTHYROIDOTOMY.pptxzbendj

Presentation

1. J.CHAMA CRICOTHYROIDOTOMY /TRACHEOSTOMY

2. Introduction Cricothyroidotomy, also known as cricothyrotomy, is an emergency procedure It is used to obtain an airway when other methods ( eg , laryngeal mask airway [LMA] and endotracheal intubation) are ineffective or contraindicated.

3. Cont… Establishing an effective airway in the face of medical emergencies is a skill that healthcare providers must master to prevent patient morbidity or mortality.

4. Indications Cricothyroidotomy is indicated upon failure to obtain an airway with traditional methods in the following situations : Trauma causing oral, pharyngeal, or nasal hemorrhage Facial muscle spasms or laryngospasm Uncontrollable emesis Upper airway stenosis or congenital deformities Clenched teeth Tumor, cancer, or another disease process or trauma causing mass effect

5. Cont… Airway obstruction indications include the following : Oropharyngeal edema ( eg , anaphylaxis) Foreign body obstruction The following are relative indications for cricothyroidotomy :

6. Cont… Cervical spine immobilization secondary to injury Maxillofacial injuries Non emergent indications include the following: Prolonged intubation Maxillofacial, laryngeal, or oral surgery Bronchoscopy

7. Contraindications The only absolute contraindication to surgical cricothyroidotomy is age. However, the exact age at which a surgical cricothyrotomy can be safely performed is controversial and has not been well defined.

8. Cont… Lower age limits for Cricothyrotomy is 12 years In patients below this cut off age, needle cricothyrotomy is indicated because infants and children younger than 12 years have a smaller cricothyroid membrane and a more funnel-shaped, rostral , and compliant larynx

9. Technical considerations A permanent tracheostomy should be placed within 24 hours. Needle cricothyrotomy can be used for approximately 40 minutes, after which time carbon dioxide accumulates

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11. Cont… The success rate for cricothyrotomy has been similarly high (89%-100 %) whether in the field or in the ED

12. Technique consideration There are 3 main approaches to cricothyroidotomy: Needle cricothyroidotomy Percutaneous cricothyroidotomy using the Seldinger technique and Surgical cricothyroidotomy

13. Needle Cricothyroidotomy Needle cricothyroidotomy may be divided into the following steps: 1. Position the patient, apply lidocaine (if indicated), and prepare a sterile field, including cleansing with antiseptic solution. 2. Identify anatomic landmarks. Palpate the thyroid cartilage (the first prominent landmark on the anterior neck), the cricoid cartilage (caudal to the thyroid cartilage), and the area between them, which is the cricothyroid space that contains the membrane .

14. Cont… 3. With the dominant hand, insert the angiographic catheter, attached to the syringe filled with normal saline, into the cricothyroid membrane, directing it caudally at a 45 o angle. 4. As the needle is advanced, apply negative pressure to the syringe. A distinct pop can be felt as the needle traverses the membrane and enters the trachea. In addition, air bubbles will appear in the fluid-filled syringe.

15. Percutaneous Cricothyroidotomy ( Seldinger Technique ) Percutaneous cricothyroidotomy using the Seldinger technique may be divided into the following steps : 1. Follow steps 1-4 from needle cricothyroidotomy substituting a finder needle attached to a syringe for the angiographic catheter. 2. Remove the syringe from the needle, and advance the guide wire through the needle. Remove the needle once the guide wire is in place.

16. Cont… 3. Use the scalpel to make a small stab incision in the skin close to the guide wire. 4. Place the dilator into the airway catheter, and insert the 2 devices together over the wire. 5. Remove both the dilator and the guide wire once the airway tube is secured in the trachea. 6. Secure the tube in place with appropriate tape.

17. Complications Early complications of cricothyroidotomy may include the following: Bleeding Incorrect placement, resulting in possible creation of a false passage through tissue Subcutaneous emphysema Obstruction Esophageal or mediastinal perforation Aspiration Vocal cord injury Pneumothorax

18. Cont… Laryngeal injury Posterior tracheal wall perforation Thyroid perforation Hypercarbia (needle cricothyroidotomy)

19. Cont… Late complications of cricothyroidotomy may include the following: Dysphonia Infections Hematoma Persistent stoma Scarring Glottic or subglottic stenosis Laryngeal stenosis Tracheoesophageal fistula Tracheomalacia

20. TRACHEOSTOMY (TRACHEOTOMY) Tracheostomy is a surgical opening in the trachea (windpipe) that forms a temporary or permanent opening to make breathing easier. The terms "tracheotomy" and " tracheostomy " are used interchangeably The opening is called a stoma. Emergency tracheostomy is performed as a lifesaving procedure

21. Indications Tracheostomy is done only in those cases in which intubation by a mouth or nasal tube is not a feasible option. There are broadly four groups of patients on whom tracheostomy needs to be performed: 1. To relieve breathing difficulties by any blockage in the airway passages for example- · Foreign body Impactation in the airways. · Acute infection of the airways · Edema of the airways · Paralysis of vocal cords following injury · Tumors of the vocal cords · Trauma in the region

22. Cont… 2. To improve respiratory functions by reducing the length of the airway, which may be required in special lung conditions like- - Bronchopneumonia · Bronchitis with Emphysema · Chest injury In these conditions the tracheostomy tube also helps in aspiration of excessive secretion that may be caused due to infection or injury

23. Cont… 3. Respiratory nerve damage temporary or permanent causing paralysis of chest muscles that assist in breathing. In these situations performing assisted or positive pressure respirations may be required in conditions like- · Unconsciousness associated with head injuries · Barbiturate poisoning · Poliomyelitis · Tetanus These patients may also aspirate their gastric content into the lungs and a tracheostomy tube may be helpful for aspiration these secretions.

24. Cont… 4. As a preliminary step in certain surgeries on the upper airway.

25. Advantages of tracheostomy - Reduces patient discomfort · Reduces need for sedation · Improves ability to maintain oral and bronchial hygiene · Reduces risk of trauma to the windpipe and trachea · Makes breathing easier with less effort for a sick patient · Easier to move off assisted breathing using a ventilator.

26. Procedure The patient is made to lie down on their back with the neck & head extended by keeping a pillow under the shoulder and neck. Local anaesthesia or general anaesthesia is used for the procedure. A horizontal cut is made across the neck above the ' sternal notch' using a knife. The skin is separated and surrounding tissues are dissected to expose the trachea. The 2nd or 3rd of the tracheal ring is incised for the tracheostomy tube to be placed.

27. Cont… A suitable size tracheostomy tube is then introduced inside. While choosing the tube, the smallest feasible tube should be used. A general rule is that the tube should be three fourths of the diameter of the trachea. The cuff of the tube is inflated by using 2-5 ml of air and it is held in place by using a necktie. The incision is closed using skin sutures by the side of the tracheostomy tube. Dressing is applied for the wound to heal.

28. Complications   Common complications with tracheostomy are- Wound infections Air leakage Improper air entry Tracheal ring narrowing or Stenosis (usually with high tracheostomy ) Ulceration of the trachea or main bronchi Entrapment of air under the skin (called surgical emphysema), this is a self-limiting condition that resolves spontaneously.

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