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Tracheostomy

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  • Supralaryngeal obstruction.
  • Secure airway access.
  • Prolonged intubation and mechanical ventilation.
  • Inability to control secretions.

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Emergency Cricothyroidotomy

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  • Inability to obtain an oral or nasopharyngeal airway in a patient who requires emergent intubation.
  • Severe facial or head and neck trauma.
  • Acute loss of the airway due to supralaryngeal obstruction secondary to tumor, anaphylaxis, foreign body, trauma, or burn injury.

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Tracheostomy

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  • Significant coagulopathy can be considered a relative contraindication because bleeding into the airway can be catastrophic.

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Emergency Cricothyroidotomy

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  • There are few contraindications to cricothyroidotomy in the emergent setting with a patient in extremis.

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  • If possible, patient preparation should include the use of a folded sheet, sandbag, or other supporting device placed transversely under the shoulders; this helps in extending the neck and exposing the operative area.
  • Endotracheal intubation is also extremely useful to maintain the airway during the procedure.
  • In emergent situations when the patient is in respiratory distress, there may not be any time for such preparations.

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  • A replacement tracheostomy tube should be available at the patient's bedside at all times, and close monitoring is necessary in the first several days after tracheostomy.
  • The inhaled air should be humidified since the upper airway is bypassed.
  • Frequent endotracheal suctioning is often required to clear secretions.
  • In the comatose patient, continuous pulse oximetry and frequent arterial blood gas monitoring may be needed.
  • Delayed bleeding in the wound can often be difficult to visualize because the tracheostomy tube hinders exposure.
    • In such situations, packing of the wound with a long piece of hemostatic material (eg, Surgicel) may control the bleeding.
    • Packing with small pieces should be avoided to prevent aspiration into the airway.
  • The initial tracheostomy tube is usually left in place for a minimum of 5–7 days, after which it may be removed and replaced.
  • The polypropylene sutures in the tracheal flaps can be cut and removed at the time of the first tracheostomy tube change if the change goes smoothly.

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  • Tracheal stenosis.
  • Subglottic stenosis.
  • Tracheoesophageal fistula.
  • Bleeding.

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