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Primary Surgery Vol.2 – Trauma |  |
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Primary Surgery Vol.2 – Trauma | |
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Any of those given below for a formal tracheostomy when the patient is in immediate danger of death, and there is no time to do a formal tracheostomy.
Put anything under the patient’s shoulders that will extend his neck, and make his larynx more prominent.
Find the prominence of his thyroid cartilage in the midline, and follow it downwards to the prominence of his cricoid cartilage, as in A, Fig. 52-3. Feel these on your own throat now.
Use your finger nail to mark the depression formed by his cricothyroid membrane in the midline between his thyroid and cricoid cartilages.
You can now insert needles or a knife.
Insert 2 or more short wide bore (1.6 mm or larger) needles through the patient’s cricothyroid membrane (B). Give him oxygen through one of them if necessary. Or, use a disposable needle and cannula (’Medicut’) and leave it in place.
Make a vertical midline incision over the patient’s thyroid and cricoid cartilages (C). Retract the subcutaneous tissues between your fingers. Spread the wound apart until you can see his cricothyroid membrane.
Insert the first 2 cm of the tip of a solid bladed knife horizontally through the patient’s cricothyroid membrane as near his cricoid cartilage as you can (D). This will avoid his cricothyroid arteries which run across the membrane superiorly.
CAUTION! Stand clear as you cut, you may be showered with droplets of blood and secretions as he coughs through his tracheostomy wound.
Widen the opening in his cricothyroid membrane. Put the handle of the scalpel into it horizontally, and turn it through 90
(E). If you don’t have a tracheostomy tube, put any convenient tube into the hole.
Do an elective tracheostomy as soon as you can. If you delay it, perichondritis, stenosis, and subglottic oedema may follow.
Children and desperate emergencies only. A formal tracheostomy after intubation is safer.
![\includegraphics[scale=0.45]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-52/fig/52-3.eps}](images/img-0018.png)
There will not be time to make a flap, so make a vertical cut just above the patient’s suprasternal notch. Make room underneath his skin with any convenient blunt instrument.
Neglect bleeding for the time being, unless it makes finding his trachea difficult. Leave his first and second rings and cut his third and fourth. There will be less chance of a stricture here. Turn the knife sideways. He will cough profusely. Insert a tracheostomy tube and stitch it to his skin.
The main indications in trauma are: (1) When intubation fails or is unsatisfactory, and there is no other way of maintaining an injured patient’s airway. (2) When intubation has to be prolonged for more than 48 hours. Acute respiratory infection in children is the most common overall indication.
Intubation which has failed or is impossible in a patient with: (1) Severe cyanosis who is dying of respiratory obstruction. (2) Severe jaw injuries. (3) Severe laryngeal injuries. (4) Severe burns of the face.
Severe chest injuries in which a patient with a flail chest or lung contusion is becoming increasingly cyanosed and has failed to respond to the insertion of a chest drain for a thorax or pneumothorax.
Severe head injuries in which a patient is in deep coma and hasalready had burr holes and treatment for cerebral oedema. He has been intubated and hyperventilated with a ventilator. He is now beginning to run the risk of complications from his tracheal tube. Oral and bronchoscopic suction are proving inadequate.
Also: (1) Respiratory obstruction due to a diphtheritic membrane orsome other respiratory infection, especially in a child. (2) The need for prolonged ventilation. (3) Massive secretions needing frequent bronchoscopy. (4) Poliomyelitis, with respiratory paralysis. (5) Respiratory obstruction following thyroidectomy.
A sucker and catheter. A tracheal retractor or hook. A suitable tracheal tube, as listed above. The inner tube should be 3 mm longer than the outer one, so that secretions remain inside it. If you aim to prevent secretions accumulating, or to provide continuous anaesthesia with positive pressure ventilation, use a cuffed tube with a long curve, so that it makes an adequate airtight seal. Choose it carefully. Don’t use a too small tube. If it is too long, it may reach to a patient’s carina and block one of his bronchi. An incorrectly fitting tube may erode an artery and cause severe bleeding.
(1) Intravenous ketamine. (2) Give the patient a general anaesthetic and pass a tracheal tube. (3) Infiltrate his tissues with a local anaesthetic solution (A 5.4). Local anaesthesia on a struggling patient is difficult; if you use it, find some sturdy helpers. Before any tracheostomy, warn the patient that he may not be able to talk immediately after the operation.
If you are inexperienced, make a 5 cm vertical incision starting just below the patient’s cricoid cartilage, as in A, Fig. 52-4. When you have had several successes, make a transverse incision 5 cm long 2 cm below the border of his cricoid cartilage. Cut through the patient’s subcutaneous fat, and his cervical fascia (C).
CAUTION! (1) From now on use blunt dissection. Use it to raise short flaps and expose his anterior jugular vein and the underlying muscles.
Use blunt dissection to define and separate the fibrous median raphe between his right and left sternohyoid muscles. His sternothyroid muscles lie slightly deeper, find them and retract them laterally. You will now see the isthmus of his thyroid gland and part of his trachea. They vary considerably.
If the isthmus of his thyroid is small, there is no need to divide it.
If the isthmus of his thyroid is large and interferes with your approach to his trachea, divide it. Make a small horizontal incision through his pre–tracheal fascia over the lower border of his cricoid cartilage. Put a small haemostat into the incision and feel behind his thyroid isthmus and its fibrous attachment to the front of his trachea (D). When you have found the plane of cleavage, use blunt dissection to separate the isthmus from the trachea. Put a large haemostat on each side of the isthmus, and cut it. Later, oversew the cut surfaces or tie them (E).
Put sutures into the skin edges ready to close the wound round the tube later.
Insert a tracheal hook below his cricoid cartilage and pull his trachea forwards and upwards (not illustrated). Have a sucker and a catheter ready.
CAUTION! Control all bleeding before you open the patient’s trachea. Cut the membrane below its second or third ring transversely, and keep the sucker near the opening. Then stand clear. If there is blood in his trachea, he will cough it everywhere.
Turn a flap (F) containing his second tracheal ring downwards and insert the tube. The flap will act as a guide to direct the tube into his trachea and will make changing it easier. A flap largely eliminates the great danger of a tracheostomy, which is inability to replace the tube quickly when it has come out accidently. When the tube is safely in place, stitch the flap to his skin.
CAUTION! (1) Don’t disturb his first tracheal ring. (2) Don’t remove any trachea. (3) Don’t incise more than 40% of the circumference of his trachea, or severe stenosis may follow.
Inject 2 ml of lignocaine into the stoma in his trachea; he will tolerate the tube more easily with his mucosa anaesthetized.
With the obturator in the tube, place the tube in the patient’s trachea (G). You will find this easier if you use the tracheal dilator (H). Remove the obturator, and replace it by the inner tube.
The tube must not slip out, so stitch it and tie it in two places: (1) On either side of the tube pass a silk suture through a bite of skin and tie it through the slots on the outer tracheal tube. (2) Tie the tube in place with tapes round the patient’s neck. Tie it with his head well flexed, or the tapes may become slack when he sits up in bed with his head forward.
Pack vaseline gauze round the tube, and bring the edges of the skin incision together with sutures. Leave a little space round the tube, to minimize the danger of subcutaneous emphysema.
![\includegraphics[scale=0.46]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-52/fig/52-4.eps}](images/img-0019.png)
CAUTION! (1) Don’t stitch his skin tool ightly or too loosely round the tube. Surgical emphysema can be caused by: (a) closing his skin too tightly round the tube (causing him to drive air out into his tissues when he coughs round a partly blocked tube), or (b) closing it too loosely, enabling him to draw air into his tissues when he makes a panic inspiration through a blocked tube. (2) To avoid emphysema, don’t let the tube become blocked. (3) If you use a cuffed tube, avoid too short a cuff or too high a pressure inside it. (4) Deflate the cuff 4-hourly for 15 minutes to reduce the risk of his tracheal mucosa necrosing.
THE POSTOPERATIVE CARE OF A TRACHEOSTOMY Keep the patient in a steam room to prevent crusts forming in the tube. If necessary use a steam kettle or squirt a fine spray of saline into the tube every 15 minutes. Suck out secretions with a soft sterile catheter. Suck them out only as you withdraw it. Avoid prolonged or too frequent suction.
CAUTION! Suck out his trachea aseptically. This is no less important than catheterizing his bladder aseptically. Use a fresh, sterile catheter each time. Remove and clean the inner tube every 4 hours during the first few days.
If viscid secretions have formed, loosen them by injecting 3 ml of sterile saline solution and then aspirate.
If the tube easily slips out, change it for one with a better shape. If necessary, take a soft tissue lateral X-ray of the patient’s neck, to show how the tube is lying in his trachea.
CAUTION! (1) Try not to change the outer tube before the fourth postoperative day. If you take it out too soon, it may be difficult to replace. Check the tension of the tapes regularly. (2) Minimize the risk of infection by sucking out his trachea regularly under careful aseptic precautions.
Later, insert a smaller tube and tell the patient to try to breathe and speak with his finger over the hole. As soon as he can do this easily, remove the tube.
If there is FIERCE BLEEDING while you are inserting a tracheostomy tube the blood may be coming from: (1) The veins of the patient’s anterior jugular system. (2) The isthmus of his thyroid. (3) The wall of his trachea. If blood enters his trachea round the tracheostomy tube, immediately insert a cuffed tube. Then open the wound and tie any bleeding vessels. Next time make a vertical incision.
If the patient’s tracheostomy TUBE SLIPS OUT, you may have: (1) Made the tracheostomy in the wrong place. (2) Used the wrong shape of tube. (3) Failed to adjust the tapes round his neck. (4) Not stitched the outer tube’s flanges to his skin.
If the INNER TUBE BLOCKS, change it frequently, humidify the air he breathes, and suck regularly.
If his TRACHEA BECOMES STENOSED, it has probably done so because you opened it below the level of the second tracheal ring.
If he CANNOT TOLERATE THE REMOVAL OF THE TUBE, the reason may be psychogenic. If he is an adult, gradually reduce its size, then cork it for progressively longer periods before removing it.
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Primary Surgery Vol.2 – Trauma | |
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