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Control of the airway is the first priority in the resuscitation of a critically ill patient. Tracheostomy has long been relied upon in desperate moments to secure an airway. Modern Emergency Physicians have many options for airway management. They are skilled in a variety of invasive, noninvasive, and surgical procedures to optimize the management of a patient’s airway. The role of tracheostomy for emergent airway access has diminished as newer, safer, and equally effective techniques have evolved. Familiarity with the methods for tracheostomy is still valuable. Knowledge of proper techniques, possible indications, limitations, and likely complications will guide one’s judgment in critical moments, when it most counts. Understanding the procedure for a tracheostomy will allow Emergency Physicians to properly care for a problem or complication when a patient with a tracheostomy tube presents to the Emergency Department.

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A surgical approach to the airway relies upon a sound knowledge of the anatomy of the neck and a safe approach to the trachea. A careful review of this anatomy illustrates how critical it is to remain in the midline in order to avoid morbidity and mortality. External landmarks are useful in identifying the significant structures of the airway1,2 (Figure 15-1). The laryngeal prominence is a useful guide to the thyroid cartilage. The cricoid cartilage can be identified as a ring just inferior to the thyroid cartilage. In the absence of edema or a hematoma, a finger marched down the midline from the cricoid cartilage can palpate and identify the cartilaginous rings of the trachea. In an emergent situation, these external landmarks may be all a physician has to guide the establishment of a surgical airway.

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FIGURE 15-1
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Lateral view of the topographic anatomy of the neck.

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The neck is a complex three-dimensional structure with numerous vital structures coursing through a small space (Figures 15-2, 15-3, 15-4, 15-5, and 15-6). The cervical portion of the airway is anterior, superficial, and midline. It is covered by skin, subcutaneous tissue, and numerous muscles (Figure 15-2). The basic cartilaginous framework of the airway begins superiorly at the hyoid bone and continues inferiorly with the larynx and trachea (Figure 15-3). The external skeleton of the larynx comprises the hyoid bone, thyroid cartilage, and cricoid cartilage.3 The hyoid bone is a U-shaped structure attached to the mandible, tongue, and base of the skull by muscles. It is the most stable portion of the airway. Even in the presence of pathology, the hyoid bone is remarkably constant in position and can be considered a stable landmark.4–6

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FIGURE 15-2
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The superficial muscles and airway structures in the neck.

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