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
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.
Lateral view of the topographic anatomy of the neck.
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
The superficial muscles and airway structures in the
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