Surgical airways, although once common, now are rarely used in emergency situations in developed countries. With their wide variety of intubating medications and sophisticated airway devices, clinicians usually have no need to apply a knife to the neck to get an emergent airway. Yet, when a patient needs an immediate airway and no other method is practicable, a surgical airway may be the best option. Some type of knife and a tube—even if they are not the optimal choices—are nearly always available. Having to perform a surgical airway is much more likely in austere medical situations than in normal circumstances.
Prediction of Difficult Surgical Airway
A quick assessment can determine whether obtaining a surgical airway may be problematic. These are not contraindications, only observations to suggest that a surgical airway may be difficult. Use the mnemonic "SHORT" to recall what to observe, or to ask if there is sufficient time: Does the patient have (a) evidence of previous neck Surgery? (b) a Hematoma or abscess in the anterior neck? (c) Obesity or other neck enlargement, such as from subcutaneous emphysema or edema? (d) prior Radiation to the neck area? or (e) a Tumor in the neck area?82
In reality, in an emergency, the answers to those questions may not matter; you have to get an airway no matter what the situation. Knowing that these problems exist, however, may sway you toward another airway option, if it is available.
Cricothyrotomy is lifesaving. "This is an emergency procedure to be done at the site of injury, without anesthesia, with any sharp knife at hand."83
To locate the correct site for a cricothyrotomy, use the "4-finger rule." When you lay the tip of the small finger in the sternal notch, the tip of the index finger lies over the cricothyroid membrane. This works for most adults. For a child, lift their hand to their neck to use their fingers.
Emergency cricothyroidotomies have been performed with scissors, pocket or hunting knives, razor blades, broken glass, and the jagged edges of the lid from a tin can. If using a scalpel, simply turning the scalpel blade's handle in the cricothyroid incision is as effective as using an intraoperative Trousseau dilator (the formal piece of equipment used in the OR to dilate the hole for a tracheostomy) to widen the hole to insert the tube. Using a skin hook allows a slightly larger-size ETT to be placed.84 (For a skin hook fashioned from a bent needle, see Fig. 21-5 in Chapter 21, Surgery/Trauma.)
Another method of putting the tube in the trachea is to use the Seldinger technique. As soon as entry is made into the trachea, pass a guide, such as a wire, through it. Then, using the eyehole at the end of the ETT, pass the tube into the trachea.
Once the cricothyroid membrane is opened, if the patient is breathing spontaneously, such as when an upper airway obstruction has been relieved, the hole only needs to be held open manually. In these cases, the incision through the cricothyroid membrane needs to be slightly larger than normal. Airways also have been held open in these circumstances with paper clips and nail clippers.
Endotrachael and Tracheostomy Tubes
Placing an ETT through an emergency cricothyrotomy is optimal. It is easily handled, is readily available in most health care settings, is long enough not to slip out, and has a small enough balloon so that it does not get torn as it passes into the trachea. A tracheostomy tube, if available, is a good alternative, although it is shorter and has a bulky balloon, potentially increasing complications in stressful situations.
A wide variety of tubes has been suggested; some have even been tested. Some will be available only in health care facilities. Others are designed for use in out-of-hospital austere circumstances. The problem is that some don't work; many are dependent on the object's design and diameter. But in these circumstances, you have to use what is available. While not a sophisticated plan, research does show that in critical situations when a cricothyrotomy tube is needed, it is best to use the largest hollow tube available that will fit through the hole. Be creative.
An excellent cricothyrotomy tube can be fashioned from the flanged portion of a 2-mL or 3-mL syringe barrel cut to 45 degrees (Fig. 8-25). Remove the syringe plunger and cut the barrel at an approximate 45-degree angle, at a point one-third of the way toward the tip (needle end). Insert the cut end of the syringe through the surgical opening at a right angle to the trachea, with the long end entering through the caudal (upper) part of the incision (Fig. 8-26). The flanges on the barrel act as a stopper and provide a site for securing the tube. The problem with this device, as with many other improvised cricothyrotomy tubes, is how to attach a BVM, if one is available. Mouth-to-tube ventilation may be the only option for an apneic patient.85
Cricothyrotomy tube cut from 3-cc syringe.
Improvised cricothyrotomy tube inserted (lateral view).
Not only have the relatively rigid and large-bore sports bottle straws been successfully used for emergency cricothyrotomies, but also, when tested, both the ribbed and flat types have about the same airway resistance as do 7.0-mm ETTs and 8.0-mm tracheostomy tubes. They also have the benefit that, if available subsequently, a standard adapter from a 7.0-mm ETT can be inserted, so a bag-valve device can be used without reintubating the patient. Of course, as with all improvised devices, the straw lacks a cuff, so the patient's mouth must be sealed during mouth-to-straw ventilations. It is, however, long and flexible enough to fit into the trachea with enough extra length for the operator to perform ventilations.86
Tubes and Small Hollow Objects
Consider any available hollow tubing as a possible cricothyrotomy tube when doing an emergency procedure. Many small hollow objects also have been suggested, although these are not often used as cricothyrotomy tubes. These include small flashlight or penlight casings, very small pill bottles, plastic throat swabs containers with the bottom cut out, and pen barrels.
Pen barrels have actually been tested. Although they are discussed in medical texts as being useful, at least the standard-issue US military ballpoint pen (Skilcraft, Alexandria, VA) produces so much airway resistance, even with the tapered tip cut off, that it is essentially useless as an airway—except, perhaps as a route for transtracheal jet ventilation or for temporary apneic oxygenation.86
The drip chamber from either regular intravenous tubing or one part of the "Y" from blood tubing has been suggested as a cricothyrotomy cannula.87,88 The drip chamber is cut ~3 cm distal to the spike that goes into the IV bag/bottle. After cutting through the skin over the cricothyroid membrane (a vertical incision is best if you are not certain of the landmarks), insert the spike through the membrane.89
Although the drip chamber supposedly fits well onto a standard BVM, tests show that it only works with some IV tubing. Even with tubing that is too small to fit well, "V-shaped" cuts can be made on both sides of the drip chamber and the BVM can be forced into or around it. Test this before inserting it into the neck, so that modifications can be made before it is in place. Also, consider attaching the BVM before inserting the tube, since attaching it may require more leverage than is possible once the tube is in place.
Protect yourself, if possible, from the spray of blood that invariably accompanies opening the trachea. If you are midline, you can control any bleeding after the tube is in place by packing the area around it with petroleum jelly-impregnated or other gauze. Sutures or cautery are rarely needed to control this bleeding. If you have strayed off midline, however, you may be into the major vessels of the neck—and won't find the trachea. Use a vertical incision and, once through the skin, feel for the cricothyroid membrane, or use the needle-guided method (as with an emergency tracheostomy, described below) if you are concerned about staying in the midline.
Because of its difficulty and potential complications, a true emergency "crash" tracheostomy should be the last option, but is useful if no other method of establishing an adequate airway is available. An emergency tracheostomy is also useful in children needing an immediate surgical airway, since their cricothyroid area is generally too small for a cricothyrotomy. It is also useful (and the author has used it successfully) for patients in whom massive neck swelling from bleeding or from subcutaneous emphysema obscures the cricothyroid landmarks. The basic principle is to stay in the midline. The following technique provides a solution and has proved easy to learn and to use.
This emergency tracheostomy technique requires only a fluid-filled syringe, a needle, a knife, and a tube. To perform the tracheostomy using this technique90: locate the midline of the neck and secure the trachea between the thumb and index finger of the nondominant hand. Incise the overlying skin transversely. Use a finder needle, attached to a saline (or any nontoxic fluid)-filled syringe, to locate and stabilize the tracheal lumen prior to incision and cannulation. Insert the needle into the midline between the prominent thyroid cartilage and the sternal notch, aiming for the anterior trachea (Fig. 8-27). Inject the fluid gently; when it flows without resistance, the needle has entered the trachea. Aspiration of air confirms correct positioning within the lumen. While holding the needle steady, make a vertical stabbing incision lateral to and against the needle (Fig. 8-28). Using the knife handle to open the stoma, remove the needle and insert a standard ETT (Fig. 8-29). Secure the tube with tape and, if necessary, pack the wound to control bleeding.
Insert fluid-filled syringe with needle into midline until there is no resistance when pushing the plunger. (Reproduced with permission from McLaughlin and Iserson.90)
Vertical incision in trachea. This is done with the needle still in place, "cutting down on" the needle. (Reproduced with permission from McLaughlin and Iserson.90)
Opening stoma with knife handle and introducing endotracheal or tracheostomy tube. (Reproduced with permission from McLaughlin and Iserson.90)
Another (slower) tracheostomy method, only appropriate in nonurgent situations, requires some equipment that may not be readily available. Based on the method described previously, it uses the Seldinger (wire-through-needle) technique. With the larynx firmly stabilized with the nondominant hand, make a 1.5- to 2.0-cm transverse or vertical incision just below the cricoid cartilage. Then pass a large-gauge needle through the incision and into the trachea. Optimally, the needle is specifically designed to accommodate the wire, such as with an arterial line or a central line kit. Using a fluid-filled syringe attached to the needle simplifies locating the trachea with the needle, as described previously. Once the trachea is entered, carefully remove the syringe and pass the wire through the needle into the trachea. Pass small (artery-dilating Howard-Kelly) forceps along the wire through the soft tissues of the neck until you feel resistance at the outside of the trachea. Open the forceps to dilate the opening down to the trachea. Then close the forceps and pass them over the wire through the tracheal wall. Advance the forceps until the tip is in the long axis of the trachea; spread the forceps and the tracheostomy tube or, if the wire is long enough, pass an ETT over the guidewire.91,92
Dislodged Tracheostomy Tube
The only sign that the tracheostomy tube is dislodged may be the inability to pass a suction catheter through it, although this can also occur when concretions block the tube.
A mature (>30 days) tracheostomy tube can usually be replaced without too much difficulty if no granulation tissue or foreign body blocks the passage. Simply replace the obturator and pass it into the mature stoma. With tracheostomies <1-month-old, it may be difficult to put a dislodged tube back into the trachea (or trying to do so may cause a false passage) due to stoma closure. In these cases, place an ETT, rather than the shorter tracheostomy tube; a tracheostomy tube can be placed once the airway is again secure.
As a guide, use a urethral catheter with the tip cut off, a suction catheter, or similar tubing connected to an oxygen source. Pass it through the ETT and then gently into the trachea. If the trachea cannot be visualized, pass a pediatric laryngoscope into the trachea, followed by the tube/guide. Once the tube is in the trachea, remove the guide.93
Post-tracheostomy bleeding can be deadly. While mild incision bleeding is typical 1 to 3 weeks post tracheostomy, 85% of tracheo-innominate artery fistula bleeds also occur in the first month. They have a mortality rate of 80% even with treatment. Post-tracheostomy bleeding is often from granulation tissue in the stoma or trachea, erosion of the thyroid vessels or gland, or the tracheal wall due to overzealous suctioning.94
Methods to help control the bleeding while getting the patient to the operating room or interventional radiology include hyperinflating the tube's cuff, putting mild anterior traction on the tube, or replacing the tracheostomy tube with an ETT and hyperinflating the balloon, which should be placed, if possible, just distal to the site of bleeding to tamponade it. The best technique is to stick one's finger into the stoma and apply local digital pressure to compress the innominate artery. If this doesn't work on one side, go to the other side.95