急救气管造口术（图文演示）

中文版：急救气管造口术（中文图文演示）

EMERGENCY   TRACHEOSTOMY
Authors
A Stefani, D Gossot
Abstract
The description of the emergency tracheostomy covers all aspects of the surgical procedure used for the management of upper airway obstruction.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: cricothyrotomy, incision.
Consequently, this operating technique is well standardized for the management of this condition.

1. Introduction
Tracheostomy should only be performed at the patient’s bedside in acute emergencies, or when the condition of the patient is such that transport to the operating room could be dangerous. In these cases, it is important to adhere to the basic principles of the procedure and strive to create the best possible working environment.
Emergency tracheostomy is indicated in severe airway compromise when endotracheal intubation is not possible. There is no time for adequate preparation, and it is unusual to have adequate, sterile instruments, good lighting or an assistant. Therefore, a standard cervical tracheostomy is not practical because it is risky and carries a high mortality; instead, less invasive techniques such as mini-tracheostomy, percutaneous tracheostomy or cricothyrotomy are preferred.

2. Cricothyrotomy
Cricothyrotomy relies on the introduction of a tracheostomy tube through the cricothyroid membrane. This superficial membrane is found between 2 surface landmarks that are easily located (the cricoid cartilage and the thyroid cartilage) and there is no danger of damaging the thyroid isthmus.
The intervention is easy and rapid when performed with special instruments that are commercially available in kit form.

3. Indications
A cricothyrotomy is indicated in emergency situations where endotracheal intubation is impossible or contraindicated (Hamilton and Kang, 1997; Isaacs and Pedersen, 1997).

The procedure is not indicated as an alternative to formal tracheostomy in elective cases.

4. Operating room

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The procedure is performed under local anesthesia, utilizing a kit containing all the necessary instruments and a tracheostomy tube. The following conditions are necessary:
- supine position;
- arms by the sides;
- neck stabilized and fixed in midposition;
- sandbag under the shoulders to place the neck in hyperextension. This can be accentuated by dropping the head of the table; however, excessive extension can cause the tracheostomy to be placed too low.

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The anesthesiologist stands at the head of the patient.
The surgeon stands to the right of the patient.
The assistant stands to the left of the patient.
The scrub nurse stands to the right of the surgeon.

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1. Operating table
2. Anesthetic unit
3. Electrocautery

5. Instruments
• Operating instruments

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1. Standard dissecting forceps
2. Metzenbaum dissecting scissors with curved tip

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1. 10 mL syringe for inflation of the tracheostomy cuff
2. Band for fastening
3. Trocar
4. Connector tubing for the ventilator

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1. Halsted-Mosquito forceps
2. Standard needle holder
3. Kelly forceps

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1. Beckman-Adson self-retaining retractor
2. Langenbeck retractors
3. Laborde dilator (3 blades)
4. Trousseau dilator (2 blades)

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With a size 11 blade on the scalpel, a horizontal incision is made between the 2 cartilages of the larynx.
The cricothyroid membrane is found immediately under the skin and is also incised horizontally with the scalpel.
The opening is dilated with the handle of the scalpel, a Kelly forceps or a dilator from the cricothyrotomy kit. Then the cannula is introduced (Brofeldt et al., 1996).
If instruments are missing or if there is not enough time to perform the above procedure, the opening can be dilated with the left hand and the cannula immediately introduced with the right hand.
The percutaneous technique (Barrachina et al., 1996) may also be used for introduction of the cannula.

7. Postop period
Compared to a conventional tracheostomy, cricothyrotomy is very quick, simple and effective, and results in fewer immediate complications. The success rate is very high (Jacobson et al., 1996).
However, maintaining a cannula in the larynx is associated with the risk of subglottic stenosis and a high incidence of dysphonia and dysphagia. Therefore, the technique should be reserved for extreme emergencies and converted to formal tracheostomy as soon as possible.

8. Reference