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Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
Stabbing of the cricothyroid membrane, or an
attempted stabbing of the trachea, so long taught as an emergency
tracheotomy, is a mistake. The author's two stage, finger guided
method is safer, quicker, more efficient, and not likely to be
followed by stenosis. To execute this promptly, the operator is
required to forget his textbook anatomy and memorize the schema (Fig.
105). The larynx and trachea are steadied by the thumb and middle
finger of the left hand, which at the same time push back the
important nerves and vessels which parallel the trachea, and render
the central safety line more prominent (Fig. 106). A long incision is
now made from the thyroid notch almost to the suprasternal notch, and
deep enough to reach the trachea. This completes the first stage.
[FIG. 107.--Illustrating the author's method of quick tracheotomy.
Second stage. The fingers are drawn ungloved for the sake of
clearness. In operating the whole wound is full of blood, and the
rings of the trachea are felt with the left index which is then moved
slightly to the patient's left, while the knife is slid down along the
left index to exactly the middle line when the trachea is incised.]
Second stage. The entire wound is full of blood and the trachea cannot
be seen, but its corrugations can be very readily felt by the tip of
the free left index finger. The left index finger is now moved a
little to the patient's left in order that the knife shall come
precisely in the midline of the trachea, and three rings of the
trachea are divided from above downward (Fig. 107). The Trousseau
dilator should now be inserted, the head of the table should be
lowered, and the patient should be turned on the side to allow the
blood to run away from the wound. If respiration has ceased, a cannula
is slipped in, and artificial respiration is begun. Oxygen
insufflation will aid in the restoration of respiration, and a pearl
of amyl nitrite should be crushed in gauze and blown in with the
oxygen. In all such cases, excessive pressure of oxygen should be
avoided because of the danger of producing ischemia of the lungs. Hope
of restoring respiration should not be abandoned for half an hour at
least. One of the author's assistants, Dr. Phillip Stout, saved a
patient's life by keeping up artificial respiration for twenty minutes
before the patient could do his own breathing.
The after-care of the tracheotomic wound is of the utmost
importance. A special day and night nurse are required. The inner tube
of the cannula must be removed and cleaned as soon as it contains
secretion. Secretion coughed out must be wiped away quickly, but
gently, before it is again aspirated. The gauze dressing covering the
wound must be changed as soon as soiled with secretions from the wound
and the air-passages. Each fresh pad should be moistened with very
weak bichloride of mercury solution (1:10,000). The outer tube must be
changed every twenty-four hours, and oftener if the bronchial
secretion is abundant. Student-physicians who have been taught my
methods and who have seen the cases in care of our nurses have often
expressed amazement at the neglect unknowingly inflicted on such cases
elsewhere, in the course of ordinary routine surgery. It is not
unusual for a patient to be sent to the Bronchoscopic Clinic who has
worn his cannula without a single changing for one or two years. In
some cases the tube had broken and a portion had been aspirated into
[FIG. 108.--Method of dressing a tracheotomic wound. A broad
quadruple, in-folded pad of gauze is cut to its centre so that it can
be slipped astride of the tube of the cannula back of the shield. No
strings, ravellings or strips of gauze are permissible because of the
risk of their getting down into the trachea.]
If the respiratory rate increases, instead of attributing it to
pulmonary complications, the entire cannula should be removed, the
wound dilated with the Trousseau forceps, the interior of the trachea
inspected, and all secretions cleaned away. Then the tracheal mucosa
below the wound should be gently touched with a sterile bent probe, to
induce cough to rid the lower air passages of accumulated secretions.
In many cases it is a life-saving procedure to insert a sterile long
malleable aspirating tube to remove secretions from the lower
air-passages. When all is clear, a fresh sterile cannula which has
been carefully inspected to see that its lumen has been thoroughly
cleaned, is inserted, and its tapes tied. Good plumbing, that is,
the maintenance at all times of a clear, clean passage in all the
pipes, natural and artificial, is the reason why the mortality in
the Bronchoscopic Clinic has been less than half of one per cent,
while in ordinary routine surgical care in all hospitals collectively
it ranges from 10 to 20 per cent.
Next: Bronchial Aspiration