Emergency Tracheostomies

[cfdavid]

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This post is closely related to MilMD's "somone almost died" post. But, I figured I'd post separate.

First, how often is this procedure necessary?? Is it the kind of thing that most doctors rarely "get a chance" to do?? I'm speaking specifically of the emergency procedure, that is.

Also, is it always a surgeon that does the cutting?? What about tube placement and subsequent stitching?? Are anesth docs trained on this in emergencies or in the OR for that matter?

What are some complications to this? It seems like blood could easily enter the airway/lungs, no?

I know there are chapters written about this subject, so any anecdotal references will suffice.

cf

 

[mysophobe]

Surgeons do all the traches here, emergency or not. Blood might enter the airway, but would you rather have some blood you need to suction out or have the patient die? As far as true emergency traches go, they don't happen a whole lot around here. It's probably different anywhere you go, so you'd have to ask others to get a full picture.

 

[rn29306]

What are some complications to this? It seems like blood could easily enter the airway/lungs, no?

cf

Someone correct me if I am wrong, but if you have to aspirate something, blood is about your best choice. You'll probably have a white-out on the CXR for a day, but dramatically improves on day 2. The pH doesn't cause the flash burn and subsequent injury that stomach contents does.

 

[cchoukal]

Back home I saw a couple emergency trachs (maybe they were crichs; I wasn't sure at the time) in the ER (one by attending, one by an ER G2).

 

[mysophobe]

Prolly crichs.

 

[AJM]

Someone correct me if I am wrong, but if you have to aspirate something, blood is about your best choice. You'll probably have a white-out on the CXR for a day, but dramatically improves on day 2. The pH doesn't cause the flash burn and subsequent injury that stomach contents does.

Blood in the airways is a great culture medium -- it makes you prone to developing bacterial pneumonia a few days later. But true, it does not cause a chemical pneumonitis that one would have with aspiration of gastric contents. The post-blood-aspiration PNA is more of a concern in lung transplant patients or CF'ers.... most people with normal immune systems should (1) be able to fight off any infection and (2) be able to cough up any significant amount of residual blood.

 

[rn29306]

Blood in the airways is a great culture medium -- it makes you prone to developing bacterial pneumonia a few days later. But true, it does not cause a chemical pneumonitis that one would have with aspiration of gastric contents. The post-blood-aspiration PNA is more of a concern in lung transplant patients or CF'ers.... most people with normal immune systems should (1) be able to fight off any infection and (2) be able to cough up any significant amount of residual blood.

👍

 

[Blade28]

Always done by G Surg here.

 

[cfdavid]

So, if you were in a restaraunt and someone was choking that did not respond to the Hiemlich, could you do an emergency tracheotomy?????
Would it be feasible to improvise with "tools" readily available at a restaraunt??? For added incentive, assume it was a family member.....
What would you do? And what would you "use"?

 

[jetproppilot]

What would you do? And what would you "use"?

The proprietary trach thinghy on my keychain.

 

[Gimlet]

The proprietary trach thinghy on my keychain.

I think we need a picture of this trach thingy, Jet! That, or a link to where we can buy one of our very own.

 

[jetproppilot]

I think we need a picture of this trach thingy, Jet! That, or a link to where we can buy one of our very own.

Yeah, I'll find a link.

Cool conversation piece if nothing else, although the inventor, Ron French, ENT dude, has used his B4.

 

[jwk]

I've seen two surgical airways in 25 years. One was done for a hematoma caused by pulling out an introducer placed in the carotid (NOT by me) - a true trach by a general surgeon who we literally dragged into the OR. Major bitch - trachea was WAY deviated. Note to newbies - if you put the sheath in the carotid, DON'T pull it out - drop an ETT in before their airway becomes obstructed and call a vascular surgeon.

The other was a postop OSA surgery of some sort - the guys tongue or something else in the upper airway had a hematoma and he obstructed. This was a cric using a Melker kit - surgeon made the incision, anesthesia doc placed the wire and catheter setup.

We have annual mandatory training/review of all of our toys on our difficult airway carts for all docs and anesthetists. Cric sets, combitubes, retrograde sets, LMA fast-trachs (and now the new ones with the camera and monitor), light wands, FOB, yada, yada, yada.

Although I'm sure that anesthesia providers on rare occasions will actually need to perform a surgical airway, we simply don't do many. Why? Because we are THE airway experts. THIS IS WHAT WE DO! I firmly believe that the majority of surgical airways I've seen over the years done by ER docs, paramedics, and flight nurses, are simply because they're not as adept at intubating as we are. There's a big difference between managing airways once or twice a month in the ER and several times every day in the OR.

 

[Idiopathic]

Although I'm sure that anesthesia providers on rare occasions will actually need to perform a surgical airway, we simply don't do many. Why? Because we are THE airway experts. THIS IS WHAT WE DO! I firmly believe that the majority of surgical airways I've seen over the years done by ER docs, paramedics, and flight nurses, are simply because they're not as adept at intubating as we are. There's a big difference between managing airways once or twice a month in the ER and several times every day in the OR.

This is a good point. You dont become adept at difficult airway management by crich'ing everyone. Especially since its about as far down on the algorithm as you can go.

 

[case42]

a link: http://www.bookofjoe.com/2005/11/behindthemedspe_4.html

and picture:

and you can order one here:
http://67.154.142.139/shipperttemplate/shopdisplayproducts.asp?id=1200&mcatid=Yes

 

[jetproppilot]

a link: http://www.bookofjoe.com/2005/11/behindthemedspe_4.html

and picture:

and you can order one here:
http://67.154.142.139/shipperttemplate/shopdisplayproducts.asp?id=1200&mcatid=Yes

Thanks alot for the link.

 

[Monty Python]

a link: http://www.bookofjoe.com/2005/11/behindthemedspe_4.html

and picture:

and you can order one here:
http://67.154.142.139/shipperttemplate/shopdisplayproducts.asp?id=1200&mcatid=Yes

In all seriousness, has anyone gone through airport security with that on your keychain?

 

[jetproppilot]

In all seriousness, has anyone gone through airport security with that on your keychain?

havent tried. I'll leave it at home.

 

[Gimlet]

$135?! 😱 I guess I'll have to wait and ask for one for graduation. Unless Jet wants to talk to Mr. French about getting some samples to send his buddies on SDN (nudge, nudge, wink, wink!).

 

[MTGas2B]

In all seriousness, has anyone gone through airport security with that on your keychain?

How about MacGyver style instead; pocket knife and a hollow tube?

 

[mysophobe]

I'm going to need a rubber band, a paper clip, a pocket knife, and a pen.