ソース: ジェームズ ・ W Bonz、MD、救急医学、エール大学院医学系、ニューヘブン、コネチカット、米国
開いている輪状甲状膜切開は緊急手術です。それは輪状甲状間膜切開チューブの通過によって気道アクセスを確立する実行されます。気管内挿管の他のすべてのフォームが失敗し、自発呼吸が悪化または不可能となっているとき、これは恐れられていた「ことはできません挿管、換気できない」シナリオでは – 選択の手順です。
気道アクセスは、気管切開チューブを介して確立されます。気管カニューレは、3 つの部分で構成されています: 外側のカニューレ (または気管チューブ自体)、内套管と、閉鎖。中には、内套管を削除しながら、挿入をガイドする気管カニューレ内、閉鎖は配置されます。Obturator の遠位端が丸められ、簡単に周囲の構造にとらわれることがなく所定の位置に管をガイドする施術をできるように気管カニューレの終わりまで突き出ています。さらに、閉鎖はチューブ挿入時に組織や体液で目詰まりを防止します。 チューブを配置すると、閉鎖が削除され、内套管を気管カニューレ内に配置されます。修正手順を実行できますまた、気管内のチューブは、このビデオで示されます。
輪状甲状膜切開は重大な合併症に関連付けられてより少ない侵襲的な対策が失敗したときにのみに実行されます。しかし、それは気管切開の上最寄り (手順 2 気管軟骨輪間の開口部が作成されます)、地域の予測可能な解剖学、相対的な速さは、それを行うことができます、関連する合併症のリスクが低いため。
この手順は子供の声門下狭窄を開発のリスクの増加に関連付けられています、若い年齢が開く輪状甲状膜切開、禁忌と見なされます。ただし、年齢に関してこの手順が適切になったら専門家の間で意見の相違があります。意見が 5 歳から 12 歳に変わるし、相対禁忌と考え。幼児の気管切開術は最寄りと患者が長い針輪状甲状膜切開による気管ジェット換気でお茶を濁してきたがこのより多くの手順を実行するのに十分な。その他の禁忌では、骨折の喉頭輪状軟骨に重傷をご利用など。
A surgical cricothyrotomy is truly an emergency procedure. The procedure itself is straightforward and uncomplicated. Surgical cricothyrotomy is a lifesaving procedure in a patient who would otherwise suffer great morbidity or death from prolonged hypoxia.
Complications from a failed cricothyrotomy can be disastrous, as the loss of airway is loss of life. Most significant complications arise when an artery is lacerated, and the bleeding obscures the surgical field. The superior thyroid arteries run laterally on both sides of the midline and anastomose superficial to the inferior portion of the laryngeal prominence. With anatomic variance, it is not all that infrequent that these vessels may be encountered in the superior portion of the cricothyroid membrane, increasing the risk of laceration during the procedure.
Misplacement of the tracheostomy tube might occur even if the field is not obscured. The tube can be placed in the soft tissue when the opening is not well stabilized with the tracheal hook, or if the Trousseau dilator is not positioned within the incision in the cricothyroid membrane. Several seconds may pass before the complication is recognized, increasing the likelihood that each delivered breath distorts the recognizable anatomy. Therefore, a successful cricothyrotomy requires good knowledge of the surface anatomy, dexterity, and confidence.
Open cricothyrotomy is an emergent surgical procedure of choice in the feared “can’t intubate, can’t ventilate” scenario, which means that all other forms of endotracheal intubation have failed and the spontaneous ventilation is worsening or becoming impossible. It is performed to establish an airway access by passage of a tube through an incision in the cricothyroid membrane, which is located between the thyroid and the cricoid cartilage.
In this presentation, we will review the method for open cricothyrotomy, which includes the prepping steps and the technique for tube insertion. Following that, we will review the contraindications and complications associated with this emergency medicine procedure.
Start by positioning the patient supine with the neck extended. Next, gather all the necessary supplies. This includes: chlorhexidine, number-11 scalpel, tracheal hook, Trousseau dilator, 10cc syringe for inflating the cuff, and a tracheostomy tube.
This tube consists of an outer cannula, which is the tracheostomy tube itself, an inner cannula, and an obturator. Note that the distal end of the obturator is rounded and when it is placed inside the tube the distal tip protrudes through the open end. This allows, one, easy insertion of the tube into place without it being caught in the neighboring structures, and two, prevention of tube clogging with the surrounding tissue or fluids. If the tracheostomy tube is not available, one can use a modified endotracheal tube. To prepare this, remove the Bag Valve Mask adapter at the distal end. Next, cut the tube just distal to the site where the cuff insufflator would enter. Then reattach the adapter.
If the situation calls for local anesthesia such as when rapid sequence intubation medications have not been administrated, and the patient is awake and alert, then gather 5cc syringe with a 25G needle and 1% lidocaine with epinephrine.
If full sterile technique is observed then one should also have sterile towels, facemask, bonnet, sterile gown and sterile gloves. As with all truly emergent procedures, complete sterile technique is optional based on the time pressure of the situation.
Now let’s review the procedural steps. Clean the anterior neck with chlorhexidine by vigorous scrubbing. Full barrier precautions should be undertaken if clinically possible. This includes donning a mask, bonnet, sterile gown and gloves. To optimize the access to the site, stand on the patient’s side that matches your dominant hand, which in this case is “left” , and place sterile towels around the cleaned site to create a complete sterile field.
To locate the insertion site, first palpate the laryngeal prominence or the “Adam’s Apple”, and then move your fingers inferiorly into the depression below to find the cricothyroid membrane. If the palpation is difficult due to body habitus or pathology, the location of the cricothyroid membrane may be estimated as being four fingerbreadths above the sternal notch.
If the patient is awake, administer local anesthesia by inserting the 25-gauge needle just into the skin and creating a wheal in the midline of the expected cricothyroid membrane location. Extend the wheal by 3 cm in both superior and inferior directions.
To start, using the number 11-scalpel, make a 3-5 cm vertical incision in the midline through the skin and subcutaneous tissues. Next, with your non-dominant finger, attempt to feel the cricothyroid membrane through the incision, and then extend the incision superiorly or inferiorly to fully expose the cricothyroid membrane. Now make a 1cm horizontal incision across the cricothyroid membrane at its inferior aspect.
Next, take the tracheal hook and pull the superior portion of the incision upwards. Then using your non-dominant hand, insert the Trousseau dilator through the opening in the cricothyroid membrane, placing the bills on the superior and inferior portions of the incision. Note that the dilator handle would be on the same side as yours. Next, open the bills and rotate the handle to 90° so that it is vertical in relation to the patient. Notice that the dilator bills are now spreading away from the midline. Now, with your dominant hand place the tracheostomy tube with the obturator through the cricothyroid membrane…and remove the Trousseau dilator. Once the tube is in place, remove the obturator, insert the inner cannula of the tube and inflate the cuff using a 10 cc syringe. Next, attach a bag valve unit and ventilate the patient. Lastly, secure the tube in place using the neckties.
If using a modified endotracheal tube, the procedure is the similar. Following incision, place the tube through the cricothyroid membrane…remove the dilator…inflate the cuff… attach the bag valve unit…and secure the tube in place with an endotracheal tube holder.
“Young age is considered a contraindication to open cricothyrotomy as this procedure is associated with an increased risk of developing subglottic stenosis in children. The alternative is temporizing with transtracheal jet ventilation through a needle cricothyrotomy for long enough to perform the more involved tracheotomy procedure. Other contraindications include fractured larynx or severe injury to the cricoid cartilage.”
“Most significant complications related to this procedure arise when an artery is lacerated, and the bleeding obscures surgical field. Note that the superior thyroid arteries run laterally on both sides of the midline, and anastomose superficial to the inferior portion of the laryngeal prominence.”
“With anatomic variance, it is not all that infrequent that these vessels may be encountered in the superior portion of the cricothyroid membrane, increasing the risk of laceration during the procedure.”
“Misplacement of the tracheostomy tube might occur even if the field is not obscured. The tube can be placed in the soft tissue when the opening is not well stabilized with the tracheal hook, or if the Trousseau dilator is not positioned within the incision in the cricothyroid membrane. Several seconds may pass before the complication is recognized, increasing the likelihood that each delivered breath distorts the recognizable anatomy.”
You’ve just watched JoVE’s illustration of surgical or open cricothyrotomy. This is a lifesaving emergency procedure, but the complications from a failed cricothyrotomy can be disastrous, as loss of airway is loss of life. Although the steps are straightforward and uncomplicated, a successful procedure requires good knowledge of the surface anatomy, dexterity, and confidence. As always, thanks for watching!
